Diagnosis Assess the patient for hypertension using the BP measure at initial visit and repeated measurements taken at home or at office visits. Prehypertension: 120–139 mm Hg systolic or 80–89 mm Hg diastolic Stage 1 hypertension: 140–159 mm Hg systolic or 90–99 mm Hg diastolic Stage 2 hypertension: ≥160 mm Hg systolic or ≥100 mm Hg diastolic Hypertensive urgency If any BP measurement is greater than 180/110 mg Hg, treat the patient either immediately or within days, depending on the clinical situation and any complications present. If it is greater than 210/120 mm Hg, immediate treatment is warranted. Home BP measurement Measuring blood pressure at home is an effective strategy to help establish a hypertension diagnosis and help patients achieve their blood pressure target. Some patients’ BP may be slightly elevated when measured in office settings compared to when it is measured at home. To adjust for this, the standard practice for all patients is to use a slightly lower threshold for diagnosing hypertension using home blood pressure measurements: 135/85 mm Hg instead of 140/90 mm Hg. A pamphlet for patients, “Measuring Your Blood Pressure at Home” is available. Information about home BP measurement is also available in the AVS SmartPhrase .avsbpselfreport. Medications, substances and conditions that may affect blood pressure When making a diagnosis of hypertension, it is important to consider medications and other causes that may be increasing the patient’s blood pressure. Examples include: · Medications such as adrenal steroids, estrogen, sympathomimetics, NSAIDs, and appetite suppressants. Consider eliminating, switching to another medication, or decreasing the dose. · Alcohol, illicit drugs (e.g., cocaine and other stimulants), and smoking. Consider screening (see the Unhealthy Drinking in Adults Guideline, Detox Manual [staff intranet], and Tobacco Use Guideline). · Sodium. See “Diet” under Lifestyle Modifications (p. 5) for recommended limits. · Obstructive sleep apnea (OSA). Consider this as a potential cause of elevated blood pressure if symptoms consistent with OSA are present. Initial lab workup · EKG. · Cholesterol screening. · Diabetes screening. · Potassium and creatinine. · Sodium. (Consider for frail patients or those aged 60 years or older.) Additional workup may be needed if the patient has a comorbidity (e.g., diabetes, ASCVD). The following are generally not necessary for routine follow-up of a hypertension diagnosis: urinalysis, blood chemistry, hematocrit, general electrolytes, BUN, and liver function tests. If the patient has an abrupt increase in BP measurement, consider lab workup for secondary hypertension. 5 Treatment Goals Note: In the JNC 8 panel guideline, the goal BP changes from < 140/90 mm Hg to < 150/90 mm Hg starting at age 60. In this guideline, the goal BP makes the same change but not until age 80. Please see the Evidence Summary (p. 12) for an explanation of the rationale behind this decision. Table 2. Blood pressure goals for risk reduction Eligible population Goal General population through age 79 BP lower than 140/90 mm Hg General population aged 80 and older 1 BP lower than 150/90 mm Hg Patients with diabetes BP lower than 140/90 mm Hg Patients with ASCVD BP lower than 140/90 mm Hg Patients with chronic kidney disease (CKD) with albuminuria 2 BP lower than 130/80 mm Hg without albuminuria 2 BP lower than 140/90 mm Hg 1 Consider using this goal for frail elderly patients and patients under age 80 who are not tolerating pharmacologic treatment. 2 Whether moderately increased (30–300 mcg/mg, previously called “microalbuminuria”) or severely increased (> 300 mcg/mg, previously called “macroalbuminuria”). Initiating Treatment Table 3. When to initiate treatment Diagnosis Lifestyle modifications Drug treatment 1 Prehypertension At diagnosis Drug treatment not recommended Stage 1 hypertension At diagnosis Consider at or before 6 months of lifestyle modifications if BP goals unmet Stage 2 hypertension At diagnosis At diagnosis 1 For frail elderly patients, standing blood pressure measurements should be considered before initiating drug treatment. If patient is hypotensive when standing but has mild hypertension when seated, pharmacologic treatment may cause more harm than good. 6 Lifestyle Modifications Lifestyle modifications should be encouraged for all patients, regardless of stage of hypertension. Tobacco cessation Quitting smoking, a primary risk factor for cardiac disease, has immediate as well as long-term benefits for patients with hypertension and the people with whom they live. See the Tobacco Use Screening and Intervention Guideline for recommendations. Weight management The risk of serious health conditions—such as diabetes, heart disease, arthritis, and stroke, as well as high blood pressure—increases with a body mass index (BMI) of 25 or higher. (BMI = weight in kilograms divided by height in meters squared [kg/m2 ].) Overweight is defined as a BMI of 25 to 29.9, obesity as a BMI of 30 or higher. While most overweight or obese adults can lose