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Guideline Summary
Guideline Title
Hypertension diagnosis and treatment.
Bibliographic Source(s)
Luehr D, Woolley T, Burke R, Dohmen F, Hayes R, Johnson M, Kerandi H, Margolis K, Marshall M, O'Connor P, Pereira C, Reddy G, Schlichte A, Schoenleber M. Hypertension diagnosis and treatment. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Nov. 67 p. [127 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Institute for Clinical Systems Improvement (ICSI). Hypertension diagnosis and treatment. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Nov. 68 p.

Scope

Disease/Condition(s)

Hypertension

Guideline Category
Counseling
Diagnosis
Evaluation
Management
Risk Assessment
Screening
Treatment
Clinical Specialty
Cardiology
Family Practice
Geriatrics
Internal Medicine
Pharmacology
Preventive Medicine
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Pharmacists
Physician Assistants
Physicians
Guideline Objective(s)
  • To increase the percentage of hypertensive patients age 18 years and older whose blood pressure is under control
  • To improve the assessment of hypertensive patients age 18 years and older
  • To increase the percentage of hypertensive patients age 18 years and older who receive patient education, with a focus on the use of non-pharmacological treatments
  • To increase the percentage of patients age 18 years and older with uncontrolled hypertension who have a plan of care
  • To increase the percentage of hypertensive patients age 18 years and older not at blood pressure goal, who have a change in subsequent pharmacological therapy
Target Population

Adults age 18 years or older, excluding pregnancy

Interventions and Practices Considered

Diagnosis/Evaluation/Screening

  1. Medical history and physical examination, including 2 or more blood pressure measurements separated by 2 minutes in accordance with recommended techniques
  2. Blood pressure considerations for special populations (chronic kidney disease, cardiovascular disease, coronary artery disease or left ventricular hypertrophy, chronic heart failure, elderly – over age 60, type 2 diabetes mellitus)
  3. Laboratory screen, including 12-lead electrocardiogram, urinalysis, fasting blood glucose or A1c, hematocrit, serum sodium, potassium, creatinine (estimated or measured glomerular filtration rate), calcium, and lipid profile (total cholesterol, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL] cholesterol, and triglycerides)

Risk Assessment/Treatment/Follow-Up

  1. Risk assessment and treatment based on blood pressure level, presence or absence of target organ damage, and other risk factors, such as smoking, dyslipidemia, diabetes
  2. Evaluation for secondary hypertension
  3. Lifestyle modifications, including weight reduction and maintenance, the Dietary Approaches to Stop Hypertension (DASH) diet, reduction of dietary sodium, moderation of alcohol intake, physical activity, tobacco avoidance, relaxation and stress management
  4. Drug therapy, including thiazide diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, angiotensin receptor blockers, and combinations of these drugs
  5. Patient education
  6. Referral for consultation for resistant hypertension
  7. Follow-up and continuing care, including change of treatment if necessary
Major Outcomes Considered
  • Risk of non-fatal and fatal cardiovascular disease in individuals with hypertension
  • Morbidity and mortality from cardiovascular disease in individuals with hypertension
  • Adequate control of blood pressure (<140 mm Hg systolic and <90 mm Hg diastolic)

Methodology

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

A consistent and defined process is used for literature search and review for the development and revision of Institute for Clinical Systems Improvement (ICSI) guidelines. The literature search was divided into two stages to identify systematic reviews, (stage I) and randomized controlled trials, meta-analysis and other literature (stage II). PubMed was searched for literature from January 2010 through May 2012.

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

Following a review of several evidence rating and recommendation writing systems, Institute for Clinical System Improvement (ICSI) has made a decision to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Crosswalk between ICSI Evidence Grading System and GRADE


ICSI GRADE System Previous ICSI System
 
High, if no limitation Class A: Randomized, controlled trial
 
Low Class B: [observational]
  Cohort study
 
  Class C: [observational]
Non-randomized trial with concurrent or historical controls
Low   Case-control study
Low   Population-based descriptive study
*Low   Study of sensitivity and specificity of a diagnostic test
*Following individual study review, may be elevated to Moderate or High depending upon study design
 
  Class D: [observational]
Low   Cross-sectional study
    Case series
  Case report
 
Meta-analysis Class M: Meta-analysis
Systematic Review   Systematic review
Decision Analysis   Decision analysis
Cost-Effectiveness Analysis   Cost-effectiveness analysis
 
Low Class R: Consensus statement
Low   Consensus report
Low   Narrative review
 
Guideline Class R: Guideline
 
Low Class X: Medical opinion

Evidence Definitions

High Quality Evidence = Further research is very unlikely to change confidence in the estimate of effect.

Moderate Quality Evidence = Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

Low Quality Evidence = Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate or any estimate of effect is very uncertain.

In addition to evidence that is graded and used to formulate recommendations, additional pieces of literature will be used to inform the reader of other topics of interest. This literature is not given an evidence grade and is instead identified as a Reference throughout the document.

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

Guideline Development Process

A work group consisting of 6 to 12 members that includes physicians, nurses, pharmacists, other healthcare professionals relevant to the topic, and an Institute for Clinical Systems Improvement (ICSI) staff facilitator develops each document. Ordinarily, one of the physicians will be the leader. Most work group members are recruited from ICSI member organizations, but if there is expertise not represented by ICSI members, 1 or 2 members may be recruited from medical groups, hospitals, or other organizations that are not members of ICSI. Patients on occasion are invited to serve on work groups.

The work group meets for seven to eight three-hour meetings to develop the guideline. A literature search and review is performed and the work group members, under the coordination of the ICSI staff facilitator, develop the algorithm and write the annotations and footnotes and literature citations.

Once the final draft copy of the guideline is developed, the guideline goes to the ICSI members for critical review.

Revision Process of Existing Guidelines

ICSI scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature. For documents that are revised on a 24-month schedule, ICSI checks with the work group on an annual basis to determine if there have been changes in the literature significant enough to cause the document to be revised earlier or later than scheduled.

For yearly reviewed documents, ICSI checks with every work group 6 months before the scheduled revision to determine if there have been changes in the literature significant enough to cause the document to be revised earlier than scheduled.

Literature Search

ICSI staff, working with the work group to identify any new pertinent clinical trials, systematic reviews, or regulatory statements and other professional guidelines, conduct a literature search.

Revision

The work group will meet for 1 to 2 three-hour meetings to review the literature, respond to member organization comments, and revise the document as appropriate.

A second review by members is indicated if there are changes or additions to the document that would be unfamiliar or unacceptable to member organizations. If a review by members is not needed, the document goes to the appropriate steering committee for approval according to the criteria outlined above.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations

Category Quality Definitions Strong Recommendation Weak Recommendation
High Quality Evidence Further research is very unlikely to change the work group's confidence in the estimate of effect. The work group is confident that the desirable effects of adhering to this recommendation outweigh the undesirable effects. This is a strong recommendation for or against. This applies to most patients. The work group recognizes that the evidence, though of high quality, shows a balance between estimates of harms and benefits. The best action will depend on local circumstances, patient values or preferences.
Moderate Quality Evidence Further research is likely to have an important impact on the work group's confidence in the estimate of effect and may change the estimate. The work group is confident that the benefits outweigh the risks, but recognizes that the evidence has limitations. Further evidence may impact this recommendation. This is a recommendation that likely applies to most patients. The work group recognizes that there is a balance between harms and benefit, based on moderate quality evidence, or that there is uncertainty about the estimates of the harms and benefits of the proposed intervention that may be affected by new evidence. Alternative approaches will likely be better for some patients under some circumstances.
Low Quality Evidence Further research is very likely to have an important impact on the work group's confidence in the estimate of effect and is likely to change. The estimate or any estimate of effect is very uncertain. The work group feels that the evidence consistently indicates the benefit of this action outweighs the harms. This recommendation might change when higher quality evidence becomes available. The work group recognizes that there is significant uncertainty about the best estimates of benefits and harms.
Cost Analysis

Guideline developers reviewed published cost analyses.

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

Critical Review Process

The purpose of critical review is to provide an opportunity for the clinicians in the member groups to review the science behind the recommendations and focus on the content of the guideline. Critical review also provides an opportunity for clinicians in each group to come to consensus on feedback they wish to give the work group and to consider changes necessary across systems in their organization to implement the guideline.

All member organizations are expected to respond to critical review guidelines. Critical review of guidelines is a criterion for continued membership within the Institute for Clinical Systems Improvement (ICSI).

After the critical review period, the guideline work group reconvenes to review the comments and make changes, as appropriate. The work group prepares a written response to all comments.

Document Approval

Each document is approved by the Committee for Evidence-Based Practice (CEBP). The committee will review and approve each guideline/protocol, based on the following criteria:

  • The aim(s) of the document is clearly and specifically described.
  • The need for and importance of the document is clearly stated.
  • The work group included individuals from all relevant professional groups and had the needed expertise.
  • Patient views and preferences were sought and included.
  • The work group has responded to all feedback and criticisms reasonably.
  • Potential conflicts of interest were disclosed and do not detract from the quality of the document.
  • Systematic methods were used to search for the evidence to assure completeness and currency.
  • Health benefits, side effects, risks and patient preferences have been considered in formulating recommendations.
  • The link between the recommendation and supporting evidence is clear.
  • Where the evidence has not been well established, recommendations based on community practice or expert opinion are clearly identified.
  • Recommendations are specific and unambiguous.
  • Different options for clinical management are clearly presented.
  • Clinical highlights and recommendations are easily identifiable.
  • Implementation recommendations identify key strategies for health care systems to support implementation of the document.
  • The document is supported with practical and useful tools to ease clinician implementation.
  • Where local resource availability may vary, alternative recommendations are clear.
  • Suggested measures are clear and useful for quality/process improvement efforts.

Once the document has been approved, it is posted on the ICSI Web site and released to members for use.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report -- November 2012 External Web Site Policy. In addition, ICSI has made a decision to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This document is in transition to the GRADE methodology. Transition steps incorporating GRADE methodology for this document include the following:

  • Priority placed upon available systematic reviews in literature searches.
  • All existing Class A (randomized controlled trials [RCTs]) studies have been considered as high quality evidence unless specified differently by a work group member.
  • All existing Class B, C and D studies have been considered as low quality evidence unless specified differently by a work group member.
  • All existing Class M and R studies are identified by study design versus assigning a quality of evidence. Refer to Crosswalk between ICSI Evidence Grading System and GRADE (see below in the "Definitions" section).
  • All new literature considered by the work group for this revision has been assessed using GRADE methodology.

The recommendations for the diagnosis and treatment of hypertension are presented in the form of an algorithm with 13 components, accompanied by detailed annotations. An algorithm is provided in the original guideline document External Web Site Policy for Hypertension Diagnosis and Treatment. Clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.

Class of evidence (Low Quality, Moderate Quality, High Quality, Meta-analysis, Systematic Review, Decision Analysis, Cost-Effectiveness Analysis, Guideline, and Reference) ratings are defined at the end of the "Major Recommendations" field.

Clinical Highlights

  • Confirmation of hypertension is based on the initial visit, plus one or more follow-up visits with at least two blood pressure measures at each visit. (Annotation #2; Aim #2)
  • Standardized blood pressure measurement techniques (including out-of-office or home blood pressure measurements) should be employed when confirming an initially elevated blood pressure and for all subsequent measures during follow-up and treatment for hypertension. (Annotation #2, Appendix A - see original guideline document; Aim #2)
  • A thiazide-type diuretic should be considered as initial therapy in most patients with uncomplicated hypertension. (Annotation #6; Aim #1)
  • Physician reluctance to initiate and intensify treatment is a major obstacle to achieving treatment goals. (Annotation #8, 11; Aims #3, 4)
  • Systolic blood pressure level should be the major factor for the detection, evaluation, and treatment of hypertension, especially in adults 50 years and older. (Annotation #7; Aim #2)
  • Fewer than 50% of patients with hypertension will be controlled with a single drug. (Annotation #8; Aims #1, 4, 5)

Hypertension Diagnosis and Treatment Algorithm Annotations

  1. Screening and Identification of Elevated Blood Pressure Greater Than or Equal to 140/90

    The entry point to this guideline is through the NGC summary of the ICSI Preventive Services for Adults guideline. Patients should receive routine blood pressure screening and identification of elevated blood pressure in the manner recommended in that guideline. The standards for blood pressure measurement can be found in Appendix A of the original guideline document.

    Special Populations

    Existing guidelines recommend lower blood pressure goals for certain groups. The Hypertension Diagnosis and Treatment work group has concluded that a goal of <140/90 mm Hg is acceptable.

    A review of seven trials (22,089 participants) comparing patients randomized to lower or to standard blood pressure targets (140-160/90-100 mm Hg) found that lower targets did not reduce mortality, myocardial infarction, stroke, congestive heart failure, or end-stage renal disease [Meta-analysis]. The results in subgroups with diabetes or chronic kidney disease (CKD) were consistent with the overall results (i.e., no benefit). Subsequently, the results of the ACCORD trial in diabetic patients were published and will be detailed in the section related to blood pressure goals in diabetic patients [High Quality Evidence]). The discussion below weighs evidence from trials with other interventions that may have resulted in different blood pressure levels in the treatment arms (e.g., active drug versus placebo), observational studies and expert opinion.

    Chronic Kidney Disease

    Hypertension is a major risk factor for as well as a consequence of CKD and end-stage renal disease (ESRD).

    Current Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) and National Kidney Foundation/Disease Outcomes Quality Initiative (NKF/DOQI) recommendations call for treatment of blood pressure to <130/80 in patients with CKD. However, no single, adequately powered intent-to-treat randomized control trial has shown a benefit of this blood pressure goal in CKD [High Quality Evidence], [Systematic Review], [Meta-analysis], and meta-analysis of available trials shows a relative risk of ESRD of 1.01 for lower versus standard blood pressure goals [Systematic Review].

    In the Modification of Diet in Renal Disease study, 585 individuals with CKD (mean estimated glomerular filtration rate [eGFR] 39 ml/min/1.73 m2) were randomized to a low blood pressure (mean arterial pressure [MAP] 92 mm Hg, corresponding to <125/75 mm Hg) or usual care condition (mean arterial pressure 107 mm Hg, corresponding to <140/90 mmHg). At completion of the study (mean 2.2 years of follow-up), the rate of progression of kidney disease did not differ between blood pressure groups; however, the low blood pressure goal (achieved blood pressure 126/77 versus 134/81 mmHg) slowed the decline in GFR in a subgroup of 156 patients with proteinuria (>1 g/24 hours) [High Quality Evidence]. A registry follow-up of all individuals in the Modification of Diet in Renal Disease study 6.2 years later suggested that individuals originally randomized to the low blood pressure target had a decreased incidence of end-stage kidney disease (62%), compared to those in the usual care group (70%) [Low Quality Evidence]. In the African American Study of Kidney Disease and Hypertension (African-American Study of Kidney Disease), 1,094 African Americans with CKD (GFR 20-75 mL/min/1.73 m2) were randomized to a low mean arterial pressure goal (<92 mm Hg) or to a usual mean arterial pressure goal (<107 mm Hg). Those achieving a blood pressure of 128/78 experienced renal deterioration at the same rate as those achieving a blood pressure of 141/85 [High Quality Evidence]. There was no difference in cardiovascular events by blood pressure group [High Quality Evidence]. In a long-term follow-up of the cohort, a lower risk of renal deterioration was seen in participants with baseline proteinuria (equivalent to albuminuria >300 mg/24 hours) initially assigned to the lower blood pressure goal, although no significant benefit of the lower blood pressure goal was seen overall [High Quality Evidence].

    Hence, prior recommendations by some other groups (JNC7) for lower blood pressure goals in all patients with CKD are based on expert opinion and not fully supported by available prospective clinical trials.

    The above studies do support a lower blood pressure goal (<130/80) in patients with nephrotic level of proteinuria and perhaps in those with moderate proteinuria. The benefit of more aggressive antihypertensive treatment appears to be for preventing renal but not necessarily cardiovascular endpoints. Treatment goals should be considered on an individual patient basis based on clinical judgment and patient preference.

    Cardiovascular Disease

    A reappraisal of evidence from randomized trials in patients with chronic heart disease or previous stroke does not show consistent evidence that cardiovascular disease risk is further reduced by more intensive lowering of blood pressure [Low Quality Evidence]. This evidence is not definitive, i.e., limitations include few trials designed to evaluate specific blood pressure goals, small differences in achieved blood pressure in many trials, and the use of active agents and corresponding placebo on top of multiple antihypertensive and other cardiovascular therapies. American Heart Association (AHA)/American College of Cardiology (ACC) guidelines published in 2007 called for goal office blood pressures less than 130/80 mm Hg in patients with coronary disease, carotid disease, peripheral artery disease, abdominal aortic aneurysm, or a 10-year Framingham risk score of >10% [Low Quality Evidence]. These recommendations are based on expert opinion and limited clinical evidence. A subgroup analysis of 6,400 participants of the International Verapamil SR-Trandolapril Study (INVEST) who had diabetes and coronary artery disease assessed the relationship between the degree of blood pressure control and adverse cardiovascular outcomes [Systematic Review]. Tight control defined as systolic blood pressure to <130 mm Hg was not associated with fewer adverse cardiovascular outcomes compared to usual control (<140-130 mm Hg).

    Based on current evidence, pursuing blood pressure goals lower than <140/90 should be considered on an individual patient basis based on clinical judgment and patient preference.

    Coronary Artery Disease or Left Ventricular Hypertrophy

    Concerns have been raised that excessive lowering of diastolic blood pressure increases the risk of coronary events in patients with established coronary artery disease or left ventricular hypertrophy by lowering diastolic perfusion pressure in the coronary circulation. This is known as the J-curve hypothesis. In a recently published secondary analysis of patients 80 years of age or older with hypertension and stable coronary artery disease and treated with either verapamil or atenolol-based therapy, a J-shaped phenomenon was observed in terms of increased risk of all-cause death, non-fatal myocardial infarction, or non-fatal stroke [Meta-analysis]. The systolic and diastolic blood pressure levels below which these event rates were increased were ≤140 or ≤70 mm Hg, respectively. As a result, it would appear prudent to avoid lowering blood pressure to ≤140/70 mm Hg in very elderly patients (75 and older) with coronary artery disease or left ventricular hypertrophy. In elderly patients with isolated systolic hypertension, some authors recommend against lowering the diastolic blood pressure below 55-60 mm Hg [High Quality Evidence], [Meta-analysis]. This may require compromise of the goal level of systolic blood pressure achieved.

    Chronic Heart Failure

    There is a strong relationship between hypertension and developing heart failure, and numerous studies have demonstrated reduced incidence of heart failure with antihypertensive therapy [Guideline]. AHA/ACC guidelines call for goal office blood pressures <120/80 mm Hg for patients with a history of heart failure [Low Quality Evidence]. In heart failure with decreased systolic function in particular, many of the medications for which there is demonstrated benefit also lower blood pressure, and low normal or slightly hypotensive values are often seen during optimal therapy. However, there are no intent to treat randomized clinical trials to support lower blood pressure goals in patients with either systolic or diastolic chronic heart failure. Hence these recommendations are based on expert opinion and limited clinical evidence.

    Systolic heart failure therapy should not be interrupted for low normal blood pressure readings. Whether therapy should specifically be titrated to a lower goal than <140/90 mm Hg should be considered on an individual patient basis based on clinical judgment, target drug dosing and patient preference.

    Elderly – Over Age 60

    Multiple randomized placebo-controlled clinical trials have demonstrated benefit of the treatment of hypertension in people over 60 with systolic blood pressure >160 mm Hg [High Quality Evidence], [Low Quality Evidence]. There does not appear to be an upper age limit to this benefit, extending well beyond 80 years of age [High Quality Evidence]. Based on the achieved systolic blood pressure levels in placebo-controlled randomized trials of treatment for isolated systolic hypertension with initial systolic blood pressure >160 mm Hg, the evidence supports the safety and benefit of lowering systolic blood pressure into the 140s in patients over age 60 [High Quality Evidence]. However, no randomized control trial has recruited exclusively elderly patients with isolated Stage 1 systolic hypertension (140-159 mm Hg), and therefore there is weaker evidence of the benefit or safety of initiating treatment or titrating therapy for systolic blood pressure levels below 160 mm Hg. A recent large Chinese trial (N=9,711) included 3,179 patients over age 65 [High Quality Evidence]. All participants had blood pressure 140-180/90-100 mm Hg while taking a low-dose diuretic. Using low-dose felodipine or placebo as initial therapy, a mean blood pressure of 138/83 was achieved in the intervention group, compared with 142/85 in the comparison group. In the subgroup over age 65, mean achieved blood pressure in the two groups was 140/81 and 146/84, respectively. The primary outcome of time to first stroke was significantly decreased by 27% overall (p=0.002), and by 44% (p<0.001) in the subgroup over age 65. Other key outcomes (coronary events, cardiovascular mortality and total mortality) were also significantly reduced overall and in the elderly. This new evidence from a subgroup of a randomized trial provides moderate support for broad benefits from treating the elderly to a mean systolic blood pressure of 140 mm Hg. Treating to lower systolic goals should be considered on the basis of clinical judgment and patient preference. In older patients with isolated systolic hypertension, a blood pressure goal of <150 may be acceptable, particularly if the patient tolerates treatment poorly or is already on two-three medications including a diuretic. Only one randomized placebo-controlled trial that demonstrated benefit in the elderly had an explicit goal blood pressure, which was <150/80 mm Hg in the intervention group [High Quality Evidence].

    Type 2 Diabetes Mellitus

    The HOT, ADVANCE and ACCORD trials are all large randomized clinical trials that allow comparison of more-stringent versus less-stringent blood pressure levels on major cardiovascular outcomes in type 2 diabetes [High Quality Evidence]. The ADVANCE trial found that those in the intensive group, with mean systolic blood pressure 135 mm Hg, had lower total mortality and cardiovascular mortality, relative to those treated to higher systolic blood pressure levels. The ACCORD trial found no difference in major cardiovascular outcomes between a more-intensive blood pressure intervention targeting systolic blood pressure <120 mm Hg compared to a standard intervention targeting systolic blood pressure between 130 and 139 mm Hg. The more-intensive blood pressure regimen was associated with no benefit on pre-specified composite outcome measures, but a small reduction in the rate of stroke was observed. However, those treated to systolic blood pressure <120 mm Hg had greater medication use and more serious adverse events [High Quality Evidence].

    The above studies support a systolic blood pressure goal <140 mm Hg for people with type 2 diabetes.

    Only the HOT trial specifically targeted diastolic blood pressure. In the HOT trial, targeting a lower diastolic blood pressure was associated with fewer cardiovascular events in subjects with type 2 diabetes. The average achieved diastolic blood pressure values in the three HOT intervention arms ranged from 81 to 85 mm Hg. Based on results from the ADVANCE and ACCORD trials, it appears likely that achieved systolic blood pressure values in the mid-130 range will usually be associated with diastolic blood pressure values well below 80 mm Hg. Therefore, to simplify clinical guidelines across various conditions, and to simplify quality measures, the work group recommends a diastolic blood pressure goal of <90 mm Hg.

    The work group will continue to review the blood pressure goal to consider any new evidence and the recommendations of other national practice guidelines (e.g., American Diabetes Association [ADA] and JNC8) that are expected to announce revisions. The general recommendation of blood pressure <140/90 does not preclude setting individual patient goals lower than that based on patient characteristics, comorbidities, risks or the preference of an informed patient.

  1. Confirm Elevated Blood Pressure

    Recommendations:

    • All elevated blood pressure readings should be confirmed [High Quality Evidence, Strong Recommendation].
    • A standardized blood pressure measurement process is important for correctly identifying hypertensive patients [Moderate Quality Evidence, Strong Recommendation].
    • A combination of office and out-of-office blood pressure measurement should be used to confirm the diagnosis of hypertension [Moderate Quality Evidence, Strong Recommendation].
    • Self-monitoring of blood pressure should be encouraged in most patients.

    If an elevated blood pressure reading has been obtained, the blood pressure level should be confirmed. Confirmation is based on a combination of one or more follow-up visits with at least two blood pressure readings at each visit and out-of-office blood pressure measurements or 24-hour ambulatory blood pressure monitoring. Unconfirmed hypertension should be coded as indicated in the original guideline document.

    Standardized Office Blood Pressure Measurement

    Accurate, reproducible blood pressure measurement is important to allow comparisons between blood pressure values and to correctly classify blood pressure. Incorrectly labeling a hypertensive patient as normotensive may increase risk for vascular events, since risk rises with increasing blood pressure. Labeling a patient with normal blood pressure as a hypertensive can affect insurability, employment, morbidity from medications, loss of time from work, and unnecessary lab and clinician visits [Guideline], [Low Quality Evidence].

    Standardized blood pressure technique should be employed when confirming an elevated reading and for all subsequent readings during follow-up and treatment for hypertension. See Appendix A, "Standards for Blood Pressure Measurement," in the original guideline document.

    Automated blood pressure measurement, measured using a standardized technique, can be used as a substitute for standardized blood pressure measurement and may reduce white-coat effect and other errors seen with casual clinic blood pressure measurement [High Quality Evidence].

    Confirmed elevated blood pressure should be classified as to the appropriate hypertension stage.

    Out-of-Office Blood Pressure Measurement

    Out-of-office, self-measured blood pressure readings provide important information regarding the diagnosis and treatment of hypertension and should be a routine component of diagnosis and monitoring [Systematic Review], [Guideline]. Home blood pressure monitoring identifies patients with white-coat hypertension (i.e., patients with elevated office blood pressure who lack evidence of hypertensive target organ damage, and who have normal out-of-office blood pressure readings) and home readings are a stronger predictor of subsequent cardiovascular events than are office readings. Moreover, home blood pressure measurements can identify patients with "masked hypertension" (i.e., normal office and elevated home readings) [Low Quality Evidence]. Studies have shown that uncertainty about the "true blood pressure" is a common reason for lack of change in treatment during a clinic visit despite an elevated office blood pressure reading. Additional readings from self-monitoring will reduce this uncertainty. It is recommended that patients obtain 2 to 3 readings while rested in the seated position, both in the morning and at night for one week prior to a clinic visit [Guideline]. Fully automated oscillometric devices using an appropriately sized upper arm cuff are preferred over aneroid devices or automated devices that measure blood pressure at the wrist or on the finger. Accuracy of the patient's automated device should be confirmed initially upon acquisition and periodically (e.g., annually) by the patient's health care professional [Low Quality Evidence]. The general home blood pressure goal with treatment is <135/85 mm Hg. Refer to the Implementation Tools and Resources Table in the original guideline document for additional blood pressure monitoring information.

    24-Hour Blood Pressure Measurement

    Twenty-four hour ambulatory blood pressure monitoring can be used to confirm the diagnosis of hypertension and is more accurate than office blood pressure measurement for this purpose [Systematic Review]. Ambulatory blood pressure monitoring predicts subsequent cardiovascular events and target organ damage more reliably than office blood pressure measurements.

    Thresholds for ambulatory hypertension are 140/85 mm Hg for awake average, 120/70 mm Hg for asleep average and 130/80 for 24-hour average blood pressure [Low Quality Evidence].

    Ambulatory blood pressure monitoring is particularly helpful in the confirmation of white-coat or office hypertension. This phenomenon may be present in 20% to 35% of patients diagnosed with hypertension [Low Quality Evidence]. This diagnosis can also be reliably established in patients with elevated office readings who lack target organ damage by accurately measured out-of-office blood pressure readings that are consistently <135/85 mm Hg. Other clinical situations in which ambulatory blood pressure monitoring may be helpful include the assessment of drug resistance, masked hypertension, hypotensive symptoms, episodic hypertension, and suspected autonomic dysfunction.

    Ambulatory blood pressure monitoring may be inaccurate with atrial fibrillation.

    For patients with prehypertension, early intervention with healthy lifestyle changes could reduce blood pressure, decrease the rate of the progression of blood pressure to hypertensive levels with age, or prevent hypertension entirely.

    Blood Pressure Screening Clarification

    Because all stages of hypertension are associated with increased vascular events, the previous classifications of mild and moderate hypertension were discarded in favor of stages that emphasize these risks. The current classification emphasizes systolic as well as diastolic standards, as systolic hypertension has been associated with increased fatal and nonfatal cardiovascular events, and treatment has been shown to reduce cardiovascular morbidity and mortality (see Table 1 of the original guideline document) [Guideline], [Low Quality Evidence], [High Quality Evidence].

    A proposed follow-up schedule, based on the initial blood pressure level as well as prior diagnosis and treatment of cardiovascular disease and risk factors, is noted in Table 2 of the original guideline document [Guideline].

    Initial encounter is defined as an International Classification of Diseases, Ninth Revision (ICD-9) code of 796.2 ("Elevated blood pressure reading without diagnosis of hypertension." Note: This category is to be used to record an episode of elevated blood pressure in a patient in whom no formal diagnosis of hypertension has been made, or as an incidental finding).

    This guideline encourages increased use of this 796.2 ICD-9 code because elevated blood pressure without hypertension is currently believed to be under reported.

  1. Complete Initial Assessment: Evaluate, Accurately Stage, and Complete Risk Assessment

    Recommendations:

    • It is important to assess and accurately stage newly confirmed hypertension.
    • A complete review of all medications (prescription and over-the-counter) and herbal supplements is very important.

    The goal of the clinical evaluation in newly confirmed hypertension is to determine whether the patient has primary or secondary hypertension, target organ disease, and other cardiovascular risk factors (risk assessment).

    The decision to treat hypertension initially with both lifestyle modification and drugs is reasonable when absolute individual risk is high.

    • Accurately Stage

      This treatment guideline is designed to be used in new or previously diagnosed hypertensive patients in conjunction with the NGC summary of the ICSI guideline Preventive Services for Adults. See Appendix A, "Standards for Blood Pressure Measurement," in the original guideline document.

      Hypertension Stages Systolic   Diastolic
      Prehypertension 120-139 or 80-89
      Stage 1 Hypertension 140-159 or 90-99
      Stage 2 Hypertension ≥160 or ≥100

      Note: Modified from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52. [Guideline]

      When systolic and diastolic pressures fall into different categories, the higher category should be selected in classifying the individual's blood pressure status.

    • Risk Assessment

      The risk for cardiovascular disease in patients with hypertension is determined not only by the level of blood pressure but also by the presence or absence of target organ damage or other risk factors such as smoking, dyslipidemia and diabetes, as shown in JNC7. These factors independently modify the risk for subsequent cardiovascular disease, and their presence or absence is determined during the routine evaluation of patients with hypertension (i.e., history, physical examination, laboratory tests).

    • Medical History

      The history should focus on modifiable lifestyle factors including weight change, dietary intake of sodium and cholesterol, level of exercise, psychosocial stressors, and patterns of alcohol and tobacco use.

      Determine all medications being used--including herbal supplements, over-the-counter, prescription, and illicit drugs--as many agents may temporarily elevate blood pressure and/or adversely affect blood pressure control [Meta-analysis], [Low Quality Evidence]. See Appendix C, "Recommended Education Messages," in the original guideline document.

      A family history of hypertension, cardiovascular disease, cerebrovascular disease, diabetes mellitus, and dyslipidemia should be documented.

      Assess for symptoms and signs of target organ disease and secondary hypertension via a directed history.

    • Physical Examination

      The initial physical examination should include the following:

      • Two or more blood pressure measurements separated by two minutes with the patient seated and after standing for at least two minutes in accordance with the recommended techniques as stated in Appendix A, "Standards for Blood Pressure Measurement," in the original guideline document
      • Verification in the contralateral arm (if values are different, the higher value should be used)
      • Measurement of height, weight, and waist circumference. Waist circumference provides incremental information regarding cardiovascular risk related to obesity [Low Quality Evidence]. See the NGC summary of the ICSI guideline Prevention and Management of Obesity (Mature Adolescents and Adults) for additional information and instructions on how to measure waist circumference.
      • Funduscopic examination for hypertensive retinopathy (i.e., arteriolar narrowing, focal arteriolar constrictions, arteriovenous crossing changes, hemorrhages and exudates, disc edema). While the reproducibility of office funduscopic findings is poor, there are clinical findings (in particular, retinal hemorrhages, papilledema) that instruct important clinical decisions.
      • Examination of the neck for carotid bruits, distended veins, or an enlarged thyroid gland
      • Examination of the heart for abnormalities in rate and rhythm, increased size, precordial heave, clicks, murmurs, and third and fourth heart sounds
      • Examination of the lungs for rales and evidence for bronchospasm
      • Examination of the abdomen for bruits, enlarged kidneys, masses, and abnormal aortic pulsation
      • Examination of the extremities for diminished or absent peripheral arterial pulsations, bruits, and edema
      • Neurological assessment
    • Initial Laboratory Studies

      Initial lab screen should include 12-lead electrocardiogram, urinalysis, fasting blood glucose or A1c, hematocrit, serum sodium, potassium, creatinine (estimated or measured glomerular filtration rate [GFR]), calcium, and lipid profile (total cholesterol, high density lipoprotein [HDL]-cholesterol, low density lipoprotein [LDL]-cholesterol and triglycerides). Additional laboratory and diagnostic studies may be required in individuals with suspected secondary hypertension and/or evidence of target-organ disease [Guideline].

      Some of these tests are needed for determining presence of target organ disease and possible causes of hypertension. Others relate to cardiovascular risk factors or provide baseline values for judging biochemical effects of therapy.

      Additional tests may be ordered at the discretion of the clinician based on clinical findings. These may include but are not limited to complete blood count, chest x-ray, uric acid, and thyroid-stimulating hormone (TSH).

      See Appendix D, "Clinical Evaluation of Confirmed Hypertension," in the original guideline document.

      [Low Quality Evidence]

    JNC7 Cardiovascular Risk Factors/Target Organ Damage

    Major Risk Factors
    • Hypertension
    • Age (older than 55 for men, 65 for women)*
    • Diabetes mellitus**
    • Elevated LDL cholesterol
    • Low HDL cholesterol**
    • Estimated glomerular filtration rate (GFR) less than 60 mL/min
    • Microalbuminuria
    • Family history of premature cardiovascular disease (men younger than 55 or women younger than 65)
    • Obesity** (body mass index greater than or equal to 30 kg/m2, waist circumference greater than 40 inches for men and greater than 35 inches in women)
    • Physical inactivity
    • Tobacco usage, particularly cigarettes
    Target Organ Damage
    • Heart
      • Left ventricular hypertrophy
      • Angina/prior myocardial infarction
      • Prior coronary revascularization
      • Heart failure
    • Brain
      • Stroke or transient ischemic attack
      • Dementia
    • CKD
    • Peripheral arterial disease
    • Retinopathy

    *Increased risk begins at approximately 55 and 65 for men and women, respectively. Adult Treatment Panel III used earlier age cut points to suggest the need for earlier action.

    **Components of the metabolic syndrome. Reduced HDL and elevated triglycerides are components of the metabolic syndrome. Abdominal obesity is also a component of metabolic syndrome.

    Modified from the Seventh Report of the Joint National Committee in Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52. [Guideline]

    A point scale approach for estimating 10-year coronary heart disease risk can also be used. See Appendix B, "Ten-Year Cardiovascular Disease Risk Calculator (Risk Assessment)," in the original guideline document.

  1. Is Secondary Cause Suspected?

    The term "secondary hypertension" implies that a patient's blood pressure elevation is the result of an underlying discoverable disease process. Secondary causes account for only a small percentage of all documented cases of hypertension, but their detection is important as appropriate intervention may be curative and lead to reversal of hypertension. Keep in mind that some lifestyle risk factors like obesity and excessive alcohol use may also contribute to hypertension and treatment resistance but are not usually classified as secondary causes.

    Evaluate for features suggestive of secondary hypertension. Suspect a diagnosis of secondary hypertension in patients with an abrupt onset of symptomatic hypertension, with Stage 2 hypertension, hypertensive crisis, sudden loss of blood pressure control after many years of stability on drug therapy, drug resistant hypertension, and in those individuals with no family history of hypertension. Differential diagnosis of secondary hypertension includes:

    Diagnosis Signs/Symptoms Options for Further Evaluation
    Chronic kidney disease/obstructive uropathy Variable, may be absent Estimated GFR, urinalysis
    Renovascular hypertension Unexplained hypertension in younger women, abdominal bruit Consult with specialist
    Sleep apnea Excessive daytime sleepiness, obesity History, sleep study
    Primary aldosteronism Unprovoked hypokalemia Plasma rennin/aldosterone ratio

    24-hour urine aldosterone
    Drug-induced (prescription, over-the-counter, supplements or illicit drugs) Variable History, urine toxin screen
    Aortic coarctation Unequal blood pressure in right and left arms, delayed or absent femoral pulses Aortic imaging, consult local experts for preferred test
    Cushing syndrome Striae, moon faces, buffalo hump, truncal obesity Dexamethasone suppression test, 24-hour urine free cortisol
    Pheochromocytoma Palpitations and other paroxysmal symptoms 24-hour urine metanephrines and normetanephrines, plasma-free metanephrines
    Thyroid/parathyroid disease Variable/hypercalcemia TSH, serum PTH

    GFR, glomerular filtration rate; PTH, parathyroid hormone; TSH, thyroid-stimulating hormone

    Care should be taken to ensure advanced testing is correctly chosen and done properly to avert the need for repeat studies. This may require discussion with or referral to a specialist.

  1. Order Additional Work-up/Consider Referral

    If screening tests for secondary hypertension are positive, consider appropriate referral for additional workup and treatment.

    If you suspect a diagnosis of secondary hypertension, it is recommended that you obtain a consultation early in order to confirm the most efficient and cost-effective approach to patient evaluation and management [Guideline].

  1. Stage 1: Lifestyle +/- Drug/Stage II: Lifestyle + Start One or Two Drug(s)

    Recommendation:

    • It is strongly recommended that hypertensive patients be initially treated with and periodically reassessed for adherence to healthy lifestyle habits for both prevention and treatment of hypertension [High Quality Evidence, Strong Recommendation].

    Clinical studies show that the blood pressure-lowering effects of lifestyle modifications can be equivalent to drug monotherapy [High Quality Evidence]. Lifestyle modification is best initiated and sustained through an educational partnership between the patient and a multidisciplinary health care team. While team members may vary by clinical setting, behavior change strategies should include nutrition, exercise, and smoking cessation services. Lifestyle modifications should be reviewed and re-emphasized at least annually.

    Some patient education should occur and be documented at every hypertension care visit. For recommended education messages, see Appendix C in the original guideline document.

    Implementing team-based care including pharmacists and nurses should be considered an effective way to improve blood pressure control in hypertensive patients.

    Six lifestyle behaviors – not smoking, limiting the use of alcohol, obtaining adequate physical activity, limiting sodium intake, having a diet that emphasizes fruits and vegetables and maintaining a normal weight – are associated with a decade or more of increased life expectancy. Individuals who adopt this lifestyle, at any age, have significantly lower risk of developing hypertension and subsequent heart failure.

    Limit Sodium

    Reducing sodium intake in the control diet group increased blood pressure control 2.3-fold. The work group recommends a daily intake of less than 1,500 mg of sodium for most persons [Low Quality Evidence].

    Increase Vegetables and Minimize Animal-based Fats (Dietary Approaches to Stop Hypertension [DASH] diet)

    Among subjects with hypertension baseline, the DASH diet increased blood pressure control twofold over control (63% vs 32%; 95% confidence interval, 1.4–2.9) [Low Quality Evidence]. Compared to those consuming the least amounts of fruit daily (15.6 grams/day), those consuming the most (222.7 grams/day) had a 45% lower risk of hypertension [Low Quality Evidence]. The age-adjusted prevalence of self-reported hypertension was significantly different between the four diet groups, ranging from 15.0% in male meat eaters to 5.8% in male vegans, and from 12.1% in female meat eaters to 7.7% in female vegans, with fish eaters and vegetarians having similar and intermediate prevalences. Mean systolic and diastolic blood pressures were significantly different between the four diet groups, with meat eaters having the highest values and vegans the lowest values [Low Quality Evidence].

    Weight Reduction and Maintenance

    In multivariable analyses, every 1-kg/m2 increase in body mass index was associated with an 11% (95% confidence interval [CI], 9 to 13) increase in heart failure risk. Compared with lean participants, overweight participants had a 49% (95% CI, 32 to 69) and obese participants had a 180% (95% CI, 124 to 250) increase in heart failure risk [Low Quality Evidence], with increasing body mass index a significant predictor of hypertension [Low Quality Evidence]. One study showed that behaviorally based treatment resulted in 3-kg (6.6-lb.) greater weight loss in intervention than controls. Among patients with severe obesity, a lifestyle intervention involving diet combined with physical activity resulted in clinically significant weight loss and favorable changes in cardiometabolic risk factors [High Quality Evidence].

    Exercise

    To promote and maintain health, all healthy adults aged 18 to 65 years of age need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 minutes on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 minutes on three days each week. Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation. For example, a person can meet the recommendation by walking briskly for 30 minutes twice during the week and then jogging for 20 minutes on two other days. Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-minute minimum by performing bouts each lasting 10 or more minutes. Vigorous-intensity activity is exemplified by jogging and causes rapid breathing and a substantial increase in heart rate. In addition, every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week [Low Quality Evidence].

    Fitness is a strong and independent predictor of all-cause and cardiovascular disease mortality, but exercise is often overlooked from a clinical perspective [Low Quality Evidence], [Meta-analysis]. Barriers to implementation are myriad. Meeting the challenge of an implementation of effective lifestyle change at the community level requires a system for the identification of at-risk populations, an optimization of the knowledge base and practices of health care clinicians, and a piloting of targeted biobehavioral intervention programs [Low Quality Evidence]. Exercise in Medicine is a non-profit initiative launched by the American College of Sports Medicine (ACSM) and the American Medical Association (AMA), and provides operationalized approaches for the multifaceted manners needed to facilitate behavioral change (http://www.exerciseismedicine.org External Web Site Policy).

    Moderation of Alcohol Intake

    Limit alcohol use to one serving per day for women, two per day for men, with a maximum of five per week for women and nine per week for men. Overall, interventions to reduce alcohol consumption caused small but statistically significant reductions in both systolic (3.4 mm Hg, 95% CI: 0.9 to 6.0) and diastolic (3.4 mm Hg, 95% CI: 1.5 to 5.4) blood pressure. Thirty percent (95% CI: 21% to 39%) of patients receiving a structured intervention to reduce alcohol consumption were likely to achieve a reduction of at least 10 mm Hg in systolic blood pressure [Meta-analysis].

    No Smoking

    13.6/1,000 person-years develop preventable heart failure [Low Quality Evidence].

    Review of Non-prescription and Supplement Use

    Over-the-counter medications and supplements can cause increases in blood pressure. Use of caffeine pills, non-steroidal anti-inflammatory drugs (NSAIDs), cold medicine (such as pseudoephedrine, phenylephrine) and herbal supplements such as bitter orange, ephedra (ma-huang), ginseng, guarana, licorice and St. John's wort should be evaluated in patients with hypertension. Please see the NGC summary of the ICSI guideline Healthy Lifestyles for additional information on smoking cessation, exercise, nutrition and alcohol moderation.

    Drug Therapy

    A thiazide-type diuretic should be considered as initial therapy in most patients with uncomplicated hypertension [High Quality Evidence, Strong Recommendation].

    • For patients with Stage 2 hypertension, consider initial therapy with two drugs including a diuretic paired with one of the other recommended first-line drugs.

    A thiazide-type diuretic should be considered as initial therapy in most patients with uncomplicated hypertension [Low Quality Evidence]. Because thiazide-type diuretics have been shown to be as good as or superior to other drug classes in preventing cardiovascular disease morbidity and mortality, they should be considered preferred initial therapy in most patients [Guideline]. However, studies support the use of specific alternative drugs as initial therapy in the presence of specific co-existing diseases. Diuretics are generally inexpensive [Meta-analysis], [High Quality Evidence]. Thiazide-type diuretics are especially useful for patients age 55 years or older with hypertension and additional risk factors for cardiovascular disease including the metabolic syndrome and for patients age 60 years or older with isolated systolic hypertension [High Quality Evidence]. The risk of diabetes mellitus is higher with diuretic and beta-blockers than other first-line choices, and this may be a consideration for patients at higher risk for this disorder [Meta-analysis]. Studies have demonstrated the cost effectiveness in older patients of selecting drugs using evidence-based guidelines [Cost-Effectiveness Analysis]. In patients for whom diuretics are contraindicated or poorly tolerated, use of an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta-blocker, or calcium channel blocker is appropriate. The lowest recommended dose of the chosen drug should be used initially. If tolerated, the dose can be increased or additional medications added to achieve goal blood pressure.

    Other considerations when selecting initial drug therapy include age, race, cost, drug interactions, side effects, and quality of life issues. In general, diuretics and calcium channel blockers appear to be more effective as an initial treatment of hypertension in African Americans. Evidence from a recent large trial suggests that ACE inhibitors may be less effective in African Americans than thiazide-type diuretics in controlling blood pressure and in preventing stroke and cardiovascular disease [Low Quality Evidence].

    Other classes of drugs should be reserved for special situations or as additive therapy. Co-existing medical conditions may also justify the use of one of these classes of drugs. An example is the use of an ACE inhibitor in a patient with heart failure or diabetic nephropathy. Please see the NGC summary of the ICSI guideline Diagnosis and Management of Type 2 Diabetes Mellitus in Adults for further information. ACE inhibitors and angiotensin receptor blockers have been shown to be beneficial for patients with renal disease (both diabetic and non-diabetic) by reducing proteinuria and slowing the rate of decline in renal function [Meta-analysis], [High Quality Evidence]. ACE inhibitors have also been shown to provide symptomatic relief and prolong life for patients with heart failure and are the initial drug of choice for this condition. ACE inhibitors also reduce the risk of subsequent myocardial infarction and progression to heart failure for patients who experience a large myocardial infarction associated with impairment of left ventricular function. They also may reduce risk for patients with (or at high risk for) cardiovascular disease [High Quality Evidence]. ACE inhibitors and angiotensin-receptor blockers have similar blood-pressure-lowering effects, but angiotensin-receptor blockers are less often associated with the side effect of cough [Systematic Review]. Initial monotherapy with one of these agents is appropriate in these patient populations. A diuretic should be added if blood pressure response is not satisfactory.

    Based on meta-analyses of previous studies, beta-blockers may be less efficacious than other first-line alternatives in patients who are 60 years and older, especially for stroke prevention [Meta-analysis]. Thus, use of these drugs as initial therapy in older patients probably should be restricted to situations where there is another indication for their use (e.g., heart failure, previous myocardial infarction, angina). They still should be considered alternative first-line agents in younger patients, where they appear to lessen cardiovascular morbidity as well as other recommended drugs. Beta-blockers reduce the risk of sudden death and recurrent myocardial infarction for patients with an initial myocardial infarction.

    Long-acting dihydropyridine calcium channel blockers have been shown to be effective for patients age 60 years or older with isolated systolic hypertension. Co-existing medical conditions may also justify the use of one of these classes of drugs. Evidence from a recent large study refutes concerns about increased risk of myocardial infarction, cancer or gastrointestinal bleeding from use of long-acting calcium channel blockers. However, data does suggest that this class of drugs may be less effective in preventing heart failure [High Quality Evidence]. Data supporting potential dangers of calcium antagonists are limited to short-acting preparations (especially nifedipine) that are not approved for the treatment of hypertension.

    A majority of patients will require more than one drug for blood pressure control. Combination therapies that include a diuretic are often effective, lessen the risk for side effects (by use of low doses of each component drug), and enhance adherence by simplification of the treatment program. For patients with CKD, three or more drugs may be needed to achieve goal. Although limited scientific evidence supports the use of combination therapy as initial drug treatment for hypertension, several observations favor such an approach [Low Quality Evidence].

    Refer to the original guideline document for more information on drug therapy.

  1. Blood Pressure at Goal?

    Goal office blood pressures should be less than 140/90 mm Hg for adults with uncomplicated hypertension (in the absence of comorbidities). Goal blood pressures measured out of the office setting should be less than 135 mm Hg systolic and less than 85 mm Hg diastolic.

  1. Change Treatment

    If the patient has been prescribed one or more antihypertensive agents and acceptable response has not been achieved, several issues should be addressed or revisited prior to adding or changing drug therapy. These include adherence to appropriate lifestyle modifications, consistent use of prescribed drugs, and tolerance of treatment modalities. Non-adherence rates to prescribed medications are estimated at 50% and are slightly higher for both elderly and adolescent patients [Low Quality Evidence]. The factors that lead to non-adherence are multifactorial: misunderstanding of the treatment and the reason for it, adverse reactions (or fear of them), complex dosing regimens, financial constraints or simple forgetfulness. Depression has also been identified as a risk factor in noncompliance with treatment for acute or chronic conditions [Systematic Review]. Asking open-ended/non-judgmental questions about treatment regimens can lead to a good discussion between the clinician and patient about why the patient may have difficulty adhering. There are a number of recommendations that in various combinations may lead to better patient adherence. These suggestions are based on available evidence from randomized clinical trials that evaluated the usefulness of adherence interventions. To increase adherence on a long-term basis, provide education about the medication and how it fits with the treatment plan, simplify the regimen (e.g., less frequent dosing [data shows compliance rates average 79% with once-daily dosing, 69% with twice-daily dosing, 65% with three-times-daily dosing and 51% with four-times-daily dosing]) [Systematic Review], combination medications, controlled-release dosage forms), use patient adherence aids (e.g., pillboxes, alarms), offer support group sessions, send reminders for medication refills and appointments, cue medications to daily events (e.g., breakfast, bedtime), offer positive reinforcement (acknowledge the patient's efforts to adhere), monitor with regular clinician follow-up, and actively involve family members and significant others [Low Quality Evidence]. Since there is not a simple test to accurately measure adherence, there are some practical methods that can be used for all patients at every visit: asking the patient about missed doses, watching treatment response, tracking missed appointments, tracking prescription refills, asking about issues of cost, and monitoring side effects. Although patients will generally overestimate their adherence, simply asking the question will help identify up to 50% of low-adherence patients.

    When choosing antihypertensive drugs, preference should be given to long-acting drugs that can be dosed once daily to enhance long-term compliance [Low Quality Evidence]. Combination antihypertensive medications may also improve adherence by decreasing pill burden.

    If medication adherence appears to be a non-factor and the patient is still not meeting blood pressure goals, standardized instruction in self-blood-pressure measurement will allow assessment of "white-coat" syndrome. Clinicians should also consider interfering substances that can adversely affect blood pressure including non-steroidal anti-inflammatory drugs, contraceptives, sympathomimetics, antidepressants, glucocorticoids, nasal decongestants, licorice-containing substances (e.g., chewing tobacco), cocaine, cyclosporine and erythropoietin. Intermittent use of alcohol, particularly in alcoholics who are binge drinkers, may cause difficulties with widely fluctuating blood pressures.

    Once antihypertensive drug therapy is initiated, most patients should return for follow-up and medication adjustments at least at monthly intervals until blood pressure goal is reached.

    If blood pressure goals are not met and adherence has been addressed, the clinician has three options for subsequent therapy:

    • Add a second drug from another class.
    • Substitute an agent from another class.
    • Increase the dose of the initial drug.

    Individualized drug selection is based on several principles:

    • If the initial response to one drug is adequate, continue the same drug.
    • If the response is partial on one agent, increase the dose or add a second drug of a different class.
    • If there is little response, substitute another single drug from a different class.
    • Consider thiazide diuretic use early or as a first addition.
    • Consider loop diuretic agents instead of thiazide or thiazide-like diuretics when creatinine is greater than 2.0 mg/dL or estimated glomerular filtration rate is less than 30 mL/min per 1.73 m2.
    • Do not combine two drugs of the same class.
    • Fewer than 50% of patients with hypertension will be controlled with a single drug.
    • The use of combination agents can be effective.

    When choosing between adding agents and increasing the dose of current therapies, consider the dose response curve of the agent. Within the usual prescribed dose range, the blood pressure response curve is fairly flat for most classes of antihypertensive medications (thiazide diuretic, ACE inhibitors, angiotensin receptor blockers and beta-blockers). If a patient is taking a mid-range dose and is >5-10 mm Hg above systolic or diastolic goal, adding a second agent is more likely to be effective than increasing dose. Calcium channel blockers, alpha-blockers and direct vasodilators have a more linear dose response curve. Greater reductions in blood pressure can be achieved with dose adjustments of these agents; however, side effects are also dose dependent.

    For most patients, two or more drugs in combination may be needed to reach hypertension goals. Systolic blood pressure control for adults with cardiovascular comorbidities is poor [Low Quality Evidence]. The combination of a diuretic appropriate for level of renal function with an ACE inhibitor or angiotensin receptor blocker is often an effective two-drug program. A diuretic ACE inhibitor combination has been shown to reduce both the macrovascular and microvascular complications of type 2 diabetes [High Quality Evidence].

    The combination of an ACE inhibitor with an angiotensin receptor blocker has little additional effect on blood pressure compared to either monotherapy and may be associated with increased risk of adverse effects including renal dysfunction and hyperkalemia [High Quality Evidence]. However, this combination is more effective than either monotherapy alone in reducing proteinuria [Meta-analysis].

    The combination of a calcium channel antagonist with an ACE inhibitor is as effective or more effective than the traditional combination of a diuretic with a beta-blocker in lowering blood pressure and reducing cardiovascular events [High Quality Evidence], [Guideline].

    Non-specific symptoms such as fatigue, lightheadedness, or vaguely impaired cognition may be due to an acute decline in blood pressure level and may resolve within four to six weeks while continuing the drug. Other minor drug-related symptoms unrelated to blood pressure change may also resolve in time without discontinuing the drug. Non-office standardized blood pressure measurement is desirable to monitor blood pressure control.

  1. Resistant Hypertension

    Resistant hypertension is present when blood pressure goals are not met despite compliance with optimal doses of three antihypertensive drugs of different classes with one of the agents being a diuretic. Patient characteristics associated with resistant hypertension include older age, female gender, African American race, obesity and the presence of CKD, diabetes, or left ventricular hypertrophy. Numerous reasons may exist for an inadequate or poor response [Guideline], [High Quality Evidence], [Low Quality Evidence].

    Differential diagnosis includes the following:

    Pseudo-resistant hypertension:

    • Improper blood pressure measurement (overinflation of the cuff inducing a pain response, using a cuff that is too small for the arm, or measurement of blood pressure before letting the patient rest quietly in the sitting position).
    • Poor adherence to antihypertensive therapy. Lack of complete adherence to the drug program may be present in up to 40% of patients on multiple drug programs. Patients should be asked in a non-threatening way how successful they are in taking all of their medications in the doses prescribed. Questions should be directed to out-of-pocket costs, side effects, and dosing inconvenience. Family members may provide useful information regarding compliance. Review of pharmacy records for timely prescription renewals may be helpful.
    • Brachial arteries may be heavily calcified or arteriosclerotic and cannot be fully compressed (pseudo-hypertension), leading to inaccurately high cuff measurements.
    • Clinic or white-coat hypertension. Twenty-four hour blood pressure monitoring or accurate out-of-clinic blood pressure measurement should be obtained in all patients with resistant hypertension.

    Lifestyle factors:

    • Obesity
    • Excessive dietary sodium intake directly increases blood pressure and blunts the effectiveness of most antihypertensive drugs. Effects of salt are most pronounced in the elderly, African Americans, and in patients with CKD.
    • Excessive alcohol intake
    • Illicit drug use

    Drug-related causes:

    • Several classes of drugs may directly increase blood pressure or interfere with the blood-pressure-lowering effect of antihypertensive therapies. These include non-steroidal anti-inflammatory agents, sympathomimetics (decongestants, diet pills, cocaine), stimulants (methylphenidate, dexmethylphenidate, dextroamphetamine, amphetamine, methamphetamine, modafinil), alcohol, contraceptives, estrogen, cyclosporine, erythropoietin, corticosteroids, natural licorice and herbal compounds (ephedra, ma-huang).

    Over-the-counter medication use:

    • Over-the-counter medications and supplements can cause increases in blood pressure. Use of caffeine pills, NSAIDs, cold medicine (such as pseudoephedrine, phenylephrine, and herbal supplements such as bitter orange, ephedra [ma-nuang], ginseng, guarana, licorice and St. John's wort should be evaluated in patients with hypertension.

    Secondary causes:

    • More common secondary causes include CKD, primary aldosteronism and renovascular hypertension. Uncommon causes include pheochromocytoma, Cushing's syndrome and aortic coarctation.

    Secondary medical diagnoses that can contribute include obesity and obstructive sleep apnea.

    A common cause of resistant hypertension is lack of control of extra-cellular volume due to inadequate diuretic therapy. Full doses of a diuretic appropriate for level of renal function should be used. In patients with CKD who have an estimated glomerular filtration rate less than 30 mL/minute, loop diuretics may be necessary for effective volume control. Furosemide is short acting and should be given twice daily. Torsemide is a longer acting loop diuretic that can be used once daily. The drug regimen should also include near maximal doses of two of the following additional classes of drugs:

    • ACE inhibitor
    • Calcium channel blocker
    • Angiotensin receptor blocker
    • Beta-adrenergic-blocker or other anti-adrenergic agent
    • Direct vasodilator
  1. Further Management Needed

    Consider hypertension consultation if a patient's blood pressure is not controlled on three or four medications, including a thiazide diuretic, or if secondary hypertension is suspected.

  1. Blood Pressure at Goal

    Recommendations:

    • On follow-up visits, history and physical examination should be directed toward detection of hypertensive target organ damage [Moderate Quality Evidence, Strong Recommendation].
    • In patients with office blood pressure at goal who demonstrate progressive target organ disease, home monitoring may be beneficial [Low Quality Evidence, Weak Recommendation].

    Once blood pressure is at goal and stable, the patient should be seen at a minimum once a year by the clinician to assess patient adherence, patient satisfaction, and any changes in target organ status. Patients' comorbidities such as heart failure, associated diseases such as diabetes, and need for laboratory tests influence the frequency of visits [Guideline]. Lifestyle modifications should be reviewed, re-emphasized, and documented annually. Patients should monitor blood pressure more frequently by home monitoring or by other allied health professionals.

    Ongoing care can be facilitated by clinicians or specially trained allied health care professionals who provide education, reinforcement, realistic short- and long-term goal setting, and adjustment of medications according to the individual clinical situation. Intervention strategies that seek to involve the patient in decision-making can improve long-term adherence to therapy and thus improve blood pressure control. Additionally, such an ongoing relationship might better identify those patients who are suitable candidates for a reduction in or withdrawal from antihypertensive drug therapy following a prolonged interval of excellent blood pressure control [Systematic Review].

    On follow-up visits, history and physical examination should be directed to target organ damage (cardiac exam, neck/renal bruits, lung exam, chest and shortness of breath), laboratory tests related to medication safety and assessment of overall cardiovascular risk.

    One may consider decreasing the dosage or number of antihypertensive drugs while maintaining lifestyle modification if:

    • Patient has uncomplicated hypertension that is well controlled.
    • Blood pressure has been maintained and documented for at least 1 year.

Definitions:

Following a review of several evidence rating and recommendation writing systems, Institute for Clinical System Improvement (ICSI) has made a decision to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Crosswalk between ICSI Evidence Grading System and GRADE


ICSI GRADE System Previous ICSI System
 
High, if no limitation Class A: Randomized, controlled trial
 
Low Class B: [observational]
  Cohort study
 
  Class C: [observational]
Non-randomized trial with concurrent or historical controls
Low   Case-control study
Low   Population-based descriptive study
*Low   Study of sensitivity and specificity of a diagnostic test
*Following individual study review, may be elevated to Moderate or High depending upon study design
 
  Class D: [observational]
Low   Cross-sectional study
    Case series
  Case report
 
Meta-analysis Class M: Meta-analysis
Systematic Review   Systematic review
Decision Analysis   Decision analysis
Cost-Effectiveness Analysis   Cost-effectiveness analysis
 
Low Class R: Consensus statement
Low   Consensus report
Low   Narrative review
 
Guideline Class R: Guideline
 
Low Class X: Medical opinion

Evidence Definitions

High Quality Evidence = Further research is very unlikely to change confidence in the estimate of effect.

Moderate Quality Evidence = Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

Low Quality Evidence = Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate or any estimate of effect is very uncertain.

In addition to evidence that is graded and used to formulate recommendations, additional pieces of literature will be used to inform the reader of other topics of interest. This literature is not given an evidence grade and is instead identified as a Reference throughout the document.

Strength of Recommendations

Category Quality Definitions Strong Recommendation Weak Recommendation
High Quality Evidence Further research is very unlikely to change the work group's confidence in the estimate of effect. The work group is confident that the desirable effects of adhering to this recommendation outweigh the undesirable effects. This is a strong recommendation for or against. This applies to most patients. The work group recognizes that the evidence, though of high quality, shows a balance between estimates of harms and benefits. The best action will depend on local circumstances, patient values or preferences.
Moderate Quality Evidence Further research is likely to have an important impact on the work group's confidence in the estimate of effect and may change the estimate. The work group is confident that the benefits outweigh the risks, but recognizes that the evidence has limitations. Further evidence may impact this recommendation. This is a recommendation that likely applies to most patients. The work group recognizes that there is a balance between harms and benefit, based on moderate quality evidence, or that there is uncertainty about the estimates of the harms and benefits of the proposed intervention that may be affected by new evidence. Alternative approaches will likely be better for some patients under some circumstances.
Low Quality Evidence Further research is very likely to have an important impact on the work group's confidence in the estimate of effect and is likely to change. The estimate or any estimate of effect is very uncertain. The work group feels that the evidence consistently indicates the benefit of this action outweighs the harms. This recommendation might change when higher quality evidence becomes available. The work group recognizes that there is significant uncertainty about the best estimates of benefits and harms.
Clinical Algorithm(s)

A detailed and annotated clinical algorithm is provided in the original guideline document External Web Site Policy for the diagnosis and treatment of hypertension.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Adequate control of hypertension
  • Prevention of end-organ damage due to hypertension
  • Improved assessment of patients with hypertension
  • Improved patient education about modifiable risk factors and the use of non-pharmacological treatments
  • Increased percentage of patients not at blood pressure goal who have a care plan or a change in treatment
Potential Harms

The combination of an angiotensin-converting enzyme (ACE) inhibitor with an angiotensin receptor blocker has little additional effect on blood pressure compared with either monotherapy and may be associated with increased risk of adverse effects including renal dysfunction and hyperkalemia.

See Table in Annotation 6 of the original guideline document for common side effects of recommended drugs.

Qualifying Statements

Qualifying Statements
  • The information contained in this Institute for Clinical Systems Improvement (ICSI) Health Care Guideline is intended primarily for health professionals and other expert audiences.
  • This ICSI Health Care Guideline should not be construed as medical advice or medical opinion related to any specific facts or circumstances. Patients and families are urged to consult a health care professional regarding their own situation and any specific medical questions they may have. In addition, they should seek assistance from a health care professional in interpreting this ICSI Health Care Guideline and applying it in their individual case.
  • This ICSI Health Care Guideline is designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinician's judgment or to establish a protocol for all patients with a particular condition.

Implementation of the Guideline

Description of Implementation Strategy

Once a guideline is approved for general implementation, a medical group can choose to concentrate on the implementation of that guideline. When four or more groups choose the same guideline to implement and they wish to collaborate with others, they form a guideline action group.

In the action groups, each medical group sets specific goals they plan to achieve in improving patient care based on the particular guideline(s). Each medical group shares its experiences and supporting measurement results within the action group. This sharing facilitates a collaborative learning environment. Action group learnings are also documented and shared with interested medical groups within the collaborative.

Currently action groups may focus on one guideline or a set of guidelines such as hypertension, lipid treatment, and tobacco cessation.

Detailed measurement strategies are presented in the original guideline document to help close the gap between clinical practice and the guideline recommendations. Summaries of the measures are provided in the National Quality Measures Clearinghouse (NQMC).

Implementation Recommendation Highlights

Prior to implementation, it is important to consider current organizational infrastructure that address the following:

  • System and process design
  • Training and education
  • Culture and the need to shift values, beliefs and behaviors of the organization

The following system changes were identified by the guideline work group as key strategies for health care systems to incorporate in support of implementation of this guideline.

  • Develop systems that provide for staff education on proper blood pressure measurement. (See Appendix A, "Standards for Blood Pressure Measurement," in the original guideline document). Based on surveys that show the variability of blood pressure measurement, training sessions should be arranged by your medical facility (review the steps in Appendix A and the rationale that accompanies the document – see the original guideline document). Accurate, reproducible blood pressure measurement is important to correctly classify blood pressure. Inconsistencies may result from using defective equipment and not standardizing the technique. The education and training standards found in Appendix A of the original guideline document are consistent with American Heart Association and National Heart, Lung, and Blood Institute recommendations.
  • Develop systems for providing patient education on hypertension management. (See Appendix C, "Recommended Education Messages," in the original guideline document). The appendix contains educational messages that will support goals of patient education and self-involvement in ongoing hypertension management. Major components of the education message are:
    • Basic information about what blood pressure is, what the blood pressure numbers mean, and how high blood pressure affects your life
    • Lifestyle modifications
    • Pharmacologic therapy
    • Ongoing management
  • Consider the use of motivational interviewing as a method for addressing behavior change. Motivational interviewing is defined as a client-centered, directive counseling style for eliciting behavior change by helping patients to explore and resolve ambivalence. Rather than telling a client what changes to make, the interviewer elicits "change talk" from them, taking into account an individual's priorities and values.
Implementation Tools
Chart Documentation/Checklists/Forms
Clinical Algorithm
Quality Measures
Quick Reference Guides/Physician Guides
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.
Related NQMC Measures

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Luehr D, Woolley T, Burke R, Dohmen F, Hayes R, Johnson M, Kerandi H, Margolis K, Marshall M, O'Connor P, Pereira C, Reddy G, Schlichte A, Schoenleber M. Hypertension diagnosis and treatment. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Nov. 67 p. [127 references]
Adaptation

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

Date Released
1995 Jun (revised 2012 Nov)
Guideline Developer(s)
Institute for Clinical Systems Improvement - Nonprofit Organization
Guideline Developer Comment

Organizations participating in the Institute for Clinical Systems Improvement (ICSI): Affiliated Community Medical Centers; Allina Medical Clinic; Aspen Medical Group; Baldwin Area Medical Center; Brown Clinic; Center for Diagnostic Imaging/Medical Scanning Consultants; CentraCare; Central Lakes Medical Clinic; Chippewa County – Montevideo Hospital & Clinic; Cuyuna Regional Medical Center; Essentia Health; Fairview Health Services; Family HealthServices Minnesota; Family Practice Medical Center; Fergus Falls Medical Clinic; Gillette Children's Specialty Healthcare; Grand Itasca Clinic and Hospital; Hamm Clinic; HealthEast Care System; HealthPartners Central Minnesota Clinics; HealthPartners Medical Group & Regions Hospital; Hennepin County Medical Center; Hennepin Faculty Associates; Howard Young Medical Center; Hudson Physicians; Hutchinson Area Health Care; Hutchinson Medical Center; Integrity Health Network; Lake Region Healthcare Corporation; Lakeview Clinic; Mankato Clinic; MAPS Medical Pain Clinics; Marshfield Clinic; Mayo Clinic; Mercy Hospital and Health Care Center; Midwest Spine Institute; Minnesota Association of Community Health Centers; Minnesota Gastroenterology; Multicare Associates; New Richmond Clinic; North Central Heart Institute; North Clinic; North Memorial Health Care; Northwest Family Physicians; Obstetrics and Gynecology Specialists; Olmsted Medical Center; Park Nicollet Health Services; Planned Parenthood Minnesota, North Dakota, South Dakota; Quello Clinic; Raiter Clinic; Rice Memorial Hospital; Ridgeview Medical Center; River Falls Medical Clinic; Riverwood Healthcare Center; South Lake Pediatrics; Southside Community Health Services; Stillwater Medical Group; University of Minnesota Physicians; Winona Health

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: icsi.info@icsi.org; Web site: www.icsi.org External Web Site Policy.

Source(s) of Funding
  • The Institute for Clinical Systems Improvement (ICSI) provided the funding for this guideline. The annual dues of the member medical groups and sponsoring health plans fund ICSI's work. Individuals on the work group are not paid by ICSI, but are supported by their medical group for this work.
  • ICSI facilitates and coordinates the guideline development and revision process. ICSI, member medical groups, and sponsoring health plans review and provide feedback but do not have editorial control over the work group. All recommendations are based on the work group's independent evaluation of the evidence.
Guideline Committee

Hypertension Diagnosis and Treatment Work Group

Composition of Group That Authored the Guideline

Work Group Members: David Luehr, MD (Work Group Leader) (Integrity Health Network) (Family Medicine); Tony Woolley, MD (Work Group Leader) (Park Nicollet Health Services) (Internal Medicine/Nephrology); Allyson Schlichte, PharmD, MBA (Fairview Health Services) (Pharmacy); Rynn Burke, MD (HealthPartners Medical Group and Regions Hospital) (Internal Medicine/Nephrology); Karen Margolis, MD, MPH (HealthPartners Medical Group and Regions Hospital) (Internal Medicine); Patrick O'Connor, MD, MPH (HealthPartners Medical Group and Regions Hospital) (Family Medicine); Ganga Reddy, MBBS (HealthPartners Medical Group and Regions Hospital) (Internal Medicine); Michael Schoenleber, MD (HealthPartners Medical Group and Regions Hospital) (Family Medicine); Faith Dohmen, RN (Hennepin County Medical Center) (Nursing); Henry Kerandi, MD (Minnesota Association of Community Health Centers) (Family Medicine); Chrystian Pereira, PharmD (University of Minnesota) (Pharmacy); Mary Johnson (Patient Partner): Melissa Marshall, MBA (Institute for Clinical Systems Improvement [ICSI]) (Clinical Systems Improvement Facilitator); Rochelle Hayes, BS (ICSI) (Systems Improvement Coordinator)

Financial Disclosures/Conflicts of Interest

The Institute for Clinical Systems Improvement (ICSI) has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols.

In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report, Clinical Practice Guidelines We Can Trust (2011).

Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group.

The complete ICSI policy regarding Conflicts of Interest is available at the ICSI Web site External Web Site Policy.

Disclosure of Potential Conflicts of Interest

Rynn Burke, MD, RN, FAAP, FACP (Work Group Member)
MD, Internal Medicine & Pediatrics, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: MDH Committee on Pandemic Planning
Guideline Related Activities: Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS)
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Faith Dohmen, RN (Work Group Member)
Patient Engagement Programs Coordinator, Hennepin County Medical Center
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Mary M. Johnson, (Work Group Member)
National, Regional, Local Committee Affiliations: St. Catherine University, St. Paul MN Alumnae Council
Guideline Related Activities: ICSI Patient Advisory Council, ICSI Reducing Avoidable Readmissions Effectively, and Low Back Pain
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Consulting: HCMC policies and procedures

Henry M. Kerandi, MD (Work Group Member)
Family Medicine, Minnesota Association of Community Health Centers
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

David Luehr, MD, MPH (Work Group Co-Leader)
Family Medicine, Integrity Health Network
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Karen Margolis, MD, MPH (Work Group Member)
MD, Internal Medicine, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: Board Membership, Archives of Internal Medicine Editorial Board
Guideline Related Activities: Aspirin Guideline
Research Grants: NIH Grant Reviewer and Pending Grants: Hypertension, Diabetes, Women's Health, Aspirin in the Elderly
Financial/Non-Financial Conflicts of Interest: None

Patrick J. O'Connor, MD, MPH (Work Group Member)
Family Medicine and Geriatrics, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: American Diabetes Association Standard of Care
Guideline Related Activities: Diagnosis and Management of Type 2 Diabetes, Lipid Management, Prevention and Diagnosis of Obesity, Healthy Lifestyles
Research Grants: National Heart, Lung, and Blood Institute (NHLBI); National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); Agency for Healthcare Research and Quality (AHRQ) for improved Diabetes Care
Financial/Non-Financial Conflicts of Interest: Consulting: Penn State, John Hopkins (Diabetes Care Improvement)
Patents: Patent pending of software for Diabetes and Cardiovascular clinical decision support

Chrystian R. Pereira, PharmD, BCPS (Work Group Member)
Assistant Professor/Clinical Specialist, University of Minnesota
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Ganga S. Reddy, MBBS (Work Group Member)
Internal Medicine, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Allyson M. Schlichte, PharmD, MBA (Work Group Member)
Medication Therapy Management Operations Lead, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Michael Schoenleber, MD (Work Group Member)
Family Medicine, HealthPartners Medical Group and Regions
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: Healthy Lifestyles
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Tony Woolley, MD (Work Group Co-Leader)
Internal Medicine/Hypertension, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: Lipid Management, Aspirin
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Institute for Clinical Systems Improvement (ICSI). Hypertension diagnosis and treatment. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Nov. 68 p.

Guideline Availability

Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org External Web Site Policy; e-mail: icsi.info@icsi.org.

Availability of Companion Documents

The following is available:

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org External Web Site Policy; e-mail: icsi.info@icsi.org.

In addition, various resources are available in the appendices of the original guideline document External Web Site Policy, including standards for blood pressure measurement, a 10-year cardiovascular disease risk calculator, recommended education messages, information on clinical evaluation of confirmed hypertension, and accountability measures for hypertension treatment in adults.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on May 5, 1999. The information was verified by the guideline developer on July 6, 1999. This summary was updated by ECRI on April 19, 2001. The updated information was verified by the guideline developer as of June 28, 2001. This summary was updated again on June 18, 2002 and verified by the guideline developer on August 8, 2002. This NGC summary was updated again by ECRI Institute on January 28, 2004, July 28, 2004, December 15, 2005, January 31, 2007, and most recently on April 16, 2009. This summary was updated by ECRI Institute on July 20, 2010 following the U.S. Food and Drug Administration advisory on Orlistat. This NGC summary was updated again by ECRI Institute on April 5, 2011. This NGC summary was updated by ECRI Institute on February 8, 2012.

Copyright Statement

This NGC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Guideline) is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

The abstracted ICSI Guidelines contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Guidelines are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Guidelines are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Guidelines are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Guidelines.

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