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Vanderbilt Health Affiliated NetworkCare Path GuideHypertension Table of ContentsI. INTRODUCTIONXII. HYPERTENSION IDENTIFICATION AND CLASSIFICATIONXIII. HYPERTENSION MANAGEMENTX? Treatment AlgorithmX? Treatment ThresholdsX? Pharmacotherapy StandardsX? Special Considerations for Certain PopulationsX? Antihypertensive Classes, Agents and Doses TableXIV. PATIENT EDUCATIONX? Methodology: Accurate HBPMX? HBPM TechniquesX? Prescribe Lifestyle Modification: BMI, Diet, Exercise, ResourcesXVI. REFERENCESX [I.] INTRODUCTIONHypertension AwarenessApproximately 75 million (one in three) adults in the U.S. have hypertension (HTN). Of those, one in five is unaware of their condition. HTN is a risk factor for developing life-threatening medical conditions, including cardiovascular disease (CVD), myocardial infarction (MI), heart failure (HF), aneurysm, cardiovascular accident (CVA), transient ischemic attack (TIA) and chronic kidney disease (CKD). Such risks may be reduced by appropriate management of HTN. Additionally, HTN is often accompanied by other vascular risk factors, including hyperlipidemia and diabetes. Approximately 71% of patients with diabetes also have HTN.Hypertension Disease BurdenMorbidity and MortalityHTN is a widely prevalent medical condition, affecting an estimated 32% of American adults. The prevalence of HTN, based on CDC-collected patient self-reporting, varies regionally and rises to 38.6% of adults over the age of 20 in Tennessee and neighboring Southeastern states, per data from 2017. Results from the Framingham Heart Study found the average lifetime risk of developing HTN to be 90% in U.S. adults over age 55. The CDC estimates the number of deaths in 2014 directly or indirectly related to HTN at 410,000—more than 1,100 per day. Cost BurdenHTN is responsible for a national cost burden of approximately $49 billion per year in medical expenses, medications and missed days of work. Data collected in the Medical Expenditure Panel Survey from 2003–2014 shows an annual adjusted estimated healthcare cost that is $2,000 higher for Americans with HTN compared to those without HTN.Hypertension CausesNon-modifiable risk factors for HTN include ethnicity and genetic predisposition. The lifetime risk of developing HTN is higher in African Americans (93%) and Hispanics (92%) than among Caucasians (86%) and Asians (84%), according to the Multi-Ethnic Study of Atherosclerosis (MESA). Certain rare genetic mutations and several single-nucleotide polymorphisms have been identified as potential contributing factors, but more research is needed to better understand how this translates to HTN risk. Based on current data, these genetic variants contribute to about 3.5% of variability in blood pressure (BP).Environmental risk factors for HTN include being overweight, having a sedentary lifestyle, using tobacco or alcohol, and eating a high-sodium, low-potassium diet. These risk factors are considered modifiable, and patients should be educated on lifestyle changes that may reduce their risk of HTN.HTN may result from certain medical conditions, such as endocrinologic disorders, obstructive sleep apnea or renal disease. Some medications and other substances—such as tobacco, alcohol and caffeine—can also increase BP. This care path guide will cover when to screen for secondary causes of HTN in section III.Hypertension ScreeningHTN is often a silent condition, showing no discernible signs or symptoms. This clinical silence explains the commonly noted lack of patient awareness of the condition prior to screening. HTN screening should be performed at every office visit. Community health screenings and access to home and/or public BP monitors may also improve individual awareness of HTN. In community settings, appropriate management is contingent upon the individual following up with his or her clinician for formal diagnosis and treatment.The Case for a Care Path GuideRecent studies have demonstrated that inadequate, unnecessary, uncoordinated and inefficient care are responsible for waste in the healthcare system that may account for 35–50% of the nearly $3 trillion the United States spends annually on healthcare. Care path guides become tools for education, reporting, measurement and continuous improvement. Reduction of unnecessary variability is their primary goal. Care paths are designed to standardize care to reduce variability and assure a consistent level of quality for patients across time, venue and provider, combining workflow-friendly, evidence-based practice principles. The goal of this care path guide is to achieve improved patient outcomes by enhancing the awareness, screening, diagnosis, medical management and patient knowledge of HTN. Additionally, the CDC estimates that only half of patients with HTN are able to maintain control over their condition, so regularly monitoring individuals identified with uncontrolled HTN while making medication adjustments until control is achieved is preferred. HTN treatment is outlined in section III.Health Status Measures and Patient-Reported Outcome MeasuresHealth status measures (HSM) in general and patient-reported outcome measures (PROMs - see sidebar I-1) in particular are becoming important standard components of patient care. These measures are validated tools that furnish insight into patient-relevant issues, improve patient/provider communication and guide individual management. They provide a method to objectify outcomes and quality in a manner that can be shared with patients. These measures require patient participation and have been shown to improve patient engagement in their own healthcare. These outcome measures are an important component of value-based care and are increasingly important in health policy and reimbursement. [Sidebar I-1]PROM ToolsThe following PROMs help clinicians evaluate general and behavioral health status that could affect outcomes and guide treatment:ARMS-7: A seven-question screening tool designed to assess medication adherence behaviors. The ARMS instrument is reliable and has the added benefit of identifying reasons for adherence problems.Patient Health Questionnaire-2 (PHQ-2): A two-question depression screening tool that can provide information about the patient’s mental health status.Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10: A 10-question screening tool designed to assess physical, mental and social health, including pain, fatigue and quality of life.About This GuideThis care path guide was developed by an interdisciplinary team within the Vanderbilt Health Affiliated Network to guide nursing staff, advanced practice providers, primary care clinicians and specialists in an evidence-based approach to screening, diagnosis and treatment of HTN. An evidence-based resource, the HTN care path guide is based on national and international guidelines, as well as the expert opinions of members of our network.By following this care path guide when assessing, diagnosing and treating patients with HTN, clinicians and specialists may reduce variability with the objective of standardizing the assessment to provide the proper treatment or referral, decrease costs, and individualize care more effectively by collecting health status measures that can help identify gaps in quality. The care path guide is intended to be broadly applicable, but it is not meant to substitute for clinical judgment. Clinicians and specialists should tailor processes and approaches to align with patient needs, abilities and goals for care.This care path guide is primarily designed for diagnosis and treatment of primary HTN, although it will also address recognition and appropriate referrals for cases of secondary HTN, hypertensive urgency and emergency, and HTN in pregnancy (pre-eclampsia).[Contributors]Vanderbilt Health Affiliated Network ContributorsT/F[Sidebar I-2]Care Team ModelStudies have shown the benefit of applying team-based care to the management of hypertension. Practices are encouraged to utilize non-physician care team members, such as pharmacists and nurses, to facilitate more frequent follow up with patients, faster timelines to control, and decreased physician workload.[II.] HYPERTENSION IDENTIFICATION AND CLASSIFICATIONHTN screening is performed at most office visits, measuring both systolic blood pressure (SBP) and diastolic blood pressure (DBP). [Table II-1]Screening Recommendations for HypertensionBP Range or ClassificationScreening Performed at a Minimum of Every:Optimal BP (<120/80)5 years (more often when possible)Normal BP (120–129/80) with no history of CVA or MI3 yearsHigh-Normal BP (130/80–139/89) with no history of diabetes, CKD, coronary artery disease (CAD) or elevated atherosclerotic cardiovascular disease (ASCVD) risk6 months Methodology: In-Office BP ReadingsProtocolized BP measurement prevents misdiagnosis, misclassification and overtreatment of HTN, providing a more accurate and possibly higher measure of HTN control. A data analysis of more than 22,600 adults ages 18 and older published in The Journal of Clinical Hypertension found up to 35.5% of initial BP readings were in a lower BP classification on subsequent measurements. BP measurements may be influenced by certain circumstances that may easily occur during the reading, such as a BP cuff that is too small or a patient and staff member having a conversation during the reading. Use of the following checklists can help ensure an accurate reading.PreparationWait at least 30 minutes after the patient has exercised, consumed caffeine or used tobacco products to measure BP. Have the patient sit in a chair with back support and feet on the floor for at least five minutes before measuring BP. Encourage the patient to relax and avoid talking before and during BP measurement. The healthcare professional taking the blood pressure should also avoid talking before or during readings. Unobserved automated readings are preferred when available.Instruct the patient to remove jackets and the sleeve of other clothing to expose bare skin where the BP cuff will be placed.TechniqueUse an automatic BP measuring device, preferably with the capability of taking multiple unobserved readings. Wrist and forearm cuff BP measuring devices are discouraged (except in rare cases when no brachial cuff will fit) as they tend to be less accurate than brachial cuffs. Situate the patient’s arm at heart level by supporting the arm on a desk or table.Position BP cuff at the upper arm at the level of the midpoint of the sternum (the level of the right atrium in most cases).Using an appropriate cuff size for the patient, position the artery marker over the brachial artery. For cuffs without an artery marker, position the hose over the artery. Most BP cuffs have a line indicating cut-off for appropriate size. For cuffs without a size marker, ensure the bladder of the cuff encircles at least 80 percent of the arm. If the BP cuff size varies from the standard, note it.BP should be measured and recorded in both arms for initial office visit. BP should be measured in the arm with the higher reading for subsequent visits.If the first BP reading is normal, no repeat measurements are needed.Repeat and Find Average If NeededIf the first reading is abnormal, ideally at least three measurements should be obtained. Wait one to five minutes before taking repeat BP measurements to allow adequate rest time.If BP is abnormal, minimize measurement error by averaging three readings.If irregular heart rhythm is present, take note and address this issue as outlined in the physical exam and diagnostics sections.For the first diagnosis of HTN, measure the BP in at least one ankle to exclude the possibility of aortic coarctation. Record MeasurementWhen available, utilize Bluetooth capability in the measurement device to integrate measurement with the facility EMR.If Bluetooth capability is unavailable, record BP measurement municate With the PatientProvide patient with BP levels verbally and in writing. If the patient has abnormal BP with a known history of HTN, inquire about medication(s).Note the patient’s most recent dose of antihypertensive medication. Inquire about medication adherence for uncontrolled HTN, possibly using the ARMS-7 tool.Talk with patients about goal BP and provide methodology instructions for home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM).Methodology: Subsequent Diagnostic BP ReadingsSince blood pressure can fluctuate and may be affected by certain environmental factors, a single isolated BP reading should not be used to diagnose HTN. A minimum of three readings from at least two separate occasions should be obtained and averaged to assess blood pressure, and the average BP is used to classify the patient’s blood pressure. Additional data provides a more accurate representation of the patient’s average BP. Blood pressure measurements may be taken through home BP self-measurements, ambulatory BP monitoring or during follow-up office visits. HBPM refers to self-monitoring by the patient either at home or in another non-clinical setting, such as through the use of public BP monitors provided at some retail outlets, outpatient pharmacies, health clubs, etc. HBPM is a convenient, cost-effective way for patients to monitor BP. Patient education is essential for accurate measuring. TIps for patients selecting and purchasing HBPM equipment and completing BP self-measurement can be found in section IV.ABPM is conducted using a cyclical measurement device worn by the patient, which measures the patient’s BP at various intervals over a certain time frame—usually 24 hours. ABPMs are typically set to record BP every 15–30 minutes during waking hours and every 30–60 minutes during sleeping hours. ABPM readings can be used to diagnose HTN through an average of these readings, with the added benefit of accounting for nocturnal BP variations, which are not captured by HBPM or in the clinician’s office. ABPM is the preferred method over in-office blood pressure readings, as it is a better predictor of BP-related cardiovascular disease outcomes, according to a systematic review by the U.S. Preventive Services Task Force.A follow-up office visit to measure BP is not the preferred method for BP variability and non-clinical setting assessment. Repeat BP readings obtained solely from office visits limit the amount of data that can be gathered in a given time period as compared to HBPM and ABPM. Additionally, office visits do not allow for adequate evaluation of variations between clinical and non-clinical settings, which can be seen with all classifications of high blood pressure but is especially important in distinguishing white coat HTN from true HTN.Generally, if clinical BP readings are elevated (preferably an average of three BP readings), the patient should perform HBPM. About 10 HBPM readings are preferred, with measurements taken either twice daily at the same time each day for five to seven days or taken 10 times over the course of two weeks. If HBPM is also elevated, HTN is confirmed. If HBPM is normal, ABPM may be necessary to evaluate for possible HTN versus white coat effect.Classification of HypertensionIn this care path guide, HTN classifications based solely on BP readings are not used since the treatment plan may differ significantly based on patient comorbidities. An individualized approach that accounts for other vascular risk factors is encouraged to identify and improve outcomes for patients who may require a more aggressive approach to HTN treatment. Hypertensive emergency is defined as markedly elevated BP (> 190 mmHg systolic or > 120 mmHg diastolic) in the presence of symptoms or diagnostic findings that are suggestive of new or worsening end organ damage. Examples of end organ damage include acute CVA (ischemic or hemorrhagic), intracranial hemorrhage (ICH), acute MI, unstable angina pectoris, acute left ventricular HF with associated pulmonary edema, dissecting aortic aneurysm, acute renal failure and eclampsia (which may result in seizures or coma in a hypertensive pregnant female). Hypertensive emergency is a potentially life-threatening condition requiring emergent evaluation and possibly ICU admission.Hypertensive urgency is defined as markedly elevated BP (> 190 mmHg systolic or > 120 mmHg diastolic) without new or worsening end organ damage. These patients are otherwise stable and asymptomatic, but they should undergo diagnostics to assess for signs of end organ damage (labs and ECG). If signs of new or worsening end organ damage are found on labs or ECG, this condition progresses in term and treatment to a hypertensive emergency.If no signs of current or impending end organ damage are found, patients may be treated with aggressive oral antihypertensives and should be closely monitored. White coat HTN, sometimes called “white coat effect,” is defined as HTN in a clinical setting with normal HBPM readings or in a non-clinical setting. If HBPM is normal, ABPM is recommended to confirm white coat HTN.Masked HTN is demonstrated by normal to high-normal BP readings in office with an average blood pressure in the hypertensive range based on HBPM or ABPM. It may be reasonable to screen for masked HTN if end organ damage is present or if the patient has elevated cardiovascular risk based on other conditions.Preeclampsia is HTN with proteinuria that occurs during pregnancy. This diagnosis warrants referral to a high-risk OB as it can progress to eclampsia and is associated with adverse outcomes for the mother including seizures, stroke and heart failure, as well as adverse events for the fetus, such as low-birth weight, prematurity and fetal loss. [Table II-2]Action Plan Based on BP Levels and Comorbidities ActionSystolic BP (in mmHg)Diastolic BP (in mmHg)Encourage healthy diet and daily exercise< 120< 80Lifestyle modification (and medical therapy for patients with a history of MI or CVA)120–129< 80Lifestyle modification and medical therapy in patients with diabetes, 10-year ASCVD risk >10%, or CKD 130–15980–99Lifestyle modification initially in patients without comorbidities. Medical therapy if needed after 1–3 months of lifestyle modification.140–15990–99Lifestyle modifications and begin two first-line agents 160–189100–119Symptomatic: Refer to ED> 190> 120Asymptomatic: Begin two first-line agents Basic Diagnostic Medical EvaluationA patient history and physical examination are important aspects of HTN management. This portion of the patient encounter focuses on identifying signs of end organ damage and evaluating for signs and symptoms suggestive of a secondary cause of HTN. Obtain a thorough patient history and review of systems. Inquire about:Personal history of elevated or high BPPersonal history of other vascular risk factorsFamily history of HTNRecently lifestyle changes, including weight gain, sedentary lifestyle/reduced level of physical activity, increased dietary sodium or alcohol intake, career change that resulted in increased travel and/or changes in dietary habits (eating more restaurant foods) Perform a medication review and inquire about use of other substances that can affect blood pressure.Use of medications, including nasal decongestants, NSAIDs, steroids, oral contraceptives and certain antidepressants (SNRIs, TCAs)Use of tobacco, caffeine, alcohol and certain illicit substances (cocaine, methamphetamine)Evaluate: Clinical condition of the patient. Acutely ill patients with HTN require emergency room evaluation. Patients who are clinically stable or asymptomatic can often be managed in an outpatient setting as deemed appropriate by the evaluating clinician.For indications of secondary HTN, see sidebar II-1.Physical Exam and Diagnostic StudiesA physical exam can assess for end organ damage for patients with HTN. Fundoscopic eye exam should be performed to evaluate for hypertensive retinopathy.Cardiac exam should include auscultation to evaluate for abnormal heart sounds, such as murmurs or arrhythmias.Lung auscultation should be performed. Rales may suggest pulmonary edema from congestive heart failure.Evaluate for edema in the peripheral extremities suggestive of peripheral vascular disease, heart failure or kidney disease.Pulse examination, particularly in the lower extremities, should be performed. Determine if there is a pulse delay or evidence of peripheral artery disease.Consider laboratory studies to evaluate for end organ damage in hypertensive patients. Urinalysis (UA) and albumin-creatinine ratio (ACR) should be performed to evaluate for proteinuria or other signs of renal disease. Microscopic urinalysis (preferably first void of the day) should be considered for those with 1+ proteinuria on UA.Metabolic panel:BUN, creatinine, eGFR to evaluate renal functionElectrolytes to evaluate sodium and potassium levels (which can be abnormal with either dietary or renal causes)Glucose to evaluate for diabetes; consider further evaluation for diabetes (HgA1C) for high clinical suspicion or for elevated glucose readingsLipids (serum total cholesterol and HDL cholesterol levels) to further evaluate cardiovascular riskConsider other diagnostics to evaluate for end organ damage in patients with HTN.Electrocardiogram (ECG) can be used to evaluate for cardiac issues, including signs of left ventricular hypertrophy (LVH)—a long-term consequence of untreated or poorly controlled HTN. LVH is an independent predictor of future cardiovascular events. ECG is also warranted for irregular rate or rhythm.CXR can be used to identify cardiomegaly or pulmonary edema if heart failure is suspected, and if identified, could be further categorized with echocardiogram.Echocardiogram is not recommended for all patients with signs of LVH on ECG as it may not change management or give insight to cardiovascular risk, but it may be helpful for the following patient groups:Symptoms or history of heart failureChronic, uncontrolled HTN with signs of LVH on ECG or cardiomegaly on CXRPediatric patients (≤ 18 yr old)Signs of secondary HTNPresence of heart murmur [[III.] HYPERTENSION MANAGEMENT[See Algorithm III-1 attached] Lifestyle ModificationHypertension may be improved through weight loss, exercise and dietary changes, quitting smoking and staying within guidelines for alcoholic beverages. See “Prescribe Lifestyle Modification” in section IV (Patient Education) for details.Initially, lifestyle modification is an appropriate treatment for most cases of HTN. However, for markedly elevated blood pressure (e.g., ≥ 160/100), the clinician may initially incorporate pharmacologic therapies in addition to lifestyle modification. When to Start MedicationsBP is one among many risk factors that can affect a patient’s risk of having an adverse cardiovascular event. Patients should be educated on all potential risk factors that can affect their cardiovascular health. Risk assessment tools can be used to evaluate the need for pharmacotherapy. Perhaps one of the most widely used CVD risk assessment tools is the atherosclerotic cardiovascular disease (ASCVD) risk estimator, which is based on pooled cohort equations from the American Heart Association and the American College of Cardiology. The ASCVD risk estimator calculates the risk of having atherosclerotic cardiovascular disease in 10 years based on the following factors:Age—The algorithm is based on ages 40–79, so the ASCVD risk estimator may overestimate risk for younger patients and underestimate risk for patients older than 79.SexRace—Limitations exist with race/ethnicity in the ASCVD risk calculator as the estimator is based primarily on Caucasian and African-American populations.Risk may be overestimated for certain Asian Americans (e.g., east Asian heritage) and Hispanic (e.g., Mexican Americans)Risk may be underestimated for certain Asian American (e.g., South Asian heritage), Hispanic (e.g., Puerto Ricans) and Native American populations Systolic and diastolic blood pressure (mmHg)Lipid panel results (total, LDL and HDL cholesterol)Whether or not the patient smokes, is diabetic or takes antihypertensive or lipid-lowering medicationsTreatment and monitoring recommendations are based on level of HTN and vascular risk factors.SBP of < 120 and DBP < 80: No pharmacotherapy is required for patients with normal BP, but these patients should get BP measurements at a minimum of every five years or more frequently if the opportunity presents. Lifestyle modification for prevention of HTN could also be discussed for those at risk of developing HTN (e.g., overweight, sedentary, family history of HTN).SBP of 120-129 mmHg and DBP < 80 mmHg: Patients should be counseled on lifestyle modification and re-evaluated at a minimum of every three years if they have no history of MI or CVA. SBP of 130-159 or DBP of 80-99: Patients should undergo ASCVD risk evaluation, be evaluated for other comorbidities and be counseled on lifestyle modification. Pharmacologic treatment should be initiated in higher risk patients, such patients with a known history of CVD, diabetes, CKD or a calculated 10-year risk of ASCVD ≥ 10%. Patients starting pharmacologic treatment should be re-evaluated in two to four weeks. Patients not requiring pharmacologic treatment should be re-evaluated one to three months after incorporating lifestyle modifications.SBP of 160–189 or DBP of 100–119: Patients benefit from both lifestyle modification and pharmacotherapy (two first-line agents) with re-evaluation in two to four weeks.Treatment ThresholdPharmacotherapy for HTN is based on the degree of BP elevation and may vary in threshold for treatment and selection of antihypertensive medication for certain groups. The threshold for initiating antihypertensive medications depends on the degree of BP elevation, patient age, and consideration of other cardiovascular disease (CVD) risk factors and comorbidities. Treatment of HTN is a balancing act, and several factors must be considered. Clinicians must be cognizant of the potential for harmful effects—hypoperfusion of organs (e.g., brain, kidneys), dizziness, falls, electrolyte imbalance, etc.—associated with overaggressive treatment of HTN. However, they must also bear in mind the patient’s risk for MI, CVA and other vascular disease, especially with hypertensive patients who have other vascular risk factors. 140 systolic or 90 diastolic is generally the BP threshold for initiating pharmacotherapy in patients without additional CVD risk factors in adults younger than 65 without comorbidities. 120 systolic or 80 diastolic is the threshold for initiating pharmacotherapy in patients with a history of cardiovascular disease (MI, CAD), heart failure (HF) or CVA. The SPRINT trial showed that more aggressive treatment in these higher-risk individuals reduced all-cause mortality and major vascular events, such as CVA, in these patients.130 systolic or 80 diastolic is the threshold for initiating pharmacotherapy in patients with higher risk of CVD:DiabetesCKD-III> 10% ASCVD 10-year risk of adverse cardiovascular eventsPharmacotherapy Standard RecommendationsThese three medications should be first line and may be used in the order determined by a clinician:ACE-I or ARB (avoid using ACE-I and ARB simultaneously)Thiazide diureticDihydropyridine CCBThe fourth medication should be an aldosterone receptor antagonist (ARA), also referred to as a mineralocorticoid receptor antagonist, such as spironolactone or eplerenone, unless contraindicated. Consider stopping potassium supplements when adding an ARA due to the risk of hyperkalemia.Other antihypertensive agents for special situations:Loop diuretics (CHF, CKD)BBs (recent MI or heart failure)Non-dihydropyridine CCBs (atrial fibrillation)Initiation of fixed dose combination tablets is recommended for patients if BP is ≥ 160/100 on the first or subsequent visits.[Blurb 1] Important: Certain medications should not be used simultaneously with certain other classes of medications. For instance, combining medications from the ACE-I, ARB or direct renin inhibitor classes together is not recommended and could potentially be harmful.Table III-1Special Considerations for Certain PopulationsPopulations and Comorbidities Requiring Special ConsiderationsTreatment Goals and Other ConsiderationsFirst Line AgentsSecond Line Agents African or Caribbean Ancestry<140/90 mmHg w/o comorbiditiesCCB or thiazide diuretic (Use these two agents in succession.) Thereafter, an ACE-I or ARB is recommended.Pregnant Women or Women Who May Become Pregnant< 140/90 mmHg w/o comorbiditiesRefer to high-risk OB Avoid ACE-I or ARB due to risk of fetal toxicity (all trimesters)Labetalol, methyldopa, hydralazine, nifedipine or other CCBAge > 65< 140/90 mmHg w/o comorbiditiesConsider comorbidities and risk vs benefit of pharmacotherapy.Employ a shared decision approach with patients to establish treatment goals and re-address goals periodically.Standard first line agentsConsider side effects when selecting antihypertensive agents. Senior population may be more vulnerable to adverse effects.Diabetes Mellitus (DM)< 130/ 80 mmHgStandard first line agents in the absence of albuminuriaConsider ACE-I or ARB in the presence of albuminuria for renal protection due to improved efficacy of urinary albumin excretion with these medication classes compared to other agents.Chronic Kidney Disease (CKD)< 130/80 DBP, per the 2017 ACC/AHA guidelinesRefer patients with eGFR < 30 to a nephrologist for medication management.ACE-I or ARB can reduce proteinuria but should not be used simultaneously.Monitor serum creatinine (sCr) and potassium (K+) 2 wks after dose initiation or increase and q6-12 months once on a stable dose.Secondary Stroke Prevention< 120/80 for prior history of CVA; usefulness of initiating antihypertensives after CVA or TIA is not well established in patients with BP < 140/90 without prior history of HTN.For patients with prior CVA or TIA with HTN, pharmacotherapy should be started after the first few days following the event to prevent recurrent CVA or other vascular event.Prior CVA patients may benefit from monotherapy with either a thiazide diuretic, ACE-I or ARB or from dual therapy with a thiazide diuretic and an ACE-I. Pharmacotherapy should be individualized based on other comorbidities.Metabolic SyndromeFirst line agents are similar to standard recommendations with the exception of thiazide diuretics, which are avoided or used with caution in patients with metabolic syndrome due to their ability to increase insulin resistance (increasing the risk of conversion to DM), hyperuricemia and hyperlipidemia.Atrial Fibrillation (AF)Treatment with an ARB may help reduce the risk of AF recurrence.Also consider BB or non- dihydropyridine CCB agents[Table III-2]Medication Classes, Agents and Recommended DosesMay titrate therapy every two to four weeks if targets are not being met and no evidence of significant side effectIf an equivalent combination product is available for multidrug therapy, may convert to combo drug once doses of individual agents have been stabilized* Indicates preferred agent within classMedication Classes & AgentsTypical Initial DoseTitrationMax DoseDose AdjustmentsMonitoring, Side Effects (SEs), Comments,Cautions & Contraindications (CI)Primary Agents *Lisinopril (Previnil?, Zestril?)10 mg daily#1: 20 mg#2: 40 mg 40 mg dailyLower starting dose for renal dz:2.5 mg daily for CrCl <10 mL/min;5 mg daily for CrCl of 10–30 mL/min or if on diureticMonitor:Renal Fxn (BUN, creatinine, K+, Na+ at2 weeks after starting or adjusting medication; serum creatinine (sCr) and K+ every 6–12 months.SEs:Cough, ↑K?, dizzinessCautions:Do not combine with ARB or direct renin inhibitorsCI:Pregnancy (risk of fetal toxicity)Benazepril (Lotensin?)10 mg daily#1: 20 mg#2: 40 mg40 mg dailyStart 5 mg daily if CrCl <30 mL/min or if on diureticQuinapril (Accupril?)10 mg divided daily or BID#1: 10 mg divided daily or BID #2: 40 mg divided daily or BID80 mg divided daily or BID Start 2.5 mg daily if CrCl is 20–60 mL/min or if taking diuretics;Start 10 mg daily if elderlyRamipril (Altace?)2.5 mg divided daily or BID#1: 5 mg divided daily or BID#2: 10 mg divided daily or BID20 mg divided daily or BIDStart 1.25 mg daily if CrCl < 40 mL/min or on diureticsTrandolapril (Mavik?)1 mg daily#1: 2 mg daily#2: 3 mg daily20 mg divided daily or BIDStart 0.5 mg daily if CrCl < 30 mL/min, on diuretics, or w/ hepatic cirrhosisAngiotensin II Receptor Blockers (ARB)*Losartan (Cozaar?)50 mg daily#1: 100 mg daily100 mg dailyStart 25 mg daily, w/ hypovolemiaSEs:Cough, ↑K?, dizzinessCautions:Lower dose and monitor w/ hypovolemia or diuretics; avoid combining w/ ACE-I or direct renin inhibitorsCI:pregnancy (risk of fetal toxicity)Telmisartan (Micardis?)40 mg daily#1: 80 mg daily80 mg dailyStart 20 mg, titrate slow & monitor w/ liver impairment, hypovolemiaCandesartan (Atacand?)16 mg daily#1: 32 mg daily32 mg dailyStart 4 mg daily and double dose q 2 wks up to 32 mg daily for HFrEF, moderate renal or liver impairment; CI in severe hepatic impairmentValsartan (Diovan?)160 mg daily#1: 320 mg daily320 mg dailyStart 40 mg q 12 hr and titrate to 160mg bid as tolerated for heart failure to reduce hospitalizationsIrbesartan (Azapro?)150 mg daily#1: 300 mg daily300 mg dailyStart 75 mg daily w/ hypovolemiaCalcium Channel Blockers (CCB)Dihydropyridines*Amlodipine (Norvasc?)5 mg daily#1: 10 mg daily10 mg dailyStart 2.5 mg daily for frail, elderly patients or for hepatic impairmentSEs:Pedal edema, dizziness, headache, constipationCautions:Avoid in HFrEF (If required, may use amlodipine.); lower dose w/ hepatic impairmentComments: Felodipine may be better tolerated Nifedipine ER (Atalat CC?)30 mg daily#1: 60 mg daily90 mg dailyMonitor w/ hepatic impairmentFelodipine5 mg daily#1: 10 mg daily20 mg dailyStart 2.5 mg w/ hepatic impairmentThiazide Diuretics*Chlorthalidone (Thalitone?)12.5 mg qAM#1: 25 mg qAM25 mg qAMMonitor:Renal Fxn (BUN, creatinine) and electrolytes (K+, Na+) at2 weeks after starting or adjusting medication;Serum creatinine (sCr) and K+ every 6–12 monthsSEs: Orthostasis, ED, ↓K+, ↓Na+, goutCI:Avoid if CrCl < 30 mL/minHydrochlorothiazide (Microzide?)12.5 mg qAM#1: 25 mg qAM25 mg qAMIndapamide (Lozol?)1.25 mg qAM#1: 2.5 mg qAM5 mg qAMSecondary AgentsLoop DiureticsFurosemide (Lasix?)20 mg BID40 mg BIDMonitor:Renal Fxn (BUN, creatinine) and electrolytes (K+, Na+) at2 weeks after starting or adjusting medication; serum creatinine (sCr) and K+ every 6–12 monthsCautions:HypovolemiaComments:Use w/ poor response to thiazides or w/ renal impairmentTorsemide (Demadex?)2.5 mg daily#1: 5 mg daily#2: 10 mg daily40 mg BIDBumetanide (Bumex?)0.5 mg BID#1: 1 mg BID#2: 2 mg BID 2 mg BID Potassium Sparing Diuretics, e.g., Aldosterone Receptor Antagonists (ARA) Spironolactone (Aldactone?)12.5-25 mg dailyRefer if not controlled at 25 mg dailySpecialist managedMonitor:Serum creatinine (sCr) and potassium (K+) 1 week after starting or adjusting medication and every 6–12 monthsSEs:↑K+, gynecomastiaCautions: Renal disease, CYP3A inhibitor useCI: Pregnancy, Hyperkalemia, Addison’s Eplerenone25-50 mg dailyRefer if not controlled at 50 mg dailySpecialist managedStart 25 mg daily CI if CrCl < 50 mL/min or serum creatinine > 2 mg/dL in males or > 1.8 mg/dL in females; Avoid dose >25 mg daily in post-MI CHF on a CYP3A inhibitorBeta Blockers (BBs)Cardioselective BBs*Metoprolol succinate (Toprol XL?)25 mg daily#1: 50 mg daily#2: 100 mg daily#3: 200 mg daily400 mg dailyMonitor:Heart rate (risk of bradycardia); Titrate dose by heart rate (maintain HR > 55 bpm).SEs:Fatigue, EDComments:Metoprolol succinate and bisoprolol are preferred in HFrEF.Metoprolol tartrate (Lopressor?)50 mg BID#1: 75 mg BID#2: 100 mg BID400 mg dailyAtenolol (Tenormin?)25 mg BID#1: 50 mg BID100 mg dailyStart 25 mg daily if elderly or renal impairment; not to exceed 25 mg/day if CrCl < 15 mL/min and 50 mg/day if CrCl 15–35 mL/minBisoprolol (Monocor?, Zebeta?)2.5-5 mg daily#1: 10 mg daily20 mg dailyStart 1.25 mg daily, not to exceed 10 mg daily for heart failureCombined Alpha-1 and Beta-1,2 Receptor Antagonist BBsCarvedilol IR (Coreg?) 6.25 mg BID#1: 12.5 mg BID25 mg BIDMax dose of 25 mg BID in heart failureMonitor: Heart rate (bradycardia)Comments:Carvedilol is preferred in HFrEF.SEs:Fatigue, EDCautions: Avoid abrupt cessation (rebound tachycardia).Carvedilol ER (Coreg CR?)10 mg daily#1: 20 mg daily#2: 40 mg daily80 mg dailyLabetalol (Trandate?)100 mg BID#1: 200 mg BID400 mg BID**Thiazide diuretics are appropriate for mild fluid retention (e.g., non-pitting edema), but a loop diuretic may be utilized for moderate-severe fluid retention (e.g., pitting edema, pulmonary edema, orthopnea). Avoid simultaneous use of thiazide and loop diuretics.[Table III-3]Antihypertensive Fixed Dose Combination TabletsClasses of MedicationsMedication NameCCB + ACE-IAmlodipine/Benazapril (Lotrel?)CCB + ARBAmlodipine/Valsartan (Exforge?)ACE-I + CCB + Thiazide DiureticAmlodipine/Valsartan/HCTZ (Exforge HCT?)ACE-I + Thiazide DiureticLisinopril/HCTZ (Zestoretic?)Benazepril/HCTZ (Lotensin?)Enalapril/HCTZ (Vaseretic?)ARB + Thiazide DiureticIrbesartan/HCTZ (Avalide?)Valsartan/HCTZ (Diovan HCT?)Losartan/HCTZ (Hyzaar?)BB + Thiazide Diuretic(only used in special circumstances, e.g., heart failure)Metoprolol/HCTZ (Lopressor HCT?)Bisoprolol/HCTZ (Ziac?)Atenolol/chlorthalidone (Tenoretic?)ARA + Thiazide DiureticSpironolactone/HCTZ (Aldactazide?) Hypertension Treatment Monitoring After Medication InitiationBaseline labs and routine monitoring should be obtained for certain medications (see table III-2 for medication-specific monitoring).Blood pressure should be re-evaluated every two to four weeks after starting BP medication, preferably through evaluating HBPM readings. Medication adjustments may be made by the clinician based on those results. Patients should perform HBPM as directed by the clinician regularly while medications are being adjusted and periodically once BP is controlled. BP should be re-evaluated four weeks after starting ARAs.An average of at least three readings should be used to determine whether or not the patient’s HTN is controlled. If office BP is obtained and the first reading is normal, they are considered controlled.If office BP reading is elevated, a total of at least three automated BP readings are obtained to determine if HTN is controlled.If BP is at goal (controlled HTN) and the patient is tolerating the medication well, continue at the current dose, recommend continued home blood pressure monitoring (HBPM), and re-evaluate in six to 12 months. If the patient is not tolerating the medication due to adverse side effects, change the medication (reduce the dose if previously well tolerated or discontinue the agent altogether and start a different medication). Keep in mind that certain medications need to be tapered (BBs, clonidine). Re-evaluate two to four weeks after medication change.If not at goal (uncontrolled HTN), adjust dose or add additional agent and repeat this process every two to four weeks until HTN is controlled or the patient meets the threshold for secondary HTN screening. Secondary Causes of HypertensionShould be considered if:There is clinical suspicion of secondary causes of HTN based on history and physical exam.The patient has met the appropriate threshold for screening for causes of secondary HTN:Three or more antihypertensives with persistent HTNChange in previously controlled HTN on same medication regimen without explanation An HTN specialty referral or cardiology referral could be placed for patients with resistant HTN who meet the threshold for secondary HTN screening. Alternatively, if the clinician has a strong clinical suspicion of a particular disorder, he or she may order confirmatory testing and refer the patient to the appropriate specialist.Causes of secondary HTN and clinical response:Obstructive sleep apnea – Refer to sleep specialist to confirm with polysomnogram and for treatment (CPAP, BiPAP, etc.).Chronic kidney disease – Refer to nephrologist. Renal artery stenosis – Refer to nephrologist or vascular surgeon. Thyroid disease – Order thyroid labs to confirm. Consider imaging and referral to endocrinology. Parathyroid disease – Refer to endocrinology.Primary aldosteronism – Refer to endocrinology.Cushing’s syndrome – Refer to endocrinology.Scleroderma –?Refer to dermatology or rheumatology.Pheochromocytoma – Check 24-hour urinary metanephrines, catecholamines. Refer to oncology.Coarctation of the aorta should be considered in patients under 30 years old with elevated BP on brachial measurement by obtaining a measurement of BP in the thigh, which may help identify coarctation of the aorta. If the thigh BP is lower than the brachial BP, evaluation for coarctation of the aorta should be considered.Medication-related causes may include NSAIDs, nasal decongestants, steroids, oral contraceptives and some antidepressants (SNRIs).Alcohol abuse may also cause secondary HTN. Refer to substance abuse specialist.[IV.] PATIENT EDUCATIONPatient education informs HTN patients about the skills, equipment and disease to optimize self-management of the disease, improving overall BP control and patient outcomes. Some studies show that patient education and BP self-monitoring may also have a positive impact on medication adherence and BP control., Patient Education BasicsHelp patients understand the clinical aspect of and potential complications from their condition. Advise patients that high blood pressure does not typically cause symptoms but can be a major contributing factor to disabling or potentially fatal events, such as heart attack, stroke, kidney disease and vision issues (retinopathy) to name a few. Teach patients how to use equipment and the methodology to attain accurate home BP monitoring (HBPM).Inform patients about their medications, including:How the medication worksHow to correctly take the drugPotential side effectsImportance of adherenceIdentify lifestyle modifications have potential to improve BP control.HBPM TechniquesSince HTN is a silent disease and BP measurements may vary depending on patient comfort level (home vs. clinical measurements), patients should obtain a home BP monitor to check their BP in a frequency determined by the clinician. Common frequencies include:10 times over the course of two weeks during the initial evaluation to confirm an HTN diagnosis Weekly for two weeks after a change in antihypertensive medicationTwice during the week before a scheduled office visitInstruct the patient on how to select a reliable home BP monitor (see sidebar IV-1). Instruct the patient on how to accurately conduct HBPM (see sidebar IV-2). Instruct the patient on interpretation of BP results.Educate patients about alarm symptoms that warrant emergency evaluation, such as BP of 180/120 or greater accompanied by chest pain, shortness of breath, neurologic deficits (weakness, dysarthria, imbalance), severe headache, visual disturbance, confusion and nosebleeds.Educate patients on the importance of therapy adherence and regular follow-up visits.[Sidebar IV-1] Selection of Equipment and Cuff Size for Home BP MonitoringUse a BP measurement device that has been clinically validated by either the U.S. Association for the Advancement of Medical Instrumentation (AAMI), the British and Irish Hypertension Society (BHS) or the European Society of Hypertension (ESH)., An example of a widely available, clinically validated brand is Omron. A list of brachial BP monitor models with notations for BHS or EHS clinical validation is available online at dabl Educational Trust Limited. Brachial (upper arm) BP cuffs are preferred. Wrist, forearm and finger BP cuffs are discouraged.Automated BP measurement devices are preferred over manual.Memory storage capacity is preferred over devices incapable of reading storage. Alternatively, the patient should be instructed to log their BP readings on paper or use a smartphone app.Use an appropriate cuff size. The bladder of the BP cuff should encircle at least 80% of the upper arm.Upper Arm Circumference (cm)Appropriate BP Cuff Size22–26 cmSmall Adult Arm Cuff27–34 cm(Regular or Standard) Adult Arm Cuff35–44 cmLarge Adult Arm Cuff45–52 cmAdult Thigh CuffOther Considerations for Home BP Monitors Valuable FeaturesAutomatic inflation functionalityLarge digit display for patients with impaired visionMemory storage capability for one or multiple usersAbility to average readings Bluetooth technology to integrate with EMR (if supported)Phone app integration CostWhile most insurance companies do not cover the cost of BP monitors for home use, patients may check with their insurance company as some insurance plans may offer this benefit. When HBPM is prescribed, patients with a flexible spending account (FSA) or health savings account (HSA) can cover the cost of BP monitoring equipment from these funds. A cost of $30–$100 for a clinically validated upper arm automatic BP monitor can be expected with the price for Bluetooth models falling into the upper end of this range.Where to Find BP MonitorsEncourage purchase from a retailer with a good return policy in case the monitor cannot be validated against clinical measurements. BP monitors for home use can be purchased from medical supply stores as well as mainstream retailers including, but not limited to, Walmart, Walgreens, CVS, Rite Aid, Target, Costco, Sam’s Club, etc. BP monitors are also available for purchase online through various vendors. [Sidebar IV-2] Methodology: Accurate HBPMPreparing for MeasurementEncourage patients to:Wait at least 30 minutes after exercising, consuming caffeine or using tobacco products to measure BP.Use the restroom if needed before measuring BP.Remove clothing covering the upper arm where the blood pressure cuff should be placed (e.g., long sleeves, jackets).Sit in a sturdy chair with back support (e.g., dining table chair), with legs uncrossed and feet on the floor.Rest arm on a table or desk (at heart level).Position BP cuff at the upper arm above the antecubital fossa (the crease of the elbow) and position the artery marker over the brachial artery. For cuffs without an artery marker, position the hose over the artery.Relax quietly and wait at least five minutes before measuring BP. Taking the MeasurementEncourage patients to:Avoid talking by patient or family during BP measurement. Record the BP readings. Repeating as NecessaryEncourage patients to:For the first home BP measurement, measure and record BP in both arms unless contraindicated (lymphedema, etc). If there is a substantial difference between arms (> 15 mmHg) measure BP in the arm with the higher reading for future measurements.Wait at least one minute prior to obtaining repeat BP measurements.Average the BP readings. Use at least three readings on at least three occasions to obtain an average BP for clinical decision making.Prescribe Lifestyle ModificationExplain BMISince there is a correlation between elevated body mass index (BMI) and HTN, patients who are overweight (BMI of 25–29.9) or obese (BMI > 30) should be encouraged to lose weight. While not a guarantee, weight loss may help reduce BP levels in some patients. The CDC offers an online BMI calculator that can help patients track their BMI.Ask About ExerciseAll patients, regardless of BMI, should be encouraged to engage in at least 150 minutes of moderate-intensity physical activity weekly (e.g., 30 minutes of moderate intensity exercise at least five days a week). Alternatively, 75 minutes of vigorous activity per week may be a heart-healthy goal.Consider cardiac evaluation prior to recommending an exercise program for patients who have been very sedentary or for those with comorbid heart disease. The following explanations may help patients understand what different exercise levels feel like:Light-intensity exercise, at 35–50% of age-predicted maximal heart rate, may cause patients to breathe more quickly. Light-intensity exercise will not contribute to weekly totals but can help regulate blood sugar and improve all-around health. (Tip for patients: You can easily hold a conversation while doing light-intensity exercise.) Moderate-intensity exercise, at 50–70% of age-predicted maximal heart rate, causes breathing and heart rate to speed up noticeably. (Tip for patients: You can talk between huffs and puffs when doing moderate-intensity exercise.)Vigorous-intensity exercise, at 70–85% of age-predicted maximal heart rate, means heart rate and breathing speed up substantially. (Tip for patients: You are too breathless and busy concentrating and keeping pace to hold a conversation during vigorous-intensity exercise.)Discuss DietOf all recommended lifestyle modifications, a healthy diet tends to offer the most impact on blood pressure. The Dietary Approaches to Stop Hypertension (DASH) diet was explicitly designed to reduce blood pressure. This diet limits dietary sodium, red meat, fat and sugar and encourages increased consumption of vegetables, fruits, lean meats and whole grains. Such dietary changes may help reduce SBP. A downloadable PDF from the U.S. Department of Health and Human Services provides a robust description of the DASH diet (starting on page 8).Reducing dietary sodium by 25% (typically by 1,000–1,500 milligrams per day) is a simple dietary change that may also help lower SBP. Eating a diet with adequate potassium intake (3,500–5,000 milligrams per day) may also be beneficial; however, due to the risks associated with hyperkalemia, patients should be educated to avoid exceeding the recommended daily potassium intake. Keeping a food journal may help patients improve their understanding of nutrition as well as encourage healthy eating. Referral to a nutritionist may benefit patients in this area.Caffeine should usually be limited to less than 300 milligrams per day in hypertensive patients. Additionally, patients should be made aware that energy drinks and some dietary supplements can elevate blood pressure.Talk About Tobacco CessationTobacco has a vasopressor effect that raises BP, and tobacco use is also associated with increased risk of serious conditions, including CVD and cancer, independent of its association with HTN. Tobacco cessation should be strongly encouraged as smoking is a modifiable risk factor second only to HTN in associated cardiovascular mortality and morbidity. Due to the addictive nature of nicotine, smoking cessation can be challenging for most patients who smoke. Clinicians should discuss the associated risks of any type of tobacco use with patients and provide support for quitting smoking. Nicotine replacement therapy and other smoking cessation aids may be beneficial, especially in conjunction with counseling. Patients may find help for quitting the use of tobacco at Tennessee Tobacco QuitLine or Smoke Free.Ask About Alcohol ConsumptionOver-imbibing alcohol can elevate blood pressure as well as damage the heart, liver and brain. All patients, especially those with HTN, should be counseled on the effects of alcohol overconsumption. Alcohol should be limited to two or fewer drinks per day for men and one or fewer drinks per day for women.Explain to patients that a standard drink containing 14 g of alcohol is equivalent to:12 ounces of 5% alcohol by volume (ABV) beer5 ounces of 12% ABV wine1.5 ounces (one mixed drink or “shot”) of 40% ABV (or 80-proof) liquorVanderbilt Health Associated Network ResourcesVanderbilt Health Affiliated Networks Patient Education MaterialsFind patient education materials about HTN itself, HTN with specific comorbidities (CKD, PAD, etc.), HTN medications, lifestyle modifications for lowering BP and more. These resources can be accessed by Vanderbilt Health Affiliated Network professionals through Clinical References in eStar.Hypertension Center Specialists in the management of HTN can aid in evaluation for secondary causes of resistant HTN as well as management of blood pressure.615-322-3353 Nutrition ClinicRegistered dietitians at Vanderbilt Health Nutrition Clinic focus on the nutritional management of disease and can be a valuable resource for patients with HTN.615-936-3952Vanderbilt Medical Weight Loss ProgramVanderbilt Medical Weight Loss Program offers a comprehensive approach to weight management, combining a patient-individualized approach utilizing clinicians, dieticians, exercise physiologists and psychologists. Use caution with some weight-loss medications (stimulants), which can exacerbate HTN.615-322-6000Vanderbilt Surgical Weight Loss Program Vanderbilt Surgical Weight Loss Program combines surgery, exercise, nutrition and psychological care for patients who have tried and failed standard weight loss interventions and who have a BMI > 40 or a BMI > 35 with comorbidities, such as HTN and diabetes.615-322-6000Care CoordinationRegistered nurses work as care coordinators in various departments to provide patients with frequent connection, education, accountability and encouragement. 615-936-2828 Other Approved MaterialsNational organizations, including AMA, AHA and NIH, publish useful patient educational materials. , a co-sponsored website from the AMA and the AHA, has a wealth of information for clinicians as well as patient-facing materials, such as this downloadable “Questions to Ask Your Doctor” form, on its site. Additional resources include the following.AHA Printable BP LogA printable HBPM log with space to pencil in patient’s BP goal and instructions for logging a.m. and p.m. BP measurements and more.Silver SneakersA health and fitness program for adults age 65 and older, Silver Sneakers may be covered by Medicare Advantage. The website allows people to check their eligibility, locate classes or participate in exercise sessions via online instruction; however, the online instruction is paywalled.Printable Food and Activity DiaryA fill-in-the-blank, printable weekly food and activity log with space to log daily breakfast, lunch, dinner and physical activity, as well as weekly goals for diet, exercise and behavior.Eat Right. Academy of Nutrition and DieteticsThe website of the Academy of Nutrition and Dietetics, this online destination provides a wealth of food information, including recipes and tips for shopping, budgeting and reading food labels.Tennessee Tobacco QuitLineA smoking cessation program for Tennesseans that allows patients to access a counselor via toll-free phone number or utilize the online program.800-QUIT-NOW (800-784-8669)Smoke FreeA national resource with various tools available 24/7 to help people quit smoking, this program offers online services, text messaging programs, telephone counseling, smartphone apps (quitSTART and QuitGuide apps), and information about medications and nicotine replacement therapy. 800-QUIT-NOW (800-784-8669)[Appendix A]Resources and Interpretation for ASCVD Risk Estimator Websites:tools.ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/ Phone Apps:ASCVD Plus - from the American College of Cardiology Estimated 10-Year Risk of ASCVD Categories10-year Risk of ASCVD Percentage from ASCVD Risk EstimatorLow< 5 Moderate5–7.4High≥ 7.5[VI. REFERENCES]Editor’s note: The reference section is a work in progress using keyed footnotes and will remain so until the editorial is finalized. At that time, the footnotes will be compiled as endnote citations.Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017 Mar 21;166(6):430-437. doi:10.7326/M16-1785.[ACP/AAFP] Whelton P, 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. American Heart Association Journals. 2017:e13-e115. doi: 10.1161/HYP.0000000000000065.[AHA]American Heart Association Recommendations for Physical Activity in Adults and Kids. . en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults. Accessed April 10, 2019. [AMER]Berlowitz D, Foy C, Kazis L, et al. Effect of Intensive Blood Pressure Treatment on Patient Reported Outcomes. New England Journal of Medicine. 2017 Aug 24; 377(8):733-744. doi: 10.1056/NEJMoa1611179.[BERLO]High Blood Pressure Fact Sheet|Data & Statistics|DHDSP|CDC. Centers for Disease Control and Prevention. . Published June 16, 2016. Accessed March 28, 2019. [CDC]Di Palo K, Kish T. The role of the pharmacist in hypertension management. Curr Opin Cardiol. 33(4):382–387, JUL 2018. DOI: 10.1097/HCO.0000000000000527. Accessed May 20, 2019. [Di Palo]Dieleman JL, Baral R, Birger M, et al. US spending on personal health care and public health, 1996–2013. JAMA. 2016;316(24):2627–2646. [DielmanJL] Home Blood Pressure Monitoring. European Cardiology Review 2015;10(2):95–101. Published October 5, 2015. Accessed April 4, 2019 10.15420/ecr.2015.10.2.95. [ECR]Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Journal of Hypertension. 2018;39(33):3021-3104. doi:10.1097/hjh.0000000000002017. [ESC/ESH]Alcohol and Public Health - Frequently Asked Questions. CDC. . Accessed April 24, 2019. [ETOH]Fisher, NDL, Fera, LE, Dunning, JR, et al. Development of an entirely remote, non‐physician led hypertension management program. Clin Cardiol. 2019; 42: 285–291. .[FISH]HandlerJ, Zhao Y, Egan B. Impact of the Number of Blood Pressure Measurements on Blood Pressure Classification in U.S. Adults. J Clin Hypertens (Greenwich). 2012 Nov; 14(11): 751–759.Published online 2012 Oct 22. doi: 10.1111/jch.12009. Accessed May 20, 2019. [HandlerJ]Kirkland EB, Heincelman M, Bishu KG, Schumann SL. Trends in Healthcare Expenditures Among U.S. Adults With Hypertension: National Estimates, 2003–2014. Journal of the American Heart Association. . Published May 30, 2018. Accessed March 29, 2019.[JAHA]James B, Poulsen G. The Case for Capitation. Harvard Business Review. July–August 2016. . Accessed April 24, 2019.[JamesB]Kripalani S, Goggins K, Nwosu S, et al. Medication Nonadherence Before Hospitalization for Acute Cardiac Events. J Health Commun. 2015;20 Suppl 2(0):34–42. doi:10.1080/10810730.2015.1080331.[KripalaniS]Self Measured Blood Pressure Monitoring - Action Steps for Public Health Practitioners. (2019). [ebook] Million Hearts website. . Accessed April 25, 2019.[MILLION]Hypertension overview. Hypertension - NICE Pathways. hypertension. Published March 27, 2018. Accessed March 26, 2019. [NICE]Rehman S, Nelson VL. Blood Pressure Measurement. [Updated March 12, 2019]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Available from: . Accessed April 19, 2019.[REH]Kumbhani DJ. Systolic Blood Pressure Intervention Trial - SPRINT. American College of Cardiology. . Published November 13, 2017. Accessed April 19, 2019.[SPRINT]Oza R, Garcellano M, Nonpharmacologic Management of Hypertension: What Works?Am Fam Physician.?2015?Jun?1;91(11):772-776. . Accessed May 10, 2019.[OZA] ................
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