Hypertension Quick Guide
Learn about measurement technique, diagnosis criteria, initial evaluation, and treatment for hypertension in the primary care setting.
Need to refer to specialty care? Find an in-network specialist for your patients and know when to refer.
Measurement
-
Technique used for blood pressure monitoring
should adhere to national guidelines1,2 -
Home blood pressure monitoring (HBPM) important
to identify “White Coat” Hypertension (and “Masked
Hypertension”- reading lower than usual in office)
Diagnosis
-
Hypertension is diagnosed when office-based BP =140/90 repetitively over 2-3 office visits, at 1-4 week intervals
-
Diagnosis can be made on a single visit, if BP is =
180/110 with evidence of CVD -
Isolated Systolic Hypertension is defined as SBP
>140 with a normal DBP
Category |
Office BP |
HBPM |
|
---|---|---|---|
SBP |
DBP |
||
Normal BP |
<130 |
<85 |
<135 and/or <85 |
High-normal BP |
130-139 |
85-89 |
>=135 and/or >=85 |
Stage 1 hypertension |
140-159 |
90-99 |
>=135 and/or >=85 |
Stage 2 hypertension |
>=160 |
>=100 |
>=135 and/or >=85 |
Initial Evaluation
-
Confirm diagnosis and stage of hypertension
-
Laboratory testing should include: basic metabolic panel, lipids,
U/A, and EKG, with additional testing, as warranted, to detect/
confirm HTN mediated organ damage -
Evaluate for secondary causes of HTN (primary aldosteronism,
renovascular, drugs/meds, sleep apnea, CKD, and others),
if indicated -
Calculate 10-yr risk of a first ASCVD event (Note: CKD patients are high risk patients)
-
Assess other relevant comorbid conditions and complications of
HTN
BP Measurement Plan According to Office Blood Pressure Levels |
||
---|---|---|
<130/85 | 130-169/85-99 | >160/100 |
Remeasure within 3 years (1 year in those with other risk factors) |
If possible, confirm with |
Confirm within a |
Treatment
Treatment Targets
-
Achieve patient-specific treatment targets, taking into account comorbidities, estimated longevity, risk of hypertension, adherence, and cost
Target BP |
Risk Profiles and Comorbid Disorders |
<140/90 |
ACSVD risk <10% |
<130/80 |
ACSVD risk >=10% Known CAD, prior stroke or TIA, COPD HFpEF HFrEF and achieved maximally tolerated doses of GDMT Diabetes |
<120/80 |
Chronic Kidney Disease Diabetes with moderate to severe albuminuria (ACR>30 mg/g) or lower on maximally tolerated approved doses |
Treatment Targets
-
Includes lifestyle modification promoting a healthy diet, limited alcohol and caffeine consumption, weight reduction, cessation of tobacco use, regular exercise, stress management, and avoiding medications/drugs that increase BP
-
Patients with High-Normal BP and 10-yr risk for ASCVD risk <10% can be managed with non-pharmacologic therapy, while those with risk >10% should also receive medication
-
A BP decrease of 20/10 mmHg associated with a 50% decrease in cardiovascular risk
-
First-line treatment should include single pill, combination pill, or multiple pills using a CCB + ARB/ACE or in Black patients, a thiazide-like diuretic + CCB or CCB + ARB.
-
ARBs (not ACE) should be used in Black patients as angioedema is ~3X more common with ACE inhibitors in these patients
-
Use once-daily regimens providing 24-hour blood pressure control, whenever possible.
-
Recognize/address behavioral health disorders and social determinants of health. Screen with PHQ 2/9 annually.
-
Often both office-based and HBPM results are useful to guide treatment (see link for home devices https://www.validatebp.org/3)
-
Evaluate/promote medication adherence at each visit, prior to escalation of treatment
-
Both video and telephone-only visits can be effectively utilized for HTN management
o Have patients secure readings that day
o Providers should appropriately document in EMR (may be utilized for quality measurement).
Resistant Hypertension
Resistant hypertension is defined as persistent, appropriately
measured, BP >140/90 mmHg in a patient treated with three
or more antihypertensive medications, including a diuretic, on optimal (or maximally tolerated) doses
Treatment
-
Optimize lifestyle modification and medication
adherence -
Reassess possible secondary causes of hypertension
-
If GFR <30 or volume overloaded, use a loop diuretic
-
Add a low dose of spironolactone if K <4.5 mmol/L and
GFR >45 ml/min. If contraindicated/not tolerated, use
eplerenone or potassium-sparing diuretic -
Other additional treatments include doxazosin,
clonidine, hydralazine, beta-blockers or other available
antihypertensive class not already in use -
Giving one antihypertensive medication in the evening
may address end-of-dose effect
When to Refer to a Specialist
Nephrology
-
Resistant hypertension
-
To clarify the cause and treatment of comorbid CKD and management of related complications
Endocrinology
-
Evaluation and treatment of endocrine causes of secondary hypertension
-
Treatment of other poorly controlled endocrine disorders that impact HTN care (DM, hyper/hypothyroidism, hypogonadism)
Cardiology
-
For treatment of concomitant cardiac disease (CAD, HF, Afib)
-
Assessment/treatment of renovascular hypertension
Find a specialist
Next Steps
Learn about team-based care and referral options at the Mount Sinai Health System
Download a printable version of this quick reference guide
Return to the Chronic Condition Management Hub
[1] Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020;75:1334–135.
[2]Whelton PK, Carey, RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCMA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-248.