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Guideline Summary
Guideline Title
Essential hypertension.
Bibliographic Source(s)
University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2009 Feb. 15 p.
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2003 Apr. 13 p. [8 references]

The University of Michigan Health System made a minor update to this guideline in April 2013 to include revised thresholds for diabetes testing.

Scope

Disease/Condition(s)

Essential hypertension

Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Treatment
Clinical Specialty
Cardiology
Family Practice
Internal Medicine
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To accurately diagnose hypertension
  • To improve blood pressure (BP) control
  • To decrease hypertension-related morbidity and mortality
  • To encourage patient's self-involvement
  • To provide appropriate education and follow-up
  • To provide cost-effective care
Target Population

Adults age 18 and older

Interventions and Practices Considered

Diagnosis and Initial Evaluation

  1. Blood pressure measurement (office, home blood pressure monitoring, ambulatory blood pressure monitoring)
  2. History and physical examination
  3. Laboratory tests and diagnostic procedures (e.g., potassium, blood glucose, creatinine, calcium, urinalysis, lipid panel, electrocardiogram, hematocrit)
  4. Other testing and/or referral for secondary hypertension or complicated hypertension
  5. Risk stratification

Treatment/Management

  1. Lifestyle modifications
    • Modification of dietary sodium
    • Potassium
    • Dietary changes
    • Weight reduction and maintenance
    • Adequate physical activity
    • Tobacco avoidance
    • Moderate alcohol intake
  2. Drug therapy
    • Diuretics (thiazide or loop)
    • Beta blockers
    • Angiotensin converting enzyme (ACE) inhibitors
    • Angiotensin II receptor antagonists (ARBs)
    • Calcium channel blockers
    • Aldosterone inhibitors
    • Renin inhibitors
    • Peripheral alpha blockers in combination with thiazide or other agent
    • Centrally-acting alpha-2 agonists
    • Direct vasodilators
  3. Monitoring blood pressure control (home blood pressure monitoring) and follow-up
  4. Special considerations for pregnancy
  5. Ongoing diabetes screening
Major Outcomes Considered
  • Reductions in blood pressure
  • Cardiovascular and cerebrovascular morbidity and mortality
  • Treatment costs
  • Side effects of medications

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Preliminary evidence was identified using literature considered relevant in the 7th report of the Joint Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. That report utilized literature searches of the preceding reports and added a systematic search of literature from January 1997 through April 2003.

A search of more recent literature was conducted on Medline prospectively using the major keywords of: hypertension, human adults, English language, clinical trials, guidelines, and published from 1/1/03 through 5/1/07. Terms used for specific topic searches within the major key words included: alpha 1 blocker, angiotensin converting enzyme inhibitors, angiotensin II receptor antagonist, beta blockers (selective and non-selective), calcium channel blockers (dihydropyridine and non-dihydropyridine forms), centrally acting alpha-2 agonist, diuretics (thiazide and non-thiazide, loop, potassium-sparing), vasodilator (direct), avoidance (alcohol, stress, tobacco), blood pressure monitoring (ambulatory, home), dietary (caffeine, calcium, garlic, magnesium, onion, potassium, sodium), exercise, disease-based management (stroke, coronary artery disease, cardiac, heart failure, arterial fibrillation, peripheral vascular disease, diabetes, chronic kidney disease, metabolic syndrome), and resistant hypertension. Detailed search terms and strategy available from the guideline developer upon request.

The search was conducted in components each keyed to a specific causal link in a formal problem structure (available from the guideline developer upon request). The search was supplemented with very recent information available to expert members of the panel, including abstracts from recent meetings and results of clinical trials. Negative trials were specifically sought. The search was a single cycle.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational trials
  4. Opinion of expert panel
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Consensus of the guideline team after reviewing the evidence and discussion

Rating Scheme for the Strength of the Recommendations

Strength of recommendation:

I = Generally should be performed

II = May be reasonable to perform

III = Generally should not be performed

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

University of Michigan Health System (UMHS) guidelines are reviewed by leadership and in clinical conferences of departments to which the content is most relevant. This guideline was reviewed by the Division of Cardiovascular Medicine, Department of Family Medicine, Division of General Medicine, and Division of Geriatric Medicine.

Recommendations

Major Recommendations

Note from the University of Michigan Health System (UMHS) and the National Guideline Clearinghouse (NGC): The following guidance was current as of February 2009. Because UMHS occasionally releases minor revisions to its guidance based on new information, users may wish to consult the original guideline document External Web Site Policy for the most current version.

Note from NGC: The following key points summarize the content of the guideline. Refer to the full text for additional information, including detailed information on selection of drugs, dosing, possible side effects, and cost of medications and considerations for pregnant patients. The levels of evidence (A, B, C, D) and grades of recommendations (I-III) are defined at the end of the "Major Recommendations" field.

Diagnosis

  • Although a single, carefully taken blood pressure (BP) reading may predict future cardiovascular risk, for clinical purposes this risk is better identified by taking the mean BP level from recordings over several visits.
  • Home and ambulatory blood pressure monitoring helps improve BP control, and identifies "white coat" and "masked" hypertension [IIA].
  • If home BP monitoring is used, careful calibration of the BP monitor and thorough patient education are essential.
  • Individuals with mean BP >140/80 should be screened for diabetes [IB].

Treatment

  • For patients without diabetes or end organ damage, target of BP therapy is <140/90 mmHg [IA].
  • For patients with diabetes or end organ damage (e.g., renal insufficiency, retinopathy, congestive heart failure [CHF], coronary artery disease [CAD], peripheral vascular obstructive disease [PVOD], cerebrovascular disease), aggressive treatment of hypertension (HTN) provides significant improvements in clinical outcomes [IA]. Systolic goals have not been specifically defined. A target systolic blood pressure of 140 mmHg or less [ID] and diastolic BP goal of 80 mmHg or less [IB] is recommended based on trials to date.
  • Treatment of systolic blood pressure (SBP) over 160 mmHg is important in reducing cerebrovascular accident (CVA) and congestive heart failure risk [IA].
  • Lifestyle modifications to lower BP are important adjuncts to drug therapy [IA].
  • Begin therapy with a thiazide diuretic for almost all patients. Add second and third agents as needed to achieve effective BP reduction goals [IA].
    • Angiotensin-converting enzyme (ACE) inhibitors and long-acting dihydropyridine calcium channel blockers are the first choice additional agents.
    • Specific illnesses may guide the choice of agent(s), e.g.,:
      • ACE inhibitors (angiotensin II receptor antagonists [ARBs] for those unable to tolerate ACE inhibitors) for patients with renal disease or diabetes with microalbuminuria or left ventricular (LV) dysfunction
      • Beta-blockers for those with coronary artery disease or congestive heart failure
  • Over 70% of individuals require two or more drugs to achieve BP goals. A fixed combination therapy may be cost-effective. Once a day medications increase compliance and are preferred.

Definitions:

Levels of Evidence

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational trials
  4. Opinion of expert panel

Strength of Recommendation

I = Generally should be performed

II = May be reasonable to perform

III = Generally should not be performed

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Conclusions were based on prospective randomized controlled trials (RCTs) if available, to the exclusion of other data; if randomized controlled trials were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Improved diagnosis of hypertension
  • Improved prediction of future cardiovascular risk
  • Improved blood pressure control
  • Decreased hypertension-related end-organ damage and consequent morbidity and mortality
  • Improved patient involvement in care
Potential Harms

Thiazide Diuretics

  • Increase the frequency of sexual dysfunction in men and women and initially may cause interruptions in daily routine for micturition
  • Cause a short-term increase in low-density lipoprotein (LDL) cholesterol; however, long-term trials have shown minimal change and outcome studies show no clinical impact
  • Slightly increase risk for diabetes (The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial [ALLHAT])
  • Increase uric acid and precipitate attacks of gout
  • Hypokalemia is uncommon at usual (12.5-25 mg) doses but occurs relatively often at doses of 50 mg or more.

Beta-blockers

  • Fatigue and impotence are uncommon side effects at the recommended low doses.
  • Though beta blockers may raise triglycerides and lower high-density lipoprotein (HDL) cholesterol, these effects have not been found to be clinically significant in outcome.

Angiotensin-Converting Enzyme (ACE) Inhibitors

  • Angioedema is a rare side effect (0.1%) which may be life-threatening and may occur at any point in the treatment. The incidence may be higher in African Americans.
  • Renal impairment may occur in patients with bilateral renal artery stenosis or unilateral renal artery stenosis with a single kidney.
  • All in this class induce cough equally, which may be disabling enough with some patients to result in the need to discontinue the drug; cough occurs more often in women.

Angiotensin II Receptor Blockers (ARBs)

  • Angioedema has been rarely reported with losartan, but has occurred in patients with prior angioedema on angiotensin-converting enzyme inhibitors.
  • Losartan has a uricosuric effect that is unique compared to others in this class.

Calcium Channel Blocking Agents

  • Edema may occur and is more pronounced with the dihydropyridine agents.
  • Bradycardia is a side effect of verapamil and diltiazem, but renders them useful agents in the treatment of atrial fibrillation/supraventricular tachycardia [SVT]).
  • Verapamil and diltiazem may increase risk for statin myopathy (cytochrome 3A4 inhibition).

Aldosterone Inhibitors

  • When used in patients with chronic kidney disease, or concurrently with potassium sparing agents (ACEI, ARB, triamterene), they carry significant risk for life-threatening hyperkalemia.
  • Combination therapy is generally restricted to patients with systolic heart failure and requires close follow-up.
  • Gynecomastia and breast pain are common side effects with spironolactone, causing discontinuation in about 10%.

Renin Inhibitors

  • As with other rennin-angiotensin-aldosterone system (RAAS) agents, aliskiren can cause an increase in serum creatinine, and potassium especially is used in combination with an ACE inhibitor or ARB.

Peripheral Alpha Blockers

  • Alpha blockers may cause first dose syncope, so they are generally started at bedtime and slowly titrated up in dose. They may cause fluid retention and edema. The ALLHAT study showed a 25% increase in cardiac events in the doxazosin vs. chlorthalidone group.

Centrally-acting Alpha-2 Agonists

  • Dry mouth and sedation are common; may induce bradycardia.
  • Rebound hypertension may occur with sudden discontinuation of clonidine.

Direct Vasodilators

  • Induce reflex tachycardia and thus should be combined with a beta blocker or non-dihydropyridine calcium channel blocker.
  • Due to increase fluid retention, they should also be combined with a diuretic.
  • Hydralazine may produce a lupus erythematosus-like syndrome; the syndrome is extremely rare when the daily dose is less than 200 mg. Headache, palpitations, anorexia, nausea and at least twice daily dosing requirements limit the usefulness of this drug.
  • Side effects of Minoxidil include hypertrichosis and fluid accumulation in serous cavities, including the pericardium.

Contraindications

Contraindications
  • Atenolol, propranolol, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (ARB), and rennin inhibitors are contraindicated in pregnancy.
  • All ACE inhibitors and ARB are relatively contraindicated in patients with bilateral or equivalent renal artery stenosis.
  • Short-acting dihydropyridine calcium channel blockers (DHP CCBs) are relatively contraindicated for all coronary artery disease.
  • Non-DHP CCBs and alpha blockers are relatively contraindicated in congestive heart failure (CHF) -- systolic.
  • Diuretics, ACE inhibitors, and ARBs are relatively contraindicated in patients taking lithium.
  • Alpha blockers should not be used as initial therapy but may be added to a thiazide or other outcome-improving agent for additional blood pressure (BP) control or when prostatism treatment is desired.
  • DHP CCB alone is relatively contraindicated in patients with chronic renal disease.
  • Beta-blockers, non-DHP CCB, and alpha-2 agonists are relatively contraindicated in patients with bradycardia and heart block.

Refer to Table 1 in the original guideline document for additional contraindications and cautions in selecting antihypertensive medications for patients with coexisting conditions.

Qualifying Statements

Qualifying Statements

These guidelines should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific clinical procedure or treatment must be made by the physician in light of the circumstances presented by the patient.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2009 Feb. 15 p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1997 (revised 2009 Feb)
Guideline Developer(s)
University of Michigan Health System - Academic Institution
Source(s) of Funding

University of Michigan Health System

Guideline Committee

Hypertension Guideline Team

Composition of Group That Authored the Guideline

Team Leader: Masahito Jimbo, MD, Family Medicine

Team Members: William E. Barrie, MD, General Medicine; Michael P Dorsch, PharmD, Pharmacy; R Van Harrison, PhD, Medical Education; Kenneth A. Jamerson, MD, Cardiovascular Medicine

Guidelines Oversight Team: Connie Standiford, MD; William Chavey, MD; Van Harrison, PhD

Financial Disclosures/Conflicts of Interest

The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed. Disclosure of a relationship is not intended to suggest bias in the information presented, but is made to provide readers with information that might be of potential importance to their evaluation of the information.

Team Member Relationship Company
William Barrie, MD (none)  
Michael P. Dorsch, PharmD Speakers Bureau Bristol-Myers Squibb, Sanofi-Avantis
R. Van Harrison, PhD (none)  
Kenneth Jamerson, MD Grant Consultant, Speakers Bureau Novartis, King Abbott, Bristol-Myers Squibb, GlaxoSmithKline, King, Merck, Novartis, Sankyo, Sanofi-Aventis, Bristol-Myers Squibb, Merck, Novartis
Masahito Jimbo, MD (none)  
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2003 Apr. 13 p. [8 references]

The University of Michigan Health System made a minor update to this guideline in April 2013 to include revised thresholds for diabetes testing.

Guideline Availability

Electronic copies: Available from the University of Michigan Health System Web site External Web Site Policy.

Availability of Companion Documents

Continuing Medical Education (CME) information is available from the University of Michigan Health System Web site External Web Site Policy.

Patient Resources

The following are available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on March 19, 2003. The information was verified by the guideline developer on April 23, 2003. This NGC summary was updated by ECRI on September 13, 2005. The updated information was verified by the guideline developer on September 20, 2005. This NGC summary was updated by ECRI Institute on August 18, 2009. The updated information was verified by the guideline developer on September 11, 2009. This summary was updated ECRI Institute on April 25, 2012 following the U.S. Food and Drug Administration (FDA) advisory on Aliskiren-containing Medications.

Copyright Statement

This NGC summary is based on the original guideline, which is copyrighted by the University of Michigan Health System (UMHS).

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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