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

Why Focus on Hypertension?

■ Although improving, hypertension control remains poor nationally and at

Intermountain. Nationally, only 31% of patients with diagnosed hypertension have it adequately controlled.1 At Intermountain, preliminary data shows that only 66% of SelectHealth patients are adequately controlled. Patients treated by providers educated on hypertension risks, and who received patient education on these risks, were better able to control their blood pressure.2

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

■ Patients lack awareness. 29% of patients aren’t aware that they have high blood pressure.1 Those who are aware often don’t understand the seriousness of the condition and the risk it poses. Sometimes their healthcare providers’ approach contributes to this.

■ Healthcare providers often undertreat. Why? Sometimes physicians are not convinced a patient is truly hypertensive, often attributing elevated readings to “white-coat” hypertension. Also, physicians may not be convinced of the benefits of aggressive lifestyle management or drug therapy. They may be concerned about the cost or possible side effects of new medications—or responding to a patient’s concern.

Appropriate Care CAN Significantly Reduce Risk

■ Frequent, accurate blood pressure readings are vital to the diagnosis and ongoing management of hypertension. Readings should take place—and be recorded—both in the office and outside the office (by the patient). Also, ambulatory blood pressure monitoring (ABPM) should be used whenever “white-coat” hypertension is a question. SelectHealth covers the use of ABPM.

■ Effective blood pressure control can be achieved in most hypertensive patients. To achieve control, many patients may require 2 or more antihypertensive medications—at adequate doses—as well as lifestyle modification.5, 6

■ In clinical trials, antihypertensive therapy has been associated with the following average risk reductions: 35-40% in stroke incidence, 20-25% in myocardial infarction incidence, and more than 50% in heart failure incidence.7 A useful tool to help you assess risk/benefit for individual patients is the Heart Foundation’s “Modified New Zealand Cardiovascular Risk Calculator,” based on Framingham data.8

National Heart, Lung, and Blood Institute (NHLBI) GuidelinesThe recommendations in this CPM are derived from the NHLBI’s clinical practice guide-lines: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), published in 2003.9 These guidelines featured updated blood pressure categories, including a new “prehypertension” level. They also emphasized the use of diuretics (usually thiazide diuretics) as part of a medication plan for hypertension in most patients. A new report, JNC 8, is anticipated in 2009; an update to this CPM will incorporate these udpated guidelines.

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

C A R E C A R E P R O C E S S P R O C E S S M O D E LM O D E L

M AY 2 0 0 8

Hypertension Evaluation and Treatment

What’s new since JNC 7?Since JNC 7 was published in 2003, additional hypertension research has focused on topics such as: ■ The relative benefits of ACE inhibitors, ARBs, and ACE-ARB combination therapy.10

■ The benefits of treating hypertension in the elderly (>80 years old).11

■ Doubts about atenolol as a suitable drug for hypertensive patients, especially for prevention of stroke or reduction of cardiovascular mortailty.12

A future CPM revision will consider this research along with JNC 8 (anticipated in 2009). In the meantime, physicians are encouraged to use clinical judgment based on emerging evidence.

Measure Blood Pressurea

If hypertensive or prehypertensive,

Perform Diagnostic Workup:

Assess for CV risk factorsc, identifiable causesd, and CV and target organ diseasee

■ History & Physical

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

■ EKG

Blood Pressure Measurement Techniques

Method Notes

In-office Average of 2 readings, 5 minutes apart, seated in chair, with elevated readings confirmed in contralateral arm. Repeat on each of 2 or more office visits.

Ambulatory Indicated for evaluation of “white-coat” hypertension. Absence of a 10-20 percent BP decrease during sleep may indicate increased CVD risk. Persons with an average awake BP of more than 135/85 mm Hg or sleeping BP more than 125/75 are generally considered to be hypertensive. This monitoring is covered by many insurance companies.

Patient self-monitoring

Provides information on response to therapy. Is useful for evaluating “white-coat” hypertension and may help improve adherence to therapy. Persons with an average BP of more than 135/85 mmHg measured at home are generally considered to be hypertensive.

Classification of Blood Pressure Category Systolic

mm HgDiastolic mm Hg

Normal <120 AND <80

Prehypertension 120-139 OR 80-89

Hypertension, Stage 1 140-159 OR 90-99

Hypertension, Stage 2 >160 OR >100

CV Risk Factors

■ Obesity (body mass index >30 kg/m2)

■ Dyslipidemia

■ Diabetes mellitus

■ Cigarette smoking

■ Physical inactivity

■ Microalbuminuria or estimated GFR <60 mL/min

■ Age (>55 for men, >65 for women)

■ Family history of premature CVD (men age <55, women age <65)

Table a

Table c

Table b

Identifiable Causes

■ Primary aldosteronism (frequent in patients with diabetes mellitis type 2)

■ Sleep apnea■ Drug induced/related■ Chronic kidney disease■ Renovascular disease■ Cushing’s syndrome or steroid therapy■ Pheochromocytoma■ Coarctation of aorta■ Thyroid/parathyroid disease

Table d

CV and Target Organ Disease

■ Heart• left ventricular hypertrophy• angina or prior MI• prior coronary revascularization• heart failure

■ Stroke or TIA■ Chronic kidney disease■ Peripheral arterial disease■ Retinopathy

Table e

Table fAdvise Lifestyle Modifications (BP MAWDS)f ■ Encourage self-monitoringa.

■ Provide BP Tracker, BP Basics, and diet education booklets.

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

Lifestyle Modifications (BP MAWDS) SBP reduction (range) supported by clinical trials

Medication - Take medications as prescribed. na

Activity - Perform regular aerobic activity (e.g., brisk walking) at least 30 minutes per day most days of the week. 4-9 mm Hg

Weight Management - Maintain normal body weight (BMI 18.5 - 24.9 kg/m2). 5-20 mm Hg / 10 kg

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

8-14 mm Hg2-8 mm Hg2-4 mm Hg

Stress Management and No Smoking na

EV

AL

UA

TI

ON

Derived from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).8

Classify Blood Pressureb

Hypertension Evaluation and Treatment

Begin Drug Therapy

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

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

■ Optimize dosages or add additional drugs

■ Assess for causes of resistant hypertensionh

■ Reassess for identifiable causesd of hypertension

■ Consider consultation with hypertension specialist

Causes of Resistant Hypertension■ Inadequate diuretic therapy

■ Improper BP measurement

■ Excess sodium intake

■ Excess alcohol intake

■ Medication problems

■ Inadequate doses

■ Drug actions and interactions (e.g., NSAIDS, illicit drugs, sympathomimetics, oral contraceptives)

■ Over-the-counter (OTC) drugs and herbal supplements

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

Drug Therapy

PrehypertensionSBP 120-139 orDBP 80-89

None

Stage 1 HypertensionSBP 140-159 orDBP 90-99

■ Thiazide-type diuretics for most

■ May consider ACEI, ARB, BB, CCB, or combination

Stage 2 HypertensionSBP >160 orDBP >100

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

Compelling Indications(Treat to goal of <140/90 mmHg, or <130/80 mmHg for

patients with diabetes, chronic kidney disease, or heart failure)

Drug Therapy

PrehypertensionSBP 120-139 orDBP 80-89

Only as needed for compelling indicationsg

Stage 1 HypertensionSBP 140-159 orDBP 90-99

■ Drug(s) for compelling indicationsg

■ Other antihypertensive drugs as needed(diuretics, ACEI, ARB, BB, CCB)

Stage 2 HypertensionSBP >160 orDBP >100

Compelling Indications

Drugs

■ Heart failure THIAZ, BB, ACEI, ARB, ALDO ANT, LOOP

■ Post myocardial infarction

BB, ACEI, ARB,ALDO ANT

■ High CVD risk THIAZ, BB, ACEI, CCB

■ Diabetes Front-line: ACEI, ARBOthers: THIAZ, BB, CCB

■ Chronic kidney disease

ACEI, ARB, LOOP

■ Recurrent stroke prevention

THIAZ + CCB combo, ACEI

Compelling Indications?g

Goal BPmet?

(<140/90 mm Hg, or <130/80 mm Hg for

patients with diabetes or chronic kidney

disease)

Table h

NO

YES NO

TR

EA

TM

EN

T

Table g

Drug abbreviation key:

ACEI = ace inhibitorALDO ANT = aldosterone receptor antagonistARB = angiotensin receptor blockerBB = beta blockerCCB = calcium channel blocker LOOP = loop diureticTHIAZ = thiazide diuretic

YES

Thiazide Diuretics (THIAZ)■ chlorothiazide1st tier (Diuril3rd tier) ■ chlorthalidone1st tier (Hygroton3rd tier) ■ hydrochlorothiazide1st tier

(Microzide3rd tier, HydroDIURIL3rd tier)■ indapamide1st tier (Lozol3rd tier)■ metolazone1st tier (Mykrox3rd tier,

Zaroxolyn3rd tier)

Loop Diuretics■ bumetanide1st tier (Bumex3rd tier) ■ furosemide1st tier (Lasix3rd tier)■ torsemide1st tier (Demadex3rd tier)

K + - Sparing Diuretics■ amiloride1st tier (Midamor3rd tier) ■ triamterene1st tier (Dyrenium3rd tier)

Aldosterone Receptor Antagonists■ spironolactone1st tier (Aldactone3rd tier) ■ eplerenone (Inspra2nd tier)

ACE Inhibitors (ACEI)■ benazepril1st tier (Lotensin3rd tier)■ captopril1st tier (Capoten3rd tier)■ enalapril1st tier (Vasotec3rd tier)■ fosinopril1st tier (Monopril3rd tier)■ lisinopril1st tier (Prinivil3rd tier)■ moexipril1st tier (Univasc3rd tier)■ perindopril (Aceon2nd tier)■ quinapril1st tier (Accupril3rd tier)■ ramipril1st tier (Altace3rd tier)■ trandolapril1st tier (Mavik3rd tier)

Angiotensin Receptor Blockers (ARB) ■ candesartan (Atacand Step)■ eprosartan (Teveten Step)■ irbesartan (Avapro Step)■ losartan (Cozaar2nd tier)■ olmesartan (Benicar Step)■ telmisartan (Micardis Step)■ valsartan (Diovan2nd tier)

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

References

1. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. 2003; 290:199-206.

2. Roumie CL, Elasy TA, Greevy R, et al. Improving Blood Pressure Control through Provider Education, Provider Alerts, and Patient Education. Ann Intern Med. 2006 Aug 1;145(3):165-75.

3. Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension. 2004;44:398-404.

4. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, for the Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-1913.

5. Cushman WC, Ford CE, Cutler JA, et al, and the ALLHAT Collaborative Research Group. Success and predictors of blood pressure control in diverse North American settings: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). J Clin Hypertens (Greenwich). 2002;4:393-404.

6. Black HR, Elliott WJ, Neaton JD, et al. Baseline characteristics and elderly blood pressure control in the CONVINCE trial. Hypertension. 2001;37:12-18.

7. Neal B, MacMahon S, Chapman N, and the Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Lancet. 2000;356:195519-64.

8. Heart Foundation. Hypertension Management Guide for Doctors. 2004;6-7. Available at: www.heartfoundation.org.au/document/NHF/hypertension_management_guide_2004.pdf Accessed Jan 9, 2008.

9. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252. Also at: www.nhlbi.nih.gov/guidelines/hypertension. Accessed Jan 9, 2008.

10. Yusuf S, Teo K, Pogue J, et al. Telmisartan, Ramipril, or both in patients at high risk for vascular events. NEJM. 2008;358:1547-1559.

11. Beckett N, Peters R, Fletcher A, et al. Treatment of hypertension in patients 80 years of age or older. NEJM. 2008;10.1056/NEJMoa0801369. At: content.nejm.org/cgi/content/full/NEJMoa0801369. Accessed April 2, 2008.

12. Beckett N, Peters R, Fletcher A, et al. Atenolol in hypertension: is it a wise choice? Lancet. 2004;364(9446):1684-9.

Beta Blockers

Preferred:■ carvedilol1st tier (Coreg3rd tier) ■ metoprolol extended release1st tier (Toprol XL3rd tier) Other:■ atenolol1st tier (Tenormin3rd tier

Note: Recent research has cast doubts about atenolol as a suitable drug for hypertensive patients, especially for prevention of stroke or reduction of cardiovascular mortailty.12

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

(InnopranXL2nd tier)■ timolol1st tier (Blocadren3rd tier)

Alpha Blockers■ doxazosin1st tier (Cardura3rd tier)■ terazosin1st tier (Hytrin3rd tier)

Calcium Channel Blockers—non-dihydropyridines■ diltiazem immediate or extended

release1st tier (Cardia XT1st tier, Diltia XT1st tier, Cardizem3rd tier, Cardizem CO3rd tier, Cardizem SE3rd

tier, Dilacor XR3rd tier, Tiazac3rd tier)■ verapamil SR1st tier

(Calan SR3rd tier, Isoptin SR3rd tier)

Calcium Channel Blockers—dihydropyridines■ amlodipine1st tier (Norvasc3rd tier)■ felodipine1st tier (Plendil3rd tier)■ isradipine 1st tier (Dynacirc CR3rd tier)■ nicardipine sustained release

(Cardene SR3rd tier)■ nifedipine long-acting1st tier

(Adalat CC3rd tier, Procardia XL3rd tier)

■ nisoldipine (Sular3rd tier)

Combination Drugs ACEI and Diuretic■ captopril/hydrochlorothiazide1st tier (Capozide3rd tier)■ enalapril/hydrochlorothiazide1st tier (Vaseretic3rd tier)■ lisinopril/hydrochlorothiazide1st tier (Prinzide3rd tier)■ moexipril HCI/hydrochlorothiazide1st tier (Uniretic3rd tier)■ quinapril HCI/hydrochlorothiazide1st tier (Accuretic3rd tier)

ARB and Diuretic■ candesartan cilexetil/hydrochlorothiazide

(Atacand HCT Step)■ eprosartan mesylate/hydrochlorothiazide

(Teveten HCT Step)■ irbesartan/hydrochlorothiazide (Avalide Step)■ losartan potassium/hydrochlorothiazide (Hyzaar2nd tier)■ telmisartan/hydrochlorothiazide (Micardis HCT Step)■ valsartan/hydrochlorothiazide (Diovan HCT2nd tier)■ olmesartan HCT (Benicar HCT Step)

ARB and CCB ■ amlodipine/valsartan (Exforge2nd tier)■ amlodipine/olmesartan (Azor Step)

BB and Diuretic■ atenolol/chlorthalidone1st tier (Tenoretic3rd tier)■ bisoprolol fumarate/hydrochlorothiazide1st tier

(Ziac3rd tier)■ propranolol/hydrochlorothiazide1st tier (Inderide3rd tier)■ metoprolol/hydrochlorothiazide (Lopressor HCT3rd tier)

Direct Renin Inhibitor ■ aliskiren (Tekturna Step)

Diuretic and Diuretic■ amiloride HCI/hydrochlorothiazide1st tier

(Moduretic3rd tier)■ spironolactone/hydrochlorothiazide1st tier

(Aldactazide3rd tier)■ triamterene/hydrochlorothiazide1st tier

(Dyazide3rd tier, Maxzide3rd tier)

CCB and ACEI ■ amlodipine/benazepril1st tier (Lotrel3rd tier)■ enalapril/felodipine1st tier (Lexxel3rd tier)■ trandolapril/verapamil (Tarka2nd tier)

Blood Pressure Medications

©2004-2008 Intermountain Healthcare. All rights reserved.Patient and Provider Publications 801.442.2963 IHCEDCPM008 - 05/08

This and other materials to support best practice can be found at intermountainhealthcare.org/clinicalprograms.

These notations represent formulary information at the time of publication. For more recent information, visit selecthealth.org and use the prescription search function in the “For Members” area or call one of the following SelectHealth numbers: 442-4912 or 1-800-442-3129.