Hypertension Clinical Module

CME credit available from Harvard Medical School through November 2026.

Published Materials

• Summary Brochure
• Evidence Document
• Reference Card
• Tear off
• Patient Brochure

The goal of this educational program is to provide primary care clinicians with a review of evidence-based practices to identify patients with hypertension, establish treatment goals, utilize interventions to achieve goals, and promote adherence to treatment.

Cardiovascular (CV) disease is the leading cause of death in adults, with hypertension as a leading CV disease risk factor.^1,2 Despite the CV risk from hypertension nearly 3 in 4 patients with hypertension have blood pressure (BP) that is above the recommended treatment goal.^3,4 Even in older adults, treating blood pressure to the recommended treatment goal leads to an immediate reduction in CV events.⁵

Blood pressure screening is a routine part of primary care practice, but how those measurements are taken can impact the results. Patients should have repeated measurements while resting calmly with the correct cuff size. Home monitoring, with a validated blood pressure cuff, can help confirm the diagnosis and aid in identifying best treatment options.⁶

Use the American College of Cardiology and American Heart Association (ACC/AHA) BP classifications to start treatment⁴

Patients who are 65 and older should use systolic blood pressure (SBP) to guide treatment. ASCVD risk is assessed using the Pooled Cohort Equation.

^{Recommend lifestyle interventions for patients with elevated BP}

Start medication when indicated

Any of four medication classes can be used to treat hypertension: angiotensin receptor blockers (ARBs), angiotensin converting enzyme inhibitors (ACEIs), thiazide diuretics, or calcium channel blockers (CCBs). For patients who are >20 mm Hg above their BP goal, two medications will be needed (such as an ARB with a CCB). Monitor response to treatment titrate medication as needed. Although side effects are common in older adults taking blood pressure lowering medication, randomized controlled trials found that intensive treatment to BP goal did not lead to significantly more side effects, including injurious falls.⁷

Steps can be taken to help patients meet their treatment goals.

1. Find a time of day that works best for the patient to take prescribed BP lowering medications. Taking medication in the morning or the evening did not change CV events.⁸
2. Continue to titrate and add antihypertensive medications as needed.
3. Utilize combination antihypertensives, many of which are generic and at a cost similar to single agents.
4. Assess for other causes of hypertension in patients not responding to multiple medications.
5. Support patients with lifestyle changes.

Patient resources

• DASH diet – a link to DASH diet basics and recipes
• NIH tips to reduce sodium
• AHA home BP monitoring tips
  • English
  • Spanish
  • Chinese
• BP Log
• Validate BP – a link to validated home BP monitors

Information current at time of publication, November 2023.

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

References

1. Tsao CW, et al. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation. 2023;147(8):e93-e621.

2. Willey JZ, et al. Population attributable risks of hypertension and diabetes for cardiovascular disease and stroke in the northern Manhattan study. J Am Heart Assoc. 2014;3(5):e001106.

3. Centers for Disease Control and Prevention (CDC). Hypertension Cascade: Hypertension Prevalence, Treatment and Control Estimates Among US Adults Aged 18 Years and Older Applying the Criteria From the American College of Cardiology and American Heart Association’s 2017 Hypertension Guideline—NHANES 2017–2020. May 12, 2023; https://millionhearts.hhs.gov/data-reports/ hypertension-prevalence.html. Accessed June 20, 2023.

4. Whelton PK, 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. J Am Coll Cardiol. 2018;71(19):e127-e248.

5. Chen T, et al. Time to Clinical Benefit of Intensive Blood Pressure Lowering in Patients 60 Years and Older With Hypertension: A Secondary Analysis of Randomized Clinical Trials. JAMA Intern Med. 2022;182(6):660-667.

6. Krist AH, et al. Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2021;325(16):1650-1656.

7. Bundy JD, et al. Estimating the Association of the 2017 and 2014 Hypertension Guidelines With Cardiovascular Events and Deaths in US Adults: An Analysis of National Data. JAMA Cardiol. 2018;3(7):572-581.

8. Mackenzie IS, et al. Cardiovascular outcomes in adults with hypertension with evening versus morning dosing of usual antihypertensives in the UK (TIME study): a prospective, randomised, open-label, blinded-endpoint clinical trial. Lancet. 2022;400(10361):1417-1425.