Current Approaches to Detection, Evaluation,

and Management of High Blood Pressure

Presented by
 

Department of Epidemiology
Department of Medicine
Center for Continuing Education

Release Date: November 1, 2018

Expiration Date: March 31, 2021

Estimated time to complete the activity: 45 minutes

 NOTES
Reference Materials may be found by clicking on the “Hypertension Guidelines” and
“Presentation Slides” buttons below the recording.
Complete CME and CEU Information may be found by clicking on the “CE Credit Handout”
button below the recording.
Technical requirements may be found by clicking on the “Viewing Requirements” link
below the recording.
Evaluation, Post-test, and Credit Claiming instructions and link will be available following
participation in the session.
If you have other questions, please contact Tulane University CCE at cme@tulane.edu or
504-988-5466.

This session was originally recorded between May and October 2018.
 GRANT SUPPORT
IMPACTS is supported by a grant from the National Heart, Lung, and Blood Institute of
the National Institutes of Health under Award Number R01HL133790. The content is
solely the responsibility of the authors and does not necessarily represent the official
views of the National Institutes of Health.
TULANE UNIVERSITY CENTER FOR CONTINUING EDUCATION DISCLOSURE POLICY
•This activity has been planned and implemented in accordance with the ACCME® and
IACET Accreditation Requirements to ensure balance, independence, objectivity, and
scientific rigor.

•All individuals responsible for content, regardless of role(s), are required to document
financial relationships or the absence of relationships with commercial interests, and
all potential conflicts of interest must be resolved prior to the activity.

•Disclosure of off-label, experimental or investigational use of drugs or devices must

also be made known to the audience.
 DISCLOSURES
Listed below is information disclosed by those participating in the activity as presenters, moderators, and in other roles. Any real or apparent conflicts of interest related to the content of
their participation or presentations have been resolved.
Last Name First Name Role in the Activity Disclosure
Bouyelas Lindsey Committee Member Nothing to disclose
Brooks Kenya Facilitator Nothing to disclose
Chen Jing Co-activity Director Nothing to disclose
Epperson Melinda Director, Tulane CCE; Planning Committee Nothing to disclose
He Jiang Department Chair Epidemiology Nothing to disclose
Grant: Amgen, Glaxo Smith Kline, Astra Zeneca;
Speakers Bureau: Gilead Sciences, Fresenius
Kleinpeter Myra Chair, Tulane CCE Advisory Committee Medical Care, OPKO; Stock: BD, Abbvie, P&G;
Board Member: Orleans Parish Medical Society,
New Orleans East Hospital
Vice Dean of Academic Affairs, Tulane University
Krane N. Kevin Nothing to disclose
School of Medicine
Krousel-Wood Tonette Activity Director, Speaker Nothing to disclose
Lambuth Kailin Committee Member Nothing to disclose
Educational Evaluation & Research Specialist, Tulane
Lind Caroline Nothing to disclose
CCE
Peacock Erin Committee Member Nothing to disclose
Program Coordinator - Education & Evaluation, Tulane
Refvem Sarah Nothing to disclose
CCE
Schmidt Pamala Assistant Director, Tulane CCE Nothing to disclose
Sliwinski Roblynn Department Administrator, Tulane CCE Nothing to disclose
Chair, Writing committee, ACC/AHA Task Force
Whelton Paul Speaker on Clinical Practice Guidelines; Chair, SPRINT,
ALLHAT, TOHP, and TONE trials
 OBJECTIVES
At the conclusion of this educational activity, the participants should be
better able to effectively:

•Apply the new hypertension definition, classification and treatment target.

•Apply non-pharmacological treatments for hypertension management.
•Apply pharmacologic treatment for hypertension management.
•Treat special populations with high BP (African Americans, older persons) and with
comorbid conditions (Diabetes, CKD, CVD, CHF etc.).
Implementation of Multifaceted Patient-Centered Treatment
Strategies for Intensive Blood Pressure Control
(IMPACTS)

Seminar on Current Approaches to Detection, Evaluation,

and Management of High Blood Pressure

Paul K. Whelton, MB, MD, MSc

Show Chwan Chair of Global Public Health
Tulane University School of Public Health and Tropical Medicine
Tulane University School of Medicine
 2017 Guideline for the Prevention, Detection, Evaluation
and Management of High Blood Pressure in Adults
• Initiative lead by
– American College of Cardiology
– American Heart Association
• Nine additional partners
– American Academy of Physician Assistants
– American College of Preventive Medicine
– American Geriatrics Society
– American Pharmacists Association
– American Society of Hypertension
– American Society of Preventive Cardiology
– Association of Black Cardiologists
– National Medical Association
– Preventive Cardiovascular Nurses Association
• Writing committee
• Multidisciplinary (21 members)
• No relationships with industry
• Independent External Review Committee (10 members)
• Systematic review/meta-analyses (selected questions)
• Processes standardized
• ACC/AHA Guideline Task Force processes
• 15 easy to navigate self contained sections
• 106 recommendations (448 evidence tables)
• Each recommendation characterized by:
• Class (strength) of Recommendation (COR)
• Level of evidence (LOE)
• Extensive peer review (internal & external)
• Approved by 11 professional societies governing bodies
BP Measurement
 Office BP Readings: Checklist for Accurate Measurements
Key Points
Step 1: Prepare patient
Step 2: Use proper technique
Step 3: Take proper measurements
Step 4: Document BP readings
Step 5: Average readings
Step 6: Provide readings to patient
Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017;Epub ahead of print
Specific Instructions
-Have patient relax, sitting in a chair (feet on floor, back supported) for >5
min.
-Avoid caffeine, exercise, and smoking for ≥ 30 min before measurement.
-Ensure bladder emptied.
-No talking during rest period or measurement.
-Remove clothing covering location of cuff placement.
-Measurements while patient sitting/lying on exam table do not fulfill criteria.
-Use validated BP measurement device that is calibrated periodically.
-Support patient’s arm (e.g., resting on a desk).
-Position middle of cuff on patient’s upper arm at mid-sternum (right atrium).
-Use correct cuff size, such that the bladder encircles 80% of the arm.
-Either stethoscope diaphragm or bell may be used for auscultatory readings.
-At first visit, record BP in both arms. Subsequently, use arm with higherBP.
-Separate repeated measurements by 1–2 min.
-For auscultatory readings, estimate SBP by palpation and inflate cuff 20–30
mm Hg above. Deflate 2 mm Hg per second and listen for Korotkoff sounds.
-Note time of most recent BP medication before measurements.
-Record SBP and DBP.
-Use average of ≥2 readings obtained on ≥2 occasions to estimate level of BP.
-Provide patients SBP/DBP readings both verbally and in writing.
 Basic testing Fasting blood glucose*
Complete blood count
Lipid profile
Serum creatinine with eGFR*
Serum sodium, potassium, calcium*
Thyroid-stimulating hormone
Urinalysis
Electrocardiogram
Optional testing Echocardiogram
Uric acid
Urinary albumin to creatinine ratio
*May be included in metabolic panel. eGFR indicates estimated glomerular filtration rate.

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

Classification of BP
 BP Classification (JNC 7 and ACC/AHA Guidelines)
SBP DBP 2003 JNC7 2017 ACC/AHA

<120 and <80 Normal BP Normal BP

120–129 and <80 Elevated BP

Major area
Prehypertension of
130–139 or 80–89 Stage 1 hypertension difference

140–159 or 90-99 Stage 1 hypertension Stage 2 hypertension

≥160 or ≥100 Stage 2 hypertension Stage 2 hypertension

• Blood Pressure should be based on an average of ≥2 careful readings on ≥2 occasions

• Adults with SBP or DBP in two categories should be designated to the higher BP category

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017;Epub ahead of print

 Out of Office BP Readings
Greater use of out of office BP measurements (ABPM or HBPM) for confirmation
of office hypertension and recognition of White Coat/Masked Hypertension

In adults not taking antihypertensive medication

Confirmed (Sustained) Hypertension

• Elevated office and out of office average BP
• Substantially higher risk of CVD compared to adults with normal office and out of office BPs
• Require therapy (nonpharmacological or combined nonpharmacological and antihypertensive drug therapy)

White Coat Hypertension (WCH)

• Office Hypertension not confirmed by out of office BP readings
• Present in about 10-25% of adults with office hypertension
• CVD risk profile more like adults with normal BP than adults with sustained hypertension
• May not need treatment for hypertension (should be monitored for development of sustained hypertension)

Masked Hypertension (MH)

• Normal office BP but out of office BP hypertension
• Present in about 10-25% of adults with normal office BP
• CVD risk profile more like adults with sustained hypertension than adults without hypertension
• Should be considered for antihypertensive drug therapy

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017;Epub ahead of print

 Underlying cause of high BP in about 10% of adults with hypertension
Common causes
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Uncommon causes
Pheochromocytoma/paraganglioma
Cushing’s syndrome
Hypothyroidism
Hyperthyroidism
Aortic coarctation (undiagnosed or repaired)
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary aldosteronism
Acromegaly
Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].
 Threshold for Treatment

- Nonpharmacological (lifestyle change) therapy

- Nonpharmacological and antihypertensive drug therapy

 Ischemic Heart Disease Mortality Rates, by Age
Prospective Studies Collaboration (61 observational cohorts)
1 million adults (12.7 million person-years of follow-up), with 34,000 IHD Deaths
SBP DBP Age at risk:
256 256
80-89 y
128 128
70-79 y
64 64
60-69 y
32 32
IHD 50-59 y
mortality 16 16
40-49 y
(absolute risk 8 8
and 95% CI)
4 4
2 2

1 1

120 140 160 180 70 80 90 100 110

Usual SBP (mm Hg) Usual DBP (mm Hg)

Lewington S. et al. Lancet. 2002;360:1903-1913.

 BP and Predicted Risk of Clinical Cardiovascular Disease
• ASCVD risk varies greatly at same level of BP

• With higher BP, increase in ASCVD risk:

– Small in adults at low risk for ASCVD
– Much greater in those at high risk for ASCVD

• In BP treatment trials with participants with different levels of CVD risk:

– Reduction in RR constant
– Reduction in absolute risk much greater in those at higher risk for ASCVD
Adult CVD Risk at two levels of SBP Meta-analysis: 26 RCT groups (n = 51,917)

Muntner P, Whelton PK. JACC. 2017;69:2446-2456. BP Lowering Treat. Trialists’ Collab. Lancet.2014;384:591-598.
 Number of Avoidable CVD Events, by baseline risk and extent of SBP lowering

69

57 54
Cardiovascular events avoided per 1000

44
37

36
31

19
28

>21
20 16
18
16-21
14
10

%)
11-15

D(
10

CV
16

of
5 <11
Systolic blo 12

risk
od pressure 8
r eduction (m
m Hg )

5-y
4

Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet.2014;384:591-598.

 2017 ACC/AHA BP Guideline: Thresholds for Treatment
SBP DBP CVD Risk/other
Recommended Treatment
circumstances
<120 and <80 N/A Healthy Lifestyle

120–129 and <80 N/A Nonpharmacological therapy

130-139 or 80-89 No CVD/10-yr ASCVD risk <10%* Nonpharmacological therapy

130–139 or 80–89 CVD/10-year ASCVD risk ≥ 10%

Antihypertensive drug
≥130 or ≥80 Diabetes or CKD therapy
+ (plus nonpharmacological
therapy)
≥130 Age ≥65 years

≥140 or ≥90 N/A

* AHA/ACC 2013 Pooled Cohort CVD Risk Equations

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017;Epub ahead of print

BP Target during Treatment
 Systolic Blood Pressure Intervention Trial (SPRINT)
Research Question
Examine effect of more intensive high blood pressure treatment
than is currently recommended

Randomized Controlled Trial

Target Systolic BP
9,361 randomized
≥50 years
SBP 130-180 mm Hg
Intensive Treatment Additional CVD risk indicator Standard Treatment
Goal SBP < 120 mm Hg Goal SBP < 140 mm Hg

Compare outcome experience

The SPRINT Research Group. N Engl J Med. 2015;373:2103-2116

 Systolic Blood Pressure Intervention Trial (SPRINT)

Method of BP Measurement

• Five minutes of quiet rest prior to BP measurements

• Omron 907XL Electronic Oscillometric Sphygmomanometer

• Proper patient positioning and cuff size

• BP readings recorded automatically,

– With or without staff in attendance

• Readings averaged

The SPRINT Research Group. N Engl J Med. 2015;373:2103-2116

Systolic BP During Follow-up

Year 1
Average SBP
Mean SBP/DBP
136.2/76.3 mm Hg Standard (During Follow-up)

Standard: 134.6 mm Hg

Mean SBP/DBP
121.4/68.7 mm Hg
Intensive
Intensive: 121.5 mm Hg

Average number of
antihypertensive
medications
The SPRINT Research Group. N Engl J Med. 2015;373:2103-2116

Number of
participants
 Systolic BP Intervention Trial
1.0
0.1
Primary Outcome (CVD mortality, MI, non-MI ACS, Stroke, HF)
0.08
25% reduction

Cumulative Hazard
0.8
Standard treatment Hazard ratio
0.06 0.75 (95% Cl, 0.64-0.89)
0.6 Intensive treatment
0.04

0.4 0.02

0
0.2 0 1 2 3 4 5

0
1 2 3 4 5
Years
1.0
0.1 Death from any Cause
0.8 0.08
Cumulative Hazard

27% reduction
0.06
0.6 Standard treatment
Hazard ratio
0.04 0.73 (95% Cl, 0.60-0.90)
0.02 Intensive treatment
0.4
0
0 1 2 3 4 5
0.2

0
1 2 3 4 5
Years
The SPRINT Research Group. N Engl J Med. 2015;373:2103-2116
 SPRINT: PRIMARY OUTCOME
Subgroup Hazard Ratio (95% Cl)

Overall
Previous CKD
No
Yes
Age
< 75 yr
≥ 75 yr
Sex
Female
Male
Race
Black
Nonblack
Previous cardiovascular disease
No
Yes
Systolic blood pressure
≤ 132 mm Hg
> 132 to < 145 mm Hg
≥ 145 mm Hg

0.50 0.75 1.00 1.20

Intensive Treatment Better Standard Treatment Better

The SPRINT Research Group. N Engl J Med.

2015;373:2103-2116
 Hazard Ratios (95% CI) for Major Cardiovascular Disease
at Different Levels of Achieved Systolic BP
Network Meta-analysis (42 RCTs: N = 144,220) Key Findings

•In randomized comparisons,

progressive reduction in risk of CVD
at lower levels of achieved SBP down
to levels below current US &
European recommendations

120-124 mm Hg vs. higher SBPs

•Similar findings for stroke, CHD and
all-cause mortality

•Similar pattern in sensitivity

analyses where
• SPRINT results excluded
130-134 mm Hg vs. higher SBPs • Results from four trials with
risk for bias excluded

•Consistent results with direct meta-

analysis

140-144 mm Hg vs. higher SBPs

•Similar findings for CVD benefit in
several other meta-analyses
(e.g. Bangalore et al, Verdecchia
150-154 mm Hg vs. higher SBPs et al., and Thomopoluset al.)
Bundy JD et al.
JAMA Cardiol.
2017;2:775-781.
 2017 ACC/AHA Evidence Review Committee
Meta-analysis: 19 RCTs with 1.8-8.4y follow-up
More intensive blood pressure lowering (including to SBP <130 mm Hg) significantly reduced CV risk
CV Event Relative Risk 95% CI
Major CVD 0.81 0.70-0.94
MI 0.86 0.76-0.99
Stroke 0.77 0.65-0.91
Heart failure 0.75 0.56-0.99
Reboussin DM et al. J Am Coll Cardiol. 2017;Epub ahead of print

2017 ACC/AHA BP Guideline

Based on the totality of the findings, the 2017 ACC/AHA BP Guideline Writing Committee
were unanimous in their opinion that a target of <130 mm Hg during antihypertensive
therapy is desirable for prevention of MI, stroke, heart failure, and major CVD events

Whelton PK et al. Hypertension/J Am Coll Cardiol 2017;Epub ahead of print

 2017 ACC/AHA BP Guideline: Treatment Targets
SBP DBP CVD Risk Recommended Treatment

<120 and <80 N/A N/A

120–129 and <80 N/A N/A
130-139 or 80-89 No CVD and 10-year
ASCVD risk <10%

130–139 or 80–89 Clinical CVD or 10-year

ASCVD risk ≥ 10%
SBP <130 and DBP <80 mm Hg
≥130 or ≥80
Diabetes or CKD
≥140 or ≥90
N/A

≥130
Age ≥65 years SBP <130 mm Hg

Whelton PK et al. Hypertension/J Am Coll Cardiol 2017;Epub ahead of print

 Why is 2017 ACC/AHA Guideline SBP target higher than in SPRINT?

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print]

 BP Targets in other Guideline Recommendations

• 2016 Canadian Guidelines:

• Intensive BP treatment to target SBP ≤ 120 mm Hg in high risk patients (Grade B)

• Shared decision-making necessary for the safe implementation of intensive BP control

• 2016 Australian Guideline:

• High CVD risk, <120 mm Hg SBP target can improve CVD outcomes (Strong)

• Close follow-up is recommended to identify treatment-related adverse effects (Strong)

• 2017 ADA (Target BP <130/80 mm Hg in adult DM patients at high risk for CVD)
Adverse Events During Intensive Antihypertensive Drug Therapy
• Electrolyte abnormalities and small decrease in eGFR are possible

• Some risk of hospitalization

– Biological and clinical implications uncertain

• Balance of benefits and adverse effects

– Should not be equally weighted
» Preventing major CVD events and death more important than adverse events

– Even when equally weighted, cost effectiveness analysis suggests

benefits outweigh adverse effects by a substantial margin:

“cost-effective at typical thresholds for value in health care

and remains so even with substantially higher adverse event rates”
Richman IB et al. JAMA Cardiol. 2016;1:872-879

• Clinicians can manage/mitigate adverse effects

– By modifying intensity of treatment or discontinuing treatment
   Intervention Dose Approximate Impact on SBP
Hypertension Normotension
Weight loss Calorie reduction Best goal is ideal body weight. Expect about 1 mm -5 mm Hg -2/3 mm Hg
& physical activity Hg for every 1-kg reduction in weight.

Healthy diet DASH diet Diet rich in fruits, vegetables, whole grains, and -11 mm Hg -3 mm Hg
low-fat dairy products, with reduced saturated and
total fat.
Dietary Reduced intake Optimal goal <1500 mg/d, but at least a 1000-mg/d -5/6 mm Hg -2/3 mm Hg
sodium reduction in most adults.
Dietary Enhanced intake 3500–5000 mg/d, preferably by diet rich in -4/5 mm Hg -2 mm Hg
potassium through diet potassium.
Physical Aerobic ● 90–150 min/wk (65%–75% heart rate reserve) -5/8 mm Hg -2/4 mm Hg
activity
Dynamic resistance ● 90–150 min/wk (50%–80% 1 rep maximum) -4 mm Hg -2 mm Hg
 
● 6 exercises, 3 sets/exercise, 10 repetitions/set
 
Isometric resistance
● 4 × 2 min (hand grip), 1 min between exercises, -5 mm Hg -4 mm Hg
30%–40% max. voluntary contraction, 3 sessions/wk
(8–10 wk)
Moderation Alcohol consumption In individuals who drink alcohol, reduce alcohol to: -4 mm Hg -3 mm Hg
in alcohol ● Men: ≤2 drinks daily
intake ● Women: ≤1 drink daily

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017;Epub ahead of print

 Choice of Drug Therapy in Treatment of Hypertension
• First-step agents:
– Compelling indication
• Use agent(s) that concurrently lower BP (e.g. post-MI, SIHD, HF)

– No compelling indication
• Achieving BP goal more important than choice of drug therapy

• Diuretic or CCB often good choice, but

• Drugs from following classes acceptable
– Diuretic (esp. long-acting thiazide-type agent such as chlorthalidone)
– Calcium channel blocker (CCB)
– Angiotensin converting enzyme inhibitor (ACEI)
– Angiotensin receptor blocker (ARB)

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

 Choice of Drug Therapy in Treatment of Hypertension
• Combination drug therapy
– Initial treatment with two drugs in most patients
• esp. in blacks and adults with stage 2 hypertension with BP ≥20/10 above target

– Use agents with complimentary modes of action

• e.g. diuretic or CCB with ACEI or ARB

– Use combination pill when feasible

– In blacks with hypertension but without HF or CKD (including those with DM):
• Initial treatment should include thiazide-type diuretic or CCB

– Simultaneous use of ACEI and ARB not recommended

• Potentially harmful

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

 Antihypertensive Drug Treatment: Follow-up

• Adults initiating a new or adjusted drug regimen for

treatment of hypertension should have a follow-up
evaluation of adherence and response to treatment at
monthly intervals until control is achieved

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

 Antihypertensive Drug Treatment: Older Adults

• In adults ≥65 years, with average SBP ≥130 mm Hg:

– if noninstitutionalized ambulatory community-dwelling adult,

treat to <130 mm Hg

– If high burden of comorbidity and limited life expectancy,

treatment decisions should be based on clinical judgement
and patient preference, using a team-based approach to
assess risk/benefit of potential treatment

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

 Antihypertensive Drug Treatment: Diabetes Mellitus

• In adults with hypertension and DM,

• If average BP ≥130/90 mm Hg, initiate antihypertensive

drug therapy and treat to <130/90 mm Hg

• All first-line classes of antihypertensives (i.e., diuretics,

ACE inhibitors, ARBs, and CCBs) useful and effective

• Consider ACEI or ARBs in presence of albuminuria

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

39

Antihypertensive Drug Treatment: Heart Failure

Hypertension and heart failure with reduced ejection factor (HFrEF)

• Prescribe guideline directed medical therapy (GDMT)

• Nondihydropyridine CCBs not recommended

• BP goal: <130/80 mm Hg

Hypertension and
• If symptoms of heart
volumefailure with
overload, preserved
prescribe ejection factor (HFpEF)
diuretics

• If high BP persists, prescribe ACE inhibitors or ARBs and beta blockers

• BP goal: <130 mm Hg

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

 Antihypertensive Drug Treatment: Ischemic Heart Disease
• Adults with hypertension and stable ischemic heart disease (SIHD)
– Use GDMT medications (e.g., beta blockers, ACE inhibitors, or ARBs) for compelling
indications (e.g., previous MI, stable angina)

– Add other drugs (e.g. dihydropyridine CCBs, thiazide diuretics, and/or mineralocorticoid
receptor antagonists) as needed to control hypertension

– If hypertension persistent and angina, add dihydropyridine CCBs to GDMT beta blockers

– In adults who have had an MI or ACS, reasonable to continue GDMT beta blockers for
treatment of hypertension beyond 3 years

– In patients with CAD (without HFrEF) and angina who had MI > 3 years previously,
consider beta blockers and/or CCBs

– BP target: <130/80 mm Hg

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

 Antihypertensive Drug Treatment: CKD

• Adults with hypertension and CKD

– Treatment with ACE inhibitors reasonable to slow kidney disease progression:
• Stage 3 (eGFR 20 - <60 mL/min/1.73 M2) or higher

• Stage 1 or 2 with albuminuria ≥300 mg/d, or ≥300 mg/g albumin-to-

creatinine ratio [or equivalent in first morning void]

– Use of ARBs reasonable if ACE inhibitors not tolerated

– BP goal: SBP <130/80 mm Hg

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

 Strategies to Improve Hypertension Treatment and Control
• Adherence strategies
– Once daily dosing/combination pills

• Strategies to promote lifestyle modification

• Team-based care
– Health professionals: physicians, nurses, pharmacists
– Patient
– Staff: office staff and community health workers Shared Decision-making
– Others: spouse, relatives, friends

• Use (active) of EHR and Patient Registries

• Telehealth strategies

• Performance measures and quality Improvement initiatives

• Financial incentives
 Resistant Hypertension: Diagnosis, Evaluation, and Treatment

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

 Hypertensive Emergency and Urgency
• Severe hypertension (BP >180/120 mmHg):

• Emergency: if acute, life-threatening manifestations of target organ damage

(hypertensive encephalopathy, subarachnoid or intracerebral hemorrhage, acute ischemic
stroke or MI, pulmonary edema, unstable angina, aortic dissection, acute renal failure),
severe preeclampsia/eclampsia, or pheochromocytoma crisis:

• Admit to ICU for continuous BP monitoring and parenteral

antihypertensive drug therapy

• Reduce SBP to <140 within first hour (<120 mm Hg for aortic dissection)

• Urgency: if no compelling indication:

• Reduce SBP no more than 25% in first hour and if stable to 160/100 within next 2-
6 hours and cautiously to normal during next 24-48 hours

Whelton PK et al. Hypertension/J Am Coll Cardiol. 2017 [Epub ahead of print].

 Summary

• Accurate BP measurement to improve diagnosis and

management of hypertension

• More intensive BP control than previously recommended

to reduce risk of CVD and mortality

• Employ strategies known to improve BP contol

46

Thank You
 Evaluation, Post-test & Claiming Credit
Thank you for participating in the Current Approaches to Detection, Evaluation, and Management of High
Blood Pressure educational activity recorded between May and October 2018 and presented by the Tulane
University Center for Continuing Education, Department of Epidemiology, and Department of Medicine.

In the upper right corner of your screen, please click on the “Click HERE for the Survey” button to evaluate
the content, complete the post-test, and claim credit. This enduring material requires successful completion of
a post-test prior to claiming credit with a minimum performance level of 75% (6 of 8 questions).

Your feedback is important! Please complete the evaluation regardless of your desire to claim AMA PRA
Category 1 Credit™ or CEUs. Evaluations are downloaded as aggregate data to maintain anonymity of your
responses.
 
Questions?
Please contact
Tulane University Center for Continuing Education
504-988-5466 cme@tulane.edu