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Latest revision as of 17:03, 25 April 2024

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [5]; Associate Editor(s)-In-Chief: Yazan Daaboul; Serge Korjian; Ryan Norman; Arzu Kalayci, M.D. [6]

Overview

To review the 2017 AHA/ACC guidelines on HTN, click here.

Blood Pressure Goals

Recommendations for treatment goals from recent clinical practice guidelines are tabulated below. However, treated based on underlying risk rather than a blood pressure target may be more effective^[1]. The logic supporting a target of 130/80 mm Hg has been disputed^[2] and the Cochrane Collaboration found insufficient evidence to determine a treatment goal for adults^[3] or adults over 65 years of age^[4].

If the goal is 130/80, proper measurement includes (distilled from Table 8 of the ACC/AHA guidelines^[5], executive summary^[6]):

having the patient sit quietly for 5 minutes before a reading is taken
supporting the limb used to measure BP
ensuring the BP cuff is at heart level
using the correct cuff size
for auscultatory readings, deflating the cuff slowly
the timing of BP measurements in relation to ingestion of the patient’s medication should be standardized
a single reading is inadequate for clinical decision-making. An average of 2 to 3 BP measurements obtained on 2 to 3 separate occasions will minimize random error and provide a more accurate basis for estimation of BP.

If the above measurement methods are not use, a preliminary study from Kaiser Northern California suggests a target of 140 mm Hg^[7].

AHA^[5] vs Roerecke^[8] estimates of relationship between routine, auscultated BP measurement and gold standard ambulatory measurement.
Clinic (routine) AHA, 2017^[5]	Clinic (routine) Roerecke, 2018^[8]	Clinic (automated) Roerecke, 2018^[8]	Home (self) AHA, 2017	Daytime, ambulatory †	Nighttime ambulatory AHA, 2017^[5]	24 hour ambulatory^[8] AHA, 2017^[5]^[5] †
120/80	125/82	120/80	120/80	120/80	100/65	115/75
130/80	145/85	130/80	130/80	130/80	110/65	125/75
140/90	150/90	135/85	135/85	135/85	120/70	130/80
160/100	160/95	145/90	145/90	145/90	140/85	145/90
Notes: † Benegas found that the 24-hour ambulatory systolic pressure may better predict mortality than the daytime systolic blood pressure.^[9] The article by Benegas was subsequently retracted in 2020^[10] but later republished in 2023 now stating that the nighttime blood pressure was the strongest predictor^[11].

Practice guidelines comparison^[6]^[12]^[13]
	Goal < 60 years old	Goal >= 60 years old	High risk
JNC-8, 2014^[13]	140/90	150/90*
ACP/AAFP, 2017^[12]	Not applicable	150 or 140 if high risk
HEDIS and MIPS QI Measures	< 140/90
Kaiser, 2019^[14]	140/90		Kaiser states "In adults with ASCVD, CKD, age > 75 years, or 10-year ASCVD risk > 10%, consider treating to a goal SBP of < 130 mm Hg" This is consistent with more agressive treatment in the SPRINT trial^[15].
AHA/ACC/others, 2017^[6]	< 130/80†
* Treat to 140/90 if age >=60 with DMII or CKD. † Treat if > 140/90 or 130/80 if high risk which is defined as existing cardiovascular disease, 10-year cardiovascular risk ≥10%, diabetes, or CKD.

Newer randomized controlled trials have identified conflicting benefits to more intensive therapy.

Randomized controlled trials of lower treatment goals
	Patients			BP target in intervention group	Final BP in intervention group	Primary outcome (composite) (Hazard ratio)
	Baseline blood pressure	Estimated cardiac risk (calculated with pooled cohort equation)	Outcome rate in the control group	BP target in intervention group	Final BP in intervention group	Primary outcome (composite) (Hazard ratio)
ACCORD, 2010^[16]	140/76	All patients were diabetic 9% for anglo women and 23% for anglo men	2.1% per year	SBP 120 vs 140	119/64	0.88 (95% CI: 0.73 to 1.06)
SPRINT, 2015^[15]	140/78	No diabetics 16% for anglo women and 23% for anglo men (20% overall)	2.2% per year	SBP 120 vs 140	121/67	0.75 (95% CI: 0.64 to 0.89)
HOPE-3, 2016^[17]	138/82	16% for anglo women and 23% for anglo men	1.7% per year*	No target BP. Intervention group all received candesartan 16 mg per day plus hydrochlorothiazide 12.5 mg per day	128/76	0.93 (95% CI: 0.79 to 1.10)
Notes: * 1.7% is the sum of the two co-primary outcomes. The HOPE-3 also reported 4.4% over 5.6 years.

In the ACCORD (Action to Control Cardiovascular Risk in Diabetes) randomized controlled trial patients with average blood pressure of 140/76 mm Hg and diabetes did not benefit from targeting a systolic blood pressure of less than 120 mm Hg (average 119/64 mm Hg), as compared with less than 140 mm Hg.^[16]
- Assuming the average patient in this trial was a nonsmoker and was diabetic, the estimated 10-year cardiovascular risk is 9% for anglo women and 23% for anglo men.
In the SPRINT randomized control trial, patients with an average blood pressure of 140/78 mm Hg and at high risk for CVD but who do not have a history of stroke or diabetes, intensive BP control (target SBP <120 mm Hg) that lowered systolic blood pressure to an average of 121/67 mm Hg improved CV outcomes and overall survival compared to standard therapy, while modestly increasing the risk of some serious adverse events^[15].
- Assuming the average patient in this trial was not diabetic, 50% were smokers (per their publication)), 33% were women, and LDL was 113 (per their publication Friedrwald estimate is 191 - 53 - 125/5)) the estimated 10-year cardiovascular risk is 12% for anglo women and 20% for anglo men.
- The number needed to treat (NNT), is about 200 (185) for the primary outcome (1.65% vs 2.19%) by dropping the systolic pressure by 15 mm Hg.
In the HOPE-3 trial randomized controlled trial, patients with an average blood pressure of 138/82 mm HG and with intermediate risk who did not have cardiovascular disease lowering systolic blood pressure to an average of 128 mm Hg was insignificantly beneficial. ^[17]
- Assuming the average patients in this trial was a nonsmoker and not diabetic, the estimated 10-year cardiovascular risk is 10% for anglo women and 19% for anglo men.
- Benefit was found in a subgroup analysis of patients with systolic blood pressure above 144 mm Hg (mean 154 mm Hg).

Debate exists on how low should physicians target blood pressure in their patients especially in light of studies that have shown a J or U-shaped curve phenomenon associated with hypertension treatment where low and very high blood pressure values are associated with increased risk of cardiovascular events.^[18] A less strict target in diabetic and elderly patients is in the new ADA and ESH/ESC 2013 clinical practice guidelines respectively. This rationale is supported by the fact that lower SBP targets in diabetic patients have not been shown to generate better outcomes.^[19] Similarly, treatment of stage 1 hypertension in elderly patients and targeting SBP values to <140 mmHg have not been well substantiated and may sometimes carry more risk than benefit.^[20]

Practice Guidelines

American College of Cardiology / American Heart Association

The ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 2017 clinical practice guidelines^[5], executive summary^[6], and underlying systematic review^[6] by the ACC/AHA taskforce recommend a treatment goal for everyone is <130/80 mm Hg:

	Definition	Treatment
Elevated blood pressure	Systolic BP, 120–129 mm Hg - and - Diastolic BP, <80 mm Hg	Lifestyle
Stage 1 hypertension	Systolic BP, 130–139 mm Hg - or - Diastolic BP, 80–89 mm Hg	Lifestyle and Medications if high risk*
Stage 2 hypertension	Systolic BP, ≥140 mm Hg - or - Diastolic BP, ≥90 mm Hg	Lifestyle and Medications
* High risk defined as existing cardiovascular disease or 10-year cardiovascular risk ≥10% (calculator and alternative calculator with facts box)

American College of Physicians / American Academy of Family Physicians

For patients aged 60 or more, the American College of Physicians and American Academy of Family Physicians clinical practice guideline^[12] and underlying systematic review^[21] from 2017 recommend:

" initiate treatment in adults aged 60 years or older with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg"
"consider initiating or intensifying pharmacologic treatment in adults aged 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mm Hg"
"consider initiating or intensifying pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mm Hg"

Eighth Joint National Committee (JNC 8)

JNC 8 recommendations in 2014 for BP goals:^[13]

Strong evidence for BP goal less than 150/90 mm Hg for patients above age 60.
Strong evidence exists for a diastolic goal of less than 90 mm Hg for hypertensive patients between ages 30 - 59.
There is insufficient evidence for patients below age 60 for a systolic goal, or in those below age 30 for a diastolic goal, so the panel recommended a BP of less than 140/90 mm Hg for those groups based on expert opinion.

Kaiser Guidelines

The Kaiser Permanente hypertension protocol ^[22] and San Francisco safety net clinics ^[23] Kaiser Permanente approached chronic disease with a model using “...implementation, dissemination, and performance feedback approaches...” with a goal of exceeding 85% control of hypertension in their patient population2. The strategies proposed were 1) hypertension registry 2) standardization of blood pressure measurements 3) internal treatment algorithm 4) multidisciplinary approach ^[22].

1. Creating a hypertension patient registry (2000 and 2004)

Facilitate provider performance feedback with an accurate capture of all hypertensive patients in one database.
Required one hypertension code and at least one antihypertensive medication OR diagnosis of stroke, CKD, CAD, or DM.
There was a 60% increase in growth of registry that corresponded with a 30% increase in hypertension control.

2. Simplified intensification of therapy

One consistent algorithm was utilized for treatment protocols and laminated cards were given to all physicians as reminders.
Thiazide or combination pill (Lisinopril-HCTZ 20-25 ½ pill) as first line, regardless of stage.
B-blockers removed from first line options.

3. Standardized blood pressure measurements: staff trained and continuously evaluated through validated peer review and feedback (did they say anything about how long to rest)?

Bare arm during measurement
Arm supported at heart level
Appropriate cuff side
No talking during measurement

These techniques accompanied by consistent peer training and feedback led to a reduction in technique errors by 40%.

4. Team-based interdisciplinary BP checks by RNs and pharmacists.

BP check visits led by non-physicians facilitated access, more frequent visits, and treatment intensification

Blood pressure control outcomes for Kaiser

A recent Kaiser study has achieved 90% blood pressure control within their Medicare population^[24] while the national average remains around 70% in the same population per HEDIS measures by NCQA^[25].

Implementation of a modified Kaiser protocol in a vulnerable population led to an increase in the percent of patients with controlled hypertension from a baseline of 68% to 74% over the course of fifteen months.^[23].

Clinical outcomes for Kaiser

Regarding efficacy in the real world^[26], Kaiser Permanente Northern California has published findings that their decline and cardiovascular mortality exceeds the national decline^[27]. An unpublished report states that death from cardiac disease is now less than common death from cancer in Kaiser Permanente Northern California^[28].

Kaiser Permanente Southern California has shown that death from heart disease is now less common that death from cancer^[29].

A preliminary study from Kaiser Northern California suggests a target of 140 mm Hg^[30].

ESH/ESC 2013 Guidelines

ESH/ESC 2013 Guidelines. Approach to medical therapy of hypertension.

Adult aged ≥18 years
with hypertension

Implement lifestyle interventions
(continue throughout management)

Set blood pressure goal
Inititate BP lowering-medication

General population
(no diabetes or CKD)

Diabetes
or CKD present

Age ≥60 years

Age <60 years

All ages
Diabetes present
No CKD

All ages
CKD present with
or without diabetes

Blood pressure goal
SBP <150 mm Hg
DBP <90 mm Hg

Blood pressure goal
SBP <140 mm Hg
DBP <90 mm Hg

Nonblack

Black

All races

Initiate thiazide-type diuretic
or ACEI or ARB or CCB,
alone or in combination

Initiate thiazide-type diuretic
or CCB, alone or in combination

Initiate ACEI or ARB, alone or in combination with other drug class.

Select a drug treatment titration strategy
A. Maximize 1^st medication before adding 2^nd
OR
B. Add 2^nd medication before reaching maximum dose of 1^st medication
OR
C. Start with 2 medication classes separately or as fixed-dose combination

At goal blood pressure?

Yes

No

Reinforce medication and lifestyle adherence.

For strategies A and B:
Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI & ARB).
For strategy C:
Titrate doses of initial medications to maximum.

At goal blood pressure?

Yes

No

Reinforce medication and lifestyle adherence.

Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI & ARB).

At goal blood pressure?

Yes

No

Reinforce medication and lifestyle adherence.

Add additional medication class (eg, β-blocker, aldosterone antagonist, or others) and/or refer to physician with expertise in HTN management.

No

At goal blood pressure?

Yes

Continue current treatment
and monitoring.

Antihypertensive Agents & Indications

Common Antihypertensive Agents

Several classes of medications are used in the treatment of hypertension namely diuretics, ACE inhibitors, angiotensin receptor blockers, beta-blockers, alpha-blockers, and direct vasodilators. Below is a list of common oral agents used in the treatment of hypertension.

JNC8: Common oral antihypertensive agents^[31]

Class	Drug	Usual Dose Range (mg/day)
Thiazide Diuretics	Chlorothiazide	125-500
	Chlorthalidone	12.5-25
	Hydrochlorothiazide	12.5-50
	Polythiazide	2-4
	Indapamide	1.25-2.5
	Metolazone	0.5-5
Loop Diuretics	Bumetanide	0.5-2
	Furosemide	20-80
	Torsemide	2.5-10
Potassium-sparing Diuretics	Amiloride	5-10
Potassium-sparing Diuretics	Triamterene	50-100
Aldosterone Receptor Diuretics	Spironolactone	25-50
Aldosterone Receptor Diuretics	Eplerenone	50-100
Beta-Blockers	Atenolol	25-100
	Betaxolol	5-20
	Bisoprolol	2.5-10
	Metoprolol	50-100
	Metoprolol extended release	50-100
	Nadolol	40-120
	Propranolol	40-160
	Propranolol long-acting	60-180
	Timolol	20-40
Beta-Blockers with intrinsic sympathomimetic activity	Acebutolol	200-800
	Penbutolol	10-40
	Pindolol	10-40
Combined Alpha- and Beta-Blockers	Carvedilol	12.5-50
Combined Alpha- and Beta-Blockers	Labetalol	200-800
ACE Inhibitors	Benazepril	10-40
	Captopril	25-100
	Enalapril	5-40
	Fosinopril	10-40
	Lisinopril	10-40
	Moexipril	7.5-30
	Perindopril	4-8
	Quinapril	10-80
	Ramipril	2.5-20
	Trandolapril	1-4
Angiotensin Receptor Blockers	Candesartan	8-32
	Eprosartan	400-800
	Irbesartan	150-300
	Losartan	25-100
	Olmesartan	20-40
	Telmisartan	20-80
	Valsartan	80-320
Nondihydropyridine Calcium Channel Blockers	Diltiazem extended release	120-540
	Verapamil immediate release	80-320
	Verapamil long acting	120-480
	Verapamil	120-360
Dihydropyridine Calcium Channel Blockers	Amlodipine	2.5-10
	Felodipine	2.5-10
	Isradipine	2.5-10
	Nicardipine sustained release	60-120
	Nifedipine long-acting	30-60
	Nisoldipine	10-40
Alpha-1 Blockers	Doxazosin	1-16
	Prazosin	2-20
	Terazosin	1-20
Centrally Acting Drugs	Clonidine	0.1-0.8
	Methyldopa	250-1000
	Reserpine	0.1-0.25
	Guanfacine	0.5-2
Direct Vasodilators	Hydralazine	25-100
Direct Vasodilators	Minoxidil	2.5-80

Choice of Initial Agent

Clinical practice guidelines vary in their recommendations for selection of initial medication^[6]^[12]^[13]^[32].

Selecting medication based on patient demographics

Some authors have proposed that either the renin level or the renin level indexed to urinary sodium excretion in 24 hours.^[33]^[34] However, the Veterans Affairs Cooperative trial suggests the initial drug may be better selected based on the patient's age, race, and gender.^[35]^[36] The patient's demographic roughly corresponds with their renin profile, but is more predictive than the renin profile.^[36] In the Veterans Affairs Cooperative, among the high renin demographic (young whites), diuretics had similar efficacy to placebo; whereas in the low renin demographic (older blacks), the ace-inhibitors had similar efficacy to placebo in the Veterans Affairs Cooperative Study Group on Antihypertensive Agents (see figure).^[35]

Another randomized controlled trial conducted in Scandinavia, but results not stratified by demographics, found that hydrochlorothiazide was less effective^[37]. Frequencies of racial and ethnic groups were not reported.

Selecting fixed-dose combination pills

Two cohort studies suggest that fixed-dose combination pills enhance adherence when compared to monotherapy^[38]^[39]. The increased adherence may lead to improved clinical outcomes^[39]. Therefore, it would not be unreasonable to consider starting combination therapy in order to increase patient compliance, a known barrier to hypertension pharmacotherapy.

Using up to 50 mg per day of hydrochlorothiazed, as recommended by Kaiser, is supported by dose-response studies summarized by the Cochrane Collaboration^[40]. Previouslky, hydrochlorothiazide a a dose of 100 mg per day, without postassium sparing therapy, was associated with increased risk of cardiac arrest^[41].

JNC7: Compelling Indications and Choice of Antihypertensive Agents^[31]

Clinical trials and basis for compelling indications for individual drug classes

Compelling Indication	Recommended Drugs	Clinical Trial Basis
Heart failure	Diuretics, Beta blockers, ACEIs, ARBs, Aldosterone antagonist	ACC/AHA Heart Failure Guideline ^[42]; MERIT-HF ^[43];COPERNICUS ^[44]; CIBIS ^[45]; SOLVD ^[46]; AIRE ^[47]; TRACE ^[48]; ValHEFT ^[49]; RALES ^[50]
Post-Myocardial infarction	Beta blockers, ACEIs, Aldosterone antagonist	ACC/AHA Post-MI Guideline ^[51]; BHAT ^[52]; SAVE ^[53]; CAPRICORN ^[54]; EPHESUS ^[55]
High coronary disease risk	Diuretics, Beta blockers, ACEIs, CCBs,	ALLHAT ^[56]; HOPE^[57]; ANBP2 ^[58]; LIFE ^[59]; CONVINCE ^[60]
Diabetes	Diuretics, Beta blockers, ACEIs, ARBs, CCBs	NKF-ADA Guideline ^[61]^[62];UKPDS ^[63]; ALLHAT ^[56]
Chronic kidney disease	ACEIs, ARBs	NFK Guideline ^[62]; Captopril Trial ^[64]; RENAAL ^[65]; IDNT ^[66]; REIN ^[67]; AASK ^[68]
Recurrent stroke prevention	Diuretics, ACEIs	PROGRESS ^[69]

Contraindicated medications

Chronic hypertension is considered an absolute contraindication to the use of the following medications:

Severe uncontrolled arterial hypertension is considered an absolute contraindication to the use of the following medications:

ESH/ESC 2013 Guidelines: Drugs to be Preferred in Specific Conditions ^[32]

Patient Characteristic	Drug
Asymptomatic organ damage
Left Ventricular Hypertrophy	ACE inhibitor, calcium antagonist, ARB
Asymptomatic atherosclerosis	Calcium antagonist, ACE inhibitor
Microalbuminuria	ACE inhibitor, ARB
Renal dysfunction	ACE inhibitor, ARB
Clinical CV event
Previous stroke	Any agent effectively lowering BP
Previous myocardial infarction	BB, ACE inhibitor, ARB
Angina pectoris	BB, calcium antagonist
Heart failure	Diuretic, BB, ACE inhibitor, ARB, mineralocorticoid receptor antagonists
Aortic aneurysm	BB
Atrial fibrillation, prevention	Consider ARB, ACE inhibitor, BB or mineralocorticoid receptor antagonist
Atrial fibrillation, ventricular rate control	BB, non-dihydropyridine calcium antagonist
ESRD/proteinuria	ACE inhibitor, ARB
Peripheral artery disease	ACE inhibitor, calcium antagonist
Other
ISH (elderly)	Diuretic, calcium antagonist
Metabolic syndrome	ACE inhibitor, ARB, calcium antagonist
Diabetes mellitus	ACE inhibitor, ARB
Pregnancy	Methyldopa, BB, calcium antagonist
Blacks	Diuretic, calcium antagonist

Methods of monitoring blood pressure

Self-monitoring of blood pressure (SMBP)

According to systematic review in 2017 ^[70], self-monitoring blood pressures alone is not an effective treatment for high blood pressure. However, as an adjunct to interventions such as patient education, medication titration, and lifestyle counselling, self-monitoring blood pressures significantly aids in controlling patient blood pressure. “Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (−3.2 mmHg, [95% CI −4.9, −1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (−1.0 mmHg [−3.3, 1.2]), to a 6.1 mmHg (−9.0, −3.2) reduction when monitoring was combined with intensive support.”

This assessment is supported by another systematic review in 2018 ^[71], who determined that self-monitoring blood pressures significantly helps control patient blood pressure by aiding in physician anti-hypertensive medication titration. “Compared with usual care, the decrease in clinic measured systolic blood pressure at 12 months in patients in both self-monitoring groups was clinically meaningful. The adjusted mean differences vs usual care: self-monitoring alone −3.5 mm Hg [95% CI −5.8 to −1.2]; and telemonitoring −4.7 mm Hg [–7.0 to −2.4]). If sustained, such reductions in blood pressure could be expected to reduce stroke risk by 20% and coronary heart disease risk by 10%.”

Digital Remote Patient Monitoring (RPM)

RPM may reduce mortality and hospital visits according to an observational study^[72].

Team-Based Care, Interdisciplinary Approach to Hypertension Management

Recent literature suggests that an interdisciplinary approach to hypertension provides higher control rates and more comprehensive management of hypertension on a population level. ^[73] ^[73] Team-based care is cost-effective^[74].

Systems-based interventions such as increasing the role of medical assistants and pharmacists in the management of hypertension has shown the most marked improvements in control. Other interventions include single-pill medical therapy, monitoring visits with medical assistants, creating a hypertension registry, and home blood pressure management. ^[75] ^[76] ^[77] ^[78]

When a team approach is used to manage hypertension, the addition of pharmacists alone were found to have the most substantial effect on hypertension control at the population level. ^[77]
There is conflicting evidence on home-monitoring alone as an effective method for increasing blood pressure control. ^[79] ^[70] ^[80]
Interventions such as optimizing single pill combination medications or promoting home blood pressure monitoring have not been shown to provide significant improvements in blood pressure when implemented alone.

Management of Hypertension in Special Populations

Diabetic Patients

According to the American Diabetes Association, BP goal for diabetic patients must be < 140/80 mmHg to reduce the progression of target organ damage but that lower systolic blood pressure targets <130 mmHg can be targeted in younger patients.^[19] The recent shift in the approach to hypertension in diabetics proposed by the 2013 ADA guidelines as well as the 2013 ESH/ESC guidelines is supported by the fact that no major trials have consistently achieved a blood pressure level below 130/80 mmHg in diabetics nor have the smaller trials shown any major benefit from intensive treatment to reach that threshold. In parallel to the ADA, the 2013 ESH/ESC guidelines only support a lower DBP goal set at 80-85 mmHg.^[32]

According to the American Diabetes Association, ACEI and ARBs are considered superior agents in diabetic patients for their renal protective effects (delay in both GFR decrease and albuminuria worsening).^[81] Although RAAS blockers such as ACEI and ARBs are beneficial their combination can sometimes have significant effects on renal function especially in high risk patients.^[82]

Thiazide-type diuretics were shown to be beneficial in reducing heart disease in diabetic patients.^[83] Despite their side effects of worsening hyperglycemia, thiazide-type diuretics were associated with stable target organ damage compared to other anti-hypertensive agents.^[84]

According to the LIFE study, beta-blockers are especially beneficial in diabetic patients with ischemic heart disease despite their controversial role as monotherapy.^[85] Even though decreased insulin sensitivity is a side effect, beta-blockers are not absolutely contraindicated in diabetes.^[86]

In the management of hypertension, CCBs are unquestionably useful in the reduction of BP values. However, their role in preventing target organ damage in diabetic patients is inferior to other agents. The ALLHAT study demonstrated that amlodipine, a DHP CCB, was less effective than thiazides in reducing heart failure.^[83] Similarly, the ABCD Trial also showed that nisoldipine, a dihydropyridine CCB was less effective than enalapril, an ACEI, in reducing ischemic heart disease.^[87]

Chronic Kidney Disease Patients

Based mostly on the results from meta-analyses of patients with proteinuria showing slower rate of CKD progression when SBP was targeted to <130 mmHg, JNC7 and the National Kidney Foundation recommended a set BP goal below 130/80 mmHg for all CKD patients and the use of more than a single agent for therapy. The recommended treatment regimen usually includes an ACEI or ARB in combination with a loop diuretic. ^[31]

In 2012, the KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease recommended that diabetic and non-diabetic patients with CKD without proteinuria or microalbuminuria should be treated if their BP measurements are consistently above 140/90 mmHg. Target of treatment in this group is to maintain blood pressure below 140/90 mmHg. In patients with CKD and microalbuminuria or proteinuria, initiation of therapy should be at BP values >130/80 mmHg with target below 130/80 mmHg. The guidelines also advocated the use ACEIs and ARBs in patients with microalbuminuria or proteinuria. Lifestyle modifications proposed included lowering salt intake to <2g per day of sodium, exercise for at least 30 minutes 5 times per week.

In contrast, the 2013 ESH/ESC guidelines updated their old recommendations, changing the blood pressure target to <140/90 mmHg, no different than the general population. They based their recommendations on three trials^[88]^[89]^[90] conducted in patients with chronic kidney disease without diabetes, that showed no difference in ESRD progression and all-cause mortality between patients randomized to low BP targets (<130 mmHg) to those randomized to a higher target (<140 mmHg). To note, observational follow-up data from 2 of these studies showed a tendency to lower adverse events in the lower target group especially in patients with proteinuria.^[20]

Patients with Metabolic Syndrome

Metabolic syndrome as a clinical concept is largely debatable, mostly since studies have shown little added benefit of the definition on the predictive power of each of the constitutive individual factors, making recommendations about hypertension treatment in this subpopulation limited.^[32]

Lifestyle modification plays the most important role in anti-hypertensive therapy in patients with metabolic syndrome.

Persistence of high BP > 140/90 mmHg still warrants pharmacologic therapy.

Management of dyslipidemia, glucose intolerance, and other concomitant comorbidities is essential for reduction of BP in patients with metabolic syndrome.^[86]

Ethnic groups

African Americans: Enforcement of DASH diet due to its association with greater reduction of BP than other ethnicities.^[91] According to the ALLHAT trial that included 15,000 Blacks, diuretics were more effective for African Americans than other classes of anti-hypertensive agents.^[83]

Mexican Americans, other Hispanic Americans, Native Americans, and Asian/Pacific Islanders have been recruited in insufficient numbers in research trials to adequately identify special considerations.^[86]

Elderly Patients

There is particular advantage in weight loss and reduced sodium intake in elderly subjects. Trial of Non-pharmacologic Interventions in the Elderly (TONE) showed that sodium intake of less than 80 mmol per day (2 g of sodium per day or 5 grams of sodium chloride salt) could allow the discontinuation of anti-hypertensive agents in 40% of elderly.^[92]

The 2013 ESH/ESC guidelines modified the approach adopted in 2007 to treat hypertension regardless of age. The new guidelines advocate holding medical therapy for elderly patients with stage 1 hypertension and initiating treatment only in those with stage 2 hypertension or greater. It is also recommended to target a SBP below 150 mmHg rather than 140mmHg. This rationale follows several studies involving elderly patients not achieving blood pressure measurements below 140mmHg. In patients below 80 years of age, treatment can be targeted below 140 mmHg if goal can be tolerated.^[32]

The HYpertension in the Very Elderly Trial (HYVET) showed that in patients older than 80 years-old with SBP >160mmHg, a significant reduction in major CV events and all-cause mortality can be seen by aiming at SBP values <150mmHg. ^[93]

The JNC7 guidelines concluded in 2004 that antihypertensive therapy should not be withheld in patients with stage 1 hypertension based on age, even though no RCTs had shown benefits from treatment in this population at the time.

Pregnant Women

Distinguishing gestational from pre-gestational hypertension in pregnant women is essential. Hypertension is not considered to be caused by pregnancy when it develops before 20 weeks of gestation.^[86]

Hypertensive women who plan to become pregnant should be instructed to use safe anti-hypertensive medications, such as methyldopa preferentially because long-term follow up studies are available. ^[94] Labetolol and nifedipine are also other treatment options that can be considered in pregnancy.^[32]

Pregnant women with stage 1 hypertension present with low cardiovascular risk and anticipated physiological lowering of blood pressure during pregnancy. Thus healthcare providers might advise mere lifestyle modification as therapy during pregnancy and breast feeding, with caution on excessive weight reduction and with possible restriction of aerobic physical activity.^[86]

The 2013 ESH/ESC guidelines recommend drug treatment of severe hypertension in pregnancy defined as SBP >160 mmHg or DBP >110 mmHg. They also advocate considering treatment in pregnant women with persistant hypertension ≥150/95 mmHg and in symptomatic patients or patients with target organ damage with BP ≥140/90 mmHg.^[32]

Patients with Hypertensive Emergency or Urgency

Hypertensive emergency is defined as high blood pressure causing acute target organ damage. Usually BP exceeds 180/20 mmHg, but can sometimes occur at even lower values in patients who do not usually have high blood pressure.

Hypertensive urgency is defined as a BP > 180/120 mmHg without target organ damage. Hypertensive urgency may or may not be symptomatic.

Triage to differentiate between hypertensive emergency and urgency is crucial for appropriate management. While hypertensive emergencies require intensive care unit (ICU) admission for close monitoring and aggressive parenteral agents, hypertensive urgencies can be managed in the emergency department with outpatient follow-up for optimization of therapy.^[86]

Treatment is based on titrated intravenous medications that act rapidly but safely especially in avoiding severe hypotension and ischemic organ damage. Nicardipine, sodium nitroprusside, labetalol, furosemide and nitrates are some of the agents used. In certain cases of volume overload-associated hypertensive emergency where diuresis is insufficient, dialysis and ultrafiltration may be of benefit.^[32]
Generally, JNC 7 outlines the acute management of hypertensive emergencies as reduction of a maximum of 25% of mean arterial BP within the first hour followed by decrease of BP to 160/100 within the next 2 to 6 hours. Normalization of blood pressure should occur at a span of 24-48 hours. Rapid decrease in BP might precipitate ischemia caused by target organ damage.^[86]

The 2013 ESH/ESC guidelines do not dwell much into the treatment of hypertensive emergencies due to the lack of evidence considering the small number of cases but recommend that treatment be individualized by the physician.^[32]

Specific clinical situations are considered exceptions to the abovementioned management plan:^[86]
- Ischemic stroke will not require immediate BP lowering to maintain cerebral perfusion.
- Aortic dissection requires SBP to be lowered immediately to < 100 mmHg if tolerated followed by rapid specific management.

Benchmarks in controlling hypertension

In the US the rate of control is estimated at 43.7% in 2017-2018 using NHANES data.^[95]

Higher rates of control are reported by:

The National Committee for Quality Assurance (NCQA)'s Healthcare Effectiveness Data and Information Set (HEDIS) for patients other than traditional Medicare^[96]
The Centers for Medicare and Medicaid Services's resource library Electronic Clinical Quality Improvement (eCQI) for Medicare patients^[97]

Barriers to blood pressure control

Health care provider barriers

Therapeutic inertia

Therapeutic inertia may contribute to the finding that in the US 62%, and in Europe 85%, of office visits with a high blood pressure the health care provider does not increase medications^[98]. In another study, "Among visits in which a diastolic blood pressure of ≥90 mm Hg and systolic blood pressure of ≥155 mm Hg were recorded, the frequency of increases in antihypertensive medications was 25.6 percent"^[99]. Similarly, another study found a rate of 17% of visits with uncontrolled hypertension having a treatment intensification^[100].

The impact of intensification and deintensification is complicated^[101].

Therapeutic inertia may be less with remote monitoring when patients submitted at least 3 elevated BP readings^[102].

Choice of follow-up intervals

Among controlled patients, short follow-up intervals (3 versus 6 months), were found in a randomized controlled trial to not improve control^[103].

Among uncontrolled patients

Short follow-up intervals (comparing < 2 weeks, 2 weeks to 1 month, and > 1 month), were found to improve speed of normalization of blood pressure and "increased probability of normalization of blood pressure at two years"^[104] Another observational study also found benefit in 2 weeks follow-up visits for hypertension as well as diabetes and cholesterol goals^[105]. Additional studies have found importance of shorter follow-up^[106].
Short follow-up intervals, were found in a randomized controlled trial to minimally improve control; however, in this study, there was slight variation in the follow-up times between study groups (34, 32, and 32 days)^[107].

Involving self-monitoring and medication self-titration

A randomized controlled trial found "self-monitoring with self-titration of antihypertensive medication compared with usual care resulted in lower systolic blood pressure at 12 months."^[108]

Patient factors

Concomittent psychological depression

Treating depression with the COACH model may help^[109].

Vulnerable populations

Underserved or vulnerable populations face additional socioeconomic barriers to hypertension control including decreased clinic resources, limited access to care, and inconsistent follow-up.

A recent cohort study with a time-series analysis conducted in San Francisco safety net clinics adapted the 2013 Kaiser protocol (details above)^[75] to fit the specific needs of safety-net clinics by focusing on 4 specific modifications^[23]:

Creating a hypertension patient registry
Simplified intensification of therapy
Standardized BP measurements
Team-based interdisciplinary BP checks by RNs and pharmacists.

Implementation of the modified Kaiser protocol led to an increase in the percent of patients with controlled hypertension from a baseline of 68% to 74% over the course of fifteen months. Overall, the results of this study demonstrated that large-scale hypertension protocols can be successfully applied to high-risk populations^[23].

Student-run free clinics

Student-run free clinics provide healthcare to a diverse population of patients including those that are: uninsured, unemployed, homeless, ethnic minority, non-native speakers, or low-income status. Student-run clinics that have published baseline rates of hypertension control show that these clinics are able to exceed national standards in their uninsured populations.

According to HEDIS (2018), the national rate of hypertension control in Medicaid patients is 58.9%^[110].

In student-run free clinics:

Wahle et al. reported a baseline hypertension control rate of 46.8% (defined by JNC 7 & 8) at Indiana University Student Outreach Clinic^[111].
Smith et al. reported a baseline hypertension control rate of 59.7% (defined by JNC 7 & 8) at 4 student run health clinics associated with the University of California San Diego^[112].
Zucker et al. reported a baseline hypertension control rate of 50% (defined by JNC 7) at a Student Family Health Care Center affiliated with the University of Medicine and Dentistry at New Jersey^[113].

Despite the challenges associated with running a student-run free clinic, these studies show it is possible to achieve rates of hypertension control comparable to patients insured by Medicaid.

References

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@@ Line 1: / Line 1: @@
-__NOTOC__
+{{tocleft}}
-{{Template:Hypertension}}
+{{Chronic hypertension}}
-{{CMG}}; {{AOEIC}} {{LG}}; '''Assistant Editor-In-Chief:''' Taylor Palmieri
+{{CMG}}; {{AOEIC}} Yazan Daaboul; Serge Korjian; [[User:RNorm|Ryan Norman]]; {{AKK}}
 ==Overview==
-There are many classes of medications for treating hypertension, together called [[antihypertensive]]s, which by varying means act by lowering [[blood pressure]]. Evidence suggests that reduction of the blood pressure by 5-6 mmHg can decrease the risk of [[stroke]] by 40%, of [[coronary heart disease]] by 15-20%, and reduces the likelihood of [[dementia]], [[heart failure]], and mortality from vascular disease.
-==Medical Therapy==
+To review the 2017 AHA/ACC guidelines on HTN, [[Chronic hypertension medical therapy#2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults|click here.]]
+==Blood Pressure Goals==
+{{details|Chronic hypertension medical therapy blood pressure goals of treatment}}
+Recommendations for treatment goals from recent [[clinical practice guideline]]s are tabulated below. However, treated based on underlying risk rather than a blood pressure target may be more effective<ref name="pmid25131978">{{cite journal| author=Blood Pressure Lowering Treatment Trialists' Collaboration| title=Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. | journal=Lancet | year= 2014 | volume= 384 | issue= 9943 | pages= 591-598 | pmid=25131978 | doi=10.1016/S0140-6736(14)61212-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25131978  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=255TICafgdf06877 Review in: Ann Intern Med. 2014 Dec 16;161(12):JC5]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25534965 Review in: Evid Based Med. 2015 Feb;20(1):21] </ref>. The logic supporting a target of 130/80 mm Hg has been disputed<ref name="pmid29357397">{{cite journal| author=Wilt TJ, Kansagara D, Qaseem A, Clinical Guidelines Committee of the American College of Physicians| title=Hypertension Limbo: Balancing Benefits, Harms, and Patient Preferences Before We Lower the Bar on Blood Pressure. | journal=Ann Intern Med | year= 2018 | volume= 168 | issue= 5 | pages= 369-370 | pmid=29357397 | doi=10.7326/M17-3293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29357397  }} </ref> and the Cochrane Collaboration found insufficient evidence to determine a treatment goal for adults<ref name="pmid30027631">{{cite journal| author=Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L| title=Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. | journal=Cochrane Database Syst Rev | year= 2018 | volume= 7 | issue=  | pages= CD010315 | pmid=30027631 | doi=10.1002/14651858.CD010315.pub3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30027631  }} </ref> or adults over 65 years of age<ref name="pmid28787537">{{cite journal| author=Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM| title=Blood pressure targets for hypertension in older adults. | journal=Cochrane Database Syst Rev | year= 2017 | volume= 8 | issue=  | pages= CD011575 | pmid=28787537 | doi=10.1002/14651858.CD011575.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28787537  }} </ref>.
+If the goal is 130/80, proper measurement includes (distilled from Table 8 of the ACC/AHA guidelines<ref name="pmid29133356">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2017 | volume=  | issue=  | pages=  | pmid=29133356 | doi=10.1161/HYP.0000000000000065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133356  }} </ref>, executive summary<ref name="pmid29133354">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2017 | volume=  | issue=  | pages=  | pmid=29133354 | doi=10.1161/HYP.0000000000000066 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133354  }} </ref>):
+* having the patient sit quietly for 5 minutes before a reading is taken
+* supporting the limb used to measure BP
+* ensuring the BP cuff is at heart level
+* using the correct cuff size
+* for auscultatory readings, deflating the cuff slowly
+* the timing of BP measurements in relation to ingestion of the patient’s medication should be standardized
+* a single reading is inadequate for clinical decision-making. An average of 2 to 3 BP measurements obtained on 2 to 3 separate occasions will minimize random error and provide a more accurate basis for estimation of BP.
+If the above measurement methods are not use, a preliminary study from [https://thrive.kaiserpermanente.org/care-near-you/northern-california/ Kaiser Northern California] suggests a target of 140 mm Hg<ref>{{cite journal|doi=10.1161/circ.136.suppl_1.14468 | author=Go AS | title = Impact of SPRINT-Based Blood Pressure Levels on Clinical Outcomes in a Large, Community-Based Population: The Kaiser Permanente Experience | journal = Circulation | year = 2018 | url = https://www.ahajournals.org/doi/abs/10.1161/circ.136.suppl_1.14468}}</ref>.
+{| class="wikitable"
+|+ AHA<ref name="pmid29133356">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2018 | volume= 71 | issue= 6 | pages= e13-e115 | pmid=29133356 | doi=10.1161/HYP.0000000000000065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133356  }} </ref> vs Roerecke<ref name="pmid30715088">{{cite journal| author=Roerecke M, Kaczorowski J, Myers MG| title=Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis. | journal=JAMA Intern Med | year= 2019 | volume= 179 | issue= 3 | pages= 351-362 | pmid=30715088 | doi=10.1001/jamainternmed.2018.6551 | pmc=6439707 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30715088  }} </ref> estimates of relationship between routine, auscultated BP measurement and gold standard ambulatory measurement.
+! Clinic (routine)
+AHA, 2017<ref name="pmid29133356"/>
+! Clinic (routine)
+Roerecke, 2018<ref name="pmid30715088"/>
+! style="font-weight:bold;" | Clinic (automated)
+Roerecke, 2018<ref name="pmid30715088"/>
+! style="font-weight:bold;" | Home (self)
+AHA, 2017
+! style="font-weight:bold;" | Daytime, ambulatory †
+! Nighttime ambulatory
+AHA, 2017<ref name="pmid29133356"/>
+! 24 hour ambulatory<ref name="pmid30715088"/>
+AHA, 2017<ref name="pmid29133356"/><ref name="pmid29133356"/> †
+|-
+| style="text-align: center;" | 120/80
+| style="text-align: center;" | 125/82
+| style="text-align: center; background-color:#9aff99;" | 120/80
+| style="text-align: center; background-color:#9aff99;" | 120/80
+| style="text-align: center; background-color:#9aff99;" | 120/80
+| style="text-align: center;" | 100/65
+| style="text-align: center;" | 115/75
+|-
+| style="text-align: center;" | 130/80
+| style="text-align: center;" | 145/85
+| style="text-align: center; background-color:#9aff99;" | 130/80
+| style="text-align: center; background-color:#9aff99;" | 130/80
+| style="text-align: center; background-color:#9aff99;" | 130/80
+| style="text-align: center;" | 110/65
+| style="text-align: center;" | 125/75
+|-
+| style="text-align: center;" | 140/90
+| style="text-align: center;" | 150/90
+| style="text-align: center; background-color:#9aff99;" | 135/85
+| style="text-align: center; background-color:#9aff99;" | 135/85
+| style="text-align: center; background-color:#9aff99;" | 135/85
+| style="text-align: center;" | 120/70
+| style="text-align: center;" | 130/80
+|-
+| style="text-align: center;" | 160/100
+| style="text-align: center;" | 160/95
+| style="text-align: center; background-color:#9aff99;" | 145/90
+| style="text-align: center; background-color:#9aff99;" | 145/90
+| style="text-align: center; background-color:#9aff99;" | 145/90
+| style="text-align: center;" | 140/85
+| style="text-align: center;" | 145/90
+|-
+| colspan="7" | Notes:<br/>
+† Benegas found that the 24-hour ambulatory systolic pressure may better predict mortality than the daytime systolic blood pressure.<ref name="pmid29669232">{{cite journal| author=Banegas JR, Ruilope LM, de la Sierra A, Vinyoles E, Gorostidi M, de la Cruz JJ et al.| title=Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality. | journal=N Engl J Med | year= 2018 | volume= 378 | issue= 16 | pages= 1509-1520 | pmid=29669232 | doi=10.1056/NEJMoa1712231 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29669232  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=30361327 Review in: BMJ Evid Based Med. 2019 Jun;24(3):114-115] </ref> The article by Benegas was subsequently retracted in 2020<ref name="pmid31995856">{{cite journal| author=Banegas JR, Ruilope LM, de la Sierra A, Vinyoles E, Gorostidi M, de la Cruz JJ | display-authors=etal| title=Retraction: Banegas JR et al. Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality. N Engl J Med 2018;378:1509-20. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 8 | pages= 786 | pmid=31995856 | doi=10.1056/NEJMc2001445 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31995856  }} </ref> but later republished in 2023 now stating that the nighttime blood pressure was the strongest predictor<ref name="Staplinde la SierraRuilope2023">{{cite journal | last1 = Staplin | first1 = Natalie | last2 = de la Sierra | first2 = Alejandro | last3 = Ruilope | first3 = Luis M | last4 = Emberson | first4 = Jonathan R | last5 = Vinyoles | first5 = Ernest | last6 = Gorostidi | first6 = Manuel | last7 = Ruiz-Hurtado | first7 = Gema | last8 = Segura | first8 = Julián | last9 = Baigent | first9 = Colin | last10 = Williams | first10 = Bryan | title = Relationship between clinic and ambulatory blood pressure and mortality: an observational cohort study in 59 124 patients | journal = The Lancet | date = May 2023 | issn = 0140-6736 | doi = 10.1016/S0140-6736(23)00733-X | pmid = 37156250 | url = }}</ref>.
+|}
+{| class="wikitable"
+|+ Practice guidelines comparison<ref name="pmid29133354">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2018 | volume= 71 | issue= 6 | pages= 1269-1324 | pmid=29133354 | doi=10.1161/HYP.0000000000000066 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133354  }} </ref><ref name="pmid28135725">{{cite journal| author=Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA et al.| title=Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. | journal=Ann Intern Med | year= 2017 | volume= 166 | issue= 6 | pages= 430-437 | pmid=28135725 | doi=10.7326/M16-1785 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28135725  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=28418540 Review in: Ann Intern Med. 2017 Apr 18;166(8):JC38] </ref><ref name="pmid24352797">{{cite journal| author=James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J et al.| title=2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). | journal=JAMA | year= 2014 | volume= 311 | issue= 5 | pages= 507-20 | pmid=24352797 | doi=10.1001/jama.2013.284427 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24352797  }} </ref>
+|-
+!
+! Goal < 60 years old
+! Goal >= 60 years old
+! High risk
+|-
+| JNC-8, 2014<ref name="pmid24352797"/>
+| 140/90
+| 150/90*
+|
+|-
+| ACP/AAFP, 2017<ref name="pmid28135725"/>
+| Not applicable
+| 150 or 140 if high risk
+|
+|-
+| [https://www.ncqa.org/hedis/measures/controlling-high-blood-pressure/ HEDIS] and [https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_236_MIPSCQM.pdf MIPS] QI Measures
+| colspan="3" |< 140/90
+|-
+|-
+| Kaiser, 2019<ref>Kaiser (2019). Adult Blood Pressure. Available at http://kpcmi.org/how-we-work/guidelines/</ref>
+| colspan="2" |140/90
+| Kaiser states "In adults with ASCVD, CKD, age > 75 years, or 10-year ASCVD risk > 10%, consider treating to a goal SBP of < 130 mm Hg"<br/>
+This is consistent with more agressive treatment in the SPRINT trial<ref name="pmid26551272"/>.
+|-
+| [[2017 ACC/AHA Hypertension Guidelines|AHA/ACC/others]], 2017<ref name="pmid29133354"/>
+|  colspan="3" | < 130/80†
+|-
+| colspan="4" | * Treat to 140/90 if age >=60 with DMII or CKD.
+† Treat if > 140/90 or 130/80 if high risk which is defined as existing cardiovascular disease, 10-year cardiovascular risk ≥10%, diabetes, or CKD.
+|}
+Newer [[randomized controlled trial]]s have identified conflicting benefits to more intensive therapy.
+{| class="wikitable"
+|+ Randomized controlled trials of lower treatment goals
+! rowspan="2" |
+! colspan="3" | Patients
+! rowspan="2" | BP target in intervention group
+! rowspan="2" | Final BP in intervention group
+! rowspan="2" | Primary outcome (composite)<br/>(Hazard ratio)
+|-
+! Baseline blood pressure
+! Estimated cardiac risk<br/>([https://openrules.ocpu.io/home/www/statins_for_cvd.html calculated with pooled cohort equation])
+! Outcome rate in the control group
+|-
+| ACCORD, 2010<ref name="pmid20228401"/>
+| 140/76
+| All patients were diabetic<br/>9% for anglo women and 23% for anglo men
+| 2.1% per year
+| SBP 120 vs 140
+| 119/64
+| 0.88 (95% CI: 0.73 to 1.06)
+|-
+| SPRINT, 2015<ref name="pmid26551272"/>
+| 140/78
+| No diabetics<br/>16% for anglo women and 23% for anglo men (20% overall)
+| 2.2% per year
+| SBP 120 vs 140
+| 121/67
+| 0.75 (95% CI: 0.64 to 0.89)
+|-
+| HOPE-3, 2016<ref name="pmid27039945"/>
+| 138/82
+| 16% for anglo women and 23% for anglo men
+| 1.7% per year*
+| No target BP.<br/>Intervention group all received candesartan 16 mg per day plus hydrochlorothiazide 12.5 mg per day
+| 128/76
+| 0.93 (95% CI: 0.79 to 1.10)
+|-
+| colspan="7" | Notes:
+ * 1.7% is the sum of the two co-primary outcomes. The HOPE-3 also reported 4.4% over 5.6 years.
+|}
+* In the ACCORD (Action to Control Cardiovascular Risk in Diabetes)  [[randomized controlled trial]] patients with average blood pressure of 140/76 mm Hg ''and diabetes'' did ''not'' benefit from targeting a systolic blood pressure of less than 120 mm Hg (average 119/64 mm Hg), as compared with less than 140 mm Hg.<ref name="pmid20228401">{{cite journal| author=ACCORD Study Group. Cushman WC, Evans GW, Byington RP, Goff DC, Grimm RH et al.| title=Effects of intensive blood-pressure control in type 2 diabetes mellitus. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 17 | pages= 1575-85 | pmid=20228401 | doi=10.1056/NEJMoa1001286 | pmc=4123215 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20228401  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20667901 Review in: Evid Based Med. 2010 Oct;15(5):142-3]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643982 Review in: Ann Intern Med. 2010 Jul 20;153(2):JC1-4, JC1-5] </ref>
+** Assuming the average patient in this trial was a nonsmoker and was diabetic, the estimated 10-year cardiovascular risk is 9% for anglo women and 23% for anglo men.
+* In the SPRINT [[randomized control trial]], patients with an average blood pressure of 140/78 mm Hg and at ''high risk'' for CVD but who do not have a history of stroke or diabetes, intensive BP control (target SBP <120 mm Hg) that lowered systolic blood pressure to an average of 121/67 mm Hg ''improved'' CV outcomes and overall survival compared to standard therapy, while modestly increasing the risk of some serious adverse events<ref name="pmid26551272">{{cite journal| author=SPRINT Research Group. Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM et al.| title=A Randomized Trial of Intensive versus Standard Blood-Pressure Control. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 22 | pages= 2103-16 | pmid=26551272 | doi=10.1056/NEJMoa1511939 | pmc=4689591 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26551272  }} </ref>.
+** Assuming the average patient in this trial was not diabetic, 50% were smokers (per their publication)), 33% were women, and LDL was 113 (per their publication Friedrwald estimate is 191 - 53 - 125/5)) the estimated 10-year cardiovascular risk is 12% for anglo women and 20% for anglo men.
+** The [[number needed to treat]] (NNT), is about 200 (185) for the primary outcome (1.65% vs 2.19%) by dropping the systolic pressure by 15 mm Hg.
+* In the HOPE-3 trial [[randomized controlled trial]], patients with an average blood pressure of 138/82 mm HG and with intermediate risk who did not have cardiovascular disease lowering systolic blood pressure to an average of 128 mm Hg was ''insignificantly'' beneficial. <ref name="pmid27039945">{{cite journal| author=Yusuf S, Lonn E, Pais P, Bosch J, López-Jaramillo P, Zhu J et al.| title=Blood-Pressure and Cholesterol Lowering in Persons without Cardiovascular Disease. | journal=N Engl J Med | year= 2016 | volume= 374 | issue= 21 | pages= 2032-43 | pmid=27039945 | doi=10.1056/NEJMoa1600177 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27039945  }} </ref>
+** Assuming the average patients in this trial was a nonsmoker and not diabetic, the estimated 10-year cardiovascular risk is 10% for anglo women and 19% for anglo men.
+** Benefit was found in a subgroup analysis of patients with systolic blood pressure above 144 mm Hg (mean 154 mm Hg).
+Debate exists on how low should physicians target blood pressure in their patients especially in light of studies that have shown a J or U-shaped curve phenomenon associated with hypertension treatment where low and very high blood pressure values are associated with increased risk of cardiovascular events.<ref name="pmid20846991">{{cite journal| author=Bangalore S, Messerli FH, Wun CC, Zuckerman AL, DeMicco D, Kostis JB et al.| title=J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. | journal=Eur Heart J | year= 2010 | volume= 31 | issue= 23 | pages= 2897-908 | pmid=20846991 | doi=10.1093/eurheartj/ehq328 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20846991 }} </ref>  A less strict target in diabetic and elderly patients is in the new ADA and ESH/ESC 2013 [[clinical practice guideline]]s respectively. This rationale is supported by the fact that lower SBP targets in diabetic patients have not been shown to generate better outcomes.<ref name="pmid23264423">{{cite journal| author=| title=Summary of revisions for the 2013 clinical practice recommendations. | journal=Diabetes Care | year= 2013 | volume= 36 Suppl 1 | issue= | pages= S3 | pmid=23264423 | doi=10.2337/dc13-S003 | pmc=PMC3537268 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23264423 }} </ref> Similarly, treatment of stage 1 hypertension in elderly patients and targeting SBP values to <140 mmHg have not been well substantiated and may sometimes carry more risk than benefit.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref>
+==Practice Guidelines==
+=== American College of Cardiology / American Heart Association ===
+The ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 2017 [[clinical practice guidelines]]<ref name="pmid29133356">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2017 | volume=  | issue=  | pages=  | pmid=29133356 | doi=10.1161/HYP.0000000000000065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133356  }} </ref>, executive summary<ref name="pmid29133354">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2017 | volume=  | issue=  | pages=  | pmid=29133354 | doi=10.1161/HYP.0000000000000066 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133354  }} </ref>, and underlying [[systematic review]]<ref name="pmid29133354">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2017 | volume=  | issue=  | pages=  | pmid=29133354 | doi=10.1161/HYP.0000000000000066 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133354  }} </ref> by the ACC/AHA taskforce recommend a treatment goal for everyone is <130/80 mm Hg:
+{| class="wikitable"
+!
+! Definition
+! Treatment
+|-
+| Elevated blood pressure
+| Systolic BP, 120–129 mm Hg<br/> - and -<br/>Diastolic BP, <80 mm Hg<br/>
+| Lifestyle
+|-
+| Stage 1 hypertension
+| Systolic BP, 130–139 mm Hg<br/> - or -<br/>Diastolic BP, 80–89 mm Hg<br/>
+| Lifestyle and<br/>Medications if high risk*
+|-
+| Stage 2 hypertension<br/>
+| Systolic BP, ≥140 mm Hg<br/> - or -<br/>Diastolic BP, ≥90 mm Hg
+| Lifestyle and<br/>Medications
+|-
+| colspan="3" | * High risk defined as existing cardiovascular disease or 10-year cardiovascular risk ≥10% ([http://www.cvriskcalculator.com/ calculator] and [https://openrules.ocpu.io/home/www/statins_for_cvd.html alternative calculator with facts box])
+|}
+=== American College of Physicians / American Academy of Family Physicians ===
+For patients aged 60 or more, the American College of Physicians and American Academy of Family Physicians [[clinical practice guideline]]<ref name="pmid28135725">{{cite journal| author=Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA et al.| title=Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. | journal=Ann Intern Med | year= 2017 | volume= 166 | issue= 6 | pages= 430-437 | pmid=28135725 | doi=10.7326/M16-1785 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28135725  }} </ref> and underlying [[systematic review]]<ref name="pmid28114673">{{cite journal| author=Weiss J, Freeman M, Low A, Fu R, Kerfoot A, Paynter R et al.| title=Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysis. | journal=Ann Intern Med | year= 2017 | volume= 166 | issue= 6 | pages= 419-429 | pmid=28114673 | doi=10.7326/M16-1754 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28114673  }} </ref> from 2017 recommend:
+* " initiate treatment in adults aged 60 years or older with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg"
+* "consider initiating or intensifying pharmacologic treatment in adults aged 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mm Hg"
+* "consider initiating or intensifying pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mm Hg"
+=== Eighth Joint National Committee (JNC 8) ===
+JNC 8 recommendations in 2014 for BP goals:<ref name="pmid24352797">{{cite journal| author=James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J et al.| title=2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). | journal=JAMA | year= 2014 | volume= 311 | issue= 5 | pages= 507-20 | pmid=24352797 | doi=10.1001/jama.2013.284427 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24352797  }} </ref>
+* Strong evidence for BP goal less than 150/90 mm Hg for patients above age 60.
+* Strong evidence exists for a diastolic goal of less than 90 mm Hg for hypertensive patients between ages 30 - 59.
+* There is insufficient evidence for patients below age 60 for a systolic goal, or in those below age 30 for a diastolic goal, so the panel recommended a BP of less than 140/90 mm Hg for those groups based on expert opinion.
+===Kaiser Guidelines===
+The Kaiser Permanente hypertension protocol <ref name="pmid24786445">{{cite journal| author=Sim JJ, Handler J, Jacobsen SJ, Kanter MH| title=Systemic implementation strategies to improve hypertension: the Kaiser Permanente Southern California experience. | journal=Can J Cardiol | year= 2014 | volume= 30 | issue= 5 | pages= 544-52 | pmid=24786445 | doi=10.1016/j.cjca.2014.01.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24786445  }} </ref> and San Francisco safety net clinics <ref name="pmid30002140">{{cite journal| author=Fontil V, Gupta R, Moise N, Chen E, Guzman D, McCulloch CE et al.| title=Adapting and Evaluating a Health System Intervention From Kaiser Permanente to Improve Hypertension Management and Control in a Large Network of Safety-Net Clinics. | journal=Circ Cardiovasc Qual Outcomes | year= 2018 | volume= 11 | issue= 7 | pages= e004386 | pmid=30002140 | doi=10.1161/CIRCOUTCOMES.117.004386 | pmc=6071320 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30002140  }} </ref> Kaiser Permanente approached chronic disease with a model using “...implementation, dissemination, and performance feedback approaches...” with a goal of exceeding 85% control of hypertension in their patient population2. The strategies proposed were 1) hypertension registry 2) standardization of blood pressure measurements 3) internal treatment algorithm 4) multidisciplinary approach <ref name="pmid24786445">{{cite journal| author=Sim JJ, Handler J, Jacobsen SJ, Kanter MH| title=Systemic implementation strategies to improve hypertension: the Kaiser Permanente Southern California experience. | journal=Can J Cardiol | year= 2014 | volume= 30 | issue= 5 | pages= 544-52 | pmid=24786445 | doi=10.1016/j.cjca.2014.01.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24786445  }} </ref>.
+. Creating a hypertension patient registry (2000 and 2004)
+* Facilitate provider performance feedback with an accurate capture of all hypertensive patients in one database.
+* Required one hypertension code and at least one antihypertensive medication OR diagnosis of stroke, CKD, CAD, or DM.
+* There was a 60% increase in growth of registry that corresponded with a 30% increase in hypertension control.
+. Simplified intensification of therapy
+* One consistent algorithm was utilized for treatment protocols and laminated cards were given to all physicians as reminders.
+* Thiazide or combination pill (Lisinopril-HCTZ 20-25 ½ pill) as first line, regardless of stage.
+* B-blockers removed from first line options.
+. Standardized blood pressure measurements: staff trained and continuously evaluated through validated peer review and feedback  (did they say anything about how long to rest)?
+* Bare arm during measurement
+* Arm supported at heart level
+* Appropriate cuff side
+* No talking during measurement
+These techniques accompanied by consistent peer training and feedback led to a reduction in technique errors by 40%.
+. Team-based interdisciplinary BP checks by RNs and pharmacists.
+* BP check visits led by non-physicians facilitated access, more frequent visits, and treatment intensification
-===Goals of Therapy===
+====Blood pressure control outcomes for Kaiser====
-In addition to alleviating symptoms of hypertension, such as headache and blurry vision, the ultimate long term goals of the management of hypertension are to reduce cardiovascular risk, prevent cardiovascular events, and reverse or ameliorate target organ damage. According to “Blood Pressure Lowering Treatment Trialists’ Collaboration” in 2000, lowering blood pressure decreases the incidence of stroke by an average of 30%, MI by an average of 20%, major cardiovascular events by an average of 21%, and heart failure by an average of more than 50%.<ref name="pmid11130523">{{cite journal| author=Neal B, MacMahon S, Chapman N, Blood Pressure Lowering Treatment Trialists' Collaboration| title=Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists' Collaboration. | journal=Lancet | year= 2000 | volume= 356 | issue= 9246 | pages= 1955-64 | pmid=11130523 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11130523 }} </ref>
+A recent Kaiser study has achieved 90% blood pressure control within their Medicare population<ref name="pmid26939059">{{cite journal| author=Jaffe MG, Young JD| title=The Kaiser Permanente Northern California Story: Improving Hypertension Control From 44% to 90% in 13 Years (2000 to 2013). | journal=J Clin Hypertens (Greenwich) | year= 2016 | volume= 18 | issue= 4 | pages= 260-1 | pmid=26939059 | doi=10.1111/jch.12803 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26939059  }} </ref> while the national average remains around 70% in the same population per HEDIS measures by NCQA<ref>NCQA. Controlling High Blood Pressure. Available at https://www.ncqa.org/hedis/measures/controlling-high-blood-pressure/</ref>.
-A set target blood pressure anticipated from medical therapy is required to steer the management and follow-up of patients with hypertension. However, a lot of debate exists on how low should physicians target blood pressure in their patients especially in light of studies that have shown a J or U-shaped curve phenomenon associated with hypertension treatment where low and very high blood pressure values are associated with increased risk of cardiovascular events.<ref name="pmid20846991">{{cite journal| author=Bangalore S, Messerli FH, Wun CC, Zuckerman AL, DeMicco D, Kostis JB et al.| title=J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. | journal=Eur Heart J | year= 2010 | volume= 31 | issue= 23 | pages= 2897-908 | pmid=20846991 | doi=10.1093/eurheartj/ehq328 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20846991 }} </ref>  Along those lines, a new trend has recently surfaced advocating a less strict target in diabetic and elderly patients seen in the new ADA and ESH/ESC 2013 guidelines respectively. This rationale is supported by the fact that lower SBP targets in diabetic patients have not been shown to generate better outcomes.<ref name="pmid23264423">{{cite journal| author=| title=Summary of revisions for the 2013 clinical practice recommendations. | journal=Diabetes Care | year= 2013 | volume= 36 Suppl 1 | issue= | pages= S3 | pmid=23264423 | doi=10.2337/dc13-S003 | pmc=PMC3537268 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23264423 }} </ref> Similarly, treatment of stage 1 hypertension in elderly patients and targeting SBP values to <140 mmHg have not been well substantiated and may sometimes carry more risk than benefit.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref>  Still it is agreed that in the general population at low to moderate cardiovascular risk a target BP below 140/90 mmHg is recommended. A more detailed discussion about targets in special populations is available below.
+Implementation of a modified Kaiser protocol in a vulnerable population led to an increase in the percent of patients with controlled hypertension from a baseline of 68% to 74% over the course of fifteen months.<ref name="pmid30002140">{{cite journal| author=Fontil V, Gupta R, Moise N, Chen E, Guzman D, McCulloch CE et al.| title=Adapting and Evaluating a Health System Intervention From Kaiser Permanente to Improve Hypertension Management and Control in a Large Network of Safety-Net Clinics. | journal=Circ Cardiovasc Qual Outcomes | year= 2018 | volume= 11 | issue= 7 | pages= e004386 | pmid=30002140 | doi=10.1161/CIRCOUTCOMES.117.004386 | pmc=6071320 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30002140  }} </ref>.
-===Approach to Medical Therapy===
+====Clinical outcomes for Kaiser====
-Pharmacologic therapy is normally initiated based on the cardiovascular risk. Failure to achieve BP goals in patients with low and moderate cardiovascular risk after three to six months of non-pharmacologic measures necessitates the initiation of pharmacologic therapy. Medical management should be reserved to patients with BP>140/90 mmHg (except in certain cases discussed below). A lot of debate exists on the optimal approach to the medical management of hypertension. With the multitude of classes and agents that can be used, several questions arise about the single best agent, the optimal combination of agents, and the best step-wise approach to medical management. Although JNC7 tried to address these issues, almost a decade has passed since the release of their recommendations, with a myriad of studies and trials presenting newer compelling evidence to update the current recommendations. The 2013 ESH/ESC guidelines for the management of hypertension have dwelled into these issues and have outlined the rationale behind adopting a new approach. Below are the algorithms for the approach to the medical therapy of hypertension presented by JNC7 in 2004 and ESH/ESC in 2013.
+Regarding efficacy in the real world<ref name="pmid10480802">{{cite journal| author=Haynes B| title=Can it work? Does it work? Is it worth it? The testing of healthcareinterventions is evolving. | journal=BMJ | year= 1999 | volume= 319 | issue= 7211 | pages= 652-3 | pmid=10480802 | doi=10.1136/bmj.319.7211.652 | pmc=1116525 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10480802  }} </ref>, Kaiser Permanente Northern California has published findings that their decline and cardiovascular mortality exceeds the national decline<ref name="pmid29625083">{{cite journal| author=Sidney S, Sorel ME, Quesenberry CP, Jaffe MG, Solomon MD, Nguyen-Huynh MN et al.| title=Comparative Trends in Heart Disease, Stroke, and All-Cause Mortality in the United States and a Large Integrated Healthcare Delivery System. | journal=Am J Med | year= 2018 | volume= 131 | issue= 7 | pages= 829-836.e1 | pmid=29625083 | doi=10.1016/j.amjmed.2018.02.014 | pmc=6005733 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29625083  }} </ref>. An unpublished report states that death from cardiac disease is now less than common death from cancer in Kaiser Permanente Northern California<ref>Atul Gawande on Priorities, Big and Small (Ep. 26) (2017). Conversations with Tyler. Available at https://medium.com/conversations-with-tyler/atul-gawande-checklist-books-tyler-cowen-d8268b8dfe53</ref>.
-<center>'''JNC7 Guidelines. Approach to medical therapy of hypertension.'''</center>
+Kaiser Permanente Southern California has shown that death from heart disease is now less common that death from cancer<ref name="pmid31050639">{{cite journal| author=Chen W, Yao J, Liang Z, Xie F, McCarthy D, Mingsum L et al.| title=Temporal Trends in Mortality Rates among Kaiser Permanente Southern California Health Plan Enrollees, 2001-2016. | journal=Perm J | year= 2019 | volume= 23 | issue=  | pages=  | pmid=31050639 | doi=10.7812/TPP/18-213 | pmc=6499114 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31050639  }} </ref>.
-[[Image:Hypertension_algorithm_JNC7.png|border|500px|center|JNC7 Guidelines. Approach to medical therapy of hypertension.]]
+A preliminary study from [https://thrive.kaiserpermanente.org/care-near-you/northern-california/ Kaiser Northern California] suggests a target of 140 mm Hg<ref>{{cite journal|doi=10.1161/circ.136.suppl_1.14468 | author=Go AS | title = Impact of SPRINT-Based Blood Pressure Levels on Clinical Outcomes in a Large, Community-Based Population: The Kaiser Permanente Experience | journal = Circulation | year = 2018 | url = https://www.ahajournals.org/doi/abs/10.1161/circ.136.suppl_1.14468}}</ref>.
+===ESH/ESC 2013 Guidelines===
 <center>'''ESH/ESC 2013 Guidelines. Approach to medical therapy of hypertension.'''</center>
 [[Image:Hypertension_algorithm_ESH.png|border|950px|center|ESH/ESC 2013 Guidelines. Approach to medical therapy of hypertension.]]
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+{{Family tree |border=2|boxstyle=background: WhiteSmoke;| | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= Adult aged ≥18 years <BR> with hypertension}}
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+{{Family tree |border=2|boxstyle=background: WhiteSmoke;| | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | |B01= Implement lifestyle interventions <br> (continue throughout management) }}
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+{{Family tree |border=2|boxstyle=background: WhiteSmoke;| | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | |C01= Set blood pressure goal <BR> Inititate BP lowering-medication}}
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+{{Family tree |border=2|boxstyle=background: WhiteSmoke;| | | | | | | E01 | | | | E02 | | | | E03 | | | | E04 | | | | | | | | | | | |E01='''Age ≥60 years'''|E02='''Age <60 years'''|E03= All ages <br> '''Diabetes present''' <br> '''No CKD'''|E04= All ages <br> '''CKD present with''' <br> '''or without diabetes''' }}
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+{{Family tree |border=2|boxstyle=background: WhiteSmoke;| | | | | | | | | | G01 | | | | G02 | | | | | | | G03 | | | | | | | | | | | |G01=<div style="text-align: center; width: 15em">Initiate thiazide-type diuretic <BR> or ACEI or ARB or CCB, <BR> alone or in combination</div>|G02=Initiate thiazide-type diuretic <BR> or CCB, alone or in combination|G03=Initiate ACEI or ARB, alone or in combination with other drug class.}}
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+----
+'''For strategies A and B:''' <BR> Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI & ARB). <br> '''For strategy C:''' <BR> Titrate doses of initial medications to maximum.</div>}}
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+----
+Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI & ARB).</div>}}
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+----
+Add additional medication class (eg, β-blocker, aldosterone antagonist, or others) and/or refer to physician with expertise in HTN management. </div>}}
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+{{Family tree |border=2|boxstyle=background: WhiteSmoke;| | | | | | | | | | | | | | | | | | | | | | | | | A44 | | | | | | | | | | | |A44=Continue current treatment<br> and monitoring. }}
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+<!--
+<center>'''JNC7 Guidelines. Approach to medical therapy of hypertension.'''</center>
+[[Image:Hypertension_algorithm_JNC7.png|border|500px|center|JNC7 Guidelines. Approach to medical therapy of hypertension.]]
+-->
-===Antihypertensive Agents & Indications===
+==Antihypertensive Agents & Indications==
-====Common Antihypertensive Agents====
+===Common Antihypertensive Agents===
 Several classes of medications are used in the treatment of hypertension namely diuretics, ACE inhibitors, angiotensin receptor blockers, beta-blockers, alpha-blockers, and direct vasodilators. Below is a list of common oral agents used in the treatment of hypertension.
-<center>'''JNC7: Common oral antihypertensive agents'''<ref name="pmid14656957">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. | journal=Hypertension | year= 2003 | volume= 42 | issue= 6 | pages= 1206-52 | pmid=14656957 | doi=10.1161/01.HYP.0000107251.49515.c2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14656957 }} </ref></center>
+<center>'''JNC8: Common oral antihypertensive agents'''<ref name="pmid14656957">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. | journal=Hypertension | year= 2003 | volume= 42 | issue= 6 | pages= 1206-52 | pmid=14656957 | doi=10.1161/01.HYP.0000107251.49515.c2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14656957 }} </ref></center>
-{| border="1" style="border-collapse:collapse; text-align:center; font-size:90%;" cellpadding="0" align="center" width="900px"
+{| style="border-collapse:collapse; text-align:center; font-size:90%;" width="900px" align="center" border="1" cellpadding="0"
 |-
-|bgcolor="#67e1ff"|'''Class''' || bgcolor="#67e1ff"|'''Drug'''||bgcolor="#67e1ff"|'''Usual Dose Range (mg/day)'''
+| bgcolor="#67e1ff" |'''Class''' || bgcolor="#67e1ff" |'''Drug'''|| bgcolor="#67e1ff" |'''Usual Dose Range (mg/day)'''
 |-
-| bgcolor="#f3f3f3" rowspan="6" |Thiazide Diuretics||Chlorothiazide ||125-500
+| rowspan="6" bgcolor="#f3f3f3" |Thiazide Diuretics||Chlorothiazide ||125-500
 |-
 | Chlorthalidone ||12.5-25
@@ Line 45: / Line 320: @@
 | Metolazone||0.5-5
 |-
-| bgcolor="#f3f3f3" rowspan="3" |Loop Diuretics|| Bumetanide||0.5-2
+| rowspan="3" bgcolor="#f3f3f3" |Loop Diuretics|| Bumetanide||0.5-2
 |-
 | Furosemide||20-80
@@ Line 51: / Line 326: @@
 | Torsemide||2.5-10
 |-
-| bgcolor="#f3f3f3" rowspan="2" |Potassium-sparing Diuretics|| Amiloride ||5-10
+| rowspan="2" bgcolor="#f3f3f3" |Potassium-sparing Diuretics|| Amiloride ||5-10
 |-
 | Triamterene ||50-100
 |-
-| bgcolor="#f3f3f3" rowspan="2" |Aldosterone Receptor Diuretics||Spironolactone ||25-50
+| rowspan="2" bgcolor="#f3f3f3" |Aldosterone Receptor Diuretics||Spironolactone ||25-50
 |-
 | Eplerenone ||50-100
 |-
-| bgcolor="#f3f3f3" rowspan="9" |Beta-Blockers|| Atenolol||25-100
+| rowspan="9" bgcolor="#f3f3f3" |Beta-Blockers|| Atenolol||25-100
 |-
 | Betaxolol||5-20
@@ Line 77: / Line 352: @@
 | Timolol ||20-40
 |-
-| bgcolor="#f3f3f3" rowspan="3" |Beta-Blockers with intrinsic sympathomimetic activity|| Acebutolol ||200-800
+| rowspan="3" bgcolor="#f3f3f3" |Beta-Blockers with intrinsic sympathomimetic activity|| Acebutolol ||200-800
 |-
 | Penbutolol||10-40
@@ Line 83: / Line 358: @@
 | Pindolol||10-40
 |-
-| bgcolor="#f3f3f3" rowspan="2" |Combined Alpha- and Beta-Blockers||Carvedilol||12.5-50
+| rowspan="2" bgcolor="#f3f3f3" |Combined Alpha- and Beta-Blockers||Carvedilol||12.5-50
 |-
 | Labetalol||200-800
 |-
-| bgcolor="#f3f3f3" rowspan="10" |ACE Inhibitors|| Benazepril ||10-40
+| rowspan="10" bgcolor="#f3f3f3" |ACE Inhibitors|| Benazepril ||10-40
 |-
 | Captopril||25-100
@@ Line 107: / Line 382: @@
 | Trandolapril||1-4
 |-
-| bgcolor="#f3f3f3" rowspan="7" |Angiotensin Receptor Blockers|| Candesartan ||8-32
+| rowspan="7" bgcolor="#f3f3f3" |Angiotensin Receptor Blockers|| Candesartan ||8-32
 |-
 | Eprosartan||400-800
@@ Line 121: / Line 396: @@
 | Valsartan||80-320
 |-
-| bgcolor="#f3f3f3" rowspan="4" |Nondihydropyridine Calcium Channel Blockers|| Diltiazem extended release ||120-540
+| rowspan="4" bgcolor="#f3f3f3" |Nondihydropyridine Calcium Channel Blockers|| Diltiazem extended release ||120-540
 |-
 | Verapamil immediate release||80-320
@@ Line 129: / Line 404: @@
 | Verapamil||120-360
 |-
-| bgcolor="#f3f3f3" rowspan="6" |Dihydropyridine Calcium Channel Blockers|| Amlodipine ||2.5-10
+| rowspan="6" bgcolor="#f3f3f3" |Dihydropyridine Calcium Channel Blockers|| Amlodipine ||2.5-10
 |-
 | Felodipine||2.5-10
@@ Line 141: / Line 416: @@
 | Nisoldipine||10-40
 |-
-| bgcolor="#f3f3f3" rowspan="3" |Alpha-1 Blockers|| Doxazosin ||1-16
+| rowspan="3" bgcolor="#f3f3f3" |Alpha-1 Blockers|| Doxazosin ||1-16
 |-
 | Prazosin||2-20
@@ Line 147: / Line 422: @@
 | Terazosin||1-20
 |-
-| bgcolor="#f3f3f3" rowspan="4" |Centrally Acting Drugs|| Clonidine ||0.1-0.8
+| rowspan="4" bgcolor="#f3f3f3" |Centrally Acting Drugs|| Clonidine ||0.1-0.8
 |-
 | Methyldopa||250-1000
@@ Line 155: / Line 430: @@
 | Guanfacine||0.5-2
 |-
-| bgcolor="#f3f3f3" rowspan="2" |Direct Vasodilators|| Hydralazine ||25-100
+| rowspan="2" bgcolor="#f3f3f3" |Direct Vasodilators|| Hydralazine ||25-100
 |-
 | Minoxidil||2.5-80
@@ Line 161: / Line 436: @@
 |}
+===Choice of Initial Agent===
+[[Clinical practice guideline]]s vary in their recommendations for selection of initial medication<ref name="pmid29133354">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2018 | volume= 71 | issue= 6 | pages= 1269-1324 | pmid=29133354 | doi=10.1161/HYP.0000000000000066 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133354  }} </ref><ref name="pmid28135725">{{cite journal| author=Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA et al.| title=Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. | journal=Ann Intern Med | year= 2017 | volume= 166 | issue= 6 | pages= 430-437 | pmid=28135725 | doi=10.7326/M16-1785 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28135725  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=28418540 Review in: Ann Intern Med. 2017 Apr 18;166(8):JC38] </ref><ref name="pmid24352797">{{cite journal| author=James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J et al.| title=2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). | journal=JAMA | year= 2014 | volume= 311 | issue= 5 | pages= 507-20 | pmid=24352797 | doi=10.1001/jama.2013.284427 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24352797  }} </ref><ref name="pmid23817082">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M et al.| title=2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). | journal=J Hypertens | year= 2013 | volume= 31 | issue= 7 | pages= 1281-357 | pmid=23817082 | doi=10.1097/01.hjh.0000431740.32696.cc | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23817082  }} </ref>.
+====Selecting medication based on patient demographics====
+[[Image:Materson et al. NEJM 1994. PMID 8177286.jpg|right|500px]]
-====Choice of Initial Agent====
+<br style="clear:left" />Some authors have proposed that either the renin level or the renin level indexed to urinary sodium excretion in 24 hours.<ref name="pmid4355699">{{cite journal| author=Laragh JH| title=Vasoconstriction-volume analysis for understanding and treating hypertension: the use of renin and aldosterone profiles. | journal=Am J Med | year= 1973 | volume= 55 | issue= 3 | pages= 261-74 | pmid=4355699 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4355699  }} </ref><ref name="pmid4337477">{{cite journal| author=Laragh JH, Baer L, Brunner HR, Buhler FR, Sealey JE, Vaughan ED| title=Renin, angiotensin and aldosterone system in pathogenesis and management of hypertensive vascular disease. | journal=Am J Med | year= 1972 | volume= 52 | issue= 5 | pages= 633-52 | pmid=4337477 | doi= | pmc= | url= }} </ref> However, the Veterans Affairs Cooperative trial suggests the initial drug may be better selected based on the patient's age, race, and gender.<ref name="pmid8177286">{{cite journal |author=Materson BJ, Reda DJ |title=Correction: single-drug therapy for hypertension in men |journal=N. Engl. J. Med. |volume=330 |issue=23 |pages=1689 |year=1994 |pmid=8177286 |doi=}}</ref><ref name="pmid9777817">{{cite journal |author=Preston RA, Materson BJ, Reda DJ, ''et al'' |title=Age-race subgroup compared with renin profile as predictors of blood pressure response to antihypertensive therapy. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents |journal=JAMA |volume=280 |issue=13 |pages=1168–72 |year=1998 |pmid=9777817 |doi=}}</ref> The patient's demographic roughly corresponds with their [[renin]] profile, but is more predictive than the renin profile.<ref name="pmid9777817"/> In the Veterans Affairs Cooperative, among the high renin demographic (young whites), diuretics had similar efficacy to placebo; whereas in the low renin demographic (older blacks), the [[Angiotensin-converting enzyme inhibitor|ace-inhibitors]] had similar efficacy to placebo in the Veterans Affairs Cooperative Study Group on Antihypertensive Agents (see figure).<ref name="pmid8177286"/>
+Another randomized controlled trial conducted in Scandinavia, but results not stratified by demographics, found that [[hydrochlorothiazide]] was less effective<ref name="pmid37039792">{{cite journal| author=Sundström J, Lind L, Nowrouzi S, Hagström E, Held C, Lytsy P | display-authors=etal| title=Heterogeneity in Blood Pressure Response to 4 Antihypertensive Drugs: A Randomized Clinical Trial. | journal=JAMA | year= 2023 | volume= 329 | issue= 14 | pages= 1160-1169 | pmid=37039792 | doi=10.1001/jama.2023.3322 | pmc=10091169 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=37039792  }} </ref>. Frequencies of racial and ethnic groups were not reported.
+====Selecting fixed-dose combination pills====
+Two [[cohort study | cohort studies]] suggest that fixed-dose combination pills enhance adherence when compared to monotherapy<ref name="pmid28050754">{{cite journal| author=Lauffenburger JC, Landon JE, Fischer MA| title=Effect of Combination Therapy on Adherence Among US Patients Initiating Therapy for Hypertension: a Cohort Study. | journal=J Gen Intern Med | year= 2017 | volume= 32 | issue= 6 | pages= 619-625 | pmid=28050754 | doi=10.1007/s11606-016-3972-z | pmc=5442007 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28050754  }} </ref><ref name="pmid29889841">{{cite journal| author=Verma AA, Khuu W, Tadrous M, Gomes T, Mamdani MM| title=Fixed-dose combination antihypertensive medications, adherence, and clinical outcomes: A population-based retrospective cohort study. | journal=PLoS Med | year= 2018 | volume= 15 | issue= 6 | pages= e1002584 | pmid=29889841 | doi=10.1371/journal.pmed.1002584 | pmc=5995349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29889841  }} </ref>. The increased adherence may lead to improved clinical outcomes<ref name="pmid29889841"/>. Therefore, it would not be unreasonable to consider starting combination therapy in order to increase patient compliance, a known barrier to hypertension pharmacotherapy.
+Using up to 50 mg per day of hydrochlorothiazed, as recommended by Kaiser, is supported by dose-response studies summarized by the Cochrane Collaboration<ref name="pmid24869750">{{cite journal| author=Musini VM, Nazer M, Bassett K, Wright JM| title=Blood pressure-lowering efficacy of monotherapy with thiazide diuretics for primary hypertension. | journal=Cochrane Database Syst Rev | year= 2014 | volume=  | issue= 5 | pages= CD003824 | pmid=24869750 | doi=10.1002/14651858.CD003824.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24869750  }} </ref>. Previouslky, hydrochlorothiazide a a dose of 100 mg per day, without postassium sparing therapy, was associated with increased risk of cardiac arrest<ref name="pmid8196728">{{cite journal| author=Siscovick DS, Raghunathan TE, Psaty BM, Koepsell TD, Wicklund KG, Lin X | display-authors=etal| title=Diuretic therapy for hypertension and the risk of primary cardiac arrest. | journal=N Engl J Med | year= 1994 | volume= 330 | issue= 26 | pages= 1852-7 | pmid=8196728 | doi=10.1056/NEJM199406303302603 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8196728  }} </ref>.
 ====JNC7: Compelling Indications and Choice of Antihypertensive Agents<ref name="pmid14656957">Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14656957 Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.] ''Hypertension'' 42 (6):1206-52.[http://dx.doi.org/10.1161/01.HYP.0000107251.49515.c2 DOI:10.1161/01.HYP.0000107251.49515.c2] PMID: [http://pubmed.gov/14656957 14656957]</ref>====
 <center>'''Clinical trials and basis for compelling indications for individual drug classes'''
-{| border="1" style="border-collapse:collapse; text-align:center; font-size:120%;" cellpadding="5" align="center" width="900px"
+{| style="border-collapse:collapse; text-align:center; font-size:120%;" width="900px" align="center" border="1" cellpadding="5"
 |- align="center"
 | bgcolor="#67e1ff" |'''Compelling Indication'''
@@ Line 173: / Line 461: @@
 | bgcolor="#67e1ff" |'''Clinical Trial Basis'''
 |- align="left"
-| bgcolor="#f3f3f3"|[[Heart failure]]
+| bgcolor="#f3f3f3" |[[Heart failure]]
 | [[Diuretics]], [[Beta blockers]], [[ACE inhibitor|ACEIs]], [[Angiotensin II receptor antagonist|ARBs]], [[Aldosterone antagonist]]
-| '''ACC/AHA Heart Failure Guideline''' <ref name="pmid11738322">Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS et al. (2001)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11738322 ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure).] ''J Am Coll Cardiol'' 38 (7):2101-13. PMID:[http://pubmed.gov/11738322 11738322]</ref>; '''MERIT-HF''' <ref name="pmid12189311">Tepper D (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12189311 Frontiers in congestive heart failure: Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF).] ''Congest Heart Fail'' 5 (4):184-185. PMID: [http://pubmed.gov/12189311 12189311]</ref>;'''COPERNICUS''' <ref name="pmid11386263">Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P et al. (2001)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11386263 Effect of carvedilol on survival in severe chronic heart failure.] ''N Engl J Med'' 344 (22):1651-8. [http://dx.doi.org/10.1056/NEJM200105313442201 DOI:10.1056/NEJM200105313442201] PMID:[http://pubmed.gov/11386263 11386263]</ref>; '''CIBIS''' <ref name="pmid7923660"> (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7923660 A randomized trial of beta-blockade in heart failure. The Cardiac Insufficiency Bisoprolol Study (CIBIS). CIBIS Investigators and Committees.] ''Circulation'' 90 (4):1765-73. PMID: [http://pubmed.gov/7923660 7923660]</ref>; '''SOLVD''' <ref name="pmid2057034">(1991) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2057034 Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators.] ''N Engl J Med'' 325 (5):293-302.[http://dx.doi.org/10.1056/NEJM199108013250501 DOI:10.1056/NEJM199108013250501] PMID: [http://pubmed.gov/2057034 2057034]</ref>; '''AIRE''' <ref name="pmid8104270"> (1993) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8104270 Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators.] ''Lancet'' 342 (8875):821-8. PMID: [http://pubmed.gov/8104270 8104270]</ref>; '''TRACE''' <ref name="pmid7477219">Køber L, Torp-Pedersen C, Carlsen JE, Bagger H, Eliasen P, Lyngborg K et al. (1995) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7477219 A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril Cardiac Evaluation (TRACE) Study Group.] ''N Engl J Med'' 333 (25):1670-6.[http://dx.doi.org/10.1056/NEJM199512213332503 DOI:10.1056/NEJM199512213332503] PMID: [http://pubmed.gov/7477219 7477219]</ref>; '''ValHEFT''' <ref name="pmid11759645">Cohn JN, Tognoni G, Valsartan Heart Failure Trial Investigators (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11759645 A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure.] ''N Engl J Med''345 (23):1667-75. [http://dx.doi.org/10.1056/NEJMoa010713 DOI:10.1056/NEJMoa010713] PMID: [http://pubmed.gov/11759645 11759645]</ref>; '''RALES''' <ref name="pmid10471456">Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10471456 The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators.] ''N Engl J Med'' 341 (10):709-17. [http://dx.doi.org/10.1056/NEJM199909023411001 DOI:10.1056/NEJM199909023411001]PMID: [http://pubmed.gov/10471456 10471456]</ref>
+| '''ACC/AHA Heart Failure Guideline''' <ref name="pmid11738322">Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS et al. (2001)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11738322 ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure).] ''J Am Coll Cardiol'' 38 (7):2101-13. PMID:[http://pubmed.gov/11738322 11738322]</ref>; '''MERIT-HF''' <ref name="pmid12189311">Tepper D (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12189311 Frontiers in congestive heart failure: Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF).] ''Congest Heart Fail'' 5 (4):184-185. PMID: [http://pubmed.gov/12189311 12189311]</ref>;'''COPERNICUS''' <ref name="pmid11386263">Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P et al. (2001)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11386263 Effect of carvedilol on survival in severe chronic heart failure.] ''N Engl J Med'' 344 (22):1651-8. [http://dx.doi.org/10.1056/NEJM200105313442201 DOI:10.1056/NEJM200105313442201] PMID:[http://pubmed.gov/11386263 11386263]</ref>; '''CIBIS''' <ref name="pmid7923660">(1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7923660 A randomized trial of beta-blockade in heart failure. The Cardiac Insufficiency Bisoprolol Study (CIBIS). CIBIS Investigators and Committees.] ''Circulation'' 90 (4):1765-73. PMID: [http://pubmed.gov/7923660 7923660]</ref>; '''SOLVD''' <ref name="pmid2057034">(1991) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2057034 Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators.] ''N Engl J Med'' 325 (5):293-302.[http://dx.doi.org/10.1056/NEJM199108013250501 DOI:10.1056/NEJM199108013250501] PMID: [http://pubmed.gov/2057034 2057034]</ref>; '''AIRE''' <ref name="pmid8104270">(1993) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8104270 Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators.] ''Lancet'' 342 (8875):821-8. PMID: [http://pubmed.gov/8104270 8104270]</ref>; '''TRACE''' <ref name="pmid7477219">Køber L, Torp-Pedersen C, Carlsen JE, Bagger H, Eliasen P, Lyngborg K et al. (1995) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7477219 A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril Cardiac Evaluation (TRACE) Study Group.] ''N Engl J Med'' 333 (25):1670-6.[http://dx.doi.org/10.1056/NEJM199512213332503 DOI:10.1056/NEJM199512213332503] PMID: [http://pubmed.gov/7477219 7477219]</ref>; '''ValHEFT''' <ref name="pmid11759645">Cohn JN, Tognoni G, Valsartan Heart Failure Trial Investigators (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11759645 A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure.] ''N Engl J Med''345 (23):1667-75. [http://dx.doi.org/10.1056/NEJMoa010713 DOI:10.1056/NEJMoa010713] PMID: [http://pubmed.gov/11759645 11759645]</ref>; '''RALES''' <ref name="pmid10471456">Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10471456 The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators.] ''N Engl J Med'' 341 (10):709-17. [http://dx.doi.org/10.1056/NEJM199909023411001 DOI:10.1056/NEJM199909023411001]PMID: [http://pubmed.gov/10471456 10471456]</ref>
 |- align="left"
-| bgcolor="#f3f3f3"|[[MI|Post-Myocardial infarction]]
+| bgcolor="#f3f3f3" |[[MI|Post-Myocardial infarction]]
 | [[Beta blockers]], [[ACE inhibitor|ACEIs]], [[Aldosterone antagonist]]
-| '''ACC/AHA Post-MI Guideline''' <ref name="pmid12383588">Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS et al. (2002)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12383588 ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina).] ''J Am Coll Cardiol'' 40 (7):1366-74. PMID: [http://pubmed.gov/12383588 12383588]</ref>; '''BHAT''' <ref name="pmid7038157"> (1982) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7038157 A randomized trial of propranolol in patients with acute myocardial infarction. I. Mortality results.]''JAMA'' 247 (12):1707-14. PMID: [http://pubmed.gov/7038157 7038157]</ref>; '''SAVE''' <ref name="pmid9506325">Hager WD, Davis BR, Riba A, Moye LA, Wun CC, Rouleau JL et al. (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9506325 Absence of a deleterious effect of calcium channel blockers in patients with left ventricular dysfunction after myocardial infarction: The SAVE Study Experience. SAVE Investigators. Survival and Ventricular Enlargement.] ''Am Heart J'' 135 (3):406-13. PMID: [http://pubmed.gov/9506325 9506325]</ref>; '''Capricorn''' <ref name="pmid11356434">Dargie HJ (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11356434 Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial.] ''Lancet'' 357 (9266):1385-90. PMID:[http://pubmed.gov/11356434 11356434]</ref>; '''EPHESUS''' <ref name="pmid12668699">Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B et al. (2003)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12668699 Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.] ''N Engl J Med'' 348 (14):1309-21. [http://dx.doi.org/10.1056/NEJMoa030207DOI:10.1056/NEJMoa030207] PMID: [http://pubmed.gov/12668699 12668699]</ref>
+| '''ACC/AHA Post-MI Guideline''' <ref name="pmid12383588">Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS et al. (2002)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12383588 ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina).] ''J Am Coll Cardiol'' 40 (7):1366-74. PMID: [http://pubmed.gov/12383588 12383588]</ref>; '''BHAT''' <ref name="pmid7038157">(1982) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7038157 A randomized trial of propranolol in patients with acute myocardial infarction. I. Mortality results.]''JAMA'' 247 (12):1707-14. PMID: [http://pubmed.gov/7038157 7038157]</ref>; '''SAVE''' <ref name="pmid9506325">Hager WD, Davis BR, Riba A, Moye LA, Wun CC, Rouleau JL et al. (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9506325 Absence of a deleterious effect of calcium channel blockers in patients with left ventricular dysfunction after myocardial infarction: The SAVE Study Experience. SAVE Investigators. Survival and Ventricular Enlargement.] ''Am Heart J'' 135 (3):406-13. PMID: [http://pubmed.gov/9506325 9506325]</ref>; '''CAPRICORN''' <ref name="pmid11356434">Dargie HJ (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11356434 Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial.] ''Lancet'' 357 (9266):1385-90. PMID:[http://pubmed.gov/11356434 11356434]</ref>; '''EPHESUS''' <ref name="pmid12668699">Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B et al. (2003)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12668699 Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.] ''N Engl J Med'' 348 (14):1309-21. [http://dx.doi.org/10.1056/NEJMoa030207DOI:10.1056/NEJMoa030207] PMID: [http://pubmed.gov/12668699 12668699]</ref>
 |- align="left"
-| bgcolor="#f3f3f3"|[[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|High coronary disease risk]]
+| bgcolor="#f3f3f3" |[[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|High coronary disease risk]]
 | [[Diuretics]], [[Beta blockers]], [[ACE inhibitor|ACEIs]], [[Calcium channel blocker|CCBs]],
 | '''ALLHAT''' <ref name="pmid12479763">ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12479763 Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).] ''JAMA'' 288 (23):2981-97. PMID: [http://pubmed.gov/12479763 12479763]</ref>; '''HOPE'''<ref name="pmid10639539">Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10639539 Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators.] ''N Engl J Med'' 342 (3):145-53. [http://dx.doi.org/10.1056/NEJM200001203420301DOI:10.1056/NEJM200001203420301] PMID: [http://pubmed.gov/10639539 10639539]</ref>; '''ANBP2''' <ref name="pmid12584366">Wing LM, Reid CM, Ryan P, Beilin LJ, Brown MA, Jennings GL et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12584366 A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly.] ''N Engl J Med'' 348 (7):583-92.[http://dx.doi.org/10.1056/NEJMoa021716 DOI:10.1056/NEJMoa021716] PMID: [http://pubmed.gov/12584366 12584366]</ref>; '''LIFE''' <ref name="pmid11937178">Dahlöf B, Devereux RB, Kjeldsen SE, Julius S, Beevers G, de Faire U et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11937178 Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol.] ''Lancet'' 359 (9311):995-1003. [http://dx.doi.org/10.1016/S0140-6736(02)08089-3 DOI:10.1016/S0140-6736(02)08089-3] PMID: [http://pubmed.gov/11937178 11937178]</ref>; '''CONVINCE''' <ref name="pmid12709465">Black HR, Elliott WJ, Grandits G, Grambsch P, Lucente T, White WB et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12709465 Principal results of the Controlled Onset Verapamil Investigation of Cardiovascular End Points (CONVINCE) trial.] ''JAMA'' 289 (16):2073-82.[http://dx.doi.org/10.1001/jama.289.16.2073 DOI:10.1001/jama.289.16.2073] PMID: [http://pubmed.gov/12709465 12709465]</ref>
 |- align="left"
-| bgcolor="#f3f3f3"|[[Diabetes]]
+| bgcolor="#f3f3f3" |[[Diabetes]]
 | [[Diuretics]], [[Beta blockers]], [[ACE inhibitor|ACEIs]], [[Angiotensin II receptor antagonist|ARBs]], [[Calcium channel blocker|CCBs]]
-| '''NKF-ADA Guideline''' <ref name="pmid12502624">Arauz-Pacheco C, Parrott MA, Raskin P, American Diabetes Association (2003)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12502624 Treatment of hypertension in adults with diabetes.]''Diabetes Care'' 26 Suppl 1 ():S80-2. PMID: [http://pubmed.gov/12502624 12502624]</ref><ref name="pmid11904577">National Kidney Foundation (2002)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11904577 K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.] ''Am J Kidney Dis'' 39 (2 Suppl 1):S1-266. PMID: [http://pubmed.gov/11904577 11904577]</ref>;'''UKPDS''' <ref name="pmid9732338"> (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9732338 Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group.]''BMJ'' 317 (7160):713-20. PMID: [http://pubmed.gov/9732338 9732338]</ref>; '''ALLHAT''' <ref name="pmid12479763">ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (2002)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12479763 Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).] ''JAMA'' 288 (23):2981-97. PMID: [http://pubmed.gov/12479763 12479763]</ref>
+| '''NKF-ADA Guideline''' <ref name="pmid12502624">Arauz-Pacheco C, Parrott MA, Raskin P, American Diabetes Association (2003)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12502624 Treatment of hypertension in adults with diabetes.]''Diabetes Care'' 26 Suppl 1 ():S80-2. PMID: [http://pubmed.gov/12502624 12502624]</ref><ref name="pmid11904577">National Kidney Foundation (2002)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11904577 K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.] ''Am J Kidney Dis'' 39 (2 Suppl 1):S1-266. PMID: [http://pubmed.gov/11904577 11904577]</ref>;'''UKPDS''' <ref name="pmid9732338">(1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9732338 Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group.]''BMJ'' 317 (7160):713-20. PMID: [http://pubmed.gov/9732338 9732338]</ref>; '''ALLHAT''' <ref name="pmid12479763">ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (2002)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12479763 Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).] ''JAMA'' 288 (23):2981-97. PMID: [http://pubmed.gov/12479763 12479763]</ref>
 |- align="left"
-| bgcolor="#f3f3f3"|[[Chronic kidney disease]]
+| bgcolor="#f3f3f3" |[[Chronic kidney disease]]
 | [[ACE inhibitor|ACEIs]], [[Angiotensin II receptor antagonist|ARBs]]
-| '''NFK Guideline''' <ref name="pmid11904577">National Kidney Foundation (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11904577 K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.] ''Am J Kidney Dis'' 39 (2 Suppl 1):S1-266. PMID: [http://pubmed.gov/11904577 11904577]</ref>; '''Captopril Trial''' <ref name="pmid8413456">Lewis EJ, Hunsicker LG, Bain RP, Rohde RD (1993) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8413456 The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group.] ''N Engl J Med'' 329 (20):1456-62. [http://dx.doi.org/10.1056/NEJM199311113292004 DOI:10.1056/NEJM199311113292004] PMID: [http://pubmed.gov/84134568413456]</ref>; '''RENAAL''' <ref name="pmid11565518">Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH et al. (2001)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11565518 Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy.] ''N Engl J Med'' 345 (12):861-9. [http://dx.doi.org/10.1056/NEJMoa011161 DOI:10.1056/NEJMoa011161]PMID: [http://pubmed.gov/11565518 11565518]</ref>; '''IDNT''' <ref name="pmid11565517">Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB et al. (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11565517 Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes.] ''N Engl J Med'' 345 (12):851-60. [http://dx.doi.org/10.1056/NEJMoa011303DOI:10.1056/NEJMoa011303] PMID: [http://pubmed.gov/11565517 11565517]</ref>; '''REIN''' <ref name="pmid9217756"> (1997)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9217756 Randomised placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of terminal renal failure in proteinuric, non-diabetic nephropathy. The GISEN Group (Gruppo Italiano di Studi Epidemiologici in Nefrologia)] ''Lancet'' 349 (9069):1857-63. PMID: [http://pubmed.gov/9217756 9217756]</ref>; '''AASK''' <ref name="pmid12123409">Wright JT, Agodoa L, Contreras G, Greene T, Douglas JG, Lash J et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12123409 Successful blood pressure control in the African American Study of Kidney Disease and Hypertension.] ''Arch Intern Med'' 162 (14):1636-43. PMID: [http://pubmed.gov/12123409 12123409]</ref>
+| '''NFK Guideline''' <ref name="pmid11904577">National Kidney Foundation (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11904577 K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.] ''Am J Kidney Dis'' 39 (2 Suppl 1):S1-266. PMID: [http://pubmed.gov/11904577 11904577]</ref>; '''Captopril Trial''' <ref name="pmid8413456">Lewis EJ, Hunsicker LG, Bain RP, Rohde RD (1993) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8413456 The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group.] ''N Engl J Med'' 329 (20):1456-62. [http://dx.doi.org/10.1056/NEJM199311113292004 DOI:10.1056/NEJM199311113292004] PMID: [http://pubmed.gov/84134568413456]</ref>; '''RENAAL''' <ref name="pmid11565518">Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH et al. (2001)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11565518 Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy.] ''N Engl J Med'' 345 (12):861-9. [http://dx.doi.org/10.1056/NEJMoa011161 DOI:10.1056/NEJMoa011161]PMID: [http://pubmed.gov/11565518 11565518]</ref>; '''IDNT''' <ref name="pmid11565517">Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB et al. (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11565517 Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes.] ''N Engl J Med'' 345 (12):851-60. [http://dx.doi.org/10.1056/NEJMoa011303DOI:10.1056/NEJMoa011303] PMID: [http://pubmed.gov/11565517 11565517]</ref>; '''REIN''' <ref name="pmid9217756">(1997)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9217756 Randomised placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of terminal renal failure in proteinuric, non-diabetic nephropathy. The GISEN Group (Gruppo Italiano di Studi Epidemiologici in Nefrologia)] ''Lancet'' 349 (9069):1857-63. PMID: [http://pubmed.gov/9217756 9217756]</ref>; '''AASK''' <ref name="pmid12123409">Wright JT, Agodoa L, Contreras G, Greene T, Douglas JG, Lash J et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12123409 Successful blood pressure control in the African American Study of Kidney Disease and Hypertension.] ''Arch Intern Med'' 162 (14):1636-43. PMID: [http://pubmed.gov/12123409 12123409]</ref>
 |- align="left"
-| bgcolor="#f3f3f3"|[[Stroke prevention|Recurrent stroke prevention]]
+| bgcolor="#f3f3f3" |[[Stroke prevention|Recurrent stroke prevention]]
 | [[Diuretics]], [[ACE inhibitor|ACEIs]]
 | '''PROGRESS''' <ref name="pmid11589932">PROGRESS Collaborative Group (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11589932 Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack.] ''Lancet'' 358 (9287):1033-41. [http://dx.doi.org/10.1016/S0140-6736(01)06178-5 DOI:10.1016/S0140-6736(01)06178-5] PMID:[http://pubmed.gov/11589932 11589932]</ref>
 |}</center>
+<br>
+<br>
+===Contraindicated medications===
+{{MedCondContrAbs
+|MedCond = Chronic hypertension|Abciximab|Alteplase|Tenecteplase|}}
+{{MedCondContrAbs
+|MedCond = Severe uncontrolled arterial hypertension|Darbepoetin alfa|Epoetin alfa|Eptifibatide|Rizatriptan|Reteplase|Streptokinase|Urokinase}}
 ====ESH/ESC 2013 Guidelines: Drugs to be Preferred in Specific Conditions <ref name="pmid23817082">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M et al.| title=2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). | journal=J Hypertens | year= 2013 | volume= 31 | issue= 7 | pages= 1281-357 | pmid=23817082 | doi=10.1097/01.hjh.0000431740.32696.cc | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23817082 }} </ref>====
-{| border="1" style="border-collapse:collapse; text-align:left; font-size:120%;" cellpadding="5" align="center" width="900px"
+{| style="border-collapse:collapse; text-align:left; font-size:120%;" width="900px" align="center" border="1" cellpadding="5"
-| align="center" bgcolor="#67e1ff"|''' Condition'''|| align="center" bgcolor="#67e1ff"|''' Drug'''
+| align="center" bgcolor="#67e1ff" |'''Patient Characteristic'''|| align="center" bgcolor="#67e1ff" |''' Drug'''
 |-
-|  bgcolor="#f3f3f3"|Asymptomatic organ damage  || bgcolor="#f3f3f3"|
+| bgcolor="#f3f3f3" |Asymptomatic organ damage  || bgcolor="#f3f3f3" |
 |-
-|  LVH  || ACE inhibitor, calcium antagonist, ARB
+|  Left Ventricular Hypertrophy  || ACE inhibitor, calcium antagonist, ARB
 |-
 |  Asymptomatic atherosclerosis  || Calcium antagonist, ACE inhibitor
@@ Line 213: / Line 511: @@
 |  Renal dysfunction  || ACE inhibitor, ARB
 |-
-| bgcolor="#f3f3f3"| Clinical CV event  || bgcolor="#f3f3f3"|
+| bgcolor="#f3f3f3" | Clinical CV event  || bgcolor="#f3f3f3" |
 |-
 |  Previous stroke  || Any agent effectively lowering BP
@@ Line 233: / Line 531: @@
 |  Peripheral artery disease  || ACE inhibitor, calcium antagonist
 |-
-|  bgcolor="#f3f3f3"|Other  || bgcolor="#f3f3f3"|
+| bgcolor="#f3f3f3" |Other  || bgcolor="#f3f3f3" |
 |-
 |  ISH (elderly)  || Diuretic, calcium antagonist
@@ Line 247: / Line 545: @@
 |}
+==Methods of monitoring blood pressure==
+=== Self-monitoring of blood pressure (SMBP)===
+According to systematic review in 2017 <ref name="pmid28926573">{{cite journal| author=Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP et al.| title=Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. | journal=PLoS Med | year= 2017 | volume= 14 | issue= 9 | pages= e1002389 | pmid=28926573 | doi=10.1371/journal.pmed.1002389 | pmc=5604965 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28926573  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=29459953 Review in: Ann Intern Med. 2018 Feb 20;168(4):JC16] </ref>, self-monitoring blood pressures alone is not an effective treatment for high blood pressure. However, as an adjunct to interventions such as patient education, medication titration, and lifestyle counselling, self-monitoring blood pressures significantly aids in controlling patient blood pressure. “Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (−3.2 mmHg, [95% CI −4.9, −1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (−1.0 mmHg [−3.3, 1.2]), to a 6.1 mmHg (−9.0, −3.2) reduction when monitoring was combined with intensive support.”
+This assessment is supported by another systematic review in 2018 <ref name="pmid29499873">{{cite journal| author=McManus RJ, Mant J, Franssen M, Nickless A, Schwartz C, Hodgkinson J et al.| title=Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. | journal=Lancet | year= 2018 | volume= 391 | issue= 10124 | pages= 949-959 | pmid=29499873 | doi=10.1016/S0140-6736(18)30309-X | pmc=5854463 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29499873  }} </ref>, who determined that self-monitoring blood pressures significantly helps control patient blood pressure by aiding in physician anti-hypertensive medication titration. “Compared with usual care, the decrease in clinic measured systolic blood pressure at 12 months in patients in both self-monitoring groups was clinically meaningful. The adjusted mean differences vs usual care: self-monitoring alone −3.5 mm Hg [95% CI −5.8 to −1.2]; and telemonitoring −4.7 mm Hg [–7.0 to −2.4]). If sustained, such reductions in blood pressure could be expected to reduce stroke risk by 20% and coronary heart disease risk by 10%.”
-===Management of Hypertension in Special Populations===
+=== Digital Remote Patient Monitoring (RPM)===
-====Ethnic groups====
+RPM may reduce mortality and hospital visits according to an observational study<ref name="pmid37973707">{{cite journal| author=Acharya M, Ali MM, Bogulski CA, Pandit AA, Mahashabde RV, Eswaran H | display-authors=etal| title=Association of Remote Patient Monitoring with Mortality and Healthcare Utilization in Hypertensive Patients: a Medicare Claims-Based Study. | journal=J Gen Intern Med | year= 2024 | volume= 39 | issue= 5 | pages= 762-773 | pmid=37973707 | doi=10.1007/s11606-023-08511-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=37973707  }} </ref>.
-* African Americans: Enforcement of DASH diet due to its association with greater reduction of BP than other ethnicities (Ref: 11136953). According to the ALLHAT trial that included 15,000 Blacks, diuretics were more effective for African Americans than other classes of anti-hypertensive agents.<ref name="pmid22025634">{{cite journal| author=Rodeheffer RJ| title=Hypertension and heart failure: the ALLHAT imperative. | journal=Circulation | year= 2011 | volume= 124 | issue= 17 | pages= 1803-5 | pmid=22025634 | doi=10.1161/CIRCULATIONAHA.111.059303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22025634 }} </ref>
-* Mexican Americans, other Hispanic Americans, Native Americans, and Asian/Pacific Islanders have been recruited in insufficient numbers in research trials to adequately identify special considerations.<ref name="pmid16512265">{{cite journal| author=Cuddy ML| title=Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1). | journal=J Pract Nurs | year= 2005 | volume= 55 | issue= 4 | pages= 17-21; quiz 22-3 | pmid=16512265 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16512265 }} </ref>
+==Team-Based Care, Interdisciplinary Approach to Hypertension Management==
+Recent literature suggests that an interdisciplinary approach to hypertension provides higher control rates and more comprehensive management of hypertension on a population level. <ref name="pmid19858431">{{cite journal| author=Carter BL, Rogers M, Daly J, Zheng S, James PA| title=The potency of team-based care interventions for hypertension: a meta-analysis. | journal=Arch Intern Med | year= 2009 | volume= 169 | issue= 19 | pages= 1748-55 | pmid=19858431 | doi=10.1001/archinternmed.2009.316 | pmc=2882164 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19858431  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20436147 Review in: Evid Based Nurs. 2010 Apr;13(2):47-8] </ref> <ref name="pmid19858431">{{cite journal| author=Carter BL, Rogers M, Daly J, Zheng S, James PA| title=The potency of team-based care interventions for hypertension: a meta-analysis. | journal=Arch Intern Med | year= 2009 | volume= 169 | issue= 19 | pages= 1748-55 | pmid=19858431 | doi=10.1001/archinternmed.2009.316 | pmc=2882164 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19858431  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20436147 Review in: Evid Based Nurs. 2010 Apr;13(2):47-8] </ref> Team-based care is cost-effective<ref name="pmid37121447">{{cite journal| author=Jacob V, Reynolds JA, Chattopadhyay SK, Nowak K, Hopkins DP, Fulmer E | display-authors=etal| title=Economics of Team-Based Care for Blood Pressure Control: Updated Community Guide Systematic Review. | journal=Am J Prev Med | year= 2023 | volume=  | issue=  | pages=  | pmid=37121447 | doi=10.1016/j.amepre.2023.04.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=37121447  }} </ref>.
+Systems-based interventions such as increasing the role of medical assistants and pharmacists in the management of hypertension has shown the most marked improvements in control. Other interventions include single-pill medical therapy, monitoring visits with medical assistants, creating a hypertension registry, and home blood pressure management. <ref name="pmid23989679">{{cite journal| author=Jaffe MG, Lee GA, Young JD, Sidney S, Go AS| title=Improved blood pressure control associated with a large-scale hypertension program. | journal=JAMA | year= 2013 | volume= 310 | issue= 7 | pages= 699-705 | pmid=23989679 | doi=10.1001/jama.2013.108769 | pmc=4270203 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23989679  }} </ref> <ref name="pmid22143452">{{cite journal| author=Hebert PL, Sisk JE, Tuzzio L, Casabianca JM, Pogue VA, Wang JJ et al.| title=Nurse-led disease management for hypertension control in a diverse urban community: a randomized trial. | journal=J Gen Intern Med | year= 2012 | volume= 27 | issue= 6 | pages= 630-9 | pmid=22143452 | doi=10.1007/s11606-011-1924-1 | pmc=3358388 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22143452  }} </ref> <ref name="pmid24933494">{{cite journal| author=Proia KK, Thota AB, Njie GJ, Finnie RK, Hopkins DP, Mukhtar Q et al.| title=Team-based care and improved blood pressure control: a community guide systematic review. | journal=Am J Prev Med | year= 2014 | volume= 47 | issue= 1 | pages= 86-99 | pmid=24933494 | doi=10.1016/j.amepre.2014.03.004 | pmc=4672378 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24933494  }} </ref> <ref name="pmid26687551">{{cite journal| author=Fortuna RJ, Nagel AK, Rose E, McCann R, Teeters JC, Quigley DD et al.| title=Effectiveness of a multidisciplinary intervention to improve hypertension control in an urban underserved practice. | journal=J Am Soc Hypertens | year= 2015 | volume= 9 | issue= 12 | pages= 966-74 | pmid=26687551 | doi=10.1016/j.jash.2015.10.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26687551  }} </ref>
+* When a team approach is used to manage hypertension, the addition of pharmacists alone were found to have the most substantial effect on hypertension control at the population level. <ref name="pmid24933494">{{cite journal| author=Proia KK, Thota AB, Njie GJ, Finnie RK, Hopkins DP, Mukhtar Q et al.| title=Team-based care and improved blood pressure control: a community guide systematic review. | journal=Am J Prev Med | year= 2014 | volume= 47 | issue= 1 | pages= 86-99 | pmid=24933494 | doi=10.1016/j.amepre.2014.03.004 | pmc=4672378 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24933494  }} </ref>
+* There is conflicting evidence on home-monitoring alone as an effective method for increasing blood pressure control. <ref name="pmid25737487">{{cite journal| author=Yi SS, Tabaei BP, Angell SY, Rapin A, Buck MD, Pagano WG et al.| title=Self-blood pressure monitoring in an urban, ethnically diverse population: a randomized clinical trial utilizing the electronic health record. | journal=Circ Cardiovasc Qual Outcomes | year= 2015 | volume= 8 | issue= 2 | pages= 138-45 | pmid=25737487 | doi=10.1161/CIRCOUTCOMES.114.000950 | pmc=4366280 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25737487  }} </ref> <ref name="pmid28926573">{{cite journal| author=Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP et al.| title=Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. | journal=PLoS Med | year= 2017 | volume= 14 | issue= 9 | pages= e1002389 | pmid=28926573 | doi=10.1371/journal.pmed.1002389 | pmc=5604965 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28926573  }} </ref> <ref name="pmid23922064">{{cite journal| author=Uhlig K, Patel K, Ip S, Kitsios GD, Balk EM| title=Self-measured blood pressure monitoring in the management of hypertension: a systematic review and meta-analysis. | journal=Ann Intern Med | year= 2013 | volume= 159 | issue= 3 | pages= 185-94 | pmid=23922064 | doi=10.7326/0003-4819-159-3-201308060-00008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23922064  }} </ref>
+* Interventions such as optimizing single pill combination medications or promoting home blood pressure monitoring have not been shown to provide significant improvements in blood pressure when implemented alone.
-====Diabetic Patients====
+==Management of Hypertension in Special Populations==
+===Diabetic Patients===
 * According to the American Diabetes Association, BP goal for diabetic patients must be < 140/80 mmHg to reduce the progression of target organ damage but that lower systolic blood pressure targets <130 mmHg can be targeted in younger patients.<ref name="pmid23264423">{{cite journal| author=| title=Summary of revisions for the 2013 clinical practice recommendations. | journal=Diabetes Care | year= 2013 | volume= 36 Suppl 1 | issue= | pages= S3 | pmid=23264423 | doi=10.2337/dc13-S003 | pmc=PMC3537268 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23264423 }} </ref>  The recent shift in the approach to hypertension in diabetics proposed by the 2013 ADA guidelines as well as the 2013 ESH/ESC guidelines is supported by the fact that no major trials have consistently achieved a blood pressure level below 130/80 mmHg in diabetics nor have the smaller trials shown any major benefit from intensive treatment to reach that threshold. In parallel to the ADA, the 2013 ESH/ESC guidelines only support a lower DBP goal set at 80-85 mmHg.<ref name="pmid23817082">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M et al.| title=2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). | journal=J Hypertens | year= 2013 | volume= 31 | issue= 7 | pages= 1281-357 | pmid=23817082 | doi=10.1097/01.hjh.0000431740.32696.cc | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23817082 }} </ref>
@@ Line 265: / Line 575: @@
 * In the management of hypertension, CCBs are unquestionably useful in the reduction of BP values. However, their role in preventing target organ damage in diabetic patients is inferior to other agents. The ALLHAT study demonstrated that amlodipine, a DHP CCB, was less effective than thiazides in reducing heart failure.<ref name="pmid22025634">{{cite journal| author=Rodeheffer RJ| title=Hypertension and heart failure: the ALLHAT imperative. | journal=Circulation | year= 2011 | volume= 124 | issue= 17 | pages= 1803-5 | pmid=22025634 | doi=10.1161/CIRCULATIONAHA.111.059303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22025634 }} </ref>  Similarly, the ABCD Trial also showed that nisoldipine, a dihydropyridine CCB was less effective than enalapril, an ACEI, in reducing ischemic heart disease.<ref name="pmid11849464">{{cite journal| author=Schrier RW, Estacio RO, Esler A, Mehler P| title=Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. | journal=Kidney Int | year= 2002 | volume= 61 | issue= 3 | pages= 1086-97 | pmid=11849464 | doi=10.1046/j.1523-1755.2002.00213.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11849464 }} </ref>
-====Chronic Kidney Disease Patients====
+===Chronic Kidney Disease Patients===
+* Based mostly on the results from meta-analyses of patients with proteinuria showing slower rate of CKD progression when SBP was targeted to <130 mmHg, JNC7 and the National Kidney Foundation recommended a set BP goal below 130/80 mmHg for all CKD patients and the use of more than a single agent for therapy. The recommended treatment regimen usually includes an ACEI or ARB in combination with a loop diuretic. <ref name="pmid14656957">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. | journal=Hypertension | year= 2003 | volume= 42 | issue= 6 | pages= 1206-52 | pmid=14656957 | doi=10.1161/01.HYP.0000107251.49515.c2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14656957 }} </ref>
+* In 2012, the KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease recommended that diabetic and non-diabetic patients with CKD without proteinuria or microalbuminuria should be treated if their BP measurements are consistently above 140/90 mmHg. Target of treatment in this group is to maintain blood pressure below 140/90 mmHg. In patients with CKD and microalbuminuria or proteinuria, initiation of therapy should be at BP values >130/80 mmHg with target below 130/80 mmHg. The guidelines also advocated the use ACEIs and ARBs in patients with microalbuminuria or proteinuria. Lifestyle modifications proposed included lowering salt intake to <2g per day of sodium, exercise for at least 30 minutes 5 times per week.
+* In contrast, the 2013 ESH/ESC guidelines updated their old recommendations, changing the blood pressure target to <140/90 mmHg, no different than the general population. They based their recommendations on three trials<ref name="pmid12435255">{{cite journal| author=Wright JT, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J et al.| title=Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. | journal=JAMA | year= 2002 | volume= 288 | issue= 19 | pages= 2421-31 | pmid=12435255 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12435255 }} </ref><ref name="pmid8114857">{{cite journal| author=Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW et al.| title=The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. | journal=N Engl J Med | year= 1994 | volume= 330 | issue= 13 | pages= 877-84 | pmid=8114857 | doi=10.1056/NEJM199403313301301 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8114857 }} </ref><ref name="pmid15766995">{{cite journal| author=Ruggenenti P, Perna A, Loriga G, Ganeva M, Ene-Iordache B, Turturro M et al.| title=Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. | journal=Lancet | year= 2005 | volume= 365 | issue= 9463 | pages= 939-46 | pmid=15766995 | doi=10.1016/S0140-6736(05)71082-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15766995 }} </ref> conducted in patients with chronic kidney disease without diabetes, that showed no difference in ESRD progression and all-cause mortality between patients randomized to low BP targets (<130 mmHg) to those randomized to a higher target (<140 mmHg). To note, observational follow-up data from 2 of these studies showed a tendency to lower adverse events in the lower target group especially in patients with proteinuria.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref>
 ====Patients with Metabolic Syndrome====
@@ Line 275: / Line 590: @@
 * Management of dyslipidemia, glucose intolerance, and other concomitant comorbidities is essential for reduction of BP in patients with metabolic syndrome.<ref name="pmid16512265">{{cite journal|author=Cuddy ML| title=Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1). | journal=J Pract Nurs | year= 2005 | volume= 55 | issue= 4 | pages= 17-21; quiz 22-3 | pmid=16512265 | doi= | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16512265 }} </ref>
+===Ethnic groups===
+* African Americans: Enforcement of DASH diet due to its association with greater reduction of BP than other ethnicities.<ref name="pmid11136953">{{cite journal| author=Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D et al.| title=Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. | journal=N Engl J Med | year= 2001 | volume= 344 | issue= 1 | pages= 3-10 | pmid=11136953 | doi=10.1056/NEJM200101043440101 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11136953 }} </ref> According to the ALLHAT trial that included 15,000 Blacks, diuretics were more effective for African Americans than other classes of anti-hypertensive agents.<ref name="pmid22025634">{{cite journal| author=Rodeheffer RJ| title=Hypertension and heart failure: the ALLHAT imperative. | journal=Circulation | year= 2011 | volume= 124 | issue= 17 | pages= 1803-5 | pmid=22025634 | doi=10.1161/CIRCULATIONAHA.111.059303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22025634 }} </ref>
+* Mexican Americans, other Hispanic Americans, Native Americans, and Asian/Pacific Islanders have been recruited in insufficient numbers in research trials to adequately identify special considerations.<ref name="pmid16512265">{{cite journal| author=Cuddy ML| title=Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1). | journal=J Pract Nurs | year= 2005 | volume= 55 | issue= 4 | pages= 17-21; quiz 22-3 | pmid=16512265 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16512265 }} </ref>
 ====Elderly Patients====
@@ Line 285: / Line 605: @@
 * The JNC7 guidelines concluded in 2004 that antihypertensive therapy should not be withheld in patients with stage 1 hypertension based on age, even though no RCTs had shown benefits from treatment in this population at the time.
-====Pregnant Women====
+===Pregnant Women===
 * Distinguishing gestational from pre-gestational hypertension in pregnant women is essential. Hypertension is not considered to be caused by pregnancy when it develops before 20 weeks of gestation.<ref name="pmid16512265">{{cite journal| author=Cuddy ML| title=Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1). | journal=J Pract Nurs | year= 2005 | volume= 55 | issue= 4 | pages= 17-21; quiz 22-3 | pmid=16512265 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16512265 }} </ref>
@@ Line 294: / Line 614: @@
 * The 2013 ESH/ESC guidelines recommend drug treatment of severe hypertension in pregnancy defined as SBP >160 mmHg or DBP >110 mmHg. They also advocate considering treatment in pregnant women with persistant hypertension ≥150/95 mmHg and in symptomatic patients or patients with target organ damage with BP ≥140/90 mmHg.<ref name="pmid23817082">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M et al.| title=2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). | journal=J Hypertens | year= 2013 | volume= 31 | issue= 7 | pages= 1281-357 | pmid=23817082 | doi=10.1097/01.hjh.0000431740.32696.cc | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23817082 }} </ref>
-====Patients with Hypertensive Emergency or Urgency====
+===Patients with Hypertensive Emergency or Urgency===
-* Hypertensive emergency is defined as high blood pressure causing acute target organ damage. Usually BP exceed 180/20 mmHg, but can sometimes occur at even lower values in patients who do not usually have high blood pressure.
+* Hypertensive emergency is defined as high blood pressure causing acute target organ damage. Usually BP exceeds 180/20 mmHg, but can sometimes occur at even lower values in patients who do not usually have high blood pressure.
 * Hypertensive urgency is defined as a BP > 180/120 mmHg without target organ damage. Hypertensive urgency may or may not be symptomatic.
@@ Line 310: / Line 630: @@
 ** Ischemic stroke will not require immediate BP lowering to maintain cerebral perfusion.
 ** Aortic dissection requires SBP to be lowered immediately to < 100 mmHg if tolerated followed by rapid specific management.
+==Benchmarks in controlling hypertension==
+In the US the rate of control is estimated at 43.7% in 2017-2018 using NHANES data.<ref name="pmid32902588">{{cite journal| author=Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB | display-authors=etal| title=Trends in Blood Pressure Control Among US Adults With Hypertension, 1999-2000 to 2017-2018. | journal=JAMA | year= 2020 | volume= 324 | issue= 12 | pages= 1190-1200 | pmid=32902588 | doi=10.1001/jama.2020.14545 | pmc=7489367 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32902588  }} </ref>
+Higher rates of control are reported by:
+* The National Committee for Quality Assurance (NCQA)'s Healthcare Effectiveness Data and Information Set (HEDIS) for patients other than traditional Medicare<ref>National Committee for Quality Assurance Controlling High Blood Pressure (CBP). Available at https://www.ncqa.org/hedis/measures/controlling-high-blood-pressure/</ref>
+* The Centers for Medicare and Medicaid Services's resource library Electronic Clinical Quality Improvement (eCQI) for Medicare patients<ref>Available at https://qpp.cms.gov/resources/resource-library (search for "quality benchmarks")</ref>
+==Barriers to blood pressure control==
+===Health care provider barriers===
+====Therapeutic inertia====
+[[Therapeutic inertia]] may contribute to the finding that in the US 62%, and in Europe 85%, of office visits with a high blood pressure the health care provider does not increase medications<ref name="pmid17242314">{{cite journal| author=Wang YR, Alexander GC, Stafford RS| title=Outpatient hypertension treatment, treatment intensification, and control in Western Europe and the United States. | journal=Arch Intern Med | year= 2007 | volume= 167 | issue= 2 | pages= 141-7 | pmid=17242314 | doi=10.1001/archinte.167.2.141 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17242314  }} </ref>. In another study, "Among visits in which a diastolic blood pressure of ≥90 mm Hg and systolic blood pressure of ≥155 mm Hg were recorded, the frequency of increases in antihypertensive medications was 25.6 percent"<ref name="pmid9869666">{{cite journal| author=Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, Kader B | display-authors=etal| title=Inadequate management of blood pressure in a hypertensive population. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 27 | pages= 1957-63 | pmid=9869666 | doi=10.1056/NEJM199812313392701 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9869666  }} </ref>. Similarly, another study found a rate of 17% of visits with uncontrolled hypertension having a treatment intensification<ref name="pmid27792661">{{cite journal| author=Mu L, Mukamal KJ| title=Treatment Intensification for Hypertension in US Ambulatory Medical Care. | journal=J Am Heart Assoc | year= 2016 | volume= 5 | issue= 10 | pages=  | pmid=27792661 | doi=10.1161/JAHA.116.004188 | pmc=5121514 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27792661  }} </ref>.
+The impact of intensification and deintensification is complicated<ref name="pmid34097300">{{cite journal| author=Aubert CE, Ha JK, Kim HM, Rodondi N, Kerr EA, Hofer TP | display-authors=etal| title=Clinical outcomes of modifying hypertension treatment intensity in older adults treated to low blood pressure. | journal=J Am Geriatr Soc | year= 2021 | volume= 69 | issue= 10 | pages= 2831-2841 | pmid=34097300 | doi=10.1111/jgs.17295 | pmc=8497391 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34097300  }} </ref>.
+Therapeutic inertia may be less with remote monitoring when patients submitted at least 3 elevated BP readings<ref name="pmid35029664">{{cite journal| author=Lee NS, Anastos-Wallen R, Chaiyachati KH, Reitz C, Asch DA, Mehta SJ| title=Clinician Decisions After Notification of Elevated Blood Pressure Measurements From Patients in a Remote Monitoring Program. | journal=JAMA Netw Open | year= 2022 | volume= 5 | issue= 1 | pages= e2143590 | pmid=35029664 | doi=10.1001/jamanetworkopen.2021.43590 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35029664  }} </ref>.
+====Choice of follow-up intervals====
+Among ''controlled'' patients, short follow-up intervals (3 versus 6 months), were found in a randomized controlled trial to not improve control<ref name="pmid14726370">{{cite journal| author=Birtwhistle RV, Godwin MS, Delva MD, Casson RI, Lam M, MacDonald SE | display-authors=etal| title=Randomised equivalence trial comparing three month and six month follow up of patients with hypertension by family practitioners. | journal=BMJ | year= 2004 | volume= 328 | issue= 7433 | pages= 204 | pmid=14726370 | doi=10.1136/bmj.37967.374063.EE | pmc=318487 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14726370  }} </ref>.
+Among ''uncontrolled'' patients
+* Short follow-up intervals (comparing < 2 weeks,  2 weeks to 1 month, and > 1 month), were found to improve speed of normalization of blood pressure and "increased probability of normalization of blood pressure at two years"<ref name="pmid20497991">{{cite journal| author=Turchin A, Goldberg SI, Shubina M, Einbinder JS, Conlin PR| title=Encounter frequency and blood pressure in hypertensive patients with diabetes mellitus. | journal=Hypertension | year= 2010 | volume= 56 | issue= 1 | pages= 68-74 | pmid=20497991 | doi=10.1161/HYPERTENSIONAHA.109.148791 | pmc=3752696 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20497991  }} </ref> Another observational study also found benefit in 2 weeks follow-up visits for hypertension as well as diabetes and cholesterol goals<ref name="pmid21949161">{{cite journal| author=Morrison F, Shubina M, Turchin A| title=Encounter frequency and serum glucose level, blood pressure, and cholesterol level control in patients with diabetes mellitus. | journal=Arch Intern Med | year= 2011 | volume= 171 | issue= 17 | pages= 1542-50 | pmid=21949161 | doi=10.1001/archinternmed.2011.400 | pmc=3692291 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21949161  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=22419770 Review in: Evid Based Med. 2012 Aug;17(4):120-1] </ref>. Additional studies have found importance of shorter follow-up<ref name="pmid28929608">{{cite journal| author=King CC, Bartels CM, Magnan EM, Fink JT, Smith MA, Johnson HM| title=The importance of frequent return visits and hypertension control among US young adults: a multidisciplinary group practice observational study. | journal=J Clin Hypertens (Greenwich) | year= 2017 | volume= 19 | issue= 12 | pages= 1288-1297 | pmid=28929608 | doi=10.1111/jch.13096 | pmc=5722664 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28929608  }} </ref>.
+* Short follow-up intervals, were found in a randomized controlled trial to minimally improve control; however, in this study, there was slight variation in the follow-up times between study groups (34, 32, and 32 days)<ref name="pmid34379277">{{cite journal| author=Fiscella K, He H, Sanders M, Cassells A, Carroll JK, Williams SK | display-authors=etal| title=Blood Pressure Visit Intensification in Treatment (BP-Visit) Findings: a Pragmatic Stepped Wedge Cluster Randomized Trial. | journal=J Gen Intern Med | year= 2021 | volume=  | issue=  | pages=  | pmid=34379277 | doi=10.1007/s11606-021-07016-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34379277  }} </ref>.
+====Involving self-monitoring and medication self-titration====
+A [[randomized controlled trial]] found "self-monitoring with self-titration of antihypertensive medication compared with usual care resulted in lower systolic blood pressure at 12 months."<ref name="pmid25157723">{{cite journal| author=McManus RJ, Mant J, Haque MS, Bray EP, Bryan S, Greenfield SM | display-authors=etal| title=Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. | journal=JAMA | year= 2014 | volume= 312 | issue= 8 | pages= 799-808 | pmid=25157723 | doi=10.1001/jama.2014.10057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25157723  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25587130 Review in: Evid Based Med. 2015 Apr;20(2):58]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25599367 Review in: Ann Intern Med. 2015 Jan 20;162(2):JC7]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25634011 Review in: Evid Based Nurs. 2015 Jul;18(3):87] </ref>
+===Patient factors===
+====Concomittent psychological depression====
+Treating depression with the COACH model may help<ref name="pmid36279299">Chen S, Conwell Y, Xue J, Li L, Zhao T, Tang W | display-authors=etal (2022) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=36279299 Effectiveness of integrated care for older adults with depression and hypertension in rural China: A cluster randomized controlled trial.] ''PLoS Med'' 19 (10):e1004019. [http://dx.doi.org/10.1371/journal.pmed.1004019 DOI:10.1371/journal.pmed.1004019] PMID: [https://pubmed.gov/36279299 36279299]</ref>.
+====Vulnerable populations====
+Underserved or [[vulnerable populations]] face additional socioeconomic barriers to hypertension control including decreased clinic resources, limited access to care, and inconsistent follow-up.
+A recent [[cohort study]] with a [[time-series analysis]] conducted in San Francisco [[safety net clinics]] adapted the 2013 Kaiser protocol (details above)<ref name="pmid23989679">{{cite journal| author=Jaffe MG, Lee GA, Young JD, Sidney S, Go AS| title=Improved blood pressure control associated with a large-scale hypertension program. | journal=JAMA | year= 2013 | volume= 310 | issue= 7 | pages= 699-705 | pmid=23989679 | doi=10.1001/jama.2013.108769 | pmc=4270203 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23989679  }} </ref> to fit the specific needs of safety-net clinics by focusing on 4 specific modifications<ref name="pmid30002140">{{cite journal| author=Fontil V, Gupta R, Moise N, Chen E, Guzman D, McCulloch CE et al.| title=Adapting and Evaluating a Health System Intervention From Kaiser Permanente to Improve Hypertension Management and Control in a Large Network of Safety-Net Clinics. | journal=Circ Cardiovasc Qual Outcomes | year= 2018 | volume= 11 | issue= 7 | pages= e004386 | pmid=30002140 | doi=10.1161/CIRCOUTCOMES.117.004386 | pmc=6071320 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30002140  }} </ref>:
+# Creating a hypertension patient registry
+# Simplified intensification of therapy
+# Standardized BP measurements
+# Team-based interdisciplinary BP checks by RNs and pharmacists.
+Implementation of the modified Kaiser protocol led to an increase in the percent of patients with controlled hypertension from a baseline of 68% to 74% over the course of fifteen months. Overall, the results of this study demonstrated that large-scale hypertension protocols can be successfully applied to high-risk populations<ref name="pmid30002140">{{cite journal| author=Fontil V, Gupta R, Moise N, Chen E, Guzman D, McCulloch CE et al.| title=Adapting and Evaluating a Health System Intervention From Kaiser Permanente to Improve Hypertension Management and Control in a Large Network of Safety-Net Clinics. | journal=Circ Cardiovasc Qual Outcomes | year= 2018 | volume= 11 | issue= 7 | pages= e004386 | pmid=30002140 | doi=10.1161/CIRCOUTCOMES.117.004386 | pmc=6071320 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30002140  }} </ref>.
+===Student-run free clinics===
+Student-run free clinics provide healthcare to a diverse population of patients including those that are: uninsured, unemployed, homeless, ethnic minority, non-native speakers, or low-income status. Student-run clinics that have published baseline rates of hypertension control show that these clinics are able to exceed national standards in their uninsured populations.
+According to HEDIS (2018), the national rate of hypertension control in Medicaid patients is 58.9%<ref>NCQA. Controlling High Blood Pressure. Available at https://www.ncqa.org/hedis/measures/controlling-high-blood-pressure/</ref>.
+In student-run free clinics:
+* Wahle et al. reported a baseline hypertension control rate of 46.8% (defined by JNC 7 & 8) at Indiana University Student Outreach Clinic<ref name="pmid28529218">{{cite journal| author=Wahle, B Meyer K, Faller M, Kochhar K, Sevilla J| title=Assessment of Hypertension Management and Outcomes at an Indianapolis Student-Run Free Clinic. | journal=J Health Care Poor Underserved | year= 2017 | volume= 28 | issue= 2 | pages= 694-706 | pmid=28529218 | doi=10.1353/hpu.2017.0068 | url=https://www.ncbi.nlm.nih.gov/pubmed/28529218}} </ref>.
+* Smith et al. reported a baseline hypertension control rate of 59.7% (defined by JNC 7 & 8)  at 4 student run health clinics associated with the University of California San Diego<ref name="pmid28166577">{{cite journal| author=Smith SD, Rojas SM, Huang J, Yang K, Vaida F| title=Longitudinal Hypertension Outcomes at Four Student-Run Free Clinic Sites. | journal=Fam Med. | year= 2017 | volume=49 | issue=1 | pages=28-34 | pmid=28166577 | url=https://www.ncbi.nlm.nih.gov/pubmed/28166577}} </ref>.
+* Zucker et al. reported a baseline hypertension control rate of 50% (defined by JNC 7) at a Student Family Health Care Center affiliated with the University of Medicine and Dentistry at New Jersey<ref name="pmid21169778">{{cite journal | author=Zucker J, Gillen J, Ackrivo J, Schroeder R, Keller S | title=Hypertension management in a student-run free clinic: meeting national standards? | journal=Acad Med. | year= 2011 | volume=86 | issue=2 | pages=239-45 | pmid=21169778 | doi=10.1097/ACM.0b013e31820465e0 | url=https://www.ncbi.nlm.nih.gov/pubmed/21169778}} </ref>.
+Despite the challenges associated with running a student-run free clinic, these studies show it is possible to achieve rates of hypertension control comparable to patients insured by Medicaid.
 ==References==

Chronic hypertension medical therapy: Difference between revisions

Latest revision as of 17:03, 25 April 2024

Overview

Blood Pressure Goals

Practice Guidelines

American College of Cardiology / American Heart Association

American College of Physicians / American Academy of Family Physicians

Eighth Joint National Committee (JNC 8)

Kaiser Guidelines

Blood pressure control outcomes for Kaiser

Clinical outcomes for Kaiser

ESH/ESC 2013 Guidelines

Antihypertensive Agents & Indications

Common Antihypertensive Agents

Choice of Initial Agent

Selecting medication based on patient demographics

Selecting fixed-dose combination pills

JNC7: Compelling Indications and Choice of Antihypertensive Agents[31]

Contraindicated medications

ESH/ESC 2013 Guidelines: Drugs to be Preferred in Specific Conditions [32]

Methods of monitoring blood pressure

Self-monitoring of blood pressure (SMBP)

Digital Remote Patient Monitoring (RPM)

Team-Based Care, Interdisciplinary Approach to Hypertension Management

Management of Hypertension in Special Populations

Diabetic Patients

Chronic Kidney Disease Patients

Patients with Metabolic Syndrome

Ethnic groups

Elderly Patients

Pregnant Women

Patients with Hypertensive Emergency or Urgency

Benchmarks in controlling hypertension

Barriers to blood pressure control

Health care provider barriers

Therapeutic inertia

Choice of follow-up intervals

Involving self-monitoring and medication self-titration

Patient factors

Concomittent psychological depression

Vulnerable populations

Student-run free clinics

References

Navigation menu

JNC7: Compelling Indications and Choice of Antihypertensive Agents^[31]

ESH/ESC 2013 Guidelines: Drugs to be Preferred in Specific Conditions ^[32]