VA/DoD Hypertension Clinical Practice Guideline

VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE DIAGNOSIS AND MANAGEMENT OF HYPERTENSION IN THE PRIMARY CARE SETTING

Department of Veterans Affairs

Department of Defense

QUALIFYING STATEMENTS

The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision-making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management.

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendations.

Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor

Version 3.0 ? 2014

Prepared by: The Diagnosis and Management of Hypertension

Working Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC

& Clinical Performance Assurance Directorate, United States Army MEDCOM

Version 3.0 ? 2014 Based on evidence reviewed through April 2014

October 2014

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Table of Contents

Table of Contents................................................................................................................................................... 3 Background............................................................................................................................................................ 5 About this Clinical Practice Guideline (CPG) ........................................................................................................... 6 Scope of this CPG ................................................................................................................................................... 6

Population .................................................................................................................................................................7 Intervention ...............................................................................................................................................................7

Key Differences in This Guideline Update .............................................................................................................. 7 Methods ................................................................................................................................................................ 8

Reconciling 2004 Guideline Recommendations.........................................................................................................9 Algorithm Format ....................................................................................................................................................10 Patient-Centered Care .............................................................................................................................................11 Implementation ....................................................................................................................................................... 12

Guideline Working Group .................................................................................................................................... 13 Algorithm ............................................................................................................................................................ 14 Recommendations............................................................................................................................................... 16 Screening, Diagnosis and Measurement of Hypertension .................................................................................... 21

Screening .................................................................................................................................................................21 Diagnosis .................................................................................................................................................................22 Measurement Techniques .......................................................................................................................................26

Adherence to Therapy ......................................................................................................................................... 29 Lifestyle Modification Therapies.......................................................................................................................... 31

Weight Reduction....................................................................................................................................................31 Exercise/Physical Activity ........................................................................................................................................32 Mind-body Therapies...............................................................................................................................................33 Dietary Modification ...............................................................................................................................................33 Sodium Reduction....................................................................................................................................................35 Alcohol Reduction....................................................................................................................................................37

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Pharmacological Therapy..................................................................................................................................... 37 Initiation of Pharmacotherapy ................................................................................................................................37 Blood Pressure Goals...............................................................................................................................................40 Hypertension Control and Follow-up.......................................................................................................................44 Monotherapy or Combination Therapy...................................................................................................................48 First-line Therapy.....................................................................................................................................................49 Alternative or Supplementary Therapies.................................................................................................................51 Specific Populations.................................................................................................................................................54

Appendix A: Evidence Review Methodology........................................................................................................ 60 Conducting the Systematic Review..........................................................................................................................60 Inclusion and Exclusion Criteria ...............................................................................................................................64 Outcomes ................................................................................................................................................................64 Literature Search Strategies ....................................................................................................................................65 Convening the Face-to-Face Meeting....................................................................................................................101 Grading Recommendations...................................................................................................................................101 Drafting and Submitting the Final CPG .................................................................................................................104

Appendix B: Evidence Table ............................................................................................................................... 105

Appendix C: Dietary Information ....................................................................................................................... 113

Appendix D: Blood Pressure Thresholds to Initiate Pharmacologic Therapy and Treatment Goals .................... 114

Appendix E: Drug Dosage Table ......................................................................................................................... 115

Appendix F: Participant List ............................................................................................................................... 118

Appendix G: Acronyms List ................................................................................................................................ 119

References......................................................................................................................................................... 122

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Background

This guideline developed under the auspices of the Veterans Health Administration (VHA) and the Department of Defense (DoD) pursuant to directives from the Department of Veterans Affairs (VA) is an update to the 2004 VA/DoD Clinical Practice Guideline for Diagnosis and Management of Hypertension in the Primary Care Setting.

Hypertension (HTN) is clinically defined as a systolic blood pressure (SBP) >140 mmHg or a diastolic blood pressure (DBP) of >90 mmHg. Prehypertension is classified as SBP 120-139 or DBP 80-89. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) went on to further classify hypertension into stages [1] (Stage 1: SBP 140159 mmHg or DBP 90-99; Stage 2: SBP >160 mmHg or DBP >100 mmHg), though the use of these stages has begun to be phased out. Hypertension is usually asymptomatic; therefore, routine screening is important in order to diagnose the condition. Also, because patients will mostly likely not feel symptoms, the asymptomatic nature of hypertension can lead to challenges with adherence to treatment.

Patients with hypertension either have primary or secondary hypertension. Primary, or essential, hypertension accounts for about 95% of cases and is a heterogeneous disorder in which different causal factors, including genetic predisposition, central adiposity, sedentary lifestyle, and dietary choices, can lead to high blood pressure. [2] Secondary hypertension is high blood pressure that results from an underlying and identifiable cause. [3] Main causes of secondary hypertension include adverse effects of medications, tobacco products or illegal drugs, renal disease, obstructive sleep apnea, pheochromocytoma, aldosteronism, and aortic coarctation.

Complications of hypertension include damage to the large arteries (macrovascular complications) that can lead to stroke, myocardial infarction (MI), or peripheral arterial diseases, as well as damage to the smaller arteries (microvascular complications) that can lead to chronic kidney disease (CKD) or retinopathy. In addition to these arterial complications, hypertension by itself can lead to left ventricular hypertrophy (LVH) and chronic heart failure (CHF), another frequent cause of death in the United States (US).

In the US, about 77.9 million adults (one out of every three) have hypertension. Of those only 81.5% are aware of their condition, 74.9% are undergoing treatment, and just over half (52.5%) have their hypertension controlled. [4] Uncontrolled hypertension has been shown to be higher in older Americans, non-Hispanic blacks and individuals with certain co-morbid conditions, including diabetes and CKD. [5]

In a 2008 study, it was found that 13% of active duty Service Members had hypertension, the majority of whom were ................
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