Essential Hypertension (New Diagnosis)

CARDIOLOGY, Clinic A/P, adults, Clinic A/P, Peds

Definition of Hypertension.
Diagnosis
Hypertension guidelines (JNC8, etc) reviewed.
Will confirm dx by obtaining measurements outside of the clinical setting before starting treatment (per USPSTF 2015).
Given BP card and instructed on how to take home BPs.
Will initiate acquisition of home BP machine. Self-Measured Blood Pressure Monitoring lowers blood pressure compared to usual care (AFP 2015).
Diagnostic studies:
-CBC, CMP, Lipid panel, TSH, UA with protein/creatine ratio; ECG; A1C if not fasting.
-Microalbuminuria and echocardiogram if indicated.
Treatment
Lifestyle modifications: Diet (DASH), reduced sodium intake, limiting alcohol consumption, exercise, weight loss, and self-measurement of BP.
Pharmacotherapy: ACT (ACEI/ARBs, CCB, Thiazides).
Compelling indications for specific antihypertensive drugs considered.
Monitoring: Will repeat basic labs yearly or earlier if necessary. BP at every visit.

—END—

 

Important Information

  • 2017 ACC/AHA Hypertension Guidelines.
  • Thiazide diuretics slow demineralization of bones, even though effect wears down four months after stopping the medication. Consider in patients with osteoporosis or at risk for osteoporosis.
  • Creatinine increase after starting ACE: ACE inhibitors (e.g. lisinopril) do not need to be stopped unless baseline creatinine increases by >30%. If you start a patient on an ACE and it is working well to control the patient’s BP but Creatinine increases, continue the Rx as long as the creatinine increase is not more than 30% above baseline.
  • Limiting sodium intake to 2400 mg/day (approximately 1 teaspoon of table salt) is recommended to lower blood pressure. Additional benefit occurs with a limit of 1500 mg/day.
  • “Self-measured blood pressure monitoring, with or without additional support (e.g., education, counseling, telemedicine, home visits, Web-based logging), lowers blood pressure when compared with usual care, although the benefits beyond 12 months are not clear (SOR A).
  • DASH:  A diet that emphasizes vegetables, fruits, and whole grains is also recommended to lower blood pressure (SOR A),
  • Limiting alcohol consumption to no more than 2 drinks/day for men, and 1 drink/day for women (SOR C) also helps.

 

References

Am Fam Physician. 2015 Jun 1;91(11):772-776.
Arch Intern Med. 1999 Feb 8;159(3):285-93. https://www.ncbi.nlm.nih.gov/pubmed/9989541 (DASH diet lowers BP independent of weight loss or lowering sodium).
N Engl J Med. 1997 Apr 17;336(16):1117-24. https://www.ncbi.nlm.nih.gov/pubmed/9099655  (Also shows DASH diet lowers BP)
Am Fam Physician. 2015 Jun 1;91(11):772-776.

Click to access hbp_low.pdf

http://hyper.ahajournals.org/content/33/1/586
Am Fam Physician. 2017 Apr 15;95(8):492-500. http://www.aafp.org/afp/2017/0415/p492.html
Pediatric Hypertension edited by Joseph T. Flynn, Julie R. Ingelfinger, Ronald J. Portman, 3rd Edition, Chapter 37, page 558
www.uptodate.com/contents/management-of-severe-asymptomatic-hypertension-hypertensive-urgencies-in-adults
www.uptodate.com/contents/evaluation-and-treatment-of-hypertensive-emergencies-in-adults

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