M AY 2 0 0 8

CARE PROCESS MODEL

Hypertension Evaluation and Treatment

Appropriate Care CAN Significantly Reduce Risk

This provider education tool was developed by the Cardiovascular and Primary Care Clinical programs at Intermountain Healthcare (Intermountain). Its purpose is to promote best care for patients with hypertension. The goal is adequate blood pressure control: <140/90 mm Hg for most patients and <130/80 mm Hg for patients with diabetes or chronic kidney disease.
Why Focus on Hypertension?

Frequent, accurate blood pressure readings are vital to the diagnosis and ongoing

management of hypertension. Readings should take placeand be recordedboth in the office and outside the office (by the patient). Also, ambulatory blood pressure monitoring (ABPM) should be used whenever white-coat hypertension is a question. SelectHealth covers the use of ABPM.

Effective blood pressure control can be achieved in most hypertensive patients.

Although improving, hypertension control remains poor nationally and at Intermountain. Nationally, only 31% of patients with diagnosed hypertension have it

adequately controlled.1 At Intermountain, preliminary data shows that only 66% of SelectHealth patients are adequately controlled. Patients treated by providers educated on hypertension risks, and who received patient education on these risks, were better able to control their blood pressure.2

To achieve control, many patients may require 2 or more antihypertensive medicationsat adequate dosesas well as lifestyle modification.5, 6

In clinical trials, antihypertensive therapy has been associated with the following average risk reductions: 35-40% in stroke incidence, 20-25% in myocardial

Hypertension is a widespread and serious problem. Hypertension affects

infarction incidence, and more than 50% in heart failure incidence.7 A useful tool to help you assess risk/benefit for individual patients is the Heart Foundations Modified New Zealand Cardiovascular Risk Calculator, based on Framingham data.8
National Heart, Lung, and Blood Institute (NHLBI) Guidelines The recommendations in this CPM are derived from the NHLBIs clinical practice guidelines: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), published in 2003.9 These guidelines featured updated blood pressure categories, including a new prehypertension level. They also emphasized the use of diuretics (usually thiazide diuretics) as part of a medication plan for hypertension in most patients. A new report, JNC 8, is anticipated in 2009; an update to this CPM will incorporate these udpated guidelines. Whats new since JNC 7?
Since JNC 7 was published in 2003, additional hypertension research has focused on topics such as: The relative benefits of ACE inhibitors, ARBs, and ACE-ARB combination therapy.10 The benefits of treating hypertension in the elderly (>80 years old).11 Doubts about atenolol as a suitable drug for hypertensive patients, especially for prevention of stroke or reduction of cardiovascular mortailty.12 A future CPM revision will consider this research along with JNC 8 (anticipated in 2009). In the meantime, physicians are encouraged to use clinical judgment based on emerging evidence.

approximately 65 million people in the United States and is the most common primary care diagnosis in America.3 The relationship between BP and risk of CV events is continuous, consistent, and independent of other risk factors. The higher the BP, the greater the chance of heart attack, heart failure, stroke, and kidney disease. For individuals 40-70 years old, each increment of 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP doubles the risk of CVD (between BP ranges of 110/75 to 185/155).4

Patients lack awareness. 29% of patients arent aware that they have high blood

pressure.1 Those who are aware often dont understand the seriousness of the condition and the risk it poses. Sometimes their healthcare providers approach contributes to this.

Healthcare providers often undertreat. Why? Sometimes physicians are not

convinced a patient is truly hypertensive, often attributing elevated readings to white-coat hypertension. Also, physicians may not be convinced of the benefits of aggressive lifestyle management or drug therapy. They may be concerned about the cost or possible side effects of new medicationsor responding to a patients concern.

The inside pages of this tool provide an algorithm and associated quick reference tables, and can be folded open and posted in your office or clinic. The back page lists blood pressure medications, including Intermountain formulary.

Hypertension Evaluation and Treatment

Derived from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).8 Table a Table b Classification of Blood Pressure
Category Systolic mm Hg <120 120-139 140-159 >160 AND OR OR OR Diastolic mm Hg <80 80-89 90-99 >100

Measure Blood Pressurea

Blood Pressure Measurement Techniques

Method Notes
Average of 2 readings, 5 minutes apart, seated in chair, with elevated readings confirmed in contralateral arm. Repeat on each of 2 or more office visits. Indicated for evaluation of white-coat hypertension. Absence of a 10-20 percent BP decrease during sleep may indicate increased CVD risk. Persons with an average awake BP of more than 135/85 mm Hg or sleeping BP more than 125/75 are generally considered to be hypertensive. This monitoring is covered by many insurance companies. Provides information on response to therapy. Is useful for evaluating white-coat hypertension and may help improve adherence to therapy. Persons with an average BP of more than 135/85 mmHg measured at home are generally considered to be hypertensive.

In-office

Normal Prehypertension Hypertension, Stage 1 Hypertension, Stage 2

Classify Blood Pressureb

Ambulatory

If hypertensive or prehypertensive,

Perform Diagnostic Workup: Assess for CV risk factorsc, identifiable causesd, and CV and target organ diseasee

Patient selfmonitoring

Table c CV Risk Factors

Table d Identifiable Causes

Table e CV and Target Organ Disease

History & Physical Labs: urinalysis, blood glucose, hematocrit, lipid panel, serum potassium, creatinine, and calcium. Optional: urinary albumin/creatinine ratio. EKG

Obesity (body mass index >30 kg/m2) Dyslipidemia Diabetes mellitus Cigarette smoking Physical inactivity Microalbuminuria or estimated GFR <60 mL/min Age (>55 for men, >65 for women) Family history of premature CVD (men age <55, women age <65)

Primary aldosteronism (frequent in patients with diabetes mellitis type 2) Sleep apnea Drug induced/related Chronic kidney disease Renovascular disease Cushings syndrome or steroid therapy Pheochromocytoma Coarctation of aorta Thyroid/parathyroid disease

Heart left ventricular hypertrophy angina or prior MI prior coronary revascularization heart failure Stroke or TIA Chronic kidney disease Peripheral arterial disease Retinopathy

Advise Lifestyle Modifications (BP MAWDS)f

Table f

Lifestyle Modifications (BP MAWDS)

Encourage self-monitoringa. Provide BP Tracker, BP Basics, and diet education booklets.

SBP reduction (range) supported by clinical trials

Lifestyle modification can be tried for up to 6 months before considering drug therapy.

Medication - Take medications as prescribed. Activity - Perform regular aerobic activity (e.g., brisk walking) at least 30 minutes per day most days of the week. Weight Management - Maintain normal body weight (BMI 18.5 - 24.9 kg/m2). Diet - Based on DASH diet (Dietary Approaches to Stop Hypertension).

na 4-9 mm Hg 5-20 mm Hg / 10 kg 8-14 mm Hg 2-8 mm Hg 2-4 mm Hg na

Adopt a diet rich in fruits, vegetables, and low-fat dairy products with reduced content of saturated and total fat Reduce dietary sodium (<2400 mg per day) Limit alcohol consumption to 2 drinks or less for most men, 1 drink or less for women and lighter-weight men

Stress Management and No Smoking

Begin Drug Therapy

Drug abbreviation key: ACEI = ace inhibitor ALDO ANT = aldosterone receptor antagonist ARB = angiotensin receptor blocker BB = beta blocker CCB = calcium channel blocker LOOP = loop diuretic THIAZ = thiazide diuretic

NO

Compelling Indications?g

YES

No Compelling Indications (Treat to goal of <140/90 mmHg)

Compelling Indications (Treat to goal of <140/90 mmHg, or <130/80 mmHg for patients with diabetes, chronic kidney disease, or heart failure)
Drug Therapy Prehypertension SBP 120-139 or DBP 80-89 Stage 1 Hypertension SBP 140-159 or DBP 90-99 Stage 2 Hypertension SBP >160 or DBP >100 Only as needed for compelling indicationsg Drug(s) for compelling indicationsg Other antihypertensive drugs as needed (diuretics, ACEI, ARB, BB, CCB)

Table g
Compelling Indications Heart failure Drugs THIAZ, BB, ACEI, ARB, ALDO ANT, LOOP BB, ACEI, ARB, ALDO ANT THIAZ, BB, ACEI, CCB Front-line: ACEI, ARB Others: THIAZ, BB, CCB ACEI, ARB, LOOP THIAZ + CCB combo, ACEI

Drug Therapy

Prehypertension SBP 120-139 or DBP 80-89 Stage 1 Hypertension SBP 140-159 or DBP 90-99 Stage 2 Hypertension SBP >160 or DBP >100

None

Post myocardial infarction High CVD risk Diabetes Chronic kidney disease Recurrent stroke prevention

Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB, or combination 2-drug combinations for most (usually thiazide-type diuretic and ACEI, ARB, BB, CCB, or combination)

Reassess

Follow up at monthly intervals until BP goal is reached. More frequent visits may be necessary for patients with Stage 2 hypertension or complicating comorbid conditions.

Table h Causes of Resistant Hypertension

Inadequate diuretic therapy Improper BP measurement Excess sodium intake Excess alcohol intake Medication problems Inadequate doses Drug actions and interactions (e.g., NSAIDS, illicit drugs, sympathomimetics, oral contraceptives) Over-the-counter (OTC) drugs and herbal supplements

Follow up at 3-6 month intervals, more frequently as needed for comorbidities

YES

Goal BP met? (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes or chronic kidney disease)

NO

Optimize dosages or add additional drugs Assess for causes of resistant hypertensionh Reassess for identifiable causesd of hypertension Consider consultation with hypertension specialist

Blood Pressure Medications

Thiazide Diuretics (THIAZ) chlorothiazide1st tier (Diuril3rd tier) chlorthalidone1st tier (Hygroton3rd tier) hydrochlorothiazide1st tier (Microzide3rd tier, HydroDIURIL3rd tier) indapamide1st tier (Lozol3rd tier) metolazone1st tier (Mykrox3rd tier, Zaroxolyn3rd tier) Loop Diuretics bumetanide1st tier (Bumex3rd tier) furosemide1st tier (Lasix3rd tier) torsemide1st tier (Demadex3rd tier) K + - Sparing Diuretics amiloride1st tier (Midamor3rd tier) triamterene1st tier (Dyrenium3rd tier) Aldosterone Receptor Antagonists spironolactone1st tier (Aldactone3rd tier) eplerenone (Inspra2nd tier) ACE Inhibitors (ACEI) benazepril1st tier (Lotensin3rd tier) captopril1st tier (Capoten3rd tier) enalapril1st tier (Vasotec3rd tier) fosinopril1st tier (Monopril3rd tier) lisinopril1st tier (Prinivil3rd tier) moexipril1st tier (Univasc3rd tier) perindopril (Aceon2nd tier) quinapril1st tier (Accupril3rd tier) ramipril1st tier (Altace3rd tier) trandolapril1st tier (Mavik3rd tier) Angiotensin Receptor Blockers (ARB) candesartan (Atacand Step) eprosartan (Teveten Step) irbesartan (Avapro Step) losartan (Cozaar2nd tier) olmesartan (Benicar Step) telmisartan (Micardis Step) valsartan (Diovan2nd tier)
Intermountain Formulary:

References Combination Drugs

ACEI and Diuretic captopril/hydrochlorothiazide1st tier (Capozide3rd tier) enalapril/hydrochlorothiazide1st tier (Vaseretic3rd tier) lisinopril/hydrochlorothiazide1st tier (Prinzide3rd tier) moexipril HCI/hydrochlorothiazide1st tier (Uniretic3rd tier) quinapril HCI/hydrochlorothiazide1st tier (Accuretic3rd tier) ARB and Diuretic candesartan cilexetil/hydrochlorothiazide (Atacand HCT Step) eprosartan mesylate/hydrochlorothiazide (Teveten HCT Step) irbesartan/hydrochlorothiazide (Avalide Step) losartan potassium/hydrochlorothiazide (Hyzaar2nd tier) telmisartan/hydrochlorothiazide (Micardis HCT Step) valsartan/hydrochlorothiazide (Diovan HCT2nd tier) olmesartan HCT (Benicar HCT Step) ARB and CCB amlodipine/valsartan (Exforge2nd tier) amlodipine/olmesartan (Azor Step)

Beta Blockers
Preferred:

carvedilol1st tier (Coreg3rd tier) metoprolol extended release1st tier (Toprol XL3rd tier) atenolol1st tier (Tenormin3rd tier
Note: Recent research has cast doubts about atenolol as a suitable drug for hypertensive patients, especially for prevention of stroke or reduction of cardiovascular mortailty.12

1. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. 2003; 290:199-206. 2. Roumie CL, Elasy TA, Greevy R, et al. Improving Blood Pressure Control through Provider Education, Provider Alerts, and Patient Education. Ann Intern Med. 2006 Aug 1;145(3):165-75. 3. Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension. 2004;44:398-404. 4. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, for the Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-1913. 5. Cushman WC, Ford CE, Cutler JA, et al, and the ALLHAT Collaborative Research Group. Success and predictors of blood pressure control in diverse North American settings: The Antihypertensive and LipidLowering Treatment to Prevent Heart Attack Trial (ALLHAT). J Clin Hypertens (Greenwich). 2002;4:393-404. 6. Black HR, Elliott WJ, Neaton JD, et al. Baseline characteristics and elderly blood pressure control in the CONVINCE trial. Hypertension. 2001;37:12-18. 7. Neal B, MacMahon S, Chapman N, and the Blood Pressure Lowering Treatment Trialists Collaboration. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Lancet. 2000;356:195519-64. 8. Heart Foundation. Hypertension Management Guide for Doctors. 2004;6-7. Available at: www.heartfoundation.org.au/document/NHF/ hypertension_management_guide_2004.pdf Accessed Jan 9, 2008. 9. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252. Also at: www.nhlbi.nih.gov/guidelines/hypertension. Accessed Jan 9, 2008. 10. Yusuf S, Teo K, Pogue J, et al. Telmisartan, Ramipril, or both in patients at high risk for vascular events. NEJM. 2008;358:1547-1559. 11. Beckett N, Peters R, Fletcher A, et al. Treatment of hypertension in patients 80 years of age or older. NEJM. 2008;10.1056/NEJMoa0801369. At: content.nejm.org/cgi/content/full/ NEJMoa0801369. Accessed April 2, 2008. 12. Beckett N, Peters R, Fletcher A, et al. Atenolol in hypertension: is it a wise choice? Lancet. 2004;364(9446):1684-9.

Other:

betaxolol1st tier (Kerlone3rd tier) bisoprolol1st tier (Zebeta3rd tier) metoprolol1st tier (Lopressor3rd tier) nadolol1st tier (Corgard3rd tier) propranolol1st tier (Inderal3rd tier) propranolol long-acting (InnopranXL2nd tier) timolol1st tier (Blocadren3rd tier)

Alpha Blockers doxazosin1st tier (Cardura3rd tier) terazosin1st tier (Hytrin3rd tier) Calcium Channel Blockers non-dihydropyridines diltiazem immediate or extended release1st tier (Cardia XT1st tier, Diltia XT1st tier, Cardizem3rd tier, Cardizem CO3rd tier, Cardizem SE3rd tier, Dilacor XR3rd tier, Tiazac3rd tier) verapamil SR1st tier (Calan SR3rd tier, Isoptin SR3rd tier) Calcium Channel Blockers dihydropyridines amlodipine1st tier (Norvasc3rd tier) felodipine1st tier (Plendil3rd tier) isradipine 1st tier (Dynacirc CR3rd tier) nicardipine sustained release (Cardene SR3rd tier) nifedipine long-acting1st tier (Adalat CC3rd tier, Procardia XL3rd tier) nisoldipine (Sular3rd tier)

BB and Diuretic atenolol/chlorthalidone1st tier (Tenoretic3rd tier) bisoprolol fumarate/hydrochlorothiazide1st tier (Ziac3rd tier) propranolol/hydrochlorothiazide1st tier (Inderide3rd tier) metoprolol/hydrochlorothiazide (Lopressor HCT3rd tier)

Direct Renin Inhibitor aliskiren (Tekturna Step) Diuretic and Diuretic amiloride HCI/hydrochlorothiazide1st tier (Moduretic3rd tier) spironolactone/hydrochlorothiazide1st tier (Aldactazide3rd tier) triamterene/hydrochlorothiazide1st tier (Dyazide3rd tier, Maxzide3rd tier)

CCB and ACEI amlodipine/benazepril1st tier (Lotrel3rd tier) enalapril/felodipine1st tier (Lexxel3rd tier) trandolapril/verapamil (Tarka2nd tier)
These notations represent formulary information at the time of publication. For more recent information, visit selecthealth.org and use the prescription search function in the For Members area or call one of the following SelectHealth numbers: 442-4912 or 1-800-442-3129.

This and other materials to support best practice can be found at

intermountainhealthcare.org/clinicalprograms.

1st tier (listed in bold) = generic drugs (usually a $5-$10 copay) 2nd tier = preferred brand name (usually a $20-$25 copay) 3rd tier = non-preferred brand name (usually $35-$50 copay) Step = Step therapy, drugs covered by SelectHealth only after alternative therapy failed

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