Hypertension

1. Screen for hypertension.

2. Use correct technique and equipment to measure blood pressure.

3. Make the diagnosis of hypertension only after multiple BP readings (i.e., at different times and during different visits).

4. In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications:

   1. Take an appropriate history.

   2. Do the appropriate physical examination.

   3. Arrange appropriate laboratory investigations.

5. In appropriate patients with hypertension (e.g., young patients requiring multiple medications, patients with an abdominal bruit, patients with hypokalemia in the absence of diuretics):

   1. Suspect secondary hypertension.

   2. Investigate appropriately.

6. Suggest individualized lifestyle modifications to patients with hypertension. (e.g., weight loss, exercise, limit alcohol consumption, dietary changes).

7. In a patient diagnosed with hypertension, treat the hypertension with appropriate pharmacologic therapy (e.g., consider the patient’s age, concomitant disorders, other cardiovascular risk factors).

8. Given a patient with the signs and symptoms of hypertensive urgency or crisis, make the diagnosis and treat promptly.

9. In all patients diagnosed with hypertension, assess response to treatment, medication compliance, and side effects at follow-up visits.

Diagnosis

• Hypertensive urgency (dBP≥130mmHg) or emergency (severe elevation of BP in the setting of any below) → Immediate diagnosis management

  • Emergency

    • Cerebrovascular

      • Hypertensive encephalopathy

      • Intracranial hemorrhage

    • Cardiac

      • Acute aortic dissection

      • Acute LV failure

      • Acute coronary syndrome

    • Renal

      • Acute kidney injury

    • Pre-eclampsia/eclampsia

    • Catecholamine-associated HTN

• Visit 1

  • Require minimum of three readings during same visit (discard first reading) - gold standard is automated office blood pressure (AOBP)

  • History and Physical (cardioresp, fundoscopy, bruits, peripheral pulse) +/- Labs

  • If AOBP ≥ 135/85 or non-AOBP ≥ 140/90, out-of-office BP should be performed before Visit 2

    • Out-of-office BP measurements can diagnose if any:

      • Daytime ambulatory BP ≥ 135/85

      • 24h ambulatory BP (ABPM) ≥ 130/80

      • Daytime home BP (7d) ≥ 135/85

        • 2 readings before breakfast, 2 readings 2h after dinner, eliminate day 1 readings and average other 6 days (total 24 readings)

• Visit 2

  • Mean OBPM (office BP measurement) ≥140/90 with macrovascular target organ damage, diabetes mellitus or CKD (eGFR<60)

• Visit 3

  • Mean OBPM ≥160/100

• Visit 4-5

  • Mean OBPM ≥140/90

Accurate BP Measurement

• Cuff with appropriate bladder size (Bladder width 40% of arm circumference and length 80-100% of arm circumference)

• Nondominant arm, unless SBP difference >10mmHg (use higher value arm)

• Rest comfortably for 5 minutes in seated position, back support, arm supported at heart level

• No caffeine/tobacco 1h, no exercise 30mins preceding

In Children

• Consider BP measured annually in children and adolescents ≥3 y of age. 

• Diagnosis of HTN if a child or adolescent if auscultatory-confirmed BP readings ≥95th percentile at 3 different visits.

  • Blood Pressure Table Pediatrics

Target

• Diabetes <130/80

• All (including elderly and CKD) <140/90

• High risk consider ≤120

  • SPRINT population ≥ 50yo

    • CV disease

    • CKD

    • FRS ≥15%

    • Age ≥75yo

Follow-up

• Assess global cardiovascular risk

  • Age ≥55yo

  • Male

  • Family Hx CAD (Age <55 in men, <65 in women)

  • Sedentary lifestyle

  • Poor dietary habits

  • Abdominal obesity

  • Dysglycemia

  • Smoking

  • Dyslipidemia

  • Stress

  • Nonadherence

• Routine labs

  • FBG and/or HbA1C

  • Lipid profile (serum total cholesterol, LDL, HDL, non-HDL, TG) fasting or non-fasting

  • K, Na, Cr

  • UA (r/o albuminuria which would guide treatment, eg ACEi/ARB)

  • EKG

• Adjusting antihypertensive drug therapy q1-2 months

• Modify health behaviours q3-6 months

  • Exercise

    • 30-60 mins of moderate-intensity dynamic exercise (walking, jogging, cycling, swimming) 4-7 days per week in addition to routine ADLs

  • Weight loss (dietary education, physical activity, behaviour modification)

    • BMI 18.5-24.9 and waist circumference <102cm for men <88cm for women

  • Alcohol consumption

    • ≤2 drinks per day (Men <14/week, women <9)

  • Diet

    • Dietary Approaches to Stop Hypertension [DASH]

      • Reduce saturated fat, cholesterol

      • Emphasis on fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains, and protein from plant sources

    • Sodium <2000mg (1 tsp salt) per day

    • Potassium increase dietary intake to reduce BP (if no risk of hyperkalemia)

  • Stress management (cognitive behaviour interventions with relaxation techniques)

  • Smoking cessation

  • Re-assess habits (steroids, licorice), meds (NSAIDs, OCP), OTC meds

Secondary Hypertension

• Rule out renovascular hypertension with imaging (eg. duplex ultrasound of renal arteries, MRA, CTA, captopril-radioisotope renal scan) if ≥2 of below

  • Sudden onset, worsening HTN and age >55 or <30*

  • Abdominal bruit*

  • HTN resistant to ≥3 drugs*

  • Serum creatinine ≥30% increase with ACE-I or ARB

  • Atherosclerotic vascular disease (smoke/DLP)

  • Recurrent pulmonary edema with hypertensive surges

  • Consider r/o fibromuscular dysplasia with CTA/MRA if any of three above* or unexplained asymmetry of kidney sizes (>1.5cm), family history of FMD, or FMD in other territory

• Rule out endocrine hypertension

  • Hyperaldosteronism (Plasma aldosterone and renin/renin activity)

    • K<3.5mmol/L or marked diuretic-induced hypokalemia (K<3)

    • HTN resistant to ≥3 drugs

    • Incidental adrenal adenoma

  • Pheochromocytoma/paraganglioma (24h urinary total metanephrines and catecholamines or 24h urine fractionated metanephrines, plasma free metanephrine/normetanephrines)

    • Paroxysmal, unexplained, labile, severe (≥180/110) HTN refractory to usual therapy

    • Symptoms of catecholamine excess (headache, palpitations, sweating, panic attacks, pallor)

    • HTN triggered by BB, MAO-i, micturition, changes in abdominal pressure, surgery, anesthesia

    • Incidental adrenal mass

    • Hereditary (MEN2A/B, neurofibromatosis type 1, Von Hippel-Lindau)

Initial Therapy

Consider dosing hypertension treatment at bedtime

• No other indications

  • Long-acting Thiazide diuretic (eg. Chlorthalidone, indapamide)

  • BB (<60yo)

  • ACE-i (nonblack)

    • Secondary analysis of ALLHAT trial showed increase 11% increased CVA risk in ACE inhibitors compared to diuretics

  • Long-acting CCB (eg. Amlodipine)

  • ARB

• Diabetes mellitus

  • ACE-i, ARB

• Cardiovascular disease

  • CAD

    • ACE-i, ARB

    • BB or CCB in stable angina

  • Recent MI

    • ACE-i (or ARB), BB

  • Heart failure

    • ACE-i (or ARB), BB

    • Aldosterone antagonist in recent CV hospitalization, acute MI, elevated BNP or NYHA class II-IV

      • Monitor potassium

  • LV hypertrophy

    • ACE-i, ARB, Long-acting CCB, Thiazide

  • Previous stroke/TIA

    • ACE-i and thiazide combination

• Non-diabetic CKD

  • ACE-i (or ARB) if proteinuria, Diuretics as additional therapy