Recognizing and Treating Hypertension 2002 Clinical Practice Guidelines for Adults > 18 Years Old Guidelines are designed to assist clinicians by providing a framework for the evaluation and treatment of patients. These guidelines outline the preferred approach for most patients. They are not intended to replace a clinician's judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem. The purpose of treating hypertension is to reduce the incidence of stroke, MI, renal failure and heart failure. Unless contraindicated or there is a compelling indication to use other medication, low dose diuretic therapy should be used as first or second line therapy. 1. ESTABLISHING THE DIAGNOSIS The diagnosis of hypertension should be based on the confirmation of elevated readings on two or more subsequent visits to the physician or health care professional over a period of one or more weeks. • Readings should be taken with the patient seated with their back supported and their arms bared and supported at heart level. • After five minutes of rest, the reading is made using an appropriate cuff size • When the readings are separated by more than 5 mm Hg additional readings should be taken and averaged • When the average of two or more blood pressure readings (taken two minutes apart and being less than 5 mmHg different) is elevated, hypertension is suspected • Additional readings are recommended in patients suspected of having "white coat" hypertension • Blood pressure should be measured at each health care encounter 2. GOAL OF THERAPY Set a clear goal of therapy based on patient’s risk • Uncomplicated hypertension or coronary heart disease (CHD) . . . . . .<140/90mmHg • Heart failure or target organ damage . . . . . . . . . . . . . . . . . . . . . . . . .<130/85mmHg • Diabetes mellitus (DM) and/or chronic kidney disease . . . . . . . . . . . .<130/80mmHg • Renal Failure with proteinuria >1gram/24hours . . . . . . . . . . . . . . . . .<125/75mmHg 3. RISK STRATIFICATION AND TREATMENT Risk stratification and treatment should include major cardiovascular risk factors and TOD/CCD (target organ disease/clinical cardiovascular disease). BLOOD PRESSURE STAGES High-normal (130-139/ 85-89 mmHg) (Optimal <120/80 mmHg) Stage 1 (140-159/90-99 mmHg) RISK GROUP A (No risk factors*, No TOD/CCD**) Lifestyle modification Lifestyle modification (up to 12 months) RISK GROUP B (At least 1 risk factor, not including diabetes; No TOD/CCD Lifestyle modification Lifestyle modification (up to 6 months) With multiple risk factors, consider medication therapy as initial therapy with lifestyle changes Lifestyle modification with medication therapy RISK GROUP C (TOD/CCD and/or diabetes mellitus) Lifestyle modification and medication therapy for patients with CHF or chronic kidney disease. Lifestyle modification with medication therapy Stages 2 and 3 (>160 / >100 mmHg) Diabetes mellitus (130-139/ 80-89mmHg) (>140/ >90mmHg) Lifestyle modification with medication therapy Lifestyle modification with medication therapy Lifestyle modification (up to 3 months) then add medication therapy if not at goal Lifestyle modification with medication therapy * Risk Factors – Tobacco use, dyslipidemia, diabetes mellitus, age>60years, gender (men and post menopausal women), history of family member (women<age 65; Men <age 55) **TOD/CCD (target organ disease/clinical cardiovascular risk disease) – Heart disease (left ventricular hypertrophy, angina, prior MI, prior CABG, heart failure), CVA or TIA, nephropathy, peripheral arterial disease or retinopathy 4. LIFESTYLE MODIFICATION Lifestyle modifications are effective at lowering blood pressure and are the cornerstone of any hypertensive treatment plan. When these changes alone do not control blood pressure, they may reduce the number and dose of anithypertensive medications. It is important that caregivers consider referrals to registered dietitians and exercise experts to help patients initiate changes, and continue to support these changes at follow-up visits. The Dietary Approaches to Stop Hypertension (DASH) study demonstrated significant reductions in systolic and diastolic LIFESTYLE ELEMENT Weight blood pressure by dietary change. The DASH diet includes 810 servings of fruits and/or vegetables and 2-3 servings of low-fat dairy products per day. This diet leads to an average 11.6/5.3mmHg blood pressure reduction. The DASH-Sodium diet adds a 1500 -2400 mg/day sodium limitation to these guidelines and can achieve an additional 3.5/2.2mmHg blood pressure reduction, which is equal to or greater than singledrug therapy. For additional provider and patient information on the DASH diet, go to http://www.nhlbi.nih.gov/health/public/heart/ hbp/dash/new _dash.pdf RECOMMENDATIONS Weight loss in patients who are overweight or obese Reduce or eliminate alcohol COMMENTS Weight loss can lower blood pressure, increase the efficacy of anti-hypertensive medications and reduce cardiovascular risk factors such as diabetes and dyslipidemia. As little as a 10 pound loss may improve blood pressure. Alcohol is a risk factor for hypertension, contributes excess calories, can reduce efficacy of antihypertensive medications, and increases the risk of stroke. Have no more than one alcoholic drink per day if you're a woman and no more than two if you're a man. "One drink" means it has no more than 1/2 ounce of pure alcohol. Examples of one drink are 12 oz. of beer, 4 oz. of wine, 1-1/2 oz. of 80-proof spirits or 1 oz. of 100-proof spirits. Exercise contributes to weight loss and reduces the risk of cardiovascular disease and overall mortality. Practitioners should assess risk, preferably with an exercise test, to guide recommendation for high-risk patients, or those with multiple risk factors, and should advise medically supervised programs if blood pressure response to exercise is a potential concern. African Americans, older patients and people with hypertension or diabetes mellitus are the most sensitive to changes in sodium intake. Processed foods (canned soups and vegetables, frozen and boxed dinners, chips, luncheon meats, etc) and foods eaten out are responsible for 50-75% of the sodium in the American diet. Additional provider and patient information is available at http://rover2.nhlbi.nih.gov/hbp/prevent/ sodium/sodium.htm and http://www.nhlbi.nih.gov/health/public/heart/ hbp/hbp_low/eat_plan.htm Adequate intakes of these nutrients contribute to control of hypertension. Food is the best source, since research has not shown consistent blood pressure improvement from supplements. Potassium, mg Calcium, mg Magnesium, mg Cooked beans, 1 c.700-1000 Baked potato, 1 med 850 Squash, sweet potato, 1 c. 900 Cooked spinach, 1c. 850 Banana, 1 med. 600 Canned tomato, 1 c. 600 Orange jc or melon, 1 c. 500 Yogurt or milk, 1 c. 300-450 Sardines w/bones, 3 oz 325 Fortified cereal, 1 c. 300 Cooked spinach, 1 c. 275 Cooked beans, 1 c. 200 Cottage cheese, 1c. 160 Tofu, 4 oz 130 Cooked spinach, 1.c 160 Pumpkin seeds, 1 oz150 Cooked beans, 1 c. 130 Halibut, 4 oz 120 Brown rice, 1 c. 85 Nuts, 1 oz 70 Haddock or cod, 4 oz 60 Alcohol Physical Activity 30-45 minutes of moderately intense physical activity most days of the week, with a target of 150 minutes per week. Limit to 2400 mg per day, although additional benefits may be obtained with restriction to 1500 mg/day Sodium Potassium, Magnesium, and Calcium Recommendations for good health – Potassium – 3500 mg/day Calcium – 1000 mg/day Magnesium – 400 mg/day Most salt substitutes contain potassium and may be helpful to some, but should not be used in patients with renal failure, and should be used with caution in patients on ACE inhibitors or angiotensin II receptor blockers. Tobacco and second-hand smoke Smoking cessation and avoidance of second-hand smoke Tobacco and its by-products increase cardiovascular risk and may make anithypertensive medications less effective. Each cigarette causes an increase in blood pressure. The cardiovascular benefits of smoking cessation are evident in one year. For specialty consults or additional information in nutrition, contact the UW Health Preventive Cardiology Program at 608-263-7420, the UW Health Nutrition Center at 608-287-2780 or one of the UW Health Outpatient Nutrition Clinics at UW Hospital – 608-263-4360, West Clinic – 608-262-9181, East Clinic – 608-2657405, University Station – 608-263-7772. Consult local facilities and providers for additional resources in your area. 2 5. TREATMENT OF HYPERTENSION This is a simplified algorithm designed to cover a large majority of hypertensive patients. See medication notes for details. Establish Diagnosis Begin or continue lifestyle modification Initiate Medication Diuretics should be part of most medication regimens and part of all 3 medication regimens General Population ▼ 1st Diuretic Coronary Artery Disease ▼ 1st B-blocker Heart Failure ▼ 1st ACE-I ARB if cough or angioedema with ACE-I and B-blocker Toprol XL if class II or III ▼ 2nd Loop Diuretic Myocardial Infarction ▼ 1st Cardioselective B-blocker and ACE-I - if systolic dysfunction ▼ 2nd ACE-I Diabetes Mellitus ▼ 1st ACE-I ARB if cough or angioedema with ACE-I African American ▼ 1st Diuretic Geriatric Patients ▼ 1st Diuretic Isolated Systolic Hypertension ▼ 1st Diuretic ▼ 2nd B-blocker or ACE-I ▼ 2nd ACE-I ▼ 2nd B-blocker ▼ 2nd DHPCCB or ACE-I if renal dysfunction or microalbuminuria ▼ 2nd B-blocker ▼ 2nd DHPCCB or B-blocker Follow up in 3 - 4 weeks Follow patients more closely if blood pressure is very high. Medication usually reach effectiveness in 3-4 weeks. If follow-up is greater than 4 weeks, patient adherence to medication or lifestyle drops significantly. Inadequate Blood Pressure Response Inadequate response at target dose or side effects Inadequate response at target dose but well tolerated ▼ Substitute another medication from a different class ▼ Add a 2nd agent from a different class (diuretic therapy – see “Initiate Medication” above) Once an adequate blood pressure response has been obtained, patients should be followed every 6 months with appropriate monitoring of labs, if needed. SELECTION OF DRUG THERAPY SHOULD BE BASED ON CLINICAL STATUS OF THE PATIENT AND COMORBIDITIES Drug Abbreviation Key ACE-I . . . . . .Angiotensin converting enzyme inhibitor ARB . . . . . .Angiotensin receptor blocker B-blocker . . .Beta-blocker CCB . . . . . . .Calcium channel blocker DHPCCB . . . .Dihydropyridine calcium channel blocker For specialty consultations or additional assistance contact the UWMF Preventive Cardiology Program at 608-263-7420 or 608-263-1530, or consult local facilities and providers for additional resources in your area. 3 6. MEDICATION NOTES DIURETICS • Diuretics are recommended for initial therapy unless a compelling indication is met • Diuretics are synergistic with all other classes of anti-hypertensives medications and should be part of most medication regimens • Low doses (12.5-25mg HCTZ) should be used unless the patient has heart failure or chronic kidney disease, then use a loop diuretic (furosemide) • Diuretics should be considered part of all 3 medication regimens • JNC VI defines resistant hypertension as not controlled on 3 medications, one of which should be a diuretic • Diuretics reduce reflex fluid retention associated with lowering blood pressure and must be added prior to calling a patient “hypertension resistant” ACE-I and ARB • ACE-I and ARBs have once daily dosing. • With the exception of captopril, based on kinetics and mechanism of action, twice daily dosing is not more effective in treating hypertension. Twice daily dosing may be better tolerated in older patients and those with CHF. • ARBs are alternatives for patients with ACE-I associated cough or angioedema • In patients over 55 years old with another cardiovascular risk factor (history of cardiovascular disease, dyslipidemia, microalbuminuria and smoking) an ACE-I, if not contraindicated, should be considered to reduce the risk of cardiovascular events. • Labs – Diuretics, ACE-I and ARB – Check BUN, creatine and potassium 6 weeks after initiation and yearly thereafter, unless symptoms suggest renal or electrolyte disorders. More frequent monitoring is recommended if other drugs that affect renal function or potassium homeostasis are being used. COMPELLING INDICATIONS DIABETES MELLITUS • ACE-I provides maximum cardiovascular and renal benefits • In patients with microalbuminuria or clinical albuminuria, use ACE-I or ARB • B-blockers and diuretics are second line agents • Benefit from MI/stroke reduction from beta blockade outweighs the risk of masking hypoglycemia • B-blockers and long-acting diltiazem are appropriate alternatives for patients who do not tolerate or whose HTN is not controlled on ACE-I plus low dose diuretic therapy HEART FAILURE • Mild symptoms – start with ACE-I • ACE-I should be titrated to the highest dose tolerated, even if blood pressure is low, as long as the patient does not become symptomatic or develop impaired renal perfusion • ARB may be substituted for ACE-I when ACE-I is not tolerated • B-blockers should be started if the patient has ischemic heart disease, is post MI, has angina or after reaching ACE-I target dose. Titrate to the highest dose tolerated • Spironolactone should be considered after the patient is placed on the maximum doses of ACE-I and B-blocker • Diuretics (usually loop) are often used acutely for fluid management ISOLATED SYSTOLIC HYPERTENSION • Low dose diuretics (12.5-25mg HCTZ)and Dihydropyridine calcium channel blocker (DHPCCB) reduce the incidence of stroke, CAD, CHF, and mortality in older patients COMMON FALLACIES REGARDING THE TREATMENT OF HYPERTENSION TOPIC Diastolic vs Systolic Hypertension Diuretics FALLACY Diastolic hypertension is associated with greater risk of stroke and mortality Metabolic and electrolyte disturbances preclude the use of diuretics in many patients If inadequate response on one antihypertensive medication, add a second that is not a diuretic TRUTH Systolic hypertension is associated with a greater risk of stoke and mortality and is the most neglected type of hypertension Low dose (12.5-25mg) hydrochlorothiazide is unlikely to have any significant effect on blood glucose levels, or depletion of electrolytes in the long-term for most patients. Concurrent use of a fixed-dose combination, such as triamterene with an ACE-I, may elevate serum potassium. When target blood pressure is not reached with one anti-hypertensive medication, the addition of low dose diuretic (12.5-25mg hydrochlorothiazide) therapy is effective and usually should be the next step Beta-blockers are a logical choice in patients with type II diabetes and coronary artery disease. Availability of generic ACE inhibitors have made them relatively inexpensive Reducing dietary sodium and other nutritional and lifestyle changes can lead to significant drops in blood pressure Alcohol may increase blood pressure in many patients. Ask patients to limit alcohol to few social occasions if they have hypertension. Beta-Blockers Beta-blockers should not be used in diabetic patients because of the potential to mask hypoglycemia ACE inhibitors are more expensive than beta-blockers Dietary sodium restriction plays a minor contribution to blood pressure control Alcohol is good for the heart ACE Inhibitors Dietary Sodium Alcohol 4 7. Medication Quick Reference Guide CLASS Diuretic FORMULARY MEDICATIONS DOSE STRENGTHS 25, 50 mg 12.5, 25 mg 0.5, 1, 2 mg 20, 40 , 80 mg 200, 400 mg 25, 50, 100 mg 50, 100 mg 25, 50, 100, 200 mg 20, 40, 80, 160 mg 5, 10 mg 10, 20, 40, 60, 80, 90 mg 60, 80, 120, 160 mg 100, 200, 300 mg 3.125, 6.25, 12.5, 25 mg 5, 10, 20, 40 mg 12.5, 25, 50, 100 mg 2.5, 5, 10, 20 mg 2.5, 5, 10, 20, 40 mg 5,10,20,40mg 25, 50, 100 mg 80, 160 mg 2.5, 5, 10 mg 2.5, 5, 10 mg 120, 180, 240, 360 mg 30, 60, 90, 120 mg 120, 180, 240, 300 mg UNITY Y Y Y Y Y Y Y PA Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y PPIC N Y N Y Y Y Y PA Y Y Y Y Y PA Y Y Y Y N Y N Y PA Tabs Y Diltia- XT Tiazac GHC MM* Y Y Y Y Y Y Y PA Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y GHC Y Y Y Y Y Y Y PA Y Y Y Y Y Y N Y Y Y Y Y Y N Y Y Y Y RELATIVE COST (Avg 30-day supply) $$ $ $$ $ $$ $ $ $$$ $$ $$ $ $$$$ $$ $$$$ $$ $ $ $$ $ $$$ $$$ $ $$ $ $$ $$ chlorthalidone hydrochlorothiazide bumetanide (loop) furosemide (loop) B-Blocker acebutololº atenololº metoprololº metoprolol XL(Toprol XLº) nadolol pindolol propranolol propranolol LA A/B-Blocker labetalol carvedilol (Coreg) ACE-I benazepril (Lotensin) captopril enalapril lisinopril (Prinivil) quinapril (Accupril) ARB losartan (Cozaar) valsartan (Diovan) Dihydropyridine CCB felodipine (Plendil) amlodipine (Norvasc) CCBºº (short-acting verapamil extended release -24 hr nifedipine is not diltiazem listed due to adverse diltiazem extended release – 24 hr cardiac side effect profile) * GHCMM= GHC Merck Medco Formulary º Cardioselective beta-blocker ºº PPIC covers verapamil tablets only. NOT capsules. PPIC ONLY covers Diltia XT (generic Dilacor) and Tiazac. PPIC does NOT cover generic Cardizem CD. N = No, not on formulary Y = Yes, on formulary PA = Prior Authorization COMBINATION THERAPY Class Potassium sparing diuretic B-Blocker Diuretic ACE-I Diuretic ARB Diuretic Formulary Medications Dose Strengths Unity PPIC GHC MM* Y Y Y Y Y Y Y Y N GHC Relative Cost (Avg 30-day supply) $ $ $ $$ $$ $$ $$ $$$ $$$ triamterene/HCTZ** atenolol/chlorthalidone propranolol/HCTZ benazepril/HCTZ (Lotensin HCT) lisinopril/HCTZ (Prinzide) losartan/HCTZ (Hyzaar) valsartan/HCTZ (Diovan HCT) Dihydropyridine CCB amlodipine/benazepril (Lotrel) ACE-I felodipine/enalapril (Lexxel) 37.5/25, 50/25, 75/50mg 50/25, 100/25 mg 40/25, 80/25 mg 5/6.25,10/12.5, 20/12.5, 20/25 mg 10/12.5, 20/12.5, 20/25 mg 50/12.5, 100/25 mg 80/12.5, 160/12.5mg, 160/25mg 2.5/5, 5/10, 5/20 mg 2.5/5, 5/5 mg Y Y Y Y Y Y Y Y Y Y N N Y N Y N N N Y Y Y N Y Y Y PA N * GHCMM= GHC Merck Medco Formulary ** HCTZ=hydrochlorothiazide; for products that do not have combination products on formulary (e.g. metoprolol), adding HCTZ is effective. N = No, not on formulary Y = Yes, on formulary PA = Prior Authorization 5 REFERENCES 1. JNC VI. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Int Med. 1997;157 (24): 24132446. 2. The American Society of Hypertension Home Page [resource on World Wide Web]. URL: http://www. ash-us.org. Available from Internet. accessed 2/1/02. 3. The American Heart Association Home Page [resource on World Wide Web]. URL: http://www.americanheart.org. Available from Internet. accessed 2/1/02. 4. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type II diabetes. (UKPDS 38). BMJ. 1998;317:703-713. 5. Hansson L, Lindholm LH, Niskanen L, et al for the CAPPP Study Group. Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPPP) randomized trial. The Lancet. 1999;353:611-616. 6. Hansson L., et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: Principal results of the Hypertension Optimal Treatment (HOT) randomized trial. The Lancet. 1998;351 (9119): 1755-1762. 7. Dagnenais GR, Yusuf S, Bourassa MG, et al for the HOPE Investigators. Effects of ramipril on coronary events in high risk persons: results of the heart outcomes prevention evaluation study. Circulation. 2001;104:522-526. 8. Sica DA, Douglas JG. The African American study of kidney disease and hypertension (AASK): new findings. J Clin Hypertension. 2001;3:244-251. 9. Byinton RP, et al. Rational, design, and baseline characteristics of the prospective randomized evaluation of the vascular effects of Norvasc trial (PREVENT). Am J of Cardiology. 1997;80(8):1087-1090. 10. Levin A, et al. Cardiovascular disease in chronic renal insufficiency. AJKD. 2000;36:S24-S30. 11. Bakris GL, Williams M, Dworkin L, et al, for the National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Preserving renal function in adults with hypertension and diabetes: a consensus approach. Am J Kidney Dis. 2000;36:646-661. 12. American Diabetes Association. The treatment of hypertension in adult patients with diabetes (Technical Review). Diabetes Care. 2002; 25:134-147. 13. Moser M (letter). Is it time for a new approach to the initial treatment of hypertension. Arch Intern Med. 2001;161:1140-1144. 6 14. Bakris GL, et al. Preserving renal function in adults with hypertension and diabetes: a consensus approach. AJKD. 2000:36:646-661. 15. Lewis EJ, Humsicker LG, Clarke WR, et al, for the Collaborative Study Group. Renoprotective effect of the angiotensin receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851-860. 16. Brenner BM, Cooper ME, DeZeeuw D, et al, for the RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345:861-869. 17. Bakris GL. A practical approach to achieving recommended blood pressure goals in diabetic patients. Arch Intern Med. 2001;161:2661-2667. 18. Tuomilehto J, Rastenyte D, Birkenhager WH, et al, for the Systolic Hypertension in Europe Trial Investigators. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. N Engl J Med. 1999;340:677-684. 19. Neaton JD, Grimm RH, Prineas RJ, et al. Treatment of Mild Hypertension Study: Final Results. JAMA. 1993;2770:713-724. 20. Sowers JR, et al. for the National Heart Lung Blood Institute, NIH National High Blood Pressure Education Program (NHBPEP). World wide web at www.nhlbi.nih.gov/health/prof/heart/hbp/hpb_diab.htm accessed 10/11/01. ACKNOWLEDGEMENTS University of Wisconsin Medical Foundation, University of Wisconsin Hospitals and Clinics, Meriter Hospital, Unity Health Insurance, Physicians Plus Insurance Corporation, Group Health Cooperative, and Community Physicians Network have cooperated in the revision of these guidelines. This task force was a multidisciplinmary work group of physicians, nurse practitioners, pharmacists and a dietitian. Patrick McBride, MD and James Stein, MD, both faculty physicians at the University of Wisconsin Medical School, led the revision efforts. Additional contributors were: Melissa Meredith, MD; Bryan Becker, MD; Lawrence Fleming, MD, MBA; Derek Hubbard, MD; Richard Day, MD; Gail Underbakke, RD,MS; Marvin Wiener, MD. Please direct questions, comments and suggestions regarding these guidelines to Pam Kittleson, RPh, UWMF provider education pharmacist, at firstname.lastname@example.org. Reviewed and updated April 2002. Scheduled for reconsideration first quarter 2004. Jointly sponsored by the University of Wisconsin Medical School, the University of Wisconsin Medical Foundation and the Office of Continuing Medical Education.