Screen for hypertension.
Use correct technique and equipment to measure blood pressure.
Make the diagnosis of hypertension only after multiple BP readings (i.e., at different times and during different visits).
In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications:
Take an appropriate history.
Do the appropriate physical examination.
Arrange appropriate laboratory investigations.
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):
Suspect secondary hypertension.
Suggest individualized lifestyle modifications to patients with hypertension. (e.g., weight loss, exercise, limit alcohol consumption, dietary changes).
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).
Given a patient with the signs and symptoms of hypertensive urgency or crisis, make the diagnosis and treat promptly.
In all patients diagnosed with hypertension, assess response to treatment, medication compliance, and side effects at follow-up visits.
Hypertensive urgency (dBP≥130mmHg) or emergency (severe elevation of BP in the setting of any below) → Immediate diagnosis management
Acute aortic dissection
Acute LV failure
Acute coronary syndrome
Acute kidney injury
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)
Mean OBPM (office BP measurement) ≥140/90 with macrovascular target organ damage, diabetes mellitus or CKD (eGFR<60)
Mean OBPM ≥160/100
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
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.
Target Organ Damage
CAD (MI, angina, ACS)
Renal (CKD, albuminuria)
All (including elderly and CKD) <140/90
High risk consider ≤120
SPRINT population ≥ 50yo
Assess global cardiovascular risk
Family Hx CAD (Age <55 in men, <65 in women)
Poor dietary habits
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)
Adjusting antihypertensive drug therapy q1-2 months
Modify health behaviours q3-6 months
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
≤2 drinks per day (Men <14/week, women <9)
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)
Re-assess habits (steroids, licorice), meds (NSAIDs, OCP), OTC meds
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*
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)
Consider dosing hypertension treatment at bedtime
No other indications
Long-acting Thiazide diuretic (eg. Chlorthalidone, indapamide)
Long-acting CCB (eg. Amlodipine)
BB or CCB in stable angina
ACE-i (or ARB), BB
ACE-i (or ARB), BB
Aldosterone antagonist in recent CV hospitalization, acute MI, elevated BNP or NYHA class II-IV
ACE-i, ARB, Long-acting CCB, Thiazide
ACE-i and thiazide combination
ACE-i (or ARB) if proteinuria, Diuretics as additional therapy
Hypertension Canada 2018.
NEJM 2015. SPRINT. http://www.nejm.org/doi/full/10.1056/NEJMoa1511939
NICE 2011 (updated 2016). https://www.nice.org.uk/guidance/cg127/chapter/1-Guidance