Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
Key Points
Key Points
- Observational studies have demonstrated graded associations between higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) and increased CVD risk.
- A large meta-analysis found a 20 mm Hg higher SBP and 10 mm Hg higher DBP were each prospectively associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. In a separate observational study including >1 million adult patients ≥30 years of age, higher SBP and DBP were associated with increased risk of CVD incidence and angina, myocardial infarction (MI), heart failure (HF), stroke, peripheral artery disease (PAD), abdominal aortic aneurysm, and chronic renal disease (CKD).
- This increased risk has been reported across a broad age spectrum, from 30 years to >80 years of age.
- CVD risk factors frequently occur in combination, with ≥3 risk factors present in 17% of patients. Lifetime risk of CVD death, nonfatal MI, and fatal or nonfatal stroke is substantially higher in adults with ≥2 CVD risk factors than in those with only 1 risk factor.
- Treating modifiable risk factors may reduce blood pressure (BP) through modification of shared pathology, and CVD risk may be reduced by treating global risk factor burden.
Diagnosis
Diagno...
...le 1. CVD Risk Factors Common in Pa...
...able 2. Environmental Risk FactorsH...
...tence of Hypertension and Related Chronic...
...creening for and management of other modifiabl...
...inition of High B...
...categorized as normal, elevated, or...
Table 3. Categories of BP in AdultsaH...
...Measurement of BP in the Office...
...is and management of high BP, proper methods are...
...ecklist for Accurate Measurement of BPHavi...
...e 5. Selection Criteria for BP Cuff...
...ce and Self-Monitoring of BP...
...ice BP measurements are recommended to confirm...
.... Procedures for Use of HBPMHaving...
...responding Values of SBP/DBP for C...
...ed and White Coat Hypertensio...
...n adults with an untreated SBP great...
...dults with white coat hypertension, periodic mon...
...g treated for hypertension with office BP reading...
...ntreated office BPs that are consisten...
...n multiple-drug therapies for hypertension and off...
...may be reasonable to screen for masked unco...
...g treated for hypertension with elevate...
Figure 1. Detection of White Coat Hyperten...
...terns Based on Office and Out-of-Offi...
...ection of White Coat Effect or Masked Un...
...tions for Secondary Forms of Hypertension...
...ening for specific form(s) of seconda...
...ult with sustained hypertension screens posit...
.... Screening for Secondary Hypertension...
...ses of Secondary Hypertension With Clinical Indi...
.... Frequently Used Medications and Other Substa...
...imary Aldosteronism
...adults with hypertension, screening for...
...lasma aldosterone: Renin activity r...
...ith hypertension and a positive scr...
...al Artery Stenosis...
...al therapy is recommended for adults with...
In adults with renal artery stenosis for whom m...
...ructive Sleep Apnea...
...with hypertension and obstructive...
Patient Evaluation
...ient Evaluation...
...able 11. Historical Features Favoring Hypertensi...
...asic and Optional Laboratory Tests for Pri...
Treatment and Pharmacological Treatment
...atment and Pharmacological Treatment...
...npharmacological Interv...
...recommended to reduce BP in adults with eleva...
...althy diet, such as the DASH (Dietary...
Sodium reduction is recommended for a...
...supplementation, preferably in dietary mod...
Increased physical activity with a structur...
...en and women with elevated BPa or hypert...
...ble 13. Best Proven Nonpharmacologic...
...reatment Threshold and the Use of CVD Ris...
...BP (I, A)...
DBP (I, C-EO)...
...e of BP-lowering medication is recommende...
...or Patients With Hypertension...
...P (I, B-R)(SR)573
...(I, C-EO)573...
...P (IIb, B-NR)573
...(IIb, C-EO)573
...e of Initial Medicat...
...on of antihypertensive drug therapy, first-line...
...of antihypertensive drug therapy with 2 first-...
...tion of antihypertensive drug therapy with...
...w-Up After Initiating Antihypertensive...
...initiating a new or adjusted drug regimen...
...trategies to Improve Control of BP in Pa...
...low-up and monitoring after initiat...
...ral Principle of Drug Therap...
...multaneous use of an ACE inhibitor, ARB, and...
...igure 4. BP Thresholds and Recommendations for Tre...
...p After Initial BP Evaluati...
Adults with an elevated BP or stage...
...ge 1 hypertension who have an estimate...
...with stage 2 hypertension should be evaluat...
...lts with a very high average BP (e...
...a normal BP, repeat evaluation every year is r...
...able 14. Oral Antihypertensive Dru...
Hypertension in Patients With Comorbidities
...on in Patients With Comorbidit...
...e Ischemic Heart Disease...
...BP (I, B-R)573...
DBP (I, C-EO)...
...BP (I, B-R)573
...I, C-EO)573
...ts with SIHD with angina and persistent un...
In adults who have had a MI or acute cor...
...blockers and/or CCBs might be considered to c...
...ure 5. Management of Hypertension...
...t Failure
...P (I, B-R)57...
...(I, C-EO)573...
...th Reduced Ejection Fraction (HFrEF)...
Adults with HFrEF and hypertension s...
...ndihydropyridine CCBs are NOT recommended...
Heart Failure With Preserved Ejection Fracti...
...ith HFpEF who present with symptoms of volume ove...
...F and persistent hypertension after management of...
...nic Kidney Disease...
...I, B-R)(SR)573...
...(I, C-EO)573
...th hypertension and CKD (stage 3 or...
...th hypertension and CKD (stage 3 or higher...
...ment of Hypertension in Patients With CKD...
...te Intracerebral Hemorrhage...
...CH who present with SBP greater than...
...ering of SBP (Table 14) to less than 140...
...7. Management of Hypertension in Patients w...
...cute Ischemic Stroke (AIS)...
...dults with AIS and elevated BP who are eligible fo...
...n AIS, BP should be less than 185/1...
...arting or restarting antihypertensive therapy duri...
...s with BP of 220/120 mm Hg or higher who did no...
...patients with BP less than 220/120 m...
...gement of Hypertension in Patients With Acute...
...y Stroke Prevention...
...viously treated hypertension who experience a s...
...ults who experience a stroke or TIA, treatment wi...
...ts not previously treated for hypertension wh...
For adults who experience a stroke or...
...ults who experience a stroke or TIA...
...adults with a lacunar stroke, a target SBP...
...n adults previously untreated for hypertension wh...
...ment of Hypertension in Patients With a Previ...
...er Comorbidities...
...After Renal Transplantation...
...(IIa, B-NR)573...
...BP (IIa, C-E...
...er kidney transplantation, it is reaso...
Peripheral Artery Disea...
...hypertension and PAD should be treated s...
...iabetes Mellitu...
...BP (I, B-R)(SR)5...
...I, C-EO)573...
...adults with DM and hypertension, all...
...adults with DM and hypertension, A...
...Fibrillation...
...ment of hypertension with an ARB ca...
...lvular Heart Disease
...dults with asymptomatic aortic stenosis, hyp...
...with chronic aortic insufficiency, treatme...
...tic Disease
...are recommended as the preferred an...
...and Ethnic Differences in Treatment...
...ck adults with hypertension but wit...
...r more antihypertensive medications are...
...regnancy...
...omen with hypertension who become pregnant, or...
...with hypertension who become pregnant should NO...
...r Persons...
...pertension with a SBP treatment goal of...
...ults (≥65 years of age) with hypertension and a...
...e Decline and Dementia...
...hypertension, BP lowering is reasonable t...
...Undergoing Surgical Procedu...
...perative...
...ents with hypertension undergoing major...
...patients with hypertension undergoing plan...
...th hypertension undergoing major surgery,...
...atients with planned elective major...
...nts undergoing surgery, abrupt preoperative discon...
...should NOT be started on the day of su...
...raoperativ...
...h intraoperative hypertension should be m...
Resistant Hypertension
Resistant Hypert...
...sistant Hypertension: Diagnosis, Evaluati...
...ive Crises—Emergencies and Urgencies...
...ts with a hypertensive emergency, ad...
For adults with a compelling condi...
...dults without a compelling condition, SB...
...gnosis and Management of a Hypertensive Crisis...
.... Intravenous Antihypertensive Drugs...
...able 16. Intravenous Antihypertensive Dr...
Patients With Hypertension
...nts With Hypertensi...
...uality of Care for Patients With Hypertension...
...tihypertensive Medication Adherence Strategies...
...hypertension, dosing of antihyperten...
...ombination pills rather than free i...
Strategies to Promote Lifestyle Modification
...havioral and motivational strategies...
...ructured, Team-Based Care Interventions for Hyper...
...ed care approach is recommended fo...
...c Health Record (EHR) and Patient Regist...
...se of the EHR and patient registries is ben...
Use of the EHR and patient registries is bene...
...ventions to Improve Hypertension Control...
...th strategies can be useful adjuncts to intervent...
...rmance Measures
...mance measures in combination with other quality...
...mprovement Strategies...
...y improvement strategies at the health system,...
...ancial Incentives...
...ntives paid to providers can be useful in achie...
...inancing strategies (e.g., insurance covera...
...of Care for Hypertensio...
...hypertension should have a clear, det...
.... Clinician’s Sequential Flow Chart for th...
...BP Thresholds for and Goals of Pharmacological...