Access to the full guideline and additional resources are available at the following link: https://www.healthquality.va.gov/guidelines/CD/htn/ Sidebar 1: Office Blood Pressure Measurement AOBP (preferred) Fully automated machine programmed to wait five minutes and record the average of three measurements separated by at least 30 seconds Standard Technique (alternative) Use a properly calibrated and validated sphygmomanometer Use an average of 2 readings Sidebar 2: Confirm Diagnosis If the follow-up clinic blood pressure value is 130 mm Hg SBP or 90 mm Hg DBP, make diagnosis of HTN without further testing Consider HBPM or ABPM to inform the diagnosis in select patients (see Recommendation 4 in the full CPG) If blood pressure is <130 mm Hg SBP and <90 mm Hg DBP, yet there is evidence of target organ damage, which may suggest the presence of masked HTN, consider HBPM or ABPM to inform the diagnosis (see Recommendation 4 in the full CPG) Module B: Treatment Sidebar 5: Initiate Drug Therapy General Population Recommend one or more of the following: Thiazide-type diuretics ACEIs or ARBs* Long-acting CCBs For patients unlikely to achieve goal with monotherapy (e.g., patients with SBP/DBP of >20/10 mm Hg above goal), consider initiating treatment with combination therapy or monotherapy with close follow up for titration and/or addition of medications based on blood pressure response Specific Populations: For patients age 65 and over, we suggest a thiazide-type diuretic for reduction in composite cardiovascular outcomes For African American patients, we recommend against using ACEIs or ARBs as monotherapy For patients with CKD, see VA/DoD CKD CPG1 *We recommend against more than one of the following three drug classes together in the same patient: ACEIs, ARBs, or direct renin inhibitors Sidebar 3: Examples of Target Organ Damage and Comorbid Conditions* Target organ damage: stroke, MI, peripheral arterial disease, LVH, CHF, CKD, and retinopathy Comorbid conditions: CKD, dyslipidemia, diabetes, obesity/overweight, OSA, and tobacco dependence *If patient has comorbid conditions, engage relevant clinical practice guidelines, 1. See the VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease. Available at: https://www.healthquality.va.gov/guidelines/CD/CKD/ 2. See the VA/DoD Clinical Practice Guideline for the Management of Dyslipidemia for Cardiovascular Risk Reduction. Available at: https://www.healthquality.va.gov/guidelines/CD/lipids/ 3. See the VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care. Available at: https://www.healthquality.va.gov/guidelines/CD/diabetes/ 4. See the VA/DoD Clinical Practice Guideline for Screening and Management of Obesity and Overweight. Available at: https://www.healthquality.va.gov/guidelines/CD/obesity/ Sidebar 4: Goals for Blood Pressure Systolic Goal (see Recommendations 6 8 in the full CPG) <130 mm Hg If less stringent goal is desired per clinical judgment and/or patient preference, aim for at least: <150 mm Hg among patients age 60 and over <140 mm Hg for patients age 60 and over with type 2 diabetes Diastolic Goal (see Recommendation 9 in the full CPG) <90 mm Hg for patients age 30 and above Obtain office blood pressure (see Sidebar 1) 1 Adult in healthcare system Go to Module B, Yes Return after acute episode resolved (typically within 4 weeks) Yes Yes Yes No No Assess the need for and implement lifestyle modification, then follow up for adherence (e.g., diet, exercise, weight loss, alcohol moderation) Screen blood pressure periodically; address other CV risk factors (including healthy diet and physical activity); in patients with known or suspected target organ damage (see Sidebar 3), consider possibility of masked HTN (consider HBPM or ABPM) No Yes Obtain history and physical and assess for target organ damage and comorbid conditions (see Sidebar 3); consider baseline testing (e.g., basic metabolic panel, urinalysis, EKG, A1c, other tests) as appropriate Yes Evaluate as indicated; consider referral Yes Initiate treatment (go to Module B) When measured properly (see Appendix G in the full CPG), is SBP 120 mm Hg or DBP 80 mm Hg? Is the patient currently being treated for HTN? Confirm diagnosis of HTN by measuring blood pressure after 1 4 weeks (see Sidebar 2); is diagnosis confirmed? Does patient have an acute injury or illness? Is secondary cause suspected? No Is SBP 130 mm Hg or DBP 90 mm Hg? No Is the patient s blood pressure at or below goal? 17 Determine blood pressure goal (see Sidebar 4) Initiate treatment if drug na ve or optimize existing therapy (see Sidebar 5) Yes Consider offering and/or adjusting HBPM with co- interventions (tailored medication titration, education, and/or lifestyle counseling No Follow up periodically; reassess preferences Follow up regularly (e.g., monthly) until: Blood pressure is at goal Treatment regimen is optimized (see Sidebar 6) Comorbid conditions and/or other patient preferences direct otherwise No Follow up annually or more frequently as dictated by comorbid conditions (to include lab monitoring, if indicated) Yes Implement SDM to assess patient values and preferences; assess the need for and implement lifestyle modification Is the patient willing to engage in pharmacotherapy? Patient refuses pharmacotherapy; consider nurse-led and dietitian-led interventions to improve blood pressure control Patient appropriate for HTN treatment The Diagnosis and Management of Hypertension in the Primary Care Setting Module A: Screening and Diagnosis VA/DoD CLINICAL PRACTICE GUIDELINES March 2020 VA/DoD CLINICAL PRACTICE GUIDELINES March 2020 Sidebar 6: Optimize Treatment Assess adherence Consider evaluating for interfering substances (some prescription medications, NSAIDs, alcohol, recreational drugs) Consider evaluating and addressing contributing lifestyle factors Optimize treatment (refer to Appendix F, Table F-1 in the full CPG) Titrate initial drug Add another agent from a different class Reevaluate diagnosis (resistant HTN, secondary causes of HTN) Consider specialty consultation for patients with resistant HTN Consider co-interventions to enhance management of HTN and improve blood pressure (pharmacist-led, nurse-led, dietitian-led) DASH Diet Protocol Nutrient Recommended Intake Saturated fat 6% of total calories Total fat 27% of total calories Carbohydrate 55% of total calories Dietary fiber 30 grams/day Protein 18% of total calories Cholesterol 150 mg/day Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/prevent weight gain Mediterranean Diet Protocol Food Item Goal Recommended Items Olive oil 4 tbsp per day Tree nuts and peanuts 3 servings per week Fresh fruits including natural fruit juices 3 servings per day Vegetables 2 servings per day Seafood (primarily fatty fish) 3 servings per week Legumes 3 servings per week Sofritoa 2 servings per week White meat In place of red meat Wine with meals 7 glasses per week, for those who drinkb Discouraged Items Soda drinks <1 drink per day Commercial baked goods, sweets, pastriesc <3 servings per week Spread fats <1 serving per day Red and processed meats <1 serving per day Guidance Conducting Home Blood Pressure Measurement Preparation Have an empty bladder; rest quietly, without talking or texting, in seated position with back supported for at least five minutes Position Sit with back supported; keep both feet flat on the floor Cuff should be on bare arm; directly above the bend of the arm, pulled taut Center of the bladder of the cuff (commonly marked on the cuff) should be placed over the arterials pulsation of the patient s bare upper arm The arm with the cuff should be supported on a flat surface Number of readings Take 2 readings at least 1 minute apart in the morning before any antihypertensive medications and 2 readings at least 1 minute apart in the evening before bed for a total of 4 readings Duration of monitoring Preferred monitoring period is 7 days; a minimum period of 3 days may be sufficient, ideally in the period immediately before the next appointment Analyzing readings For each monitoring period, average all of the readings If the first day of readings is excluded, as sometimes recommended, the minimum of preferred periods of HBPM should be 4 and 8 days, respectively Guidance Conducting Office Blood Pressure Measurement Properly prepare the patient Have the patient relax, sitting in a chair with feet flat on floor and back supported for 3 5 minutes without talking or moving around before recording the first reading Avoid caffeine, exercise, and smoking for 30 minutes before measurement Ensure that the patient has emptied his/her bladder The patient nor the observer should talk during rest period or the measurement Remove clothing covering the location of cuff placement Sitting on an examining table does not fulfill these criteria Use proper technique (attended or unattended, fully AOBP measurement is preferred) Use a validated upper-arm cuff measurement device that has been calibrated Support the patient s arm (e.g., resting on a desk) Position the middle of cuff on the patient s upper arm, level with the right atrium Use the correct cuff size so that the bladder encircles 75 100% of the upper arm Take proper measurements needed At the first visit, record blood pressure in both arms; use the arm that gives the higher reading for subsequent readings (if consistently 10 15 mm Hg higher) Separate repeated measurements by 30 seconds Properly document accurate blood pressure readings Record SBP and DBP Note the time of most recent blood pressure medication taken before measuring Use average readings Average 2 readings for the visit blood pressure For initial documentation of the patient s blood pressure, use an average of the visit readings from 2 occasions to estimate the individual s blood pressure Provide blood pressure readings to patient Provide patients their SBP/DBP readings both verbally and in writing; help the patient interpret the results For more information about blood pressure measurements, see Appendix G and Appendix H in the full CPG. For a video with instructions on measuring blood pressure at home, please click on the Home Blood Pressure Monitoring video available at this link: https://www.healthquality.va.gov/guidelines/CD/htn/ Abbreviations: A1c: glycated hemoglobin; ABPM: ambulatory blood pressure monitoring; ACEI: angiotensin-converting enzyme inhibitor; AOBP: automated office blood pressure; ARB: angiotensin II receptor blockers; AV: atrioventricular; CCB: calcium channel blocker; CHF: chronic heart failure; CKD: chronic kidney disease; cm: centimeter; CPG: clinical practice guideline; CV: cardiovascular; DASH: Dietary Approaches to Stop Hypertension; DBP: diastolic blood pressure; DHP: dihydropyridine; DoD: Department of Defense; EKG: electrocardiogram; HBPM: home blood pressure monitoring; Hg: mercury; HTN: hypertension; IR: immediate release; K+: potassium; LV: left ventricular; LVH: left ventricular hypertrophy; mg: milligram; MI: myocardial infarction; ml: milliliter; mm: millimeter; NSAIDs: nonsteroidal anti-inflammatory drugs; OSA: obstructive sleep apnea; SBP: systolic blood pressure; SDM: shared decision making; SR: sustained release; tbsp: tablespoon; VA: Department of Veterans Affairs a Sofrito is a sauce made with tomato and onion, and often includes garlic, herbs, and olive oil b Recommended wine volume per glass: 100 mL for women, 150 mL for men c Commercial baked goods, sweets, and pastries included cakes, cookies, biscuits, and custard, and did not include those that are homemade Select Antihypertensive Therapyb Select Medicationb Usual Dosage Range Comments Thiazide- Type Diuretics Chlorthalidone 12.5 25 mg daily May cause hyperuricemia/ gout Monitor K+ levels Hydrochlorothiazide 25 50 mg dailyc ACEIs Lisinopril 10 40 mg daily Avoid in pregnancy Do not use if history of angioedema Monitor K+ and kidney function ARBs Losartan (daily or divided Avoid in pregnancy Monitor K+ and kidney function Valsartan 30 320 mg daily Long-acting CCBs: DHP CCBs Amlodipine 2.5 10 mg daily May cause ankle edema, dizziness, flushing, headache, constipation Nifedipine SR 30 120 mg daily Long-acting CCBs: Non- DHP CCBs Verapamil SR (daily or divided Verapamil may cause constipation; contraindicated in 2nd or 3rd degree AV block; severe LV dysfunction Diltiazem SR 120 540 mg daily Diltiazem may decrease sinus rate; contraindicated in 2nd or 3rd degree AV block; use with caution in LV dysfunction a For complete drug information, review the manufacturer s prescribing information b Drug classes recommended as primary pharmacologic therapy for HTN for reduction in composite CV outcomes; selected medications include those listed on the VA National Formulary and DoD Basic Core Formulary; refer to the full HTN CPG for treatment recommendations and additional medications information c Hydochlorothiazide 12.5 mg may be considered as an initial dose with titration recommended to 25 50 mg daily; refer to Recommendation 25 and associated discussion in the full HTN CPG for further information