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{{CMG}}; {{AE}} {{AO}}
{{CMG}}; {{AE}} {{AO}}
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Hypertension Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertension resident survival guide#Overview|Overview]]
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align="center" | {{fontcolor|#2B3B44|Hypertension Resident Survival Guide Microchapters}}
|-
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertension resident survival guide#Classification|Classification]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Chronic hypertension resident survival guide#Overview|Overview]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertension resident survival guide#Causes|Causes]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Chronic hypertension resident survival guide#Classification|Classification]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |Diagnosis
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Chronic hypertension resident survival guide#Causes|Causes]]
:[[Hypertension resident survival guide#General Approach|General]]
:[[Hypertension resident survival guide#Complete Diagnostic Approach|Complete]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |Diagnosis
:[[Hypertension resident survival guide#Prehypertension|Prehypertension]]
:[[Chronic hypertension resident survival guide#General Approach|General]]
:[[Hypertension resident survival guide#Stage 1 Hypertension|Stage 1]]
:[[Chronic hypertension resident survival guide#Complete Diagnostic Approach|Complete]]
:[[Hypertensive crisis resident survival guide|Stage 2]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Medical Therapy
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | Treatment
:[[Hypertension resident survival guide#Choice of Regimen|Choice of Regimen]]
:[[Chronic hypertension resident survival guide#Prehypertension|Prehypertension]]
:[[Hypertension resident survival guide#Drug List|Drug List]]
:[[Chronic hypertension resident survival guide#Stage 1 Hypertension|Stage 1]]
:[[Hypertension resident survival guide#Preferred Drug Combinations|Drug Combinations]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertension resident survival guide#Do's|Do's]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | Medical Therapy
:[[Chronic hypertension resident survival guide#Choice of Regimen|Choice of Regimen]]
:[[Chronic hypertension resident survival guide#Drug List|Drug List]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypertension resident survival guide#Don'ts|Don'ts]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" | [[Chronic hypertension resident survival guide#Don'ts|Don'ts]]
|}
|}


==Overview==
==Overview==
[[Hypertension]] (HTN) is defined as a [[systolic blood pressure]] (SBP) ≥ 140 mmHg and [[diastolic blood pressure]] (DBP) ≥ 90 mmHg.<ref name="pmid14656957">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. | journal=Hypertension | year= 2003 | volume= 42 | issue= 6 | pages= 1206-52 | pmid=14656957 | doi=10.1161/01.HYP.0000107251.49515.c2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14656957  }} </ref>  It is usually detected during the screening of an asymptomatic individual, but the diagnosis is based on persistent elevation of [[blood pressure]] after an average of 2 or more [[blood pressure]] measurements taken during 2 or more health care visits.  [[Hypertension]] is classified as either primary (or essential) when the etiology cannot be identified; or secondary, when the etiology (e.g., [[hyperthyroidism]], [[pheochromocytoma]], [[renal artery stenosis]]) is known.  The presence of [[diabetes mellitus]], [[Health effects of tobacco smoking|cigarette smoking]], excessive [[sodium]] intake, [[obesity]], and [[sedentary lifestyle]] increases the risk of developing [[essential hypertension]].  Lifestyle modifications such as [[Weight loss|weight reduction]], reduction in [[alcohol]] consumption, [[exercise]]s, and reduction in salt intake are recommended to all patients in addition to pharmacological therapy, when required.
==Classification==
==Classification==
The ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 2017 [[clinical practice guidelines]]<ref name="pmid29133356">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 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. | journal=Hypertension | year= 2017 | volume=  | issue=  | pages=  | pmid=29133356 | doi=10.1161/HYP.0000000000000065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133356  }} </ref>, executive summary<ref name="pmid29133354">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2017 | volume=  | issue=  | pages=  | pmid=29133354 | doi=10.1161/HYP.0000000000000066 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133354  }} </ref>, and underlying [[systematic review]]<ref name="pmid29133354">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2017 | volume=  | issue=  | pages=  | pmid=29133354 | doi=10.1161/HYP.0000000000000066 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133354  }} </ref> by the ACC/AHA taskforce recommend a treatment goal for everyone is <130/80 mm Hg:


{|class="wikitable"
{| class="wikitable"
! Classification!!Blood pressure (mmHg)
!  
|-
! Definition
| Normal||< 120/80
! Treatment
|-
|-
| Prehypertension||120-139/80-89
|Normal blood pressure
|<120/80 mmHg
|Lifestyle
|-
|-
| Stage 1 hypertension||140-159/90-99
| Elevated blood pressure
| Systolic BP, 120–129 mm Hg<br /> - and -<br />Diastolic BP, <80 mm Hg<br />
| Lifestyle
|-
|-
| Stage 2 hypertension||≥ 160/110
| Stage 1 hypertension
| Systolic BP, 130–139 mm Hg<br /> - or -<br />Diastolic BP, 80–89 mm Hg<br />
| Lifestyle and<br />Medications if high risk*
|-
|-
| Isolated systolic hypertension||
| Stage 2 hypertension<br />
| Systolic BP, ≥140 mm Hg<br /> - or -<br />Diastolic BP, ≥90 mm Hg
| Lifestyle and<br />Medications
|-
|-
| Isolated diastolic hypertension||
| colspan="3" | * High risk defined as existing cardiovascular disease or 10-year cardiovascular risk ≥10% ([http://www.cvriskcalculator.com/ calculator] and [https://openrules.ocpu.io/home/www/statins_for_cvd.html alternative calculator with facts box])
|}
|}
==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
* [[Aortic coarctation]]
* [[Cocaine]] or [[amphetamine]] overdose
* [[Pheochromocytoma]]
* [[Preeclampsia]]
===Common Causes===
====Primary or Essential Hypertension====
* No underlying cause is identified.  Risk factors include: high [[sodium]] intake, [[obesity]], [[sedentary lifestyle]], and [[Alcoholism|excessive alcohol intake]].
====Secondary Hypertension====
* [[Aortic coarctation]]
* [[Chronic kidney disease]]
* [[Cocaine]] or [[amphetamine]] overdose
* [[Cushing's syndrome]]
* [[Hyperthyroidism]]
* [[Hypothyroidism]]
* Medications (e.g., [[oral contraceptive pills]], [[NSAIDs]])
* [[Nephrotic syndrome]]
* [[Pheochromocytoma]]
* [[Polycystic kidney disease]]
* [[Preeclampsia]]
* [[Renal artery stenosis]]
* [[Sleep apnea]]
====Pseudohypertension====
* [[Essential hypertension differential diagnosis#White Coat Hypertension|White coat hypertension]]
Click '''[[Essential hypertension causes|here]]''' for the complete list of causes.
==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
<span style="font-size:85%">Boxes in red signify that an urgent management is needed.</span>


===Common Causes===
{{familytree/start}}
{{familytree | | | | | A01 | | |A01=<div style="width:22em">'''For patient presenting with symptoms suggestive of the following:'''</div><br><div style="width:22em; text-align:left">
❑ [[Cerebral infarction]]<br>
❑ [[Intracerebral hemorrhage]]<br>
❑ [[Subarachnoid hemorrhage]]<br>
❑ [[Hypertensive encephalopathy]]<br>
❑ [[Left ventricular failure|Acute left ventricular failure]]<br>
❑ [[Myocardial infarction]]<br>
❑ [[Aortic dissection]]<br>
❑ [[Pulmonary edema|Acute pulmonary edema]]<br>
❑ [[Acute renal failure]]<br>
❑ [[Hypertensive retinopathy]]</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | B01 | | |B01= Measure the [[blood pressure]]}}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | C01 | | C02 | |C01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|'''BP ≥ 180/120'''}}</div>|C02='''BP < 180/120'''}}
{{familytree | | | |!| | | |!| | |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Does the patient have <br>any evidence of end organ damage?}}</div>|D02=Continue with the diagnosis below}}
{{familytree | |,|-|^|-|.| | | |}}
{{familytree | E01 | | E02 | |E01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div>|E02=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|No}}</div>}}
{{familytree | |!| | | |!| | |}}
{{familytree | F01 | | F02 | |F01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|[[Hypertensive emergency|<span style="color:white;">'''Hypertensive emergency'''</span>]]}}</div>|F02=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|[[Hypertensive urgency|<span style="color:white;">'''Hypertensive urgency'''</span>]]}}</div>}}
{{familytree | |`|-|v|-|'| | |}}
{{familytree | | | G01 | | |G01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Click [[Hypertensive crisis resident survival guide|<span style="color:white;">'''here of hypertensive crisis <br>resident survival guide'''</span>]]}}</div>}}
{{familytree/end}}


==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.<ref name="Mancia-2013">{{Cite journal  | last1 = Mancia | first1 = G. | last2 = Fagard | first2 = R. | last3 = Narkiewicz | first3 = K. | last4 = Redán | first4 = J. | last5 = Zanchetti | first5 = A. | last6 = Böhm | first6 = M. | last7 = Christiaens | first7 = T. | last8 = Cifkova | first8 = R. | last9 = De Backer | first9 = G. | title = 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal = J Hypertens | volume = 31 | issue = 10 | pages = 1925-38 | month = Oct | year = 2013 | doi = 10.1097/HJH.0b013e328364ca4c | PMID = 24107724 }}</ref><ref name="Chobanian-2003">{{Cite journal  | last1 = Chobanian | first1 = AV. | last2 = Bakris | first2 = GL. | last3 = Black | first3 = HR. | last4 = Cushman | first4 = WC. | last5 = Green | first5 = LA. | last6 = Izzo | first6 = JL. | last7 = Jones | first7 = DW. | last8 = Materson | first8 = BJ. | last9 = Oparil | first9 = S. | title = Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. | journal = Hypertension | volume = 42 | issue = 6 | pages = 1206-52 | month = Dec | year = 2003 | doi = 10.1161/01.HYP.0000107251.49515.c2 | PMID = 14656957 }}</ref>
Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.<ref name="Mancia-2013">{{Cite journal  | last1 = Mancia | first1 = G. | last2 = Fagard | first2 = R. | last3 = Narkiewicz | first3 = K. | last4 = Redán | first4 = J. | last5 = Zanchetti | first5 = A. | last6 = Böhm | first6 = M. | last7 = Christiaens | first7 = T. | last8 = Cifkova | first8 = R. | last9 = De Backer | first9 = G. | title = 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal = J Hypertens | volume = 31 | issue = 10 | pages = 1925-38 | month = Oct | year = 2013 | doi = 10.1097/HJH.0b013e328364ca4c | PMID = 24107724 }}</ref><ref name="Chobanian-2003">{{Cite journal  | last1 = Chobanian | first1 = AV. | last2 = Bakris | first2 = GL. | last3 = Black | first3 = HR. | last4 = Cushman | first4 = WC. | last5 = Green | first5 = LA. | last6 = Izzo | first6 = JL. | last7 = Jones | first7 = DW. | last8 = Materson | first8 = BJ. | last9 = Oparil | first9 = S. | title = Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. | journal = Hypertension | volume = 42 | issue = 6 | pages = 1206-52 | month = Dec | year = 2003 | doi = 10.1161/01.HYP.0000107251.49515.c2 | PMID = 14656957 }}</ref>
<span style="font-size:85%">'''Abbreviations:'''
'''ABPM:''' [[Ambulatory blood pressure monitoring]];
'''BP:''' [[Blood pressure]];
'''CKD:''' [[Chronic kidney disease]];
'''DBP:''' [[Diastolic blood pressure]];
'''DM:''' [[Diabetes mellitus]];
'''SBP:''' [[Systolic blood pressure]]
</span>
<br>


===General Approach===
===General Approach===
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | A01 | |A01='''Suspected hypertension<br>BP > 140/90 mmHg'''}}
{{familytree | | | | | A01 | |A01='''Suspected [[hypertension]]<br>BP > 140/90 mmHg'''}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | B01 | |B01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Blood pressure measurement'''<br>
{{familytree | | | | | B01 | |B01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Blood pressure measurement'''<br>
Before taking the BP
Before taking the BP
:❑ Sit patient quietly in a chair for 5 mins<br>
:❑ Sit patient quietly in a chair for 5 minutes<br>
:❑ Avoid [[caffeine]], [[exercise]], [[smoking]] at least 30 mins <br>
:❑ Avoid [[caffeine]], [[exercise]], [[smoking]] for at least 30 minutes <br>
:❑ Ensure appropriate cuff size<br>
:❑ Ensure appropriate cuff size<br>
❑ Take 2 readings and find the average<br>
❑ Take 2 readings and find the average<br>
❑ Take repeated measurements in patients with arrhythmia<br>
❑ Take repeated measurements in patients with [[arrhythmia]]<br>
❑ Measure BP at both arms at first visit to detect possible differences<br>
❑ Measure [[blood pressure]] at both arms at first visit to detect possible differences<br>
</div><br>
<br>Click '''[[Hypertension blood pressure measurement|here for more information regarding blood pressure measurement]]'''</div>}}
Click '''[[Hypertension blood pressure measurement|here for more information regarding blood pressure measurement]]'''}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | C01 | | C01=Office BP >140/90 mmHg on 2-3 visits}}
{{familytree | | | | | C01 | | C01=For '''office BP >140/90 mmHg''' on 2-3 visits}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | D01 | | | | D01=Does the patient have any evidence of target organ damage, DM, or CKD?}}
{{familytree | | | | | D01 | | | | D01=Does the patient have any evidence of target organ damage, [[DM]], or [[CKD]]?}}
{{familytree | | | |,|-|^|-|.| | |}}
{{familytree | | | |,|-|^|-|.| | |}}
{{familytree | | | E01 | | E02 | | E01=Yes|E02=No}}
{{familytree | | | E01 | | E02 | | |E01=Yes|E02=No}}
{{familytree | | | |!| | | |!| | | | |}}
{{familytree | | | |!| | | |!| | | | |}}
{{familytree | | | F01 | | F02 | | | | |F01=Proceed to '''[[hypertensive crisis resident survival guide]]'''|F02=Perform home BP/out-of-office monitoring}}
{{familytree | | | F01 | | F02 | | | | |F01=Proceed to '''[[hypertensive crisis resident survival guide]]'''|F02=Perform home BP/out-of-office monitoring}}
Line 84: Line 159:
{{familytree | | | H01 | | H02 | | H03 | |H01=Yes|H02=Inconclusive|H03=No}}
{{familytree | | | H01 | | H02 | | H03 | |H01=Yes|H02=Inconclusive|H03=No}}
{{familytree | | | |!| | | |!| | | |!| | |}}
{{familytree | | | |!| | | |!| | | |!| | |}}
{{familytree | | | |!| | | I01 | | |!| | |I01=Perform 24-hour ABPM}}
{{familytree | | | |!| | | I01 | | |!| | |I01=Perform 24-hour [[Ambulatory blood pressure monitoring|ABPM]]}}
{{familytree | | | |!| | | |!| | | |!| | |}}
{{familytree | | | |!| | | |!| | | |!| | |}}
{{familytree | | | |!| | | J01 | | |!| | |J01=Is the 24-hour ABPM ≤135/85?}}
{{familytree | | | |!| | | J01 | | |!| | |J01=Is the 24-hour [[Ambulatory blood pressure monitoring|ABPM]] ≤135/85?}}
{{familytree | | | |!| |,|-|^|-|.| |!| | |}}
{{familytree | | | |!| |,|-|^|-|.| |!| | |}}
{{familytree | K01 |^| K02 | | K03 |^| K04 | | K01=White-coat hypertension confirmed|K02=Yes|K03=No|K04=Hypertension confirmed}}
{{familytree | | | |!| K02 | | K03 |!| | |K02=Yes|K03=No|}}
{{familytree | |!| | | | | | | | | | | |!| | | | |}}
{{familytree | | | |!| |!| | | |`|v|'| | | |}}
{{familytree | L01 | | | | | | | | | | L02 | | |L01=<div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Continue BP monitoring<br>❑ Follow-up appointment in ....</div>|L02=Classify the patient<br> based on the BP reading}}
{{familytree | | | |`|v|'| | | | K04 | | | | | | | |K04=[[Hypertension]] confirmed}}
{{familytree | | | | | | | | | |,|-|-|-|+|-|-|-|.| | |}}
{{familytree | | | | L01 | | | | |!| |L01=[[White coat hypertension]] confirmed}}
{{familytree | | | | | | | | | M01 | | M02 | | M03 | |M01=SBP 120-139 mmHg<br>DBP - 80-89 mmHg|M02=SBP 149-159 mmHg<br>DBP 90-99 mmHg|M03=SBP >160 mmHg<br>DBP >110 mmHg}}
{{familytree | | | | | | | | | | L02 | | |L02=Classify the patient<br> based on the BP reading}}
{{familytree | | | | | | | | | |!| | | |!| | | |!| |}}
{{familytree | | | | | | |,|-|-|-|+|-|-|-|.| | |}}
{{familytree | | | | | | | | | N01 | | N02 | | N03 | |N01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Prehypertension'''</div>|N02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Stage 1 hypertension'''</div><br>Proceed to the [[Hypertension resident survival guide#Complete Diagnostic Approach|'''complete diagnostic approach''']]|N03=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Stage 2 hypertension'''<br></div>
{{familytree | | | | | | M01 | | M02 | | M03 | |M01='''SBP 120-139 mmHg'''<br>'''DBP 80-89 mmHg'''|M02='''SBP 149-159 mmHg'''<br>'''DBP 90-99 mmHg'''|M03='''SBP >160 mmHg'''<br>'''DBP >110 mmHg'''}}
Proceed to '''[[hypertensive crisis resident survival guide]]'''}}
{{familytree | | | | | | |!| | | |!| | | |!| |}}
{{familytree | | | | | | N01 | | N02 | | N03 | |N01=<div style="float: left; text-align: left; width: 15em;padding:1em;">'''[[Prehypertension]]'''</div>|N02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Stage 1 hypertension'''</div><br>Proceed to the [[Hypertension resident survival guide#Complete Diagnostic Approach|'''complete diagnostic approach''']] below|N03=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Stage 2 hypertension'''<br><br>Proceed to '''[[hypertensive crisis resident survival guide]]'''</div>}}
{{familytree/end}}
{{familytree/end}}


===Complete Diagnostic Approach===
===Complete Diagnostic Approach===
Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.<ref name="Mancia-2013">{{Cite journal  | last1 = Mancia | first1 = G. | last2 = Fagard | first2 = R. | last3 = Narkiewicz | first3 = K. | last4 = Redán | first4 = J. | last5 = Zanchetti | first5 = A. | last6 = Böhm | first6 = M. | last7 = Christiaens | first7 = T. | last8 = Cifkova | first8 = R. | last9 = De Backer | first9 = G. | title = 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal = J Hypertens | volume = 31 | issue = 10 | pages = 1925-38 | month = Oct | year = 2013 | doi = 10.1097/HJH.0b013e328364ca4c | PMID = 24107724 }}</ref><ref name="Chobanian-2003">{{Cite journal  | last1 = Chobanian | first1 = AV. | last2 = Bakris | first2 = GL. | last3 = Black | first3 = HR. | last4 = Cushman | first4 = WC. | last5 = Green | first5 = LA. | last6 = Izzo | first6 = JL. | last7 = Jones | first7 = DW. | last8 = Materson | first8 = BJ. | last9 = Oparil | first9 = S. | title = Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. | journal = Hypertension | volume = 42 | issue = 6 | pages = 1206-52 | month = Dec | year = 2003 | doi = 10.1161/01.HYP.0000107251.49515.c2 | PMID = 14656957 }}</ref>
<span style="font-size:85%">'''Abbreviations:'''
'''BMI:''' [[Body mass index]];
'''BP:''' [[Blood pressure]];
'''CNS:''' [[Central nervous system]];
'''CT:''' [[Computed tomography]];
'''CVD:''' [[Cardiovascular disease]];
'''eGFR:''' Estimated [[glomerular filtration rate]];
'''EKG:''' [[Electrocardiogram]];
'''HTN:''' [[Hypertension]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''NSAIDs:''' [[Non steroidal anti-inflammatory drugs]];
'''TSH:''' [[Thyroid stimulating hormone]];
'''UTI:''' [[Urinary tract infection]]
</span>
<br>
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Obtain a detailed history:'''<br>
{{familytree | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Obtain a detailed history:'''<br>
----
----
''History of present hypertension''<br>
''History of present [[hypertension]]''<br>
❑ Time of first diagnosis<br>
❑ Time of first diagnosis<br>
❑ Current and past BP measurements<br>
❑ Current and past BP measurements<br>
❑ Current and past antihypertensive medications<br><br>
❑ Current and past [[antihypertensive medications]]<br><br>
''Identify secondary causes of hypertension:''<br>
''Identify secondary causes of [[hypertension]]:''<br>
'''Family history'''<br>
'''Family history:'''<br>
❑ [[Chronic kidney disease]] (suggestive of [[polycystic kidney disease]])<br>
❑ [[Chronic kidney disease]] (suggestive of [[polycystic kidney disease]])<br>
❑ Premature CVD or HTN<br>
❑ Premature [[CVD]] or [[HTN]]<br>
'''History of renal disease:'''<br>
'''History of renal disease:'''<br>
❑ [[Hematuria]]<br>
❑ [[Hematuria]]<br>
❑ [[UTI]]<br>
❑ [[UTI]]<br>
❑ Analgesic abuse (suggestive of renal parenchymal disease)<br>
[[Analgesic|Analgesic abuse]] (suggestive of renal parenchymal disease)<br>
❑ [[Flank pain]]<br>
❑ [[Flank pain]]<br>
'''Medication/substance abuse'''<br>
'''Medication/substance abuse:'''<br>
❑ [[Amphetamines]]<br>
❑ [[Amphetamines]]<br>
❑ [[Cocaine]]<br>
❑ [[Cocaine]]<br>
Line 124: Line 218:
❑ [[Oral contraceptive pills]]<br>
❑ [[Oral contraceptive pills]]<br>
❑ [[Steroids]]<br>
❑ [[Steroids]]<br>
'''History suggestive of [[pheochromocytoma]]'''<br>
'''History suggestive of [[pheochromocytoma]]:'''<br>
❑ Recurrent episodes of [[sweating]], [[palpitation]] and [[hypertension]]<br>
❑ Recurrent episodes of [[sweating]], [[palpitation]] and [[hypertension]]<br>
'''History suggestive of [[hyperaldosteronism]]'''<br>
'''History suggestive of [[hyperaldosteronism]]:'''<br>
❑ [[Muscle weakness]] and [[tetany]]<br>
❑ [[Muscle weakness]] and [[tetany]]<br>
'''History suggestive of thyroid disease'''<br><br>
'''History suggestive of thyroid disease:'''<br>
❑ [[Hypothyroidism]]<br>
❑ [[Hyperthyroidism]]<br>
<br>
''History to assess risk factors''<br>
''History to assess risk factors''<br>
❑ Personal and family history of:<br>
❑ Personal and family history of:<br>
:❑ HTN and CVD<br>
:❑ [[HTN]] and [[CVD]]<br>
:❑ [[Dyslipidemia]]<br>
:❑ [[Dyslipidemia]]<br>
:❑ [[Diabetes mellitus]]<br>
:❑ [[Diabetes mellitus]]<br>
❑ Excessive sodium intake >2.4g per day<br>
❑ Excessive [[sodium]] intake >2.4g per day<br>
❑ [[Health effects of tobacco smoking|Tobacco usage]]<br>
❑ [[Health effects of tobacco smoking|Tobacco usage]]<br>
❑ [[Obesity]]<br>
❑ [[Obesity]]<br>
Line 142: Line 239:
❑ [[Sleep apnea]]<br><br>
❑ [[Sleep apnea]]<br><br>
''History to assess presence of organ damage/complications''<br>
''History to assess presence of organ damage/complications''<br>
'''CNS:'''<br>
'''CNS:'''<br>
:❑ [[Headache]]<br>
:❑ [[Headache]]<br>
:❑ [[Vertigo]]<br>
:❑ [[Vertigo]]<br>
:❑ [[Transient ischemic attack]]<br>
:❑ [[Transient ischemic attack]]<br>
:❑ [[Stroke]]<br>
:❑ [[Stroke]]<br>
'''Eyes:'''<br>
'''Eyes:'''<br>
:❑ Loss or blurring of vision<br>
:❑ [[Vision loss|Loss or blurring of vision]]<br>
'''Cardiovascular:'''<br>
'''Cardiovascular:'''<br>
:❑ History of MI or [[syncope]]<br>
:❑ History of [[MI]] or [[syncope]]<br>
:❑ [[Chest pain]] <br>
:❑ [[Chest pain]] <br>
:❑ [[Shortness of breath]]<br>
:❑ [[Shortness of breath]]<br>
:❑ [[Pedal edema]]<br>
:❑ [[Leg swelling]]<br>
:❑ [[Palpitation]]<br>
:❑ [[Palpitation]]<br>
:❑ [[Arrhythmia]]<br>
:❑ [[Arrhythmia]]<br>
:❑ [[Pedal edema]]<br>
:❑ [[Sexual dysfunction]]<br>
:❑ Sexual function<br>
'''Kidneys:'''<br>
'''Kidneys:'''<br>
:❑ [[Polyuria]]<br>
:❑ [[Polyuria]]<br>
:❑ [[Hematuria]]<br>
:❑ [[Hematuria]]<br>
Line 166: Line 262:
{{familytree | | | | B01 | | B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:'''<br>
{{familytree | | | | B01 | | B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:'''<br>
'''General examination:'''<br>
'''General examination:'''<br>
❑ Calculate BMI <br>
❑ Calculate [[Body mass index|BMI]] <br>
❑ Moon face, truncal obesity, striae (suggestive of cushing disease)<br>
❑ Moon face, truncal [[obesity]], striae (suggestive of [[Cushing's disease]])<br>
❑ Goitre, exophthalmus, pretibial myxedema (suggestive of graves disease)<br>
[[Goitre]], [[exophthalmus]], [[pretibial myxedema]] (suggestive of [[Graves' disease]])<br>
❑ Dry skin (suggestive of hypothyroidism)<br>
❑ Dry skin (suggestive of [[hypothyroidism]])<br>
'''Eyes'''<br>
'''Eyes:'''<br>
❑ [[Fundoscopy]] to diagnose retinopathy<br>
❑ [[Fundoscopy]] to diagnose [[hypertensive retinopathy]]<br>
:❑ [[Hemorrhage]] <br>
:❑ [[Hemorrhage]] <br>
:❑ [[Papilledema]]<br>
:❑ [[Papilledema]]<br>
:❑ [[Cotton wool spots]]<br>
:❑ [[Cotton wool spots]]<br>
'''Neck'''<br>
'''Neck:'''<br>
❑ Carotid bruits (suggestive of )<br>
[[Carotid bruit]]s <br>
❑ Thyroid gland enlargement (suggestive of hyperthyroidism)  <br>
[[Thyroid gland]] enlargement (suggestive of [[hyperthyroidism]])  <br>
'''Cardiovascular examination'''<br>
'''Cardiovascular examination:'''<br>
❑ Evidence of long-standing hypertension:<br>
❑ Evidence of long-standing [[hypertension]]:<br>
:❑ Cardiomegaly<br>
:❑ [[Cardiomegaly]]<br>
:❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]])
:❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]])
'''Respiratory examination'''<br>
'''Respiratory examination:'''<br>
❑ [[Crackles]]/[[crepitations]]/[[rales]]<br>
❑ [[Crackles]]/[[crepitations]]/[[rales]]<br>
 
'''Abdominal examination:'''<br>
'''Abdominal examination'''<br>
[[Bruit]]s over [[abdominal aorta]] (suggestive of [[aortic aneurysm]])<br>
Bruits over abdominal aorta (suggestive of [[aortic aneurysm]])<br>
[[Bruit]]s over [[renal artery]] (suggestive of [[renal artery stenosis]])<br>
Bruits over renal artery (suggestive of [[renal artery stenosis]])<br>
'''Extremity examination:'''<br>
<br>
'''Extremity examination'''<br>
❑ Absent or diminished femoral pulsation (suggestive of [[coarctation of aorta]])<br>
❑ Absent or diminished femoral pulsation (suggestive of [[coarctation of aorta]])<br>
❑ Bruits over renal artery (suggestive of [[renal artery stenosis]])<br>
❑ [[Pedal edema]] (suggestive of [[congestive heart failure]])<br>
❑ [[Pedal edema]] (suggestive of [[congestive heart failure]])<br>
❑ Delayed return of deep tendon reflexes (suggestive of [[hypothyroidism]])<br>
'''Neurological examination:'''<br>
'''Neurological examination'''<br>
❑ Delayed return of [[deep tendon reflex|deep tendon reflexes]] (suggestive of [[hypothyroidism]])<br>❑ Findings suggestive of [[hypertensive encephalopathy]]<br>
❑ Findings suggestive of [[hypertensive encephalopathy]]<br>
:❑ [[Confusion]]<br>
:❑ [[Confusion]]<br>
:❑ [[Coma]]<br>
:❑ [[Altered mental status]]
:❑ [[Altered mental status]]
<br>
<br>
Line 204: Line 295:
{{familytree | | | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': <br>
{{familytree | | | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': <br>
'''Routine''' <br>
'''Routine''' <br>
❑ [[Essential hypertension electrocardiogram|12-lead EKG]] (for evidence of LVH or old infarct)<br>
❑ [[Essential hypertension electrocardiogram|12-lead EKG]] (for evidence of [[Left ventricular hypertrophy|LVH]] or old [[infarct]])<br>
❑ [[Complete blood count|CBC]]  <br>
❑ [[Complete blood count|CBC]]  <br>
:❑ [[Anemia]] (associated with [[chronic renal failure]])<br>
:❑ [[Anemia]] (associated with [[chronic renal failure]])<br>
:❑ [[Polycythemia]] (may be seen in [[pheochromocytoma]])<br>
❑ [[Urinalysis]]<br>
❑ [[Urinalysis]]<br>
:❑ [[Proteinuria]] (suggestive of end organ damage)<br>
:❑ [[Proteinuria]] (suggestive of end organ damage)<br>
❑ [[calcium|Serum potassium]]<br>
❑ [[calcium|Serum potassium]]<br>
:❑ [[Hypokalemia]] (suggestive of [[hyperaldosteronism]])<br>
:❑ [[Hypokalemia]] (suggestive of [[hyperaldosteronism]])<br>
❑ [[calcium|Serum calcium]]<br>
❑ [[calcium|Serum calcium]] (high in [[hyperparathyroidism]])<br>
❑ [[creatinine|Serum creatinine]] with estimated [[glomerular filtration rate]] (eGFR)<br>
❑ [[creatinine|Serum creatinine]] with estimated [[glomerular filtration rate]] (eGFR)<br>
❑ [[Uric acid|Serum uric acid]]<br>
❑ [[Uric acid|Serum uric acid]]<br>
Line 235: Line 325:
</div>}}
</div>}}
{{familytree | | | | |!| | |}}
{{familytree | | | | |!| | |}}
{{familytree | | | | D01 | | |D01=Does this patient have an identifiable secondary etiology?}}
{{familytree | | | | D01 | | |D01='''Does the patient have an identifiable secondary etiology?'''}}
{{familytree | | |,|-|^|-|.| | |}}
{{familytree | | |,|-|^|-|.| | |}}
{{familytree | | F01 | | F02 | |F01=Yes|F02=No}}
{{familytree | | F01 | | F02 | |F01=No|F02=Yes}}
{{familytree | | |!| | | |!| | |}}
{{familytree | | |!| | | |!| | |}}
{{familytree | | G01 | | G02 | |G01=Primary hypertension|G02=Secondary hypertension}}
{{familytree | | G01 | | G02 | |G01=[[Primary hypertension]]|G02=[[Secondary hypertension]]}}
{{familytree | | |`|-|v|-|'| | |}}
{{familytree | | | | G01 | |G01=Proceed to treatment}}
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Treatment==
Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8), ESH/ESC guidelines for the management of arterial hypertension, and the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.<ref name="pmid14656957">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. | journal=Hypertension | year= 2003 | volume= 42 | issue= 6 | pages= 1206-52 | pmid=14656957 | doi=10.1161/01.HYP.0000107251.49515.c2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14656957  }} </ref><ref name="Mancia-2013">{{Cite journal  | last1 = Mancia | first1 = G. | last2 = Fagard | first2 = R. | last3 = Narkiewicz | first3 = K. | last4 = Redán | first4 = J. | last5 = Zanchetti | first5 = A. | last6 = Böhm | first6 = M. | last7 = Christiaens | first7 = T. | last8 = Cifkova | first8 = R. | last9 = De Backer | first9 = G. | title = 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal = J Hypertens | volume = 31 | issue = 10 | pages = 1925-38 | month = Oct | year = 2013 | doi = 10.1097/HJH.0b013e328364ca4c | PMID = 24107724 }}</ref><ref name="Chobanian-2003">{{Cite journal  | last1 = Chobanian | first1 = AV. | last2 = Bakris | first2 = GL. | last3 = Black | first3 = HR. | last4 = Cushman | first4 = WC. | last5 = Green | first5 = LA. | last6 = Izzo | first6 = JL. | last7 = Jones | first7 = DW. | last8 = Materson | first8 = BJ. | last9 = Oparil | first9 = S. | title = The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. | journal = JAMA | volume = 289 | issue = 19 | pages = 2560-72 | month = May | year = 2003 | doi = 10.1001/jama.289.19.2560 | PMID = 12748199 }}</ref>
Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8), ESH/ESC guidelines for the management of arterial hypertension, and the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.<ref name="pmid14656957">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. | journal=Hypertension | year= 2003 | volume= 42 | issue= 6 | pages= 1206-52 | pmid=14656957 | doi=10.1161/01.HYP.0000107251.49515.c2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14656957  }} </ref><ref name="Mancia-2013">{{Cite journal  | last1 = Mancia | first1 = G. | last2 = Fagard | first2 = R. | last3 = Narkiewicz | first3 = K. | last4 = Redán | first4 = J. | last5 = Zanchetti | first5 = A. | last6 = Böhm | first6 = M. | last7 = Christiaens | first7 = T. | last8 = Cifkova | first8 = R. | last9 = De Backer | first9 = G. | title = 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal = J Hypertens | volume = 31 | issue = 10 | pages = 1925-38 | month = Oct | year = 2013 | doi = 10.1097/HJH.0b013e328364ca4c | PMID = 24107724 }}</ref><ref name="James-2014">{{Cite journal  | last1 = James | first1 = PA. | last2 = Oparil | first2 = S. | last3 = Carter | first3 = BL. | last4 = Cushman | first4 = WC. | last5 = Dennison-Himmelfarb | first5 = C. | last6 = Handler | first6 = J. | last7 = Lackland | first7 = DT. | last8 = LeFevre | first8 = ML. | last9 = MacKenzie | first9 = TD. | title = 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). | journal = JAMA | volume = 311 | issue = 5 | pages = 507-20 | month = Feb | year = 2014 | doi = 10.1001/jama.2013.284427 | PMID = 24352797 }}</ref>


===Prehypertension===
===Prehypertension===
Line 252: Line 340:
'''SBP 120-139 mmHg<br>DBP - 80-89 mmHg'''</div>}}
'''SBP 120-139 mmHg<br>DBP - 80-89 mmHg'''</div>}}
{{familytree | | | |!| | |}}
{{familytree | | | |!| | |}}
{{familytree | | | B01 | |B01=Does the patient have [[chronic kidney disease]]<br> or [[diabetes mellitus]]?}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 15em; padding:1em;">
{{familytree | |,|-|^|-|.| |}}
❑ Initiate lifestyle modification<br>
{{familytree | C01 | | C02 | |C01=Yes|C02=No}}
{{familytree | |!| | | |!| | | |}}
{{familytree | D01 | | D02 | |D01=<div style="float: left; text-align: left; width: 15em; padding:1em;">
❑ Commence lifestyle modification, '''THEN'''<br>
❑ Initiate appropriate drug therapy if target blood pressure if not achieved </div>|D02=<div style="float: left; text-align: left; width: 15em; padding:1em;">
❑ Commence lifestyle modification<br>
❑ Follow-up/recheck blood pressure in one year<br>
❑ Follow-up/recheck blood pressure in one year<br>
❑ Ensure self-monitoring of [[blood pressure]]<br></div>}}
❑ Ensure self-monitoring of [[blood pressure]]<br></div>}}
Line 265: Line 347:


===Stage 1 Hypertension===
===Stage 1 Hypertension===
Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) and the 2013 ESH/ESC guidelines for the management of arterial hypertension.<ref name="James-2014">{{Cite journal  | last1 = James | first1 = PA. | last2 = Oparil | first2 = S. | last3 = Carter | first3 = BL. | last4 = Cushman | first4 = WC. | last5 = Dennison-Himmelfarb | first5 = C. | last6 = Handler | first6 = J. | last7 = Lackland | first7 = DT. | last8 = LeFevre | first8 = ML. | last9 = MacKenzie | first9 = TD. | title = 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). | journal = JAMA | volume = 311 | issue = 5 | pages = 507-20 | month = Feb | year = 2014 | doi = 10.1001/jama.2013.284427 | PMID = 24352797 }}</ref><ref name="Mancia-2013">{{Cite journal  | last1 = Mancia | first1 = G. | last2 = Fagard | first2 = R. | last3 = Narkiewicz | first3 = K. | last4 = Redán | first4 = J. | last5 = Zanchetti | first5 = A. | last6 = Böhm | first6 = M. | last7 = Christiaens | first7 = T. | last8 = Cifkova | first8 = R. | last9 = De Backer | first9 = G. | title = 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal = J Hypertens | volume = 31 | issue = 10 | pages = 1925-38 | month = Oct | year = 2013 | doi = 10.1097/HJH.0b013e328364ca4c | PMID = 24107724 }}</ref>
<span style="font-size:85%">'''Abbreviations:'''
'''ACEI:''' [[ACE inhibitors]];
'''ARBs:''' [[Angiotensin II receptor antagonist|Angiotensin II receptor blockers]];
'''BMI:''' [[Body mass index]];
'''BP:''' [[Blood pressure]];
'''CCBs:''' [[Calcium channel blockers]];
'''CKD:''' [[Chronic kidney disease]];
'''DASH:''' [[Dietary Approaches to Stop Hypertension]];
'''DM:''' [[Diabetes mellitus]]
</span>
<br>
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | A01 | A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Determine who to treat:'''<br>
{{familytree | | | | | | | | A01 | A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''The following categories require pharmacological treatment according to JNC 8?:'''<br>
----
----
❑ BP ≥ 150/90 mmHg in patients ≥ 60 years <br>
[[BP]] ≥ 150/90 mmHg in patients ≥ 60 years <br>
❑ BP ≥ 140/90 mmHg in patients < 60 years<br>
[[BP]] ≥ 140/90 mmHg in patients < 60 years<br>
❑ BP ≥ 140/90 mmHg in patients ≥ 18 years with <br>CKD or DM <br>
[[BP]] ≥ 140/90 mmHg in patients ≥ 18 years with <br>[[CKD]] or [[DM]] <br>
</div>}}
</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | |!| | |}}
Line 276: Line 371:
----
----
'''General population'''<br>
'''General population'''<br>
❑ BP < 150/90 mmHg in patients ≥ 60 years <br>
[[BP]] < 150/90 mmHg in patients ≥ 60 years <br>
❑ BP < 140/90 mmHg in patients < 60 years<br>
[[BP]] < 140/90 mmHg in patients < 60 years<br>
'''Patients with DM or CKD'''<br>
'''Patients with [[DM]] or [[CKD]]'''<br>
❑ BP < 140/90 mmHg in patients<br>
[[BP]] < 140/90 mmHg<br></div>}}
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | C01 | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate lifestyle modification:'''<br>
{{familytree | | | | | | | | C01 | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate lifestyle modification:'''<br>
----
----
❑ Weight reduction<br>
[[Weight reduction]]<br>
:❑ Maintain a waist circumference of <br>
:❑ Maintain a waist circumference of <br>
:* <40 inches (102cm) for men<br>
:* <40 inches (102cm) for men<br>
:* <35 inches (88cm) for women <br>
:* <35 inches (88cm) for women <br>
:* BMI of ≤25 kg/m2<br>
:* [[BMI]] of ≤25 kg/m2<br>
❑ Adopt healthy diet<br>
❑ Adopt healthy diet<br>
:❑ DASH diet (rich in fruits, vegetables, whole grains, low sodium, low-fat proteins)<br>
:❑ [[Dietary Approaches to Stop Hypertension|DASH]] diet (rich in fruits, vegetables, whole grains, low sodium, low-fat proteins)<br>
:❑ Dietary sodium intake of ≤ 100 mmol/day (2.4g Na or 6g NaCl)<br>
:❑ Dietary [[sodium]] intake of ≤ 100 mmol/day (2.4g Na or 6g NaCl)<br>
❑ Limit alcohol consumption<br>
❑ Limit [[alcohol]] consumption<br>
:❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky<br>
:❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky<br>
:❑ ≤ 1 drink/day for women<br>
:❑ ≤ 1 drink/day for women<br>
❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day <br>
❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day <br>
❑ Patient education<br>
</div>}}
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | D01 | | D01=Does the patient have DM or CKD?}}
{{familytree | | | | | | | | D01 | | D01=Does the patient have [[DM]] or [[CKD]]?}}
{{familytree | | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | | E01 | | E02 | | |E01=Yes|E02=No}}
{{familytree | | | | | | E01 | | E02 | | |E01=Yes|E02=No}}
{{familytree | | | |,|-|-|^|.| | |!| | |}}
{{familytree | | | |,|-|-|^|.| | |!| | |}}
{{familytree | | | F01 | | F02 | |!| | |F01=CKD ± DM|F02=DM only}}
{{familytree | | | F01 | | F02 | |!| | |F01=[[CKD]] ± [[DM]]|F02=[[DM]] only}}
{{familytree | | | |!| | | |`|-|v|'| | |}}
{{familytree | | | |!| | | |`|-|v|'| | |}}
{{familytree | | | |!| | | | | G02 | | G02=Consider the race of the patient}}
{{familytree | | | |!| | | | | G02 | | G02=Consider the race of the patient}}
Line 310: Line 403:
{{familytree | | | |!| | | |!| | | |!| |}}
{{familytree | | | |!| | | |!| | | |!| |}}
{{familytree | | | I03 | | | I01 | | I02 | | I01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Initiate:'''<br>
{{familytree | | | I03 | | | I01 | | I02 | | I01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Initiate:'''<br>
❑ Thiazide-type diuretic alone, '''OR'''<br>
[[Thiazide diuretic]] alone, '''OR'''<br>
❑ CCB alone, '''OR'''<br>
[[CCB]] alone, '''OR'''<br>
❑ Combination of the two classes <br>
❑ Combination of the two classes <br>
</div>|I02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate:'''<br>
</div>|I02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate:'''<br>
❑ Thiazide-type diuretic alone, '''OR'''<br>
[[Thiazide diuretic]] alone, '''OR'''<br>
❑ ACEI alone, '''OR'''<br>
[[ACEI]] alone, '''OR'''<br>
❑ ARBs alone, '''OR'''<br>
[[ARBs]] alone, '''OR'''<br>
❑ CCB alone, '''OR'''<br>
[[CCB]] alone, '''OR'''<br>
❑ Combination of all the classes <br><br>
❑ Combination of all the classes <br><br>
'''Avoid the use of ACEIs and ARBs in combination'''<br>
'''Avoid the use of [[ACEI]]s and [[ARBs]] in combination'''<br>
</div>|I03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Initiate:'''<br>
</div>|I03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Initiate:'''<br>
❑ ACE inhibitors alone, '''OR'''<br>
[[ACE inhibitors]] alone, '''OR'''<br>
❑ ARBs alone, '''OR'''<br>
[[ARBs]] alone, '''OR'''<br>
❑ ACEI or ARBs in combination with other drug class e.g., <br>
[[ACEI]] or [[ARBs]] in combination with other drug class e.g., <br>
'''Avoid the combine use of ACEIs and ARBs in a patient'''</div>}}
'''Avoid the combined use of [[ACEI]]s and [[ARBs]] in a patient'''</div>}}
{{familytree | | | |`|-|-|-|+|-|-|-|'| | |}}
{{familytree | | | |`|-|-|-|+|-|-|-|'| | |}}
{{familytree | | | | | | | J01 | | | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Has the target BP been reached?'''</div>}}
{{familytree | | | | | | | J01 | | | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Has the target [[BP]] been reached?'''</div>}}
{{familytree | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | K01 | | K02 | | |K01=Yes|K02=No}}
{{familytree | | | | | K01 | | K02 | | |K01=Yes|K02=No}}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | |!| | | L01 | |L01=Click here for <br>further therapeutic options<br>
{{familytree | | | | | |!| | | L01 | |L01=Click [[Hypertension resident survival guide#Choice of Regimen|'''here for <br>further therapeutic options''']]<br>
}}
}}
{{familytree | | | | | |`|-|v|-|'| |}}
{{familytree | | | | | |`|-|v|-|'| |}}
{{familytree | | | | | | | M01 | | |M01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Monitoring and follow-up:'''<br>
{{familytree | | | | | | | M01 | | |M01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Monitoring and follow-up:'''<br>
'''Monitor:'''<br>
'''Monitor:'''<br>
❑ Serum potassium and creatinine at least 1-2 times per year<br>
❑ Serum [[potassium]] and [[creatinine]] at least 1-2 times per year<br>
'''Follow-up visits'''<br>
'''Follow-up visits'''<br>
❑ Schedule 2-4 weekly visits to assess:<br>
❑ Schedule 2-4 weekly visits to assess:<br>
:❑ Compliance and BP control<br>
:❑ Compliance and [[BP]] control<br>
:❑ Occurrence of side effects to medications <br>
:❑ Occurrence of side effects to medications <br>
:❑ Asymptomatic end organ damage<br>
:❑ Asymptomatic end organ damage<br>
❑ 3-6 monthly visits when BP goal is achieved<br>
❑ 3-6 monthly visits when BP goal is achieved<br>
❑ Reinforce strategies to improve compliance to medication usage<br>
❑ Reinforce strategies to improve compliance to medication usage<br>
:❑ Self-monitoring of blood pressure<br>
:❑ Self-monitoring of [[blood pressure]]<br>
:❑ Simplification of drug regimen<br>
:❑ Simplification of drug regimen<br>
:❑ Telephone follow-up, reminders, home visits<br>
:❑ Telephone follow-up, reminders, home visits<br>
❑ Consider low dose [[aspirin]] only when BP is controlled<br></div>}}
❑ Consider low dose [[aspirin]] only when [[BP]] is controlled<br></div>}}
{{familytree/end}}
{{familytree/end}}


==Medications==
==Medical Therapy==
===Choice of Regimen===
===Choice of Regimen===
{{familytree/start}}
{{familytree/start}}
Line 377: Line 470:
! Initial daily dose, target dose (mg)
! Initial daily dose, target dose (mg)
! Preferred use
! Preferred use
! Preferably combined with
|-
| rowspan="4" | [[Thiazide diuretics]] || [[Chlorthalidone]] || 12.5, 12.5-25|| rowspan="4" | [[Heart failure]], [[systolic hypertension|isolated systolic hypertension]], black population|| rowspan="4" | [[ACE inhibitors]], [[ARBs]], [[calcium channel blockers]]
|-
|-
| [[Thiazide diuretics]] || [[Chlorthalidone]] || 12.5, 12.5-25
|[[Hydrochlorothiazide]] || 12.5-25, 25-100
|-
|-
|  || [[Hydrochlorothiazide]] || 12.5-25, 25-100
|[[Bendroflumethiazide]] || 5, 10
|-
|-
|  || [[Bendroflumethiazide]] || 5, 10
|[[Indapamide]] || 1.25, 1.25-2.5
|-
|-
| || [[Indapamide]] || 1.25, 1.25-2.5
| rowspan="3" | [[ACE inhibitors]] || [[Enalapril]] || 5, 20|| rowspan="3" | [[Left ventricular hypertrophy]], [[atherosclerosis]], [[renal insufficiency]], previous [[myocardial infarction]], [[heart failure]], [[atrial fibrillation]] (prevention), [[peripheral artery disease]], [[metabolic syndrome]], [[diabetes mellitus]]|| rowspan="3" | [[Calcium channel blockers]], [[thiazide diuretics]]
|-
|-
| [[ACE inhibitors]] || [[Enalapril]] || 5, 20
|[[Lisinopril]] || 10, 40
|-
|-
|  || [[Lisinopril]] || 10, 40
|[[Captopril]] || 50, 150-200
|-
|-
| || [[Captopril]] || 50, 150-200
| rowspan="5" | [[ARBs]] || [[Candesartan]] || 4, 12-32|| rowspan="5" | [[Left ventricular hypertrophy]], [[renal insufficiency]], previous [[myocardial infarction]], [[heart failure]], [[atrial fibrillation]] (prevention), [[metabolic syndrome]], [[diabetes mellitus]]|| rowspan="5" | [[Calcium channel blockers]], [[thiazide diuretics]]
|-
|-
| [[ARBs]] || [[Candesartan]] || 4, 12-32
|[[Losartan]] || 50, 100
|-
|-
|  || [[Losartan]] || 50, 100
|[[Valsartan]] || 40-80, 160-320
|-
|-
|  || [[Valsartan]] || 40-80, 160-320
|[[Eprosartan]] || 400, 600-800
|-
|-
|  || [[Eprosartan]] || 400, 600-800
|[[Irbesartan]] || 75, 300
|-
|-
| || [[Irbesartan]] || 75, 300
| rowspan="2" | [[Beta blockers]] || [[Atenolol]] || 25-50, 100|| rowspan="2" | Previous [[myocardial infarction]], [[atrial fibrillation]] (prevention and ventricular rate control), [[heart failure]],  [[Chronic stable angina|angina pectoris]], [[aortic aneurysm]], [[pregnancy]]|| rowspan="2" | [[Thiazide diuretics]] (with limitations)<br>'''Only [[Calcium channel blocker#Dihydropyridine|dihydropyridine calcium channel blockers]] should be combined with [[beta blockers]]'''
|-
|-
| [[Beta blockers]] || [[Atenolol]] || 25-50, 100
|[[Metoprolol succinate]] || 50, 100-200
|-
|-
| || [[Metoprolol succinate]] || 50, 100-200
| rowspan="3" | [[Calcium channel blockers]]|| [[Amlodipine]] || 2.5, 10|| rowspan="3" | [[Left ventricular hypertrophy]], [[pregnancy]] ([[nifedipine]]), previous [[myocardial infarction]], [[atrial fibrillation]] ([[verapamil]], [[diltiazem]]), [[metabolic syndrome]], [[peripheral artery disease]], [[atherosclerosis]], [[Chronic stable angina|angina pectoris]], [[systolic hypertension|isolated systolic hypertension]], black population|| rowspan="3" | [[ACE inhibitors]], [[ARBs]], [[thiazide diuretics]]
|-
|-
| [[Calcium channel blockers]]|| [[Amlodipine]] || 2.5, 10
|[[Diltiazem extended release]] || 120-180, 360
|-
|-
|  || [[Diltiazem extended release]] || 120-180, 360
|[[Nitrendipine]] || 10, 20
|-
|-
|  || [[Nitrendipine]] || 10, 20
|}
|}
===Preferred Drug Combinations===
==Do's==


==Don'ts==
==Don'ts==
* The combination of [[ACE inhibitors]] and [[ARBs]] in a patient is not recommended.<ref name="DoultonHe2005">{{cite journal|last1=Doulton|first1=Timothy W.R.|last2=He|first2=Feng J.|last3=MacGregor|first3=Graham A.|title=Systematic Review of Combined Angiotensin-Converting Enzyme Inhibition and Angiotensin Receptor Blockade in Hypertension|journal=Hypertension|volume=45|issue=5|year=2005|pages=880–886|issn=0194-911X|doi=10.1161/01.HYP.0000161880.59963.da}}</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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[[Category:Projects]]
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Templates]]
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Latest revision as of 23:45, 20 August 2020


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Hypertension Resident Survival Guide Microchapters
Overview
Classification
Causes
Diagnosis
General
Complete
Treatment
Prehypertension
Stage 1
Medical Therapy
Choice of Regimen
Drug List
Don'ts

Overview

Hypertension (HTN) is defined as a systolic blood pressure (SBP) ≥ 140 mmHg and diastolic blood pressure (DBP) ≥ 90 mmHg.[1] It is usually detected during the screening of an asymptomatic individual, but the diagnosis is based on persistent elevation of blood pressure after an average of 2 or more blood pressure measurements taken during 2 or more health care visits. Hypertension is classified as either primary (or essential) when the etiology cannot be identified; or secondary, when the etiology (e.g., hyperthyroidism, pheochromocytoma, renal artery stenosis) is known. The presence of diabetes mellitus, cigarette smoking, excessive sodium intake, obesity, and sedentary lifestyle increases the risk of developing essential hypertension. Lifestyle modifications such as weight reduction, reduction in alcohol consumption, exercises, and reduction in salt intake are recommended to all patients in addition to pharmacological therapy, when required.

Classification

The ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 2017 clinical practice guidelines[2], executive summary[3], and underlying systematic review[3] by the ACC/AHA taskforce recommend a treatment goal for everyone is <130/80 mm Hg:

Definition Treatment
Normal blood pressure <120/80 mmHg Lifestyle
Elevated blood pressure Systolic BP, 120–129 mm Hg
- and -
Diastolic BP, <80 mm Hg
Lifestyle
Stage 1 hypertension Systolic BP, 130–139 mm Hg
- or -
Diastolic BP, 80–89 mm Hg
Lifestyle and
Medications if high risk*
Stage 2 hypertension
Systolic BP, ≥140 mm Hg
- or -
Diastolic BP, ≥90 mm Hg
Lifestyle and
Medications
* High risk defined as existing cardiovascular disease or 10-year cardiovascular risk ≥10% (calculator and alternative calculator with facts box)

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Primary or Essential Hypertension

Secondary Hypertension

Pseudohypertension

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

 
 
 
 
For patient presenting with symptoms suggestive of the following:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure the blood pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BP ≥ 180/120
 
BP < 180/120
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have
any evidence of end organ damage?
 
Continue with the diagnosis below
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnosis

Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.[4][5]

Abbreviations: ABPM: Ambulatory blood pressure monitoring; BP: Blood pressure; CKD: Chronic kidney disease; DBP: Diastolic blood pressure; DM: Diabetes mellitus; SBP: Systolic blood pressure

General Approach

 
 
 
 
Suspected hypertension
BP > 140/90 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood pressure measurement

Before taking the BP

❑ Sit patient quietly in a chair for 5 minutes
❑ Avoid caffeine, exercise, smoking for at least 30 minutes
❑ Ensure appropriate cuff size

❑ Take 2 readings and find the average
❑ Take repeated measurements in patients with arrhythmia
❑ Measure blood pressure at both arms at first visit to detect possible differences


Click here for more information regarding blood pressure measurement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
For office BP >140/90 mmHg on 2-3 visits
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any evidence of target organ damage, DM, or CKD?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to hypertensive crisis resident survival guide
 
Perform home BP/out-of-office monitoring
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the average home BP measurement <140/90?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
Inconclusive
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform 24-hour ABPM
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the 24-hour ABPM ≤135/85?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypertension confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
White coat hypertension confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify the patient
based on the BP reading
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SBP 120-139 mmHg
DBP 80-89 mmHg
 
SBP 149-159 mmHg
DBP 90-99 mmHg
 
SBP >160 mmHg
DBP >110 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stage 1 hypertension

Proceed to the complete diagnostic approach below
 
Stage 2 hypertension

Proceed to hypertensive crisis resident survival guide
 

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.[4][5]

Abbreviations: BMI: Body mass index; BP: Blood pressure; CNS: Central nervous system; CT: Computed tomography; CVD: Cardiovascular disease; eGFR: Estimated glomerular filtration rate; EKG: Electrocardiogram; HTN: Hypertension; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; NSAIDs: Non steroidal anti-inflammatory drugs; TSH: Thyroid stimulating hormone; UTI: Urinary tract infection

 
 
 
Obtain a detailed history:

History of present hypertension
❑ Time of first diagnosis
❑ Current and past BP measurements
❑ Current and past antihypertensive medications

Identify secondary causes of hypertension:
Family history:
Chronic kidney disease (suggestive of polycystic kidney disease)
❑ Premature CVD or HTN
History of renal disease:
Hematuria
UTI
Analgesic abuse (suggestive of renal parenchymal disease)
Flank pain
Medication/substance abuse:
Amphetamines
Cocaine
Cyclosporine
Erythropoietin
Liquorice
NSAIDs
Oral contraceptive pills
Steroids
History suggestive of pheochromocytoma:
❑ Recurrent episodes of sweating, palpitation and hypertension
History suggestive of hyperaldosteronism:
Muscle weakness and tetany
History suggestive of thyroid disease:
Hypothyroidism
Hyperthyroidism

History to assess risk factors
❑ Personal and family history of:

HTN and CVD
Dyslipidemia
Diabetes mellitus

❑ Excessive sodium intake >2.4g per day
Tobacco usage
Obesity
Alcoholism >1.5 drinks/day
Metabolic syndrome
Physical inactivity
Sleep apnea

History to assess presence of organ damage/complications
CNS:

Headache
Vertigo
Transient ischemic attack
Stroke

Eyes:

Loss or blurring of vision

Cardiovascular:

❑ History of MI or syncope
Chest pain
Shortness of breath
Leg swelling
Palpitation
Arrhythmia
Sexual dysfunction

Kidneys:

Polyuria
Hematuria
Proteinuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

General examination:
❑ Calculate BMI
❑ Moon face, truncal obesity, striae (suggestive of Cushing's disease)
Goitre, exophthalmus, pretibial myxedema (suggestive of Graves' disease)
❑ Dry skin (suggestive of hypothyroidism)
Eyes:
Fundoscopy to diagnose hypertensive retinopathy

Hemorrhage
Papilledema
Cotton wool spots

Neck:
Carotid bruits
Thyroid gland enlargement (suggestive of hyperthyroidism)
Cardiovascular examination:
❑ Evidence of long-standing hypertension:

Cardiomegaly
❑ Displaced apex beat (suggestive of enlarged left ventricle)

Respiratory examination:
Crackles/crepitations/rales
Abdominal examination:
Bruits over abdominal aorta (suggestive of aortic aneurysm)
Bruits over renal artery (suggestive of renal artery stenosis)
Extremity examination:
❑ Absent or diminished femoral pulsation (suggestive of coarctation of aorta)
Pedal edema (suggestive of congestive heart failure)
Neurological examination:
❑ Delayed return of deep tendon reflexes (suggestive of hypothyroidism)
❑ Findings suggestive of hypertensive encephalopathy

Confusion
Altered mental status


 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

Routine
12-lead EKG (for evidence of LVH or old infarct)
CBC

Anemia (associated with chronic renal failure)

Urinalysis

Proteinuria (suggestive of end organ damage)

Serum potassium

Hypokalemia (suggestive of hyperaldosteronism)

Serum calcium (high in hyperparathyroidism)
Serum creatinine with estimated glomerular filtration rate (eGFR)
Serum uric acid
Fasting blood sugar

Hyperglycemia (suggestive of diabetes mellitus)

Fasting lipid profile


Additional tests based on results of the routine tests above:
Echocardiography (may reveal LVH or left ventricular mass)
24-hour urinary metanephrine and normetanephrine (elevated in pheochromocytoma)
Plasma renin activity (PRA) (low renin suggests hyperaldosteronism)
Plasma aldosterone (elevated in hyperaldosteronism)
TSH (may be high or low in hypo- and hyperthyroidism, respectively)
Serum parathyroid hormone (PTH) (To evaluate parathyroid disease)
Dexamethasone suppression test

❑ Unchanged levels of cortisol to high dose dexamethasone suggests Cushing's syndrome

❑ 24-hour free urinary cortisol (elevated in Cushing's syndrome)
Renal duplex ultrasound and magnetic resonance angiography (MRA) of renal arteries

❑ To evaluate renal artery stenosis

Chest CT angiography (To evaluate aortic coarctation)
Sleep study with O2 saturation (To evaluate sleep apnea)

 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have an identifiable secondary etiology?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary hypertension
 
Secondary hypertension
 

Treatment

Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8), ESH/ESC guidelines for the management of arterial hypertension, and the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.[1][4][6]

Prehypertension

 
 
Prehypertension
SBP 120-139 mmHg
DBP - 80-89 mmHg
 
 
 
 
 
 
 
 
 
 

❑ Initiate lifestyle modification
❑ Follow-up/recheck blood pressure in one year

❑ Ensure self-monitoring of blood pressure
 

Stage 1 Hypertension

Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) and the 2013 ESH/ESC guidelines for the management of arterial hypertension.[6][4]

Abbreviations: ACEI: ACE inhibitors; ARBs: Angiotensin II receptor blockers; BMI: Body mass index; BP: Blood pressure; CCBs: Calcium channel blockers; CKD: Chronic kidney disease; DASH: Dietary Approaches to Stop Hypertension; DM: Diabetes mellitus

 
 
 
 
 
 
 
The following categories require pharmacological treatment according to JNC 8?:

BP ≥ 150/90 mmHg in patients ≥ 60 years
BP ≥ 140/90 mmHg in patients < 60 years
BP ≥ 140/90 mmHg in patients ≥ 18 years with
CKD or DM

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Review BP goals:

General population
BP < 150/90 mmHg in patients ≥ 60 years
BP < 140/90 mmHg in patients < 60 years
Patients with DM or CKD

BP < 140/90 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate lifestyle modification:

Weight reduction

❑ Maintain a waist circumference of
  • <40 inches (102cm) for men
  • <35 inches (88cm) for women
  • BMI of ≤25 kg/m2

❑ Adopt healthy diet

DASH diet (rich in fruits, vegetables, whole grains, low sodium, low-fat proteins)
❑ Dietary sodium intake of ≤ 100 mmol/day (2.4g Na or 6g NaCl)

❑ Limit alcohol consumption

❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky
❑ ≤ 1 drink/day for women

❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have DM or CKD?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CKD ± DM
 
DM only
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the race of the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Black population
 
Non-black population
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate:

ACE inhibitors alone, OR
ARBs alone, OR
ACEI or ARBs in combination with other drug class e.g.,

Avoid the combined use of ACEIs and ARBs in a patient
 
 
Initiate:

Thiazide diuretic alone, OR
CCB alone, OR
❑ Combination of the two classes

 
Initiate:

Thiazide diuretic alone, OR
ACEI alone, OR
ARBs alone, OR
CCB alone, OR
❑ Combination of all the classes

Avoid the use of ACEIs and ARBs in combination

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Has the target BP been reached?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Click here for
further therapeutic options

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring and follow-up:

Monitor:
❑ Serum potassium and creatinine at least 1-2 times per year
Follow-up visits
❑ Schedule 2-4 weekly visits to assess:

❑ Compliance and BP control
❑ Occurrence of side effects to medications
❑ Asymptomatic end organ damage

❑ 3-6 monthly visits when BP goal is achieved
❑ Reinforce strategies to improve compliance to medication usage

❑ Self-monitoring of blood pressure
❑ Simplification of drug regimen
❑ Telephone follow-up, reminders, home visits
❑ Consider low dose aspirin only when BP is controlled
 
 

Medical Therapy

Choice of Regimen

 
 
 
 
 
 
 
 
 
 
Assess BP and cardiovascular risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild elevation of BP
Low CV risk
 
Severe elevation of BP
High CV risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider starting with a single agent
 
Consider 2-drug combination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Target BP achieved?
 
Target BP achieved?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue with current regimen
 
Yes
 
No
 
No
 
Yes
 
Continue with current regimen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Switch to a different drug
Titrate until maximum dose is reached, if necessary
 
Increase dose of present drug and titrate accordingly
 
Increase dose of present combination
 
Add a third drug and
titrate to maximum dose, if necessary
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If BP goal is not achieved

Add a second drug
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Maximum dose of 2-drug combination reached
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If BP goal is not achieved

Switch to a different 2-drug combination and titrate to the maximum dose, if necessary
OR
Add a third drug and titrate to the maximum dose, if necessary
 

Drug List

Drug Class Drug Initial daily dose, target dose (mg) Preferred use Preferably combined with
Thiazide diuretics Chlorthalidone 12.5, 12.5-25 Heart failure, isolated systolic hypertension, black population ACE inhibitors, ARBs, calcium channel blockers
Hydrochlorothiazide 12.5-25, 25-100
Bendroflumethiazide 5, 10
Indapamide 1.25, 1.25-2.5
ACE inhibitors Enalapril 5, 20 Left ventricular hypertrophy, atherosclerosis, renal insufficiency, previous myocardial infarction, heart failure, atrial fibrillation (prevention), peripheral artery disease, metabolic syndrome, diabetes mellitus Calcium channel blockers, thiazide diuretics
Lisinopril 10, 40
Captopril 50, 150-200
ARBs Candesartan 4, 12-32 Left ventricular hypertrophy, renal insufficiency, previous myocardial infarction, heart failure, atrial fibrillation (prevention), metabolic syndrome, diabetes mellitus Calcium channel blockers, thiazide diuretics
Losartan 50, 100
Valsartan 40-80, 160-320
Eprosartan 400, 600-800
Irbesartan 75, 300
Beta blockers Atenolol 25-50, 100 Previous myocardial infarction, atrial fibrillation (prevention and ventricular rate control), heart failure, angina pectoris, aortic aneurysm, pregnancy Thiazide diuretics (with limitations)
Only dihydropyridine calcium channel blockers should be combined with beta blockers
Metoprolol succinate 50, 100-200
Calcium channel blockers Amlodipine 2.5, 10 Left ventricular hypertrophy, pregnancy (nifedipine), previous myocardial infarction, atrial fibrillation (verapamil, diltiazem), metabolic syndrome, peripheral artery disease, atherosclerosis, angina pectoris, isolated systolic hypertension, black population ACE inhibitors, ARBs, thiazide diuretics
Diltiazem extended release 120-180, 360
Nitrendipine 10, 20

Don'ts

References

  1. 1.0 1.1 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". Hypertension. 42 (6): 1206–52. doi:10.1161/01.HYP.0000107251.49515.c2. PMID 14656957.
  2. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C; et al. (2017). "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 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". Hypertension. doi:10.1161/HYP.0000000000000065. PMID 29133356.
  3. 3.0 3.1 Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C; et al. (2017). "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Hypertension. doi:10.1161/HYP.0000000000000066. PMID 29133354.
  4. 4.0 4.1 4.2 4.3 Mancia, G.; Fagard, R.; Narkiewicz, K.; Redán, J.; Zanchetti, A.; Böhm, M.; Christiaens, T.; Cifkova, R.; De Backer, G. (2013). "2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension". J Hypertens. 31 (10): 1925–38. doi:10.1097/HJH.0b013e328364ca4c. PMID 24107724. Unknown parameter |month= ignored (help)
  5. 5.0 5.1 Chobanian, AV.; Bakris, GL.; Black, HR.; Cushman, WC.; Green, LA.; Izzo, JL.; Jones, DW.; Materson, BJ.; Oparil, S. (2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". Hypertension. 42 (6): 1206–52. doi:10.1161/01.HYP.0000107251.49515.c2. PMID 14656957. Unknown parameter |month= ignored (help)
  6. 6.0 6.1 James, PA.; Oparil, S.; Carter, BL.; Cushman, WC.; Dennison-Himmelfarb, C.; Handler, J.; Lackland, DT.; LeFevre, ML.; MacKenzie, TD. (2014). "2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8)". JAMA. 311 (5): 507–20. doi:10.1001/jama.2013.284427. PMID 24352797. Unknown parameter |month= ignored (help)
  7. Doulton, Timothy W.R.; He, Feng J.; MacGregor, Graham A. (2005). "Systematic Review of Combined Angiotensin-Converting Enzyme Inhibition and Angiotensin Receptor Blockade in Hypertension". Hypertension. 45 (5): 880–886. doi:10.1161/01.HYP.0000161880.59963.da. ISSN 0194-911X.