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.

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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
out-of-office blood
pressure measurements
(assessing for white
coat HTN, improper
office measurement).
Alternatively confirm
with repeated office
visits

Confirm within a
few days or weeks


 

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

References

[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.