Hypertension – Adult – Clinical Practice Guideline Table of Contents EXECUTIVE SUMMARY ........................................................................................................... 3 SCOPE ...................................................................................................................................... 4 METHODOLOGY ...................................................................................................................... 5 INTRODUCTION ....................................................................................................................... 5 RECOMMENDATIONS .............................................................................................................. 5 Establish the Diagnosis ........................................................................................... 5 Patient Evaluation ................................................................................................... 7 Treatment Goals ..................................................................................................... 7 Lifestyle Modifications ............................................................................................. 8 Table 4 – Lifestyle Modifications ........................................................................ 9 Medication Treatment............................................................................................ 11 Figure 1 - Initiation and Titration of Antihypertensive Medication ..................... 13 Table 7 - Antihypertensive Doses and Adjustment Schedules ......................... 14 Laboratory Evaluations.......................................................................................... 15 BENEFITS/HARMS OF IMPLEMENTATION ...........................................................................15 IMPLEMENTATION TOOLS/PLAN ..........................................................................................15 DISCLAIMER............................................................................................................................16 PATIENT AND PROVIDER RESOURCES ...............................................................................16 REFERENCES .........................................................................................................................16 Note: Active Table of Contents Guideline Contact for Content: Guideline Contact for Changes: Name: Heather Johnson, MD, MS Name: Lee Vermeulen Phone Number: 608-263-0836 Phone Number: 608-262-7537 Email: [email protected] Email: [email protected] 1 Coordinating Team Members: Heather Johnson, MD, MS, UW Health Preventive Cardiology, ASH Clinical Specialist in Hypertension James Stein, MD, Director, UW Health Preventive Cardiology and Advanced Hypertension Program Patrick McBride, MD, MPH, Co-Director, UW Health Preventive Cardiology Matt Tattersall, DO, Cardiology Paul Kellerman, MD, FACP, FNKF, Nephrology, ASH Clinical Specialist in Hypertension William Heifner, MD, Family Medicine Lorna Belsky, MD, Internal Medicine Michael Thom, MD, Internal Medicine Elizabeth Chapman, MD, Geriatrics Teresa Darcy, MD, Clinical Lab Jennifer Passini, MD, Hospitalist Diane Wendland, MD, Hospitalist Vonda Shaw, MS, MPH, Outpatient Preventive Cardiology & Rehabilitation Manager Katie Willenborg, PharmD, Inpatient Pharmacy Cindy Gaston, PharmD, UW Health Drug Policy Program Carl Nelson, PharmD, Unity Deb Barnish, RN, Cardiology Clinic Manager Jill Lindwall, RN, Clinical Staff Education Cindy Leeder, RN, Patient Education Stephanie Kraus, CNS, Inpatient Nursing Elaine Rosenblatt, Unity Heidi Wolf, Unity Lisa Sherven, GHC Nikki Nellen, Physicians Plus Julie Utter, Dean Care Review Individuals/Bodies: UW Health Preventive Cardiology Program, UW Health Hypertension Guideline and Registry Committee Committee Approvals/Date: Clinical Knowledge Management Council 2/27/14 Release Date: 3/7/2014 2 Guideline Title: Hypertension – Adult – Clinical Practice Guideline Executive Summary Guideline Overview A UW Health multi-disciplinary group has developed this clinical practice guideline to assist in identifying, diagnosing, treating, and monitoring adults 18 years and older with hypertension. Target Population Adult patients 18 years of age and older with hypertension Practice Recommendations 1. Lifestyle modifications are the cornerstone of treatment for every patient. See Table 4 (Lifestyle Modifications). Educate all patients to limit their sodium intake to 1500 to 2000 mg/day. 2. Patients with a new diagnosis of hypertension should have an evaluation for possible secondary causes of hypertension, especially obstructive sleep apnea. 3. An ACE-inhibitor (or angiotensin receptor blocker) and/or a calcium channel blocker may be a more effective initial medication regimen than a thiazide or thiazide-type diuretic. 4. Chlorthalidone (12.5 to 25 mg daily) is the preferred thiazide-type diuretic, rather than hydrochlorothiazide (HCTZ). 5. Consider 24-hour ambulatory blood pressure monitoring* or extended home blood pressure monitoring for patients in whom white-coat or masked hypertension is suspected, or in whom the diagnosis of hypertension or need for medications is uncertain (services offered by UW Preventive Cardiology 263-7420). * 24 hour ambulatory BP monitoring and home BP monitors may not be covered by insurance. Companion Documents None Pertinent UW Health Policies & Procedures UW Medical Foundation Blood Pressure Measurement Policy https://uconnect.wisc.edu/servlet/Satellite?cid=1121776129045&pagename=B_E XTRANET_UWHC_POLICIES%2FFlexMember%2FShow_Policy&c=FlexMembe r 3 Scope Disease/Condition(s): This Clinical Practice Guideline (CPG) focuses on hypertension in adult patients ages 18 years and older. The recommendations contained within this document do not apply to patients who are pregnant. Clinical Specialty: The following clinical specialties may reference this CPG: Internal Medicine, Family Practice, Obstetrics/Gynecology, Cardiovascular Medicine, Nephrology, Neurology, Vascular Surgery, Cardiothoracic Surgery, and Neurosurgery. Intended Users: Physicians, Nurse Practitioners/Advanced Practice Nurses, Physician Assistants CPG objective(s): To reduce the incidence of stroke, myocardial infarction, congestive heart failure, and kidney failure by appropriately identifying and treating hypertension. Interventions and Practices Considered: Screening for hypertension, lifestyle assessment and modification, appropriate blood pressure monitoring, medication therapy, and ongoing care of patients diagnosed with hypertension. Major Outcomes Considered: Prevention of the complications of hypertension. Guideline Metrics - Hypertension Performance Measures: Percentage of patients 18-79 years old with a diagnosis of hypertension whose blood pressure was <140/90 mmHg and percentage of patients ≥80 years old with a diagnosis of hypertension whose blood pressure was <150/90 mmHg during the measurement year (Based on ASH/ISH Guidelines1). The recommendations within this document meet or exceed most all externally reported metrics with the exception of target BP goals for patients >80 and those with CKD and/or diabetes. 4 Methodology The UW Health Hypertension – Adult – Clinical Practice Guideline was developed in 2007 by Patrick McBride, MD, MPH and James Stein, MD of the UW Health Preventive Cardiology Program: “Recognizing & Treating Hypertension – 2007 Clinical Practice Guidelines for Adults ≥18 years old”. In preparation for this clinical practice update, the committee reviewed the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report, a report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Additional trials and hypertension data not incorporated by the JNC 8 panel were also reviewed. After comprehensive evaluation, the committee agreed that the 2014 update of the UW Health Hypertension – Adult – Clinical Practice Guideline will be based on the 2013 Clinical Practice Guidelines for the Management of Hypertension in the Community: A statement by the American Society of Hypertension and the International Society of Hypertension, a document which currently reflects the clinical practice consensus of this committee. Cost Analysis: No formal cost analysis was performed. Introduction Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This guideline takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and use of medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Recommendations Establish the Diagnosis 1.1. Blood pressure should be measured at each health care encounter. The diagnosis of hypertension should be based on the presence of elevated blood pressures readings (≥140/90 mmHg in a clinic setting) on two or more visits. Consider all blood pressure measurements in the clinical context of the patient. Follow-up for an elevated blood pressure should be completed within one month. When blood pressure is at goal, routine blood pressure measurements should be taken every 6 months. 1.2. Blood pressures