diuretics may cause oliguria, azotemia, and reversible increases in creatinine. 3 For patients who are > 60 years, on multiple medications, or who have heart failure, consider checking sodium levels as well. 11 Evidence Summary Methods and sources To develop the Hypertension Guideline, the guideline team: · Considered recommendations from externally developed evidence-based guidelines and/or recommendations of organizations that establish community standards. · Reviewed additional literature using an evidence-based process, including systematic literature search, critical appraisal, and evidence synthesis. Externally developed guidelines considered 2014 Evidence Based Guideline for the Management of High Blood Pressure in Adults. Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) (James 2014) 2014 Kaiser National Clinical Practice Guideline: Hypertension, adopting JNC 8 2013 North California and Southern California Permanente Medical Group Hypertension Guideline 2013 Guidelines for the Management of Arterial Hypertension. European Society of Hypertension/ European Society of Cardiology 2013 and 2014 Canadian Hypertension Education Program: Recommendations for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension (Hackam 2013, Canadian Hypertension Education Program 2014) 2012 ICSI Hypertension Diagnosis and Treatment (Luehr 2012) 2011 NICE Hypertension: Clinical Management of Primary Hypertension in Adults Additional evidence review The guideline team reviewed additional evidence in the following areas: · Screening for hypertension · Blood pressure target and intensity of control · Antihypertensive pharmacological therapies · Antihypertensive therapy in the elderly · Chronotherapy (timing of medication) for hypertension · Lifestyle modification · Home monitoring of blood pressure Screening for hypertension The U.S. Preventive Services Task Force (2007) strongly recommends screening adults aged 18 years and older for high blood pressure. This is based on indirect evidence that blood pressure measurement can identify adults who are at increased risk for cardiovascular disease due to hypertension, and good direct evidence that treatment of hypertension substantially decreases the incidence of cardiovascular disease and causes few major harms. Blood pressure target and intensity of control · All the reviewed U.S., Canadian and European guidelines on the management of hypertension— with the exceptions of JNC 8 2014 and Kaiser 2014, which adopted JNC 8—recommend a goal of < 140/90 mm Hg for the general population under 80 years of age, and a goal of < 150/90 mm Hg for the very elderly (80 years of age or older). JNC 8 recommends a goal of < 140/90 mm Hg for the general population under 60 years of age, and a goal of < 150/90 mm Hg for those aged 60 years and older. · The HYVET trial (Beckett 2008) used a BP target of 150/80 mm Hg for elderly patients at least 80 years old with hypertension. This was achieved among 48% of the patients randomized to the active treatment. · There is evidence from the JATOS (JATOS Study Group 2008) and VALISH (Ogihara 2010) trials that strict BP control among elderly hypertensive patients lowers BP significantly versus moderate control, but strict control does not have a significant benefit in reducing morbidity or mortality. 12 · The pooled results of randomized controlled trials (RCTs) in two meta-analyses (Lv 2012 and 2013) show that intensive blood pressure lowering for patients with chronic kidney disease and proteinuria reduces their risk of kidney failure. An analysis performed by the authors indicates that a 10 mm Hg reduction in BP may result in an overall reduction of 22% in the risk of kidney failure. These results may not be generalized to patients with diabetic kidney disease, as these patients were not included in the majority of the included trials. · The pooled results of RCTs in two meta-analyses (Arguedas 2013 and Reboldi 2011) indicate that tight blood pressure control may reduce the risk of stroke in patients with diabetes. The intensive BP lowering, however, was not found to reduce the risk of fatal and nonfatal events when combined or when mortality, myocardial infarction, and heart failure were considered separately. Why do we differ from the JNC 8 panel in their recommendation to increase the target systolic blood pressure from 140 mm Hg to 150 mm Hg in persons aged ≥ 60 years without diabetes or CKD? 1. There is insufficient evidence to support raising the target systolic BP in patients aged ≥ 60 years. (Note: Insufficient or no evidence of benefit is not the same as evidence of no benefit.) The JNC 8 panel based their recommendation for raising the BP goal among patients aged ≥ 60 years on the HYVET, Syst-Eur (Staessen 1997), SHEP (Curb 1996), JATOS, VALISH, and Cardio-Sis (Verdecchia 2009) trials. The panel members indicated that there is moderate- to highquality evidence that treating the general population aged ≥ 60 years with high BP to a goal < 150/90 mm Hg reduces stroke, heart failure, and coronary heart disease. They also noted that low-quality evidence shows that a systolic BP goal of < 140 mm Hg in this age group provides no additional benefit versus a higher goal of systolic BP 140 to < 160 mm Hg