Management of Adult Hypertension Guideline

Transcription

1 Management of Adult Hypertension Guideline Updated by the Hypertension Task Force 3/11 Objective of Identifying and Treating Hypertension The objective of identifying and treating high blood pressure is to reduce the risk of cardiovascular disease and associated morbidity and mortality. The positive relationship between SBP and DBP and cardiovascular risk is well recognized. This relationship is significant for those with and without known coronary heart disease. It is useful to provide a classification of adult blood pressure for the purpose of identifying high-risk individuals and to provide guidelines for follow-up and treatment. Classification and initial evaluation of Adult Hypertension BP Classification SBP* mm HG DBP* mm HG Lifestyle Modification Diagnosis Initial Evaluation Normal < 120 and < 80 Encourage N/A Prehypertension or Yes FLP Stage 1 Hypertension Stage 2 Hypertension or Yes > 160 or > 100 Yes History and Physical Exam K+, Creat, FLP, UA Consider baseline EKG Consider evaluation for sleep apnea Objective of Identifying and Treating Hypertension The objective of identifying and treating high blood pressure is to reduce the risk of cardiovascular disease and associated morbidity and mortality. The positive relationship between SBP and DBP and cardiovascular risk is well recognized. This relationship is significant for those with and without known coronary heart disease. It is useful to provide a classification of adult blood pressure for the purpose of identifying high-risk individuals and to provide guidelines for follow-up and treatment. DBP= diastolic blood pressure; SBP= systolic blood pressure. * 2 or more readings at separate office visits (not including trauma or procedures). Stage of Hypertension determined by highest BP category.

2 Suggested Blood Pressure Visit Frequency SBP > 160 or DBP > 100 (stage 2) - within 15 days SBP or DBP (stage 1) - within 30 days Controlled hypertension- at least once every year Prehypertension - every year Self-Measurement of Blood Pressure Measurement of blood pressure outside of the medical office may provide valuable information for the initial evaluation of patients with hypertension and for monitoring the response to treatment. Self-measurement has four general advantages: (1) distinguishing sustained hypertension from "white-coat" hypertension; (2) assessing response to antihypertensive medication; (3) improving patient adherence to treatment; (4) potentially reducing costs. The home blood pressure goal is < 135/85 on average for patients with hypertension and diabetes. Home blood pressure goals should be individualized based on clinical judgment, patient co-morbidities and how many medications the member is on for BP. Patients should use an arm monitor that has been approved by the Association for the Advancement of Medical Instrumentation (AAMI) Standard. The patient s technique should be checked in the medical office by a health care provider within one year of purchase and subsequently every 2 years. The home monitor is considered accurate if within 5 mm Hg systolic and diastolic of an aneroid reading. Routine use of ambulatory blood pressure monitoring to diagnose "white coat hypertension" defined as persistently elevated blood pressures in a doctor's office with normal blood pressures at home or at work, is rarely necessary and has not been recommended by the JNC VII. Therapeutic Lifestyle Change Lifestyle modifications offer the potential for preventing hypertension and have been shown to be effective in lowering blood pressure and can reduce other cardiovascular risk factors at little cost and with minimal risk. Weight reduction of as little as 10 pounds reduces blood pressure in a large proportion of overweight persons with hypertension. Excessive alcohol intake is an important risk factor for high blood pressure, can cause resistance to antihypertensive therapy, and is a risk factor for stroke. Physical Activity Regular aerobic physical activity can enhance weight loss and functional health status and reduce the risk for cardiovascular disease and all-cause mortality. Benefits of physical activity on blood pressure can be seen when the individual does 30 minutes of sustained low-moderate intensity exercise done most days of the week. Activities such as walking, stair climbing, bicycling, and rowing are examples of appropriate exercise.

3 Accumulating 30 minutes of low-moderate intensity exercise (i.e. even in 5-10 minute increments) by the end of the day is another way to begin to reap the benefits of lowering blood pressure. Diet Sodium is linked to levels of blood pressure. Individual response of blood pressure to variation in sodium intake differs widely; as groups, African Americans, older people, and patients with hypertension or diabetes are more sensitive to changes in dietary sodium chloride than are others in the general population. In the Dietary Approaches to Stopping Hypertension (DASH)-Sodium trials which allowed 2400 mg of Na per day, systolic blood pressure was lowered by 5.5 mm HG and diastolic blood pressure by 3.0 mm HG more than a control diet. The DASH diet is rich in fruits, vegetables, and low-fat dairy products and with reduced saturated fat and total fat. In the DASH-Sodium trial, which allowed 1500mg of Na per day, the mean systolic blood pressure was lowered 11.5 mm HG in participants with hypertension as compared to the control high sodium diet. High dietary potassium intake may protect against the development of hypertension and improve blood pressure control in patients with hypertension. Inadequate potassium intake may increase blood pressure. Therefore, an adequate intake of potassium preferably from food sources such as fresh fruits and vegetables should be maintained. In most epidemiologic studies, low dietary calcium intake is associated with an increased prevalence of hypertension. An increased calcium intake may lower blood pressure in some patients with hypertension but the overall effect is minimal. Although it is important to maintain an adequate intake of calcium for general health, there is currently no rationale for recommending calcium supplements to lower blood pressure. The daily adult recommendation for calcium is mgs and IUs for Vitamin D. Although evidence suggests an association between lower dietary magnesium intake and higher blood pressure, no convincing data currently justify recommending an increased magnesium intake in an effort to lower blood pressure. Caffeine No direct relationship between caffeine intake and elevated blood pressure has been found in most epidemiological surveys. Dyslipidemia Addressing total cardiovascular health and assessment of cardiovascular risk are important aspects of providing complete health care for each patient. Adult patients (18 years and older) should have a their 10 year CAD risk status assessed and documented in the Problem List in Health Connect with the patient's individualized LDL goal listed and updated accordingly (use.ldlgoal dotphrase). Refer to the KPCO Adult Cardiovascular Disease and Stroke Prevention Guideline (2011). Dyslipidemia is a major independent risk factor for coronary artery disease. Treatment for dyslipidemia includes therapeutic lifestyle changes (TLC diet, increased physical

4 activity, weight management and smoking cessation).treatment and drug therapy are important adjuncts to antihypertensive treatment. Aspirin therapy In accordance with the KPCO Adult Cardiovascular Disease and Stroke Prevention Guideline(2011) when the 10 year CAD risk is high (>20%), low dose aspirin (81mg daily) is recommended for primary CVD prophylaxis in patients with hypertension. In members with DM without CAD, ASA is recommended in men age > 50 and women age > 60 with any additional CV risk factor(htn, fam hx premature CAD, smoking, dyslipidemia, albuminuria). When recommending aspirin, consider potential side effects, especially gastrointestinal bleeding. Stress Management The role of stress management techniques in treating patients with elevated blood pressure is uncertain. Tobacco Usage Cigarette smoking is a powerful risk factor for cardiovascular disease, and avoidance of tobacco in any form is essential. A significant rise in blood pressure accompanies the smoking of each cigarette. Summary of Lifestyle Changes recommended in all patients with Prehypertension & Hypertension: DASH diet (low fat, high in fruit and vegetables and low-fat dairy products) Sodium < 2300 mg/day in young healthy individuals and 1500 mg sodium/d in those age >40, all African Americans, or those with DM, HTN, or CKD) Weight reduction if BMI > 25 kg/m2 Exercise( moderate intensity level) 30 minutes on most days of the week Limit daily alcohol to 1 drink (women) or 2 drinks (men) on average Encourage Tobacco cessation NOTE: Implementation of lifestyle modifications should not delay the start of an effective antihypertensive drug regimen. See Management of Adult Hypertension Algorithm for Medication Recommendations Health Connect Smart Tools Patient Instructions

5 HYPERTENSION PI NATL.pihypertension HYPERTENSION PLAN COMPLETE PREV PI CO.htnplan HYPERTENSION PLAN BRIEF PREV PI CO.htnplanbrief HYPERTENSION HOME MONITOR PREV PI CO.htnhomemonitor Medication SmartSets ACEI, ACEI+HCTZ START CO Hypertension Smart Rx HTN Smart RXCO HTN Resistant Smart RXCO Hypertension Smart Sets Hypertension Treatment CO Hypertension Smart text Hypertension Visit CO Hypertension Follow up Visit Co Smarttools.lastbp1/.lastbp2/.lastbp3/.lastbp4 (Last 1/2/3/4 BP readings).bpgoal (BP goal for office visit and home monitoring) Hypertension Resources for Providers Risk Factor Kaiser Permanente Resource Contact Number Webinars on multiple health issues Kpwebinar.org Partners in Health Magazine Provider listing of classes available for many health issues Obesity/ Overweight Weight Management Program

6 Healthy Choice Hotline (healthychoicehotline.org) Optifast Medical Weight Management Program or kphealthyme.com Weight Watchers (kp.org/weightwatchers) Healthy Lifestyles Program Reduce Physical Inactivity DIET COUNSELING & INFORMATION Link to Kp.org/10000steps Link to kp.org/choosehealthy fitness coach.com Silver Sneakers: (senior members) DASH diet-(link to handout ) 1:1 Dietitian Consult (Health Connect - Adult Health and Wellness referral) STRESS MANAGEMENT -KP Stress Skills Class Schedule - Yoga options -Link to kp.org/healthylifestyles TOBBACO USAGE KP Health Education Class Schedule. - Freedom from Cigarettes - You CAN Quit- Stop Smoking Basics Colorado Tobacco Quit Line. (Free) Ready to quit? We can help! (link to handout Quit- Now

7 4900 HIGH BLOOD PRESSURE "High Blood Pressure Here's What You Can Do" (link to handout ) High Blood Pressure: Self Care Tips (Spanish) (link to handout MH-0600) "Managing High Blood Pressure pamphlet (English) Krames (link to handout ) "Managing High Blood Pressure pamphlet (Spanish) Krames (link to handout ) Home Blood Pressure Readings (card) (link to handout ) Check Your Blood Pressure at Home (link to handout ) Two-week Home Blood Pressure Tracker (link to handout )