Hypertension Identication and Assessment

Hypertension Causes

The lifetime risk of developing hypertension is higher in African Americans (93%) and Hispanics (92%) than among Caucasians (86%) and Asians (84%), according to the Multi-Ethnic Study of Atherosclerosis (MESA).² Certain rare genetic mutations and several single-nucleotide polymorphisms have been identified as potential contributing factors, but more research is needed to better understand how this translates to hypertension risk.² Based on current data, these genetic variants contribute to about 3.5% of variability in blood pressure (BP).²

Environmental risk factors for hypertension include excess body weight, sedentary lifestyle, tobacco or alcohol use, and a high-sodium, low-potassium diet. These risk factors are considered modifiable, and patients should be educated on lifestyle changes that may reduce their risk of hypertension.²

Hypertension may result from certain medical conditions, such as endocrinological disorders, obstructive sleep apnea or renal disease.² Some medications and other substances—such as tobacco, alcohol and caffeine—can also increase BP. This care path guide will cover when to screen for secondary causes of Hypertension (see page 12).

Hypertension Screening

Hypertension is often a silent condition, showing no discernible signs or symptoms. This clinical silence explains the commonly noted lack of patient awareness of the condition prior to screening.¹ Hypertension screening should be performed at every office visit. Community health screenings and access to home and/or public BP monitors may also improve individual awareness of hypertension. In community settings, appropriate management is contingent upon the individual following up with his or her clinician for formal diagnosis and treatment.

Hypertension screening is performed at most office visits.

Table 1: Screening Recommendations for Hypertension⁷

BP Range	Screening Performed at a Minimum of Every:
Optimal BP (<120/80) or Normal BP (120–129/80) with no history of CVA or MI	3 years
High-Normal BP (130/80–139/89) with no history of diabetes, CKD, coronary artery disease (CAD) or elevated atherosclerotic cardiovascular disease (ASCVD) risk	6 months

Methodology: In-Office BP Readings

Protocolized BP measurement prevents misdiagnosis, misclassification and overtreatment of hypertension, providing a more accurate measure of hypertension control.

A data analysis of more than 22,600 adults ages 18 and older published in The Journal of Clinical Hypertension found up to 35.5% of initial BP readings were in a lower BP classification on subsequent measurements.⁸

BP measurements may be influenced by certain circumstances that can easily occur, such as a BP cuff that is too small or a patient and staff member having a conversation while taking the measurement. Use of the following checklists can help ensure an accurate reading.

Preparation
Wait at least 30 minutes after the patient has exercised, consumed caffeine or used tobacco products to measure BP.²

Have the patient use the restroom if needed (and collect specimen if urinalysis is required by clinician).

Have the patient sit in a chair with back support and feet on the floor for at least five minutes before measuring BP.²

Encourage the patient to relax and avoid talking before and during BP measurement.² The healthcare professional taking the blood pressure must avoid talking before or during readings. Three unobserved (patient in the room alone), automated readings are the standard of care. In the absence of oscillometric (automated) measurement availability, three manual measurements may be considered if the assessor is well trained.     

Instruct the patient to remove any jacket or sweater and roll up their sleeve to expose bare skin where the BP cuff will be placed.²

• Technique
  Use an automatic BP measuring device, preferably with the capability of taking multiple unobserved readings. Wrist and forearm cuff BP measuring devices are discouraged (except in rare cases when no brachial cuff will fit) as they tend to be less accurate than brachial cuffs.⁹
• Situate the patient’s arm at heart level by supporting the arm on a desk or table.²
• Position BP cuff at the upper arm at the level of the midpoint of the sternum (the level of the right atrium in most cases).²
• Using an appropriate cuff size for the patient, position the artery marker over the brachial artery. For cuffs without an artery marker, position the hose over the artery. Most BP cuffs have a line indicating cut-off for appropriate size. For cuffs without a size marker, ensure the bladder of the cuff encircles at least 80% of the arm.² If the BP cuff size varies from the standard, note it.²
• BP should be measured and recorded in both arms for initial office visit. BP should be measured in the arm with the higher reading for subsequent visits.²
• People with normal readings/no issue with hypertension require only one measurement. Patients with an abnormal initial reading or a history of hypertension require three measurements in a row during the same office visit.
• Repeat if Needed
  If the first BP reading is abnormal or the patient has a history of hypertension, a minimum of three automated readings with a one- to five-minute rest period between each measurement should be obtained on this occasion.² The lowest of the three BP readings should be recorded.
• If irregular heart rhythm is present, take note and address this issue as outlined in the physical exam and diagnostics sections.
• For the first diagnosis of hypertension in patients under 45 years of age, measure BP in at least one ankle or thigh to exclude the possibility of aortic coarctation. Refer to a hypertension specialist if BP is abnormal in the ankle/thigh measurement.

Record Measurement

• When available, utilize Bluetooth capability in the measurement device to integrate measurement with the facility EMR. If Bluetooth capability is unavailable, record BP measurement manually.

Communicate With the Patient

• Provide patient with BP levels verbally and in writing.²
• If the patient has abnormal BP with a known history of hypertension, inquire about medication(s).
• Note the patient’s most recent dose of antihypertensive medication.
• Inquire about medication adherence for uncontrolled hypertension, possibly using the ARMS-7 tool.
• Talk with patients about goal BP and provide methodology instructions for home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM).

Methodology: Subsequent Diagnostic BP Readings

Since blood pressure can fluctuate and may be affected by certain environmental factors, an isolated BP reading should not be used to diagnose hypertension. Diagnosis requires elevated BP from at least two separate occasions. Additional data provides a more accurate representation of the patient’s average BP. Blood pressure measurements may be taken through home BP self-measurements², ambulatory BP monitoring or during follow-up office visits.

• HBPM refers to self-monitoring by the patient either at home or in another nonclinical setting, such as through the use of public BP monitors provided at some retail outlets, outpatient pharmacies, health clubs, etc. HBPM is a convenient, cost-effective way for patients to monitor BP. Patient education is essential for accurate measuring. Recommendations for patients selecting and purchasing HBPM equipment and completing BP self-measurement can be found in section IV, starting on page 13.
• ABPM is conducted using a cyclical measurement device worn by the patient, which measures the patient’s BP at various intervals over a certain time frame—usually 24 hours. ABPMs are typically set to record BP every 15–30 minutes during waking hours and every 30–60 minutes during sleeping hours. ABPM readings can be used to diagnose hypertension through an average of these readings, with the added benefit of accounting for nocturnal BP variations, which are not captured by HBPM or in the clinician’s office.
  • ABPM is the more accurate method over in-office blood pressure readings, as it is a better predictor of BP-related cardiovascular disease outcomes, according to a systematic review by the U.S. Preventive Services Task Force.²
• A follow-up office visit to measure BP is not the preferred method for BP variability and nonclinical setting assessment. Repeat BP readings obtained solely from office visits limit the amount of data that can be gathered in a given time period as compared to HBPM and ABPM. Additionally, office visits do not allow for adequate evaluation of variations between clinical and nonclinical settings, which can be seen with all classifications of high blood pressure but is especially important in distinguishing white coat hypertension from true hypertension.

Generally, if clinical BP readings are elevated (preferably the lowest of three consecutive BP readings taken consecutively during one office visit), the patient should perform HBPM. Between 12 to 24 HBPM readings are preferred.

It is recommended patients conduct HBPM and record readings at a frequency of three to four times weekly, twice daily—once before breakfast and once before dinner—for two to three weeks. Morning BP measured before taking medicine is an index to overnight blood pressure and can provide indication of early morning surge, which has been associated with increased incidences of cardiovascular events and stroke.¹⁰

If HBPM is also elevated, hypertension is confirmed. If HBPM is normal, ABPM may be necessary to evaluate for possible hypertension versus white coat hypertension.

Assessment of Hypertension

In this care path guide, hypertension assessment based solely on BP readings are not used since the treatment plan may differ significantly based on patient comorbidities. An individualized approach that accounts for other vascular risk factors is encouraged to identify and improve outcomes for patients who may require a more aggressive approach to hypertension treatment.

• Hypertensive emergency is defined as markedly elevated BP (> 190 mmHg systolic or > 120 mmHg diastolic) in the presence of symptoms or diagnostic findings that are suggestive of new or worsening end organ damage. Examples of end organ damage include acute CVA (ischemic or hemorrhagic), intracranial hemorrhage (ICH), acute MI, unstable angina pectoris, acute left ventricular HF with associated pulmonary edema, dissecting aortic aneurysm, acute renal failure and eclampsia (which may result in seizures or coma in a hypertensive pregnant female).² Hypertensive emergency is a potentially life-threatening condition requiring emergent evaluation and possibly ICU admission.
• Hypertensive urgency is defined as markedly elevated BP (> 190 mmHg systolic or > 120 mmHg diastolic) without new or worsening end organ damage. These patients are otherwise stable and asymptomatic, but they should undergo diagnostics to assess for signs of end organ damage (labs and ECG).
  • If signs of new or worsening end organ damage are found on labs or ECG, this condition progresses in term and treatment to a hypertensive emergency.
  • If no signs of current or impending end organ damage are found, patients may be treated with aggressive oral antihypertensives and should be closely monitored.²
• White coat hypertension is defined as hypertension in a clinical setting with normal HBPM readings or in a nonclinical setting. If HBPM is normal, ABPM is recommended to confirm white coat hypertension.
• Masked hypertension is demonstrated by normal to high-normal BP readings in office with an average blood pressure in the hypertensive range based on HBPM or ABPM. It may be reasonable to screen for masked hypertension if end organ damage is present or if the patient has elevated cardiovascular risk based on other conditions.²
• Preeclampsia is hypertension with proteinuria that occurs during pregnancy. This diagnosis warrants referral to a high-risk OB as it can progress to eclampsia and is associated with adverse outcomes for the mother, including seizures, stroke and heart failure, as well as adverse events for the fetus, such as low-birth weight, prematurity and fetal loss.²

Basic Diagnostic Medical Evaluation

A patient history and physical examination are important aspects of hypertension management. This portion of the patient encounter focuses on identifying signs of end organ damage and evaluating for signs and symptoms suggestive of a secondary cause of hypertension.

• Obtain a thorough patient history and review of systems. Inquire about:
  Personal history of elevated or high BP
• Personal history of other vascular risk factors
• Family history of hypertension

Recently lifestyle changes, including weight gain, sedentary lifestyle/reduced level of physical activity, increased dietary sodium or alcohol intake, career change that resulted in increased travel² and/or changes in dietary habits (eating more restaurant foods)

Perform a medication review and inquire about use of other substances that can affect blood pressure.

• Use of medications, including nasal decongestants, NSAIDs, steroids, oral contraceptives and certain antidepressants (SNRIs, TCAs)
• Use of tobacco, caffeine, alcohol and certain illicit substances (cocaine, methamphetamine)

Evaluate:

• Clinical condition of the patient. Acutely ill patients with hypertension require emergency room evaluation. Patients who are clinically stable or asymptomatic can often be managed in an outpatient setting as deemed appropriate by the evaluating clinician.

Physical Exam and Diagnostic Studies

A physical exam should assess for end organ damage for patients with hypertension.

• Fundoscopic eye exam should be performed to evaluate for hypertensive retinopathy.¹¹
• Cardiac exam should include auscultation to evaluate for abnormal heart sounds, such as murmurs or arrhythmias.
• Lung auscultation should be performed. Rales may suggest pulmonary edema from congestive heart failure.
• Evaluate for edema in the peripheral extremities suggestive of heart failure or kidney disease.
• Pulse examination, particularly in the lower extremities, should be performed. Determine if there is a pulse delay or evidence of peripheral artery disease. If a pulse delay is noted, measure BP at the ankle as well to look for coarctation.

Consider laboratory studies to evaluate for end organ damage in hypertensive patients.

• Urinalysis (UA) and albumin-creatinine ratio (ACR) should be performed to evaluate for proteinuria or other signs of renal disease. Microscopic urinalysis (preferably first void of the day) should be considered for those with 1+ proteinuria on UA.¹¹
• Metabolic panel:
• BUN, creatinine, eGFR to evaluate renal function
• Electrolytes to evaluate sodium and potassium levels (which can be abnormal with either dietary or renal causes)
• Glucose to evaluate for diabetes; consider further evaluation for diabetes (HgA1C) for high clinical suspicion or for elevated glucose readings
• A full lipid profile (serum total cholesterol, HDL, LDL and triglycerides) to further evaluate cardiovascular risk

Consider other diagnostics to evaluate for end organ damage in patients with hypertension.

• Electrocardiogram (ECG) can be used to evaluate for cardiac issues, including signs of left ventricular hypertrophy (LVH)—a long-term consequence of untreated or poorly controlled hypertension. LVH is an independent predictor of future cardiovascular events.² ECG is also warranted for irregular rate or rhythm.
• CXR can be used to identify cardiomegaly or pulmonary edema if heart failure is suspected, and if identified, could be further categorized with echocardiogram.
• Echocardiogram is not recommended for all patients with signs of LVH on ECG as it may not change management or give insight to cardiovascular risk, but it may be helpful for the following patient groups:
• Symptoms or history of heart failure
• Chronic, uncontrolled hypertension with signs of LVH on ECG or cardiomegaly on CXR
• Pediatric patients (≤ 18 yr old)
• Presence of heart murmur

Hypertension Management

Lifestyle Modification

Hypertension may be improved through weight loss, exercise and dietary changes, quitting smoking and staying within guidelines for alcoholic beverages.¹²

Initially, lifestyle modification is an appropriate treatment for most cases of hypertension. However, for markedly elevated blood pressure (e.g., ≥ 160/100), the clinician may initially incorporate pharmacologic therapies in addition to lifestyle modification.

When to Start Medications

BP is one among many risk factors that can affect a patient’s risk of having an adverse cardiovascular event. Patients should be educated on all potential risk factors that can affect their cardiovascular health.

Risk assessment tools can be used to evaluate the need for pharmacotherapy.

Perhaps one of the most widely used CVD risk assessment tools is the atherosclerotic cardiovascular disease (ASCVD) risk estimator, which is based on pooled cohort equations from the American Heart Association and the American College of Cardiology. The ASCVD risk estimator calculates the risk of having atherosclerotic cardiovascular disease in 10 years based on the following factors:

• Age—The algorithm is based on ages 40–79, so the ASCVD risk estimator may overestimate risk for younger patients and underestimate risk for patients older than 79.
• Sex
• Race—Limitations exist with race/ethnicity in the ASCVD risk calculator as the estimator is based primarily on Caucasian and African-American populations.
• Risk may be overestimated for certain Asian Americans (e.g., east Asian heritage) and Hispanic (e.g., Mexican Americans)
• Risk may be underestimated for certain Asian American (e.g., South Asian heritage), Hispanic (e.g., Puerto Ricans) and Native American populations
• Systolic and diastolic blood pressure (mmHg)
• Lipid panel results (total, LDL and HDL cholesterol)
• Whether or not the patient smokes, is diabetic or takes antihypertensive or lipid-lowering medication

Treatment of hypertension is a balancing act, and several factors must be considered. Clinicians must be cognizant of the potential for harmful effects—hypoperfusion of organs (e.g., brain, kidneys), dizziness, falls, electrolyte imbalance, etc.—associated with overaggressive treatment of hypertension. However, they must also bear in mind the patient’s risk for MI, CVA and other vascular disease, especially with hypertensive patients who have other vascular risk factors.

• 140 systolic or 90 diastolic is generally the BP threshold for initiating pharmacotherapy in patients without additional CVD risk factors in adults younger than 65 without comorbidities.
• 120 systolic or 80 diastolic is the threshold for initiating pharmacotherapy in patients with a history of cardiovascular disease (MI, CAD), heart failure (HF) or CVA.¹³ The SPRINT trial showed that more aggressive treatment in these higher-risk individuals reduced all-cause mortality and major vascular events, such as CVA, in these patients.²
• 130 systolic or 80 diastolic is the threshold for initiating pharmacotherapy in patients with higher risk of CVD:
  • Diabetes
  • CKD-III
  • > 10% ASCVD 10-year risk of adverse cardiovascular events
    

Pharmacotherapy

Standard Recommendations

• These three medications should be first line and may be used in the order determined by a clinician:²
  • ACE-I or ARB (Do not use ACE-I and ARB simultaneously.)
  • Thiazide or thiazide-like diuretic
  • Dihydropyridine calcium channel blockers
• The fourth medication should be an aldosterone receptor antagonist (ARA), also referred to as a mineralocorticoid receptor antagonist, such as spironolactone or eplerenone, unless contraindicated. Stopping potassium supplements when adding an ARA and reassessing the need for supplementation is recommended due to the risk of hyperkalemia. Plasma renin and aldosterone levels may also be drawn 
• Other antihypertensive agents for special situations:²
  • Loop diuretics (chronic heart failure, chronic kidney disease)
  • Beta blockers (recent myocardial infarction or heart failure)
  • Non-dihydropyridine calcium channel blockers (atrial fibrillation)
• Initiation of fixed dose combination tablets is recommended for patients if BP is ≥ 160/100² on the first or subsequent visits.
• Combinations of ACEs, ARBs and direct renin inhibitors should not be used.

Hypertension Treatment Monitoring After Medication Initiation

• Baseline labs and routine monitoring should be obtained for certain medications
• Blood pressure should be re-evaluated every two to four weeks after starting BP medication, preferably through evaluating HBPM readings. Medication adjustments may be made by the clinician based on those results. Patients should perform HBPM regularly as directed by the clinician while medications are being adjusted and periodically once BP is controlled. BP should be re-evaluated four weeks after starting ARAs.
• An average of at least three readings should be used to determine whether or not the patient’s hypertension is controlled.
  • If office BP is obtained and the first reading is normal, they are considered controlled.
  • If office BP reading is elevated, a total of at least three automated BP readings are obtained to determine if hypertension is controlled.
• If BP is at goal (controlled hypertension) and the patient is tolerating the medication well, continue at the current dose, recommend continued home blood pressure monitoring (HBPM), and re-evaluate in six to 12 months.
• If the patient is not tolerating the medication due to adverse side effects, change the medication (reduce the dose if previously well tolerated or discontinue the agent altogether and start a different medication). Keep in mind that certain medications need to be tapered (BBs, clonidine). Re-evaluate two to four weeks after medication change.
• If not at goal (uncontrolled hypertension), adjust dose or add additional agent and repeat this process every two to four weeks until hypertension is controlled or the patient meets the threshold for secondary hypertension screening.

Secondary Hypertension

Should be considered if:

• There is clinical suspicion of secondary causes of hypertension based on history and physical exam.
• The patient has met the appropriate threshold for screening for causes of secondary hypertension:
  • Three or more antihypertensives, one of which is a thiazide or thiazide-like diuretic, with persistent hypertension
  • Change in previously controlled hypertension on same medication regimen without explanation

If a patient still has uncontrolled hypertension on three first-line medications, plasma renin and aldosterone levels should be drawn to evaluate for hyperaldosteronism.

An hypertension specialty referral or cardiology referral could be placed for patients with resistant hypertension who meet the threshold for secondary hypertension screening. Alternatively, if the clinician has a strong clinical suspicion of a particular disorder, he or she may order confirmatory testing and refer the patient to the appropriate specialist. Remember to ask the patient about obstructive sleep apnea, alcohol use and common medications that may cause hypertension, including NSAIDs and decongestants.

Patient Education

Patient education informs hypertension patients about the skills, equipment and disease to optimize self-management of the disease, improving overall BP control and patient outcomes. Some studies show that patient education and BP self-monitoring may also have a positive impact on medication adherence and BP control.^7,14

Patient Education Basics

• Help patients understand the clinical aspect of and potential complications from their condition. Advise patients that high blood pressure does not typically cause symptoms but can be a major contributing factor to disabling events, such as vision issues (retinopathy), or potentially fatal events, such as heart attack, stroke and kidney disease, to name a few.
• Teach patients how to use equipment and the methodology to attain accurate home BP monitoring (HBPM).
• Inform patients about their medications, including:
  • How the medication works
  • How to correctly take the drug
  • Potential side effects
  • Importance of adherence
  • Identify lifestyle modifications have potential to improve BP control.

HBPM Techniques

• Since hypertension is a silent disease and BP measurements may vary depending on patient comfort level (home vs. clinical measurements), patients should obtain a home BP monitor to check their BP in a frequency determined by the clinician. Common frequencies include:
• 10 times over the course of two weeks during the initial evaluation to confirm an hypertension diagnosis
• Weekly for two weeks after a change in antihypertensive medication
• Twice during the week before a scheduled office visit
• Instruct the patient on how to select a reliable home BP monitor (see Sidebar 2 in the next column).
• Instruct the patient on how to accurately conduct HBPM (see Sidebar 3, page 14) and interpret the results.
• Educate patients about alarm symptoms that warrant emergency evaluation, such as BP of 180/120 or greater accompanied by chest pain, shortness of breath, neurologic deficits (weakness, dysarthria, imbalance), severe headache, visual disturbance, confusion and nosebleeds.
• Educate patients on the importance of therapy adherence and regular follow-up visits.

 

Sidebar 2 Selection of Equipment and Cuff Size for Home BP Monitoring

Use a BP measurement device that has been clinically validated by either the U.S. Association for the Advancement of Medical Instrumentation (AAMI), the British and Irish Hypertension Society (BHS) or the European Society of Hypertension (ESH).2,15 An example of a widely available, clinically validated brand is Omron. A list of brachial BP monitor models with notations for BHS or EHS clinical validation is available online at dabl Educational Trust Limited. Brachial (upper arm) BP cuffs are preferred. Wrist, forearm and finger BP cuffs are discouraged.15 Automated BP measurement devices are preferred over manual.15 Memory storage capacity is preferred over devices incapable of reading storage. Alternatively, the patient should be instructed to log their BP readings on paper or use a smartphone app. Use an appropriate cuff size. The bladder of the BP cuff should encircle at least 80% of the upper arm.

 

 

 

Upper Arm Circumference (cm)	Appropriate BP Cuff Size
22–26 cm	Small Adult Arm Cuff
27–34 cm	(Regular or Standard) Adult Arm Cuff
35–44 cm	Large Adult Arm Cuff
45–52 cm	Adult Thigh Cuff

 

 

Other Considerations for Home BP Monitors

Valuable Features

• Automatic inflation functionality
• Large digit display for patients with impaired vision
• Memory storage capability for one or multiple users
• Ability to average readings
• Bluetooth technology to integrate with EMR (if supported)
• Phone app integration

Cost

While most insurance companies do not cover the cost of BP monitors for home use, patients may check with their insurance company as some insurance plans may offer this benefit. When HBPM is prescribed, patients with a flexible spending account (FSA) or health savings account (HSA) can cover the cost of BP monitoring equipment from these funds. A cost of $30–$100 for a clinically validated upper arm automatic BP monitor can be expected with the price for Bluetooth models falling in the upper end of this range.

Where to Find BP Monitors

Encourage purchase from a retailer with a good return policy in case the monitor cannot be validated against clinical measurements. BP monitors for home use can be purchased from medical supply stores, mainstream retailers and online through various vendors.

Sidebar 3 Methodology: Accurate HBPM

Preparing for Measurement Encourage patients to: Wait at least 30 minutes after exercising, consuming caffeine or using tobacco products to measure BP.2 Use the restroom if needed before measuring BP.2 Remove clothing covering the upper arm where the blood pressure cuff should be placed (e.g., long sleeves, jackets).2 Sit in a sturdy chair with back support (e.g., dining table chair), with legs uncrossed and feet on the floor. Rest arm on a table or desk (at heart level).2 Position BP cuff at the upper arm above the antecubital fossa (the crease of the elbow) and position the artery marker over the brachial artery. For cuffs without an artery marker, position the hose over the artery. Relax quietly and wait at least five minutes before measuring BP.2 Taking the Measurement Encourage patients to: Avoid talking or engaging with others during BP measurement.2 Record the BP readings. Repeating as Necessary Encourage patients to: For the first home BP measurement, measure and record BP in both arms unless contraindicated (lymphedema, etc). If there is a substantial difference between arms (> 15 mmHg) measure BP in the arm with the higher reading for future measurements.2 Wait at least one minute prior to obtaining repeat BP measurements.2 Average the BP readings.2 Use at least three readings on at least three occasions to obtain an average BP for clinical decision making.

 

 

Lifestyle ModificationS

BMI

Since there is a correlation between elevated body mass index (BMI) and hypertension, patients who are overweight (BMI of 25–29.9) or obese (BMI > 30) should be encouraged to lose weight. While not a guarantee, weight loss may help reduce BP levels in some patients. The CDC offers an online BMI calculator that can help patients track their BMI.

Exercise

All patients, regardless of BMI, should be encouraged to engage in at least 150 minutes of moderate-intensity physical activity weekly (e.g., 30 minutes of moderate intensity exercise at least five days a week¹⁶). Alternatively, 75 minutes of vigorous activity per week may be a heart-healthy goal.¹⁶

Consider cardiac evaluation prior to recommending an exercise program for patients who have been very sedentary or for those with comorbid heart disease. The following explanations may help patients understand what different exercise levels feel like:

Light-intensity exercise, at 35–50% of age-predicted maximal heart rate, may cause patients to breathe more quickly. Light-intensity exercise will not contribute to weekly totals but can help regulate blood sugar and improve all-around health. (Recommendation for patients: You can easily hold a conversation while doing light-intensity exercise.)

Moderate-intensity exercise, at 50–70% of age-predicted maximal heart rate, causes breathing and heart rate to speed up noticeably. (Recommendation for patients: You can talk between huffs and puffs when doing moderate-intensity exercise.)

Vigorous-intensity exercise, at 70–85% of age-predicted maximal heart rate, means heart rate and breathing speed up substantially. (Recommendation for patients: You are too breathless and busy concentrating and keeping pace to hold a conversation during vigorous-intensity exercise.)

Diet

Of all recommended lifestyle modifications, a healthy diet tends to offer the most positive impact on blood pressure. The Dietary Approaches to Stop Hypertension (DASH) diet was explicitly designed to reduce blood pressure. This diet limits dietary sodium, red meat, fat and sugar and encourages increased consumption of vegetables, fruits, lean meats and whole grains. Such dietary changes may help reduce SBP.² A downloadable PDF from the U.S. Department of Health and Human Services provides a

robust description of the DASH diet (starting on page 8 of the downloadable HSS PDF).

Reducing dietary sodium by 25% (typically by 1,000–1,500 milligrams per day) is a simple dietary change that may also help lower SBP.²

Eating a diet with adequate potassium intake (3,500–5,000 milligrams per day) may also be beneficial²; however, due to the risks associated with hyperkalemia, patients should be educated to avoid exceeding the recommended daily potassium intake. Keeping a food journal may help patients improve their understanding of nutrition as well as encourage healthy eating. Referral to a nutritionist may benefit patients in this area.

Caffeine should usually be limited to less than 300 milligrams per day in hypertensive patients.² Additionally, patients should be made aware that energy drinks and some dietary supplements can elevate blood pressure.

Tobacco Cessation

Tobacco has a vasopressor effect that raises BP, and tobacco use is also associated with increased risk of serious conditions, including CVD and cancer, independent of its association with hypertension. Tobacco cessation should be strongly encouraged as smoking is a modifiable risk factor second only to hypertension in associated cardiovascular mortality and morbidity.⁷

Due to the addictive nature of nicotine, smoking cessation can be challenging for most patients who smoke. Clinicians should discuss the associated risks of any type of tobacco use with patients and provide support for quitting smoking. Nicotine replacement therapy and other smoking cessation aids may be beneficial, especially in conjunction with counseling. Patients may find help for quitting the use of tobacco at Tennessee Tobacco QuitLine or Smoke Free.

Alcohol Consumption

Over-imbibing alcohol can elevate blood pressure as well as damage the heart, liver and brain. All patients, especially those with hypertension, should be counseled on the effects of alcohol overconsumption.

Alcohol should be limited to two or fewer drinks per day for men and one or fewer drinks per day for women.

Explain to patients that a standard drink containing 14 g of alcohol¹⁷ is equivalent to:

• 12 ounces of 5% alcohol by volume (ABV) beer
• 5 ounces of 12% ABV wine
• 1.5 ounces (one mixed drink or “shot”) of 40% ABV (or 80-proof) liquor

Vanderbilt Health Associated Network Resources

Vanderbilt Health Affiliated Networks Patient Education Materials

Find patient education materials about hypertension itself, hypertension with specific comorbidities (CKD, PAD, etc.), hypertension medications, lifestyle modifications for lowering BP and more. These resources can be accessed by Vanderbilt Health Affiliated Network professionals through Clinical References in eStar.

Hypertension Center

Specialists in the management of hypertension can aid in evaluation for secondary causes of resistant hypertension as well as management of blood pressure.

615-322-3353

Nutrition Clinic

Registered dietitians at Vanderbilt Health Nutrition Clinic focus on the nutritional management of disease and can be a valuable resource for patients with hypertension.

615-936-3952

Vanderbilt Medical Weight Loss Program

Vanderbilt Medical Weight Loss Program offers a comprehensive approach to weight management, combining a patient-individualized approach utilizing clinicians, dieticians, exercise physiologists and psychologists. Use caution with some weight-loss medications (stimulants), which can exacerbate hypertension.

615-322-6000

Vanderbilt Surgical Weight Loss Program

Vanderbilt Surgical Weight Loss Program combines surgery, exercise, nutrition and psychological care for patients who have tried and failed standard weight-loss interventions and who have a BMI > 40 or a BMI > 35 with comorbidities, such as hypertension and diabetes.

615-322-6000

Care Coordination

Registered nurses work as care coordinators in various departments to provide patients with frequent connection, education, accountability and encouragement.

615-936-2828

Other Approved Materials

National organizations, including AMA, AHA and NIH, publish useful patient educational materials. TargetBP.org, a co-sponsored website from the AMA and the AHA, has a wealth of information for clinicians as well as patient-facing materials, such as this downloadable “Questions to Ask Your Doctor” form on its site. Additional resources include the following.

AHA Printable BP Log

A printable HBPM log with space to pencil in patient’s BP goal and instructions for logging a.m. and p.m. BP measurements and more.

SilverSneakers

A health and fitness program for adults age 65 and older, SilverSneakers may be covered by Medicare Advantage. The website allows people to check their eligibility, locate classes or participate in exercise sessions via online instruction; however, the online instruction is paywalled.

Printable Food and Activity Diary

A fill-in-the-blank, printable weekly food and activity log with space to log daily breakfast, lunch, dinner and physical activity, as well as weekly goals for diet, exercise and behavior.

Eat Right. Academy of Nutrition and Dietetics

The website of the Academy of Nutrition and Dietetics, this online destination provides a wealth of food information, including recipes and recommendations for shopping, budgeting and reading food labels.

Tennessee Tobacco QuitLine

A smoking cessation program for Tennesseans that allows patients to access a counselor via toll-free phone number or utilize the online program.

800-QUIT-NOW (800-784-8669)

Smoke Free

A national resource with various tools available 24/7 to help people quit smoking, this program offers online services, text messaging programs, telephone counseling, smartphone apps (quitSTART and QuitGuide apps), and information about medications and nicotine replacement therapy.

800-QUIT-NOW (800-784-8669)

References & Contributors List

Appendix C

Websites

tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate

cvriskcalculator.com

Phone Apps

ASCVD Plus – from the American College of Cardiology

Estimated 10-Year Risk of ASCVD Categories

10-year Risk of ASCVD	Percentage from ASCVD Risk Estimator
Low	< 5
Moderate	5–7.4
High	≥ 7.5

Appendix D

References

¹ High Blood Pressure Fact Sheet|Data & Statistics|DHDSP|CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm. Published June 16, 2016. Accessed March 28, 2019.

² Whelton P, Carey RM, Aronow WS, et al. 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. American Heart Association Journals. 2017:e13-e115. https://www.ahajournals.org/doi/10.1161/HYP.0000000000000066.

³ Kirkland EB, Heincelman M, Bishu KG, Schumann SL. Trends in Healthcare Expenditures Among U.S. Adults With Hypertension: National Estimates, 2003–2014. Journal of the American Heart Association. http://www.ahajournals.org/doi/10.1161/JAHA.118.008731. Published May 30, 2018. Accessed March 29, 2019.

⁴James B, Poulsen G. The Case for Capitation. Harvard Business Review. July–August 2016. https://hbr.org/2016/07/the-case-for-capitation. Accessed April 24, 2019.

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⁶ Di Palo K, Kish T. The role of the pharmacist in hypertension management. Curr Opin Cardiol. 33(4):382–387, JUL 2018. doi.org/10.1097/HCO.0000000000000527. Accessed May 20, 2019.

⁷ Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial  hypertension. Journal of Hypertension. 2018;39(33):3021-3104. https://doi.org/10.1097/HJH.0000000000002017.

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¹¹ Hypertension overview. Hypertension – NICE Pathways. https://pathways.nice.org.uk/pathways/hypertension. Published March 27, 2018. Accessed March 26, 2019.

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¹³ Kumbhani DJ. Systolic Blood Pressure Intervention Trial – SPRINT. American College of Cardiology. https://www.aafp.org/afp/2015/0601/p772.html. Published November 13, 2017. Accessed April 19, 2019.

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Vanderbilt Health Affiliated Network Contributors

Joshua Beckman, MD, Director, Vascular Medicine, Professor of Medicine, Vanderbilt University Medical Center

Jay Gainer, MD, Assistant Professor, Internal Medicine, Vanderbilt University Medical Center      

Gary Owen, PharmD, MPH, Population Health Clinical Pharmacist, Vanderbilt Health Affiliated Network     

Daniel Muñoz, MD, MPA, Assistant Professor, Cardiovascular Medicine, Vanderbilt University Medical Center     

Matt Luther, MD, Associate Professor of Medicine, Vanderbilt University Medical Center     

Candace McNaughton, MD, PhD, MPH, Associate Professor, Emergency Medicine Research, Vanderbilt University Medical Center

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Claude Pirtle, MD, Clinical Fellow, Vanderbilt University Medical Center Biomedical Informatics

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