Priscilla Sepe, MD

The National Institutes of Health recently announced that it is no longer going to publish guidelines and that there will never be a JNC 8. This has left much of the primary care community without clear, current, and consensus-based guidelines for the treatment of hypertension. We thought that it would be helpful to review the most recent, annually updated evidence-based guidelines from the Canadian Hypertension Education Program (CHEP).

Initial diagnosis

CHEP guidelines present a conservative approach to diagnosis, placing strong weight on the use of home blood pressure measurement and repeated BP recordings before making a diagnosis of hypertension. If a patient’s systolic blood pressure (BP) is >140 mm Hg or the diastolic blood pressure is >90 mm Hg, BP should be rechecked within 1 month. A diagnosis of hypertension can be made at the second visit if the patient has a systolic BP >180 or a diastolic BP >110, or if BP >140/90 and there is macrovascular target organ damage, diabetes mellitus or chronic kidney disease. In the absence of those criteria, one of the following must be satisfied to establish a diagnosis of hypertension:

• Office BP measurement. Average systolic BP >160 or diastolic BP >100 across three visits, or average systolic BP >140 or diastolic BP >90 across five visits.

• Ambulatory BP measurement. Average awake systolic BP >135 or diastolic BP >85, or mean 24-hour systolic BP >130 or diastolic BP >80.

• Home BP measurement. Average systolic BP >135 or diastolic BP >85 (taken twice daily over a 7-day period, first day values discarded).

If a patient has a hypertensive urgency or emergency, then the diagnosis is made at the first visit, and diagnostic tests and therapeutic plans are determined at that point. Hypertensive urgency is defined as asymptomatic diastolic BP >130, or severe elevation of BP with encephalopathy, aortic dissection, heart failure, coronary syndrome, acute kidney injury, intracranial hemorrhage, acute stroke, or eclampsia.

Laboratory evaluation

All patients should initially have blood chemistry, urinalysis, fasting glucose, fasting cholesterol, and EKG. Diabetics should have urinary albumin assessed.

Treatment goals

• Systolic BP <140 and diastolic BP <90 for most patients.

• Systolic BP <150 in the very elderly (>80 years).

• BP <140/90 in nondiabetic chronic kidney disease patients.

• BP <130/80 in diabetes mellitus patients.

Therapy

• Lifestyle. Prescribe 30-60 minutes of moderate-intensity exercise 4-7 days/wk. Resistance or weight-training exercise does not adversely influence BP in prehypertension or stage 1 hypertension. Recommend weight reduction, limiting alcohol consumption, the DASH diet, limiting sodium intake, and stress management.

• Medication. Begin antihypertensives when average systolic BP >160 or diastolic BP >100 without macrovascular organ damage or other cardiovascular risk factors, or when systolic BP >140 or diastolic BP >90 in the presence of macrovascular organ damage or other cardiovascular risk factors. For the treatment of stage 1 hypertension, it is appropriate to attempt normalization of BP with nonpharmacologic management first, particularly if the patient is low risk.

Patients without compelling indications for specific agents

Diastolic hypertension with or without systolic hypertension:

• Monotherapy with thiazide diuretic, beta-blocker (patients <60 years), angiotensin-converting enzyme (ACE) inhibitor (nonblack patients), long-acting dihydropyridine calcium channel blocker, or angiotensin receptor blocker (ARB).

• Escalate therapy if target BP goal is not achieved. Additional medication should be chosen from first-line medications not already being used. The combination of an ACE inhibitor and an ARB should not be used. If target BP is not achieved, then additional agents should be tried.

• Consider starting with two agents if initial systolic BP is 20 mm Hg, or diastolic BP is10 mm Hg, above target. Use caution in elderly.

Isolated systolic hypertension:

• Monotherapy with thiazide diuretic, calcium channel blocker, or ARB.

• Escalate therapy with another drug from the same list.

Patients with selected compelling indications for specific agents

Hypertension and coronary artery disease:

• Most patients should be on an ACE inhibitor or ARB.

• For patients with stable angina, use beta-blockers as initial therapy. Calcium channel blockers can also be used but avoid short-acting nifedipine.

Hypertension and recent myocardial infarction :

• Initial therapy with both a beta-blocker and an ACE inhibitor or ARB.

• Calcium channel blockers can be substituted for beta-blockers if necessary.

Hypertension and heart failure:

• For patients with systolic dysfunction (ejection fraction <40%), initial therapy should be an ACE inhibitor and beta-blockers.

• Add an aldosterone antagonist for recent cardiovascular hospitalization, acute MI, elevated brain natriuretic peptide, or NYHA class II-IV symptoms. Monitor for hyperkalemia.

• Use thiazide diuretics for additional BP control, or loop diuretics for volume control.

• Use a combination of hydralazine and isosorbide dinitrate if unable to use an ACE inhibitor or ARB.

Hypertension and stroke/transient ischemic attack:

• If the patient is ineligible for thrombolytic therapy, do not treat hypertension in the first 72 hours as it may exacerbate or induce ischemia. If BP is extremely elevated (systolic >220 or diastolic >120),you can reduce BP by 15%, not greater than 25%, over a 24-hour period.

• If the patient is eligible for thrombolytic therapy, then concurrent treatment for very high BP (systolic >185 or diastolic >110) should be given to avoid secondary intracranial hemorrhage.

• Post stroke: Initiate treatment with an ACE inhibitor and/or a diuretic with a target BP <140/90.

Hypertension and left ventricular hypertrophy:

• Initial therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide.

• Avoid direct arterial vasodilators.

Hypertension and nondiabetic chronic kidney disease:

• If the patient has proteinuria, initial therapy should be an ACE inhibitor, or an ARB if intolerance to ACE inhibitors.

• Escalate with thiazide diuretic for BP control, loop diuretic for volume control.

• Target BP <140/90.

• Combination of an ACE inhibitor and an ARB is not recommended.

Hypertension and diabetes mellitus:

• Initiate therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide diuretic.

• Initiate therapy with ACE inhibitor or ARB if kidney disease, cardiovascular disease, or risk factors are present.

• Be cautious in initiating with two medications in elderly patients or those with autonomic neuropathy.

• The combination of an ACE inhibitor and a dihydropyridine calcium channel blocker is preferable to an ACE inhibitor and a thiazide diuretic.

Key points

The CHEP guidelines set specific and relatively conservative criteria for both diagnosing hypertension and starting antihypertensive medications. Delaying pharmacotherapy for low-risk patients while attempting lifestyle management is acceptable, and specific recommendations are made for pharmacologic therapy.

Reference: Hackam DG, Quinn RR, Ravani P, et al. The 2013 Canadian Hypertension Education Program (CHEP) recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can. J. Cardiol. 2013;29:528-42 (see www.hypertension.ca).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Sepe is a first year resident in the Family Medicine Residency Program at Abington Memorial Hospital.

The National Institutes of Health recently announced that it is no longer going to publish guidelines and that there will never be a JNC 8. This has left much of the primary care community without clear, current, and consensus-based guidelines for the treatment of hypertension. We thought that it would be helpful to review the most recent, annually updated evidence-based guidelines from the Canadian Hypertension Education Program (CHEP).

Initial diagnosis

CHEP guidelines present a conservative approach to diagnosis, placing strong weight on the use of home blood pressure measurement and repeated BP recordings before making a diagnosis of hypertension. If a patient’s systolic blood pressure (BP) is >140 mm Hg or the diastolic blood pressure is >90 mm Hg, BP should be rechecked within 1 month. A diagnosis of hypertension can be made at the second visit if the patient has a systolic BP >180 or a diastolic BP >110, or if BP >140/90 and there is macrovascular target organ damage, diabetes mellitus or chronic kidney disease. In the absence of those criteria, one of the following must be satisfied to establish a diagnosis of hypertension:

• Office BP measurement. Average systolic BP >160 or diastolic BP >100 across three visits, or average systolic BP >140 or diastolic BP >90 across five visits.

• Ambulatory BP measurement. Average awake systolic BP >135 or diastolic BP >85, or mean 24-hour systolic BP >130 or diastolic BP >80.

• Home BP measurement. Average systolic BP >135 or diastolic BP >85 (taken twice daily over a 7-day period, first day values discarded).

If a patient has a hypertensive urgency or emergency, then the diagnosis is made at the first visit, and diagnostic tests and therapeutic plans are determined at that point. Hypertensive urgency is defined as asymptomatic diastolic BP >130, or severe elevation of BP with encephalopathy, aortic dissection, heart failure, coronary syndrome, acute kidney injury, intracranial hemorrhage, acute stroke, or eclampsia.

Laboratory evaluation

All patients should initially have blood chemistry, urinalysis, fasting glucose, fasting cholesterol, and EKG. Diabetics should have urinary albumin assessed.

Treatment goals

• Systolic BP <140 and diastolic BP <90 for most patients.

• Systolic BP <150 in the very elderly (>80 years).

• BP <140/90 in nondiabetic chronic kidney disease patients.

• BP <130/80 in diabetes mellitus patients.

Therapy

• Lifestyle. Prescribe 30-60 minutes of moderate-intensity exercise 4-7 days/wk. Resistance or weight-training exercise does not adversely influence BP in prehypertension or stage 1 hypertension. Recommend weight reduction, limiting alcohol consumption, the DASH diet, limiting sodium intake, and stress management.

• Medication. Begin antihypertensives when average systolic BP >160 or diastolic BP >100 without macrovascular organ damage or other cardiovascular risk factors, or when systolic BP >140 or diastolic BP >90 in the presence of macrovascular organ damage or other cardiovascular risk factors. For the treatment of stage 1 hypertension, it is appropriate to attempt normalization of BP with nonpharmacologic management first, particularly if the patient is low risk.

Patients without compelling indications for specific agents

Diastolic hypertension with or without systolic hypertension:

• Monotherapy with thiazide diuretic, beta-blocker (patients <60 years), angiotensin-converting enzyme (ACE) inhibitor (nonblack patients), long-acting dihydropyridine calcium channel blocker, or angiotensin receptor blocker (ARB).

• Escalate therapy if target BP goal is not achieved. Additional medication should be chosen from first-line medications not already being used. The combination of an ACE inhibitor and an ARB should not be used. If target BP is not achieved, then additional agents should be tried.

• Consider starting with two agents if initial systolic BP is 20 mm Hg, or diastolic BP is10 mm Hg, above target. Use caution in elderly.

Isolated systolic hypertension:

• Monotherapy with thiazide diuretic, calcium channel blocker, or ARB.

• Escalate therapy with another drug from the same list.

Patients with selected compelling indications for specific agents

Hypertension and coronary artery disease:

• Most patients should be on an ACE inhibitor or ARB.

• For patients with stable angina, use beta-blockers as initial therapy. Calcium channel blockers can also be used but avoid short-acting nifedipine.

Hypertension and recent myocardial infarction :

• Initial therapy with both a beta-blocker and an ACE inhibitor or ARB.

• Calcium channel blockers can be substituted for beta-blockers if necessary.

Hypertension and heart failure:

• For patients with systolic dysfunction (ejection fraction <40%), initial therapy should be an ACE inhibitor and beta-blockers.

• Add an aldosterone antagonist for recent cardiovascular hospitalization, acute MI, elevated brain natriuretic peptide, or NYHA class II-IV symptoms. Monitor for hyperkalemia.

• Use thiazide diuretics for additional BP control, or loop diuretics for volume control.

• Use a combination of hydralazine and isosorbide dinitrate if unable to use an ACE inhibitor or ARB.

Hypertension and stroke/transient ischemic attack:

• If the patient is ineligible for thrombolytic therapy, do not treat hypertension in the first 72 hours as it may exacerbate or induce ischemia. If BP is extremely elevated (systolic >220 or diastolic >120),you can reduce BP by 15%, not greater than 25%, over a 24-hour period.

• If the patient is eligible for thrombolytic therapy, then concurrent treatment for very high BP (systolic >185 or diastolic >110) should be given to avoid secondary intracranial hemorrhage.

• Post stroke: Initiate treatment with an ACE inhibitor and/or a diuretic with a target BP <140/90.

Hypertension and left ventricular hypertrophy:

• Initial therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide.

• Avoid direct arterial vasodilators.

Hypertension and nondiabetic chronic kidney disease:

• If the patient has proteinuria, initial therapy should be an ACE inhibitor, or an ARB if intolerance to ACE inhibitors.

• Escalate with thiazide diuretic for BP control, loop diuretic for volume control.

• Target BP <140/90.

• Combination of an ACE inhibitor and an ARB is not recommended.

Hypertension and diabetes mellitus:

• Initiate therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide diuretic.

• Initiate therapy with ACE inhibitor or ARB if kidney disease, cardiovascular disease, or risk factors are present.

• Be cautious in initiating with two medications in elderly patients or those with autonomic neuropathy.

• The combination of an ACE inhibitor and a dihydropyridine calcium channel blocker is preferable to an ACE inhibitor and a thiazide diuretic.

Key points

The CHEP guidelines set specific and relatively conservative criteria for both diagnosing hypertension and starting antihypertensive medications. Delaying pharmacotherapy for low-risk patients while attempting lifestyle management is acceptable, and specific recommendations are made for pharmacologic therapy.

Reference: Hackam DG, Quinn RR, Ravani P, et al. The 2013 Canadian Hypertension Education Program (CHEP) recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can. J. Cardiol. 2013;29:528-42 (see www.hypertension.ca).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Sepe is a first year resident in the Family Medicine Residency Program at Abington Memorial Hospital.

The National Institutes of Health recently announced that it is no longer going to publish guidelines and that there will never be a JNC 8. This has left much of the primary care community without clear, current, and consensus-based guidelines for the treatment of hypertension. We thought that it would be helpful to review the most recent, annually updated evidence-based guidelines from the Canadian Hypertension Education Program (CHEP).

Initial diagnosis

CHEP guidelines present a conservative approach to diagnosis, placing strong weight on the use of home blood pressure measurement and repeated BP recordings before making a diagnosis of hypertension. If a patient’s systolic blood pressure (BP) is >140 mm Hg or the diastolic blood pressure is >90 mm Hg, BP should be rechecked within 1 month. A diagnosis of hypertension can be made at the second visit if the patient has a systolic BP >180 or a diastolic BP >110, or if BP >140/90 and there is macrovascular target organ damage, diabetes mellitus or chronic kidney disease. In the absence of those criteria, one of the following must be satisfied to establish a diagnosis of hypertension:

• Office BP measurement. Average systolic BP >160 or diastolic BP >100 across three visits, or average systolic BP >140 or diastolic BP >90 across five visits.

• Ambulatory BP measurement. Average awake systolic BP >135 or diastolic BP >85, or mean 24-hour systolic BP >130 or diastolic BP >80.

• Home BP measurement. Average systolic BP >135 or diastolic BP >85 (taken twice daily over a 7-day period, first day values discarded).

If a patient has a hypertensive urgency or emergency, then the diagnosis is made at the first visit, and diagnostic tests and therapeutic plans are determined at that point. Hypertensive urgency is defined as asymptomatic diastolic BP >130, or severe elevation of BP with encephalopathy, aortic dissection, heart failure, coronary syndrome, acute kidney injury, intracranial hemorrhage, acute stroke, or eclampsia.

Laboratory evaluation

All patients should initially have blood chemistry, urinalysis, fasting glucose, fasting cholesterol, and EKG. Diabetics should have urinary albumin assessed.

Treatment goals

• Systolic BP <140 and diastolic BP <90 for most patients.

• Systolic BP <150 in the very elderly (>80 years).

• BP <140/90 in nondiabetic chronic kidney disease patients.

• BP <130/80 in diabetes mellitus patients.

Therapy

• Lifestyle. Prescribe 30-60 minutes of moderate-intensity exercise 4-7 days/wk. Resistance or weight-training exercise does not adversely influence BP in prehypertension or stage 1 hypertension. Recommend weight reduction, limiting alcohol consumption, the DASH diet, limiting sodium intake, and stress management.

• Medication. Begin antihypertensives when average systolic BP >160 or diastolic BP >100 without macrovascular organ damage or other cardiovascular risk factors, or when systolic BP >140 or diastolic BP >90 in the presence of macrovascular organ damage or other cardiovascular risk factors. For the treatment of stage 1 hypertension, it is appropriate to attempt normalization of BP with nonpharmacologic management first, particularly if the patient is low risk.

Patients without compelling indications for specific agents

Diastolic hypertension with or without systolic hypertension:

• Monotherapy with thiazide diuretic, beta-blocker (patients <60 years), angiotensin-converting enzyme (ACE) inhibitor (nonblack patients), long-acting dihydropyridine calcium channel blocker, or angiotensin receptor blocker (ARB).

• Escalate therapy if target BP goal is not achieved. Additional medication should be chosen from first-line medications not already being used. The combination of an ACE inhibitor and an ARB should not be used. If target BP is not achieved, then additional agents should be tried.

• Consider starting with two agents if initial systolic BP is 20 mm Hg, or diastolic BP is10 mm Hg, above target. Use caution in elderly.

Isolated systolic hypertension:

• Monotherapy with thiazide diuretic, calcium channel blocker, or ARB.

• Escalate therapy with another drug from the same list.

Patients with selected compelling indications for specific agents

Hypertension and coronary artery disease:

• Most patients should be on an ACE inhibitor or ARB.

• For patients with stable angina, use beta-blockers as initial therapy. Calcium channel blockers can also be used but avoid short-acting nifedipine.

Hypertension and recent myocardial infarction :

• Initial therapy with both a beta-blocker and an ACE inhibitor or ARB.

• Calcium channel blockers can be substituted for beta-blockers if necessary.

Hypertension and heart failure:

• For patients with systolic dysfunction (ejection fraction <40%), initial therapy should be an ACE inhibitor and beta-blockers.

• Add an aldosterone antagonist for recent cardiovascular hospitalization, acute MI, elevated brain natriuretic peptide, or NYHA class II-IV symptoms. Monitor for hyperkalemia.

• Use thiazide diuretics for additional BP control, or loop diuretics for volume control.

• Use a combination of hydralazine and isosorbide dinitrate if unable to use an ACE inhibitor or ARB.

Hypertension and stroke/transient ischemic attack:

• If the patient is ineligible for thrombolytic therapy, do not treat hypertension in the first 72 hours as it may exacerbate or induce ischemia. If BP is extremely elevated (systolic >220 or diastolic >120),you can reduce BP by 15%, not greater than 25%, over a 24-hour period.

• If the patient is eligible for thrombolytic therapy, then concurrent treatment for very high BP (systolic >185 or diastolic >110) should be given to avoid secondary intracranial hemorrhage.

• Post stroke: Initiate treatment with an ACE inhibitor and/or a diuretic with a target BP <140/90.

Hypertension and left ventricular hypertrophy:

• Initial therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide.

• Avoid direct arterial vasodilators.

Hypertension and nondiabetic chronic kidney disease:

• If the patient has proteinuria, initial therapy should be an ACE inhibitor, or an ARB if intolerance to ACE inhibitors.

• Escalate with thiazide diuretic for BP control, loop diuretic for volume control.

• Target BP <140/90.

• Combination of an ACE inhibitor and an ARB is not recommended.

Hypertension and diabetes mellitus:

• Initiate therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide diuretic.

• Initiate therapy with ACE inhibitor or ARB if kidney disease, cardiovascular disease, or risk factors are present.

• Be cautious in initiating with two medications in elderly patients or those with autonomic neuropathy.

• The combination of an ACE inhibitor and a dihydropyridine calcium channel blocker is preferable to an ACE inhibitor and a thiazide diuretic.

Key points

The CHEP guidelines set specific and relatively conservative criteria for both diagnosing hypertension and starting antihypertensive medications. Delaying pharmacotherapy for low-risk patients while attempting lifestyle management is acceptable, and specific recommendations are made for pharmacologic therapy.

Reference: Hackam DG, Quinn RR, Ravani P, et al. The 2013 Canadian Hypertension Education Program (CHEP) recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can. J. Cardiol. 2013;29:528-42 (see www.hypertension.ca).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Sepe is a first year resident in the Family Medicine Residency Program at Abington Memorial Hospital.