Hypertension

Background

• Hypertension is a sustained elevation of systemic arterial blood pressure.
• Hypertension is most commonly defined as systolic blood pressure (SBP) ≥ 140 mm Hg or diastolic blood pressure (DBP) ≥ 90 mm Hg, but definitions vary by professional organization and by level of cardiovascular risk.
• Onset is generally at age 20-50 years, but prevalence increases with age.
• Risk factors for hypertension include, but are not limited to, weight gain and obesity, alcohol use (particularly for men), and exposure to insulin.
• Most patients with hypertension have primary or essential hypertension, but in 10%-15% of patients it may be due to secondary causes.
• Selected lifestyle interventions, including modifications in diet, regular exercise, and restriction of alcohol intake, can lower blood pressure and prevent or reduce the likelihood of developing hypertension.
• Untreated or incompletely-treated hypertension is associated with an increased risk of cardiovascular events and mortality.

Evaluation

Initial Diagnosis

• Measure blood pressure with the appropriate cuff size in a calm, seated position and with the patient's arm supported at the level of the heart (Strong recommendation).
• A hypertension diagnosis is based on ≥ 2 blood pressure measurements per visit, at ≥ 2 visits, with systolic blood pressure (SBP) ≥ 140 mm Hg and/or diastolic blood pressure (DBP) ≥ 90 mm Hg when using manual measurement methods (Strong recommendation).

Confirmation

• Blood pressure measurements obtained outside of a clinical setting (ambulatory blood pressure monitoring [ABPM] and home BP monitoring) are recommended for the diagnostic confirmation of hypertension after the initial screening and before starting treatment (Strong recommendation).
• Consider using ABPM to screen for white coat hypertension and masked hypertension in selected patients and for confirmation of diagnosis before intensifying antihypertensive drug treatment in adults being treated for hypertension with elevated home blood pressure readings suggestive of masked uncontrolled hypertension (Weak recommendation).

Additional Testing

• Uniformly recommended testing for all patients with hypertension includes (Strong recommendation):
  • blood tests (sodium, potassium, creatinine, fasting glucose, fasting lipid profile)
  • urine tests (blood, protein)
  • electrocardiogram (ECG)
• Other tests for consideration include
  • targeted testing for suspected causes of secondary hypertension (Strong recommendation). See the Secondary Causes of Hypertension topic for additional information.
  • hemoglobin or hematocrit, serum uric acid, urine albumin (Weak recommendation)
  • echocardiogram if history, physical examination, or an ECG suggests left ventricular hypertrophy or other structural heart disease (Weak recommendation)

Assessment of 10-year Risk

• Assess 10-year risk of cardiovascular events using a risk calculator, such as the ASCVD Risk Calculator
  • there is insufficient data to support superiority of 1 risk calculator over another
  • Pooled Cohort Equations (PCE) is based on 4 United States cohorts with ethnic diversity but may overestimate risk (see Cardiovascular risk assessment topic for details)
  • Reynolds Risk Score may be more accurate than PCE based on a single study
  • SCORE is commonly used in Europe
• Consider other factors that may not be included as part of the risk calculators, such as a family history of premature coronary artery disease and elevated body mass index (see the Cardiovascular Risk Assessment topic for additional information.)

Management

Nonpharmacologic Management

• Encourage lifestyle modifications which reduce blood pressure and have other health benefits including:
  • weight reduction if overweight or obese (Strong recommendation)
  • dietary changes (decreased fat intake and increased intake of fruits, vegetables, and low-fat dairy) (Strong recommendation)
  • physical activity (Strong recommendation)
  • smoking cessation (Strong recommendation)
• Consider sodium restriction and limiting alcohol consumption, but the effects on reducing cardiovascular events or mortality are less certain (Weak recommendation).

The Decision to Initiate Medications

• The decision to start medications for blood pressure lowering should be individualized with shared decision making including considerations of
  • The patient’s estimated 10-year cardiovascular risk
  • The estimated risk reduction from medications (considering the patient’s baseline risk and systolic blood pressure)
  • The potential adverse effects and burdens of medications used
  • Any comorbidities or factors affecting risks for cardiovascular events or adverse effects
  • The patient’s values and preferences

Target Blood Pressure and Medications for Patients Without Comorbidities

• For most patients without comorbidities
  • use a target blood pressure < 140/90 mm Hg for most patients (Strong recommendation)
  • when starting antihypertensive medications:
    • use a thiazide-type diuretic, an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), or a calcium channel blocker for most patients (Strong recommendation).
      • Thiazide-type diuretics are a recommended option in most guidelines and are shown to reduce mortality.
      • ACE inhibitors or ARBs are a recommended option in most guidelines, especially for non-Black patients.
      • Calcium channel blockers are a recommended option in most guidelines, but have limited data on mortality reduction.
    • beta blockers are not recommended as an initial option in some guidelines, and may be less effective for reducing cardiovascular events than other initial drug choices.
• For selected patients ≥ 50 years old with increased 10-year cardiovascular risk who desire a more intensive approach, consider a target systolic blood pressure < 120 mm Hg using an automated blood pressure measurement device.

Target Blood Pressure and Medications for Patients With Comorbidities

• Consider comorbidities to guide the target blood pressure and initial drug selection.
  • In patients with diabetes
    • guidelines vary but targets range from < 130/80 mm Hg to < 140/90 mm Hg
    • use an ACE inhibitor or an ARB (Strong recommendation), particularly in those with microalbuminuria.
  • In patients with chronic kidney disease:
    • consider a target of at least ≤ 140/90 mm Hg and consider targets of ≤ 130/80 mm Hg or ≤ 120 mm Hg based on factors such as tolerability, presence of kidney transplantation, and other individual characteristics (Weak recommendation)
    • use an ACE inhibitor (Strong recommendation) or an ARB if there is ACE inhibitor intolerance in patients with accompanying proteinuria (Strong recommendation)
  • In patients with coronary artery disease:
    • consider a target systolic blood pressure < 120 mm Hg using an automated blood pressure measurement device
    • use an ACE inhibitor (Strong recommendation) or an ARB if there is ACE inhibitor intolerance (Strong recommendation)
    • use a beta blocker if recent myocardial infarction (Strong recommendation)
  • In patients with heart failure, use an ACE inhibitor and a beta blocker (Strong recommendation) or consider an ARB if there is ACE inhibitor intolerance (Strong recommendation).
• In older patients who may be more prone to side effects, consider a target blood pressure < 150/90 mm Hg (Weak recommendation).
• For patients with resistant hypertension, consider causes and approaches to treatment of resistant hypertension (see also the Resistant Hypertension topic).