Hypertension (HTN)

Population: Adults without diagnosis of hypertension.

Organizations

ACC/AHA 2018, ESH/ESC 2018, USPSTF 2021

Screening Recommendations

–Screen for hypertension in adults ≥ 18-y-old with office BP measurement. Obtain BP measurements outside of clinical setting before starting treatment.

–Screen for HTN using an average BP measurement based on ≥2 readings obtained on ≥2 occasions.

–Use single-visit BP measurement to diagnose HTN only in cases of severe BP elevation/grade 3 HTN (≥180/110) with clear evidence of hypertension-mediated organ damage (eg, hypertensive retinopathy, LVH, vascular or renal damage). (ESH/ESC)

–Elements of proper measurement include appropriately sized cuff at the level of right atrium, while patient is seated, ≥5 min between office entry and BP measurement.

–Screen every 3–5 y for age 18–39 without risk factors.

–Screen annually at age 40+ or if risk factors are found (prior BP ≥ 130–139/85–89, obese, overweight, Black).

Practice Pearls

• Blood pressure can be measured with programmed portable device that automatically takes BP every 20–30 min over 12–24 h, or self-measured at home 1–2 times a day or week with automated device. (USPSTF)

• Blood pressure measurements should be taken at upper arm, while seated, after resting for 5 min. (USPSTF)

• Corresponding BPs based on site/methods: office/clinic 140/90, home monitoring 135/85, daytime ambulatory monitoring 135/85, night-time ambulatory monitoring 120/70, 24-h ambulatory monitoring 130/80. (J Am Coll Cardiol. 2018;71:e127-e248)

• Electronic (oscillometric) measurement methods are preferred to manual measurements. Routine auscultatory Office BP Measurements (OBPMs) are 9/6 mmHg higher than standardized research BPs (primarily using oscillometric devices). (Can Pharm J. 2015;148(4):180-186)

• Assess global cardiovascular risk in all hypertensive patients. Informing patients of their global risk (“vascular age”) improves the effectiveness of risk factor modification.

Sources

–ACC/AHA. J Am Coll Cardiol. 2018;71:e127-e248.

–USPSTF. JAMA. 2021;325(5):476-481.

–ESC/ESH. Eur Heart J. 2018;39:3021-3104.

Organizations

ACC/AHA 2017, ESC/ESH 2018, Hypertension Canada 2018, JNC 8, ICSI 2018

Prevention Recommendations

–Persons at risk for developing HTN—family history of HTN, African ancestry, overweight or obesity, sedentary lifestyle, excess intake of dietary sodium, insufficient intake of fruits, vegetables, and potassium, excess consumption of alcohol—should undergo lifestyle changes (Table 2–5).

–Achieve and maintain normal BMI < 25, restrict sodium intake <2 g/d, moderate alcohol consumption <14 drinks/wk for men, <8–9 drinks/wk for women, increase physical exercise 30 min/d 5–7 d/wk, emphasize smoking cessation.

–Consume diet rich in vegetables, fruit, fish, nuts, whole grains, low-fat dairy products, and unsaturated fats.

–Do not supplement calcium or magnesium for the prevention or treatment of HTN.

–For patients not at risk of hyperkalemia, increase dietary potassium intake to reduce BP.

–Recommend stress management including relaxation techniques for patients whose stress might be contributing to high BP.

TABLE 2–5 LIFESTYLE MODIFICATIONS FOR PREVENTION OF HYPERTENSION
Maintain a healthy body weight for adults (BMI 18.5–24.9; waist circumference <102 cm for men and <88 cm for women). Reduce dietary sodium intake to no more than 2000 mg sodium/d (approximately 5 g of sodium chloride). Per CHEP 2015: adequate intake 2000 mg daily (all ≥ 19-y-old) (80% in processed foods; 10% at the table or in cooking); 2000 mg sodium (Na) = 87 mmol sodium (Na) = 5 g of salt (NaCl) ~1 teaspoon of table salt. Engage in regular aerobic physical activity, such as brisk walking, jogging, cycling, or swimming (30–60 min per session, 4–7 d/wk or 90–150 min/wk), in addition to the routine activities of daily living. Higher intensities of exercise are not more effective. Weight training exercise does not adversely influence BP. Isometric exercise, eg, hand grip 4×2 min, 1 min rest between exercises, 3 sessions/wk shown to reduce BP. Limit alcohol consumption to no more than 2 drinks (eg, 24 oz [720 mL] of beer, 10 oz [300 mL] of wine, or 3 oz [90 mL] of 100-proof whiskey) per day in most men and to no more than one drink per day in women and lighter-weight persons (≤14/wk for men, ≤9/wk for women). Maintain adequate intake of dietary potassium (≥90 mmol [3500 mg]/d). Above the normal replacement levels, do not supplement potassium, calcium, and magnesium for prevention or treatment of hypertension. Maintain daily K dietary intake ≥80 mmol. Consume a diet that is rich in fruits and vegetables and in low-fat dairy products with a reduced content of saturated and total fat (DASH eating plan). Offer advice in combination with pharmacotherapy (varenicline, bupropion, nicotine replacement therapy) to all smokers with a goal of smoking cessation. Consider stress management as an intervention in hypertensive patients in whom stress may be contributing to BP elevation.

TABLE 2–5 LIFESTYLE MODIFICATIONS FOR PREVENTION OF HYPERTENSION

Maintain a healthy body weight for adults (BMI 18.5–24.9; waist circumference <102 cm for men and <88 cm for women).

Reduce dietary sodium intake to no more than 2000 mg sodium/d (approximately 5 g of sodium chloride). Per CHEP 2015: adequate intake 2000 mg daily (all ≥ 19-y-old) (80% in processed foods; 10% at the table or in cooking); 2000 mg sodium (Na) = 87 mmol sodium (Na) = 5 g of salt (NaCl) ~1 teaspoon of table salt.

Engage in regular aerobic physical activity, such as brisk walking, jogging, cycling, or swimming (30–60 min per session, 4–7 d/wk or 90–150 min/wk), in addition to the routine activities of daily living. Higher intensities of exercise are not more effective. Weight training exercise does not adversely influence BP. Isometric exercise, eg, hand grip 4×2 min, 1 min rest between exercises, 3 sessions/wk shown to reduce BP.

Limit alcohol consumption to no more than 2 drinks (eg, 24 oz [720 mL] of beer, 10 oz [300 mL] of wine, or 3 oz [90 mL] of 100-proof whiskey) per day in most men and to no more than one drink per day in women and lighter-weight persons (≤14/wk for men, ≤9/wk for women).

Maintain adequate intake of dietary potassium (≥90 mmol [3500 mg]/d). Above the normal replacement levels, do not supplement potassium, calcium, and magnesium for prevention or treatment of hypertension.

Maintain daily K dietary intake ≥80 mmol.

Consume a diet that is rich in fruits and vegetables and in low-fat dairy products with a reduced content of saturated and total fat (DASH eating plan).

Offer advice in combination with pharmacotherapy (varenicline, bupropion, nicotine replacement therapy) to all smokers with a goal of smoking cessation.

Consider stress management as an intervention in hypertensive patients in whom stress may be contributing to BP elevation.

Sources

–ACC/AHA. J Am Coll Cardiol. 2018;71:e127-e248.

–USPSTF. Ann Int Med. 2015;163(10):778-787.

–ESC/ESH. Eur Heart J. 2018;39:3021-3104.

–Can J Cardiol. 2018;34:506-525.

–JAMA. 2014;311(5):507-520.

–ICSI Hypertension Work Group: 2018 Commentary.

–CHEP 2015. http://guidelines.hypertension.ca

–J Am Coll Cardiol. 2018;71(19):e127-e248.

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Information

ACC/AHA 2018, ESH/ESC 2018, USPSTF 2021

ACC/AHA 2017, ESC/ESH 2018, Hypertension Canada 2018, JNC 8, ICSI 2018