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Hypertension

CME credit available from Harvard Medical School through July 2021.

Published Materials

The goal of this program is to update prescribers on the most recent evidence and guidelines regarding the treatment of hypertension, emphasizing the importance of accurate blood pressure monitoring to inform management decisions.

Hypertension is common with over 1 in 3 Americans receiving this diagnosis. While 76% of hypertensive patients are being treated, only 54% of these patients are controlled.1 Controlling blood pressure is a critical step to prevent stroke, coronary heart disease, heart failure, and cardiovascular death.2

The first and most important step in identifying and managing hypertension is obtaining accurate blood pressure measurements. All staff should be educated on best-practices for taking a blood pressure. For a quick office card on key steps see Blood Pressure (BP) Card. Simple steps such as rechecking a blood pressure can have an impact on treatment decisions.

Checking BP twice in the same visit resulted in lower systolic blood pressure (SBP)3

The median effect of rechecking a BP (a drop of 8 mm Hg) is equivalent to the impact of starting one new hypertensive medication. In patients with an initial SBP of 140-159 mm Hg, about 50% of patients had an SBP <140 mm Hg when repeated.3 For some patients, taking their blood pressure at home will be an important component of diagnosis and management, especially in cases of suspected white coat hypertension. See the Patient resources section below for information about taking an accurate home blood pressure.

New, lower BP definitions were released in 2017 by the American College of Cardiology and the American Heart Association (ACC/AHA) in collaboration with a host of other professional societies, the first update to blood pressure guideline in over a decade.4

Change in BP definitions with the 2017 ACC/AHA guidelines

These lower definitions for hypertension and elevated BP place even more importance on the accuracy of BP measurements. The guidelines also outlined management decisions based on initial BP at diagnosis, incorporating cardiovascular risk into treatment decisions for patients with hypertension stage 1.

2017 ACC/AHA  management guidelines

The SBP goal for all patients being treated for hypertension is 130 mm Hg, with a diastolic goal of <80 mm Hg in adults <60 years old.

In treating to the goal of 130/80 mm Hg, the benefits outweigh the risk.5

Treatment Options

Non-drug treatment is the backbone of therapy such as dietary salt reduction, exercise, weight loss, and a heart healthy diet.  See the Patient Resources section at the bottom of the page for information about the Dietary Approaches to Stop Hypertension (DASH) diet and salt reduction.

Achieving the blood pressure target is more important than the drug class used to get there.6

When selecting an anti-hypertensive medication, begin with a thiazide-type diuretic, angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or a calcium channel blocker (CCB). When dual therapy is required, the combination of an ACEI + CCB prevented more CV events than an ACEI + thiazide.7 The algorithm below suggests a strategy for managing therapy, continually reassessing treatment effect to achieve the blood pressure goal.

Algorithm of treating patients with hypertension


Resources for Providers
Resources for Patients

Information current at time of publication, July 2018.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating physician based on the individual patient’s clinical condition.


References
  1. Benjamin EJ, Virani SS, Callaway CW, et al. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation. 2018;137(12):e67-e492.
  2. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet (London, England). 2014;384(9943):591-598.
  3. Einstadter D, Bolen SD, Misak JE, Bar-Shain DS, Cebul RD. Association of Repeated Measurements With Blood Pressure Control in Primary Care. JAMA internal medicine. 2018.
  4. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2018;71(19):e127-e248.
  5. Bundy JD, Mills KT, Chen J, Li C, Greenland P, He J. Estimating the Association of the 2017 and 2014 Hypertension Guidelines With Cardiovascular Events and Deaths in US Adults: An Analysis of National Data. JAMA cardiology. 2018.
  6. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ (Clinical research ed). 2009;338:b1665.
  7. Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. The New England journal of medicine. 2008;359(23):2417-2428.