Health Care Guideline

Hypertension Diagnosis and Treatment

The November 2014, Fifteenth Edition of ICSIs Hypertension Diagnosis and Treatment Health
Care Guideline incorporates a revision of our previous diagnosis content (2012) as well as an
endorsement of the 2014 Evidence Based Guideline for the Management of High Blood Pressure in
Adults Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8).
To access the endorsed Treatment content, click here.
To access the endorsed 2014 Evidence-Based Guideline for the Management of High Blood Pres-
sure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee
(JNC 8) content, click here.

How to cite this document:

Kenning I, Kerandi H, Luehr D, Margolis K, OConnor P, Pereira C, Schlichte A, Woolley T. Institute
for Clinical Systems Improvement. Hypertension Diagnosis and Treatment. Updated November 2014.
Copies of this ICSI Health Care Guideline may be distributed by any organization to the organizations
employees but, except as provided below, may not be distributed outside of the organization without the
prior written consent of the Institute for Clinical Systems Improvement, Inc. If the organization is a legally
constituted medical group, the ICSI Health Care Guideline may be used by the medical group in any of
the following ways:
copies may be provided to anyone involved in the medical groups process for developing and
implementing clinical guidelines;
the ICSI Health Care Guideline may be adopted or adapted for use within the medical group only,
provided that ICSI receives appropriate attribution on all written or electronic documents and
copies may be provided to patients and the clinicians who manage their care, if the ICSI Health
Care Guideline is incorporated into the medical groups clinical guideline program.
All other copyright rights in this ICSI Health Care Guideline are reserved by the Institute for Clinical
Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any adap-
tations or revisions or modifications made to this ICSI Health Care Guideline.

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 Health Care Guideline:
Hypertension Diagnosis and Treatment

Fifteenth Edition
Diagnosis Algorithm Text in blue in this algorithm
November 2014
indicates a linked corresponding
annotation.
1

Screening and identication of elevated

blood pressure > 140/90

Hypertension Stages Systolic Diastolic

2 (BP mmHg) (BP mmHg)

Conrm elevated Prehypertension 120-139 or 80-89

blood pressure Stage 1 hypertension 140-159 or 90-99

Stage 2 hypertension > 160 or > 100

Complete initial assessment:

accurately stage and complete
risk assessment

4 5

Is secondary yes Order additional

cause suspected? workup/consider
referral
no

See the ICSI Hypertension

Diagnosis and Treatment work
group endorsement of JNC 8
Management recommendations

www.icsi.org
Copyright 2014 by Institute for Clinical Systems Improvement 1
 Hypertension Diagnosis and Treatment
Fifteenth Edition/November 2014

Evidence Grading
Literature Search
A consistent and defined process is used for literature search and review for the development and revision
of ICSI guidelines.

GRADE Methodology
Following a review of several evidence rating and recommendation writing systems, ICSI has made a decision
to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
GRADE has advantages over other systems including the current system used by ICSI. Advantages include:
developed by a widely representative group of international guideline developers;
explicit and comprehensive criteria for downgrading and upgrading quality of evidence ratings;
clear separation between quality of evidence and strength of recommendations that includes a
transparent process of moving from evidence evaluation to recommendations;
clear, pragmatic interpretations of strong versus weak recommendations for clinicians, patients and
policy-makers;
explicit acknowledgement of values and preferences; and
explicit evaluation of the importance of outcomes of alternative management strategies.
(This document is in transition to the GRADE methodology)

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 Hypertension Diagnosis and Treatment
Fifteenth Edition/November 2014

Foreword
Related ICSI Scientific Documents
Guidelines
Diagnosis and Initial Treatment of Ischemic Stroke
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults
Healthy Lifestyles
Heart Failure in Adults
Lipid Management in Adults
Prevention and Management of Obesity for Adults
Preventive Services for Adults
Routine Prenatal Care
Stable Coronary Artery Disease

Definition
Clinicians All health care professionals whose practice is based on interaction with and/or treatment of
a patient.

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 Hypertension Diagnosis and Treatment
Fifteenth Edition/November 2014

Algorithm Annotations
1. Screening and Identification of Elevated Blood Pressure Greater
Than or Equal to 140/90
The entry point to this guideline is through the ICSI Preventive Services for Adults guideline. Patients
should receive routine blood pressure screening and identification of elevated blood pressure in the manner
recommended in that guideline.
Return to Algorithm

2. Confirm Elevated Blood Pressure

Recommendations:
A standardized blood pressure measurement process is important for correctly clas-
sifying blood pressure.
Elevated blood pressure readings should be confirmed.
Self-monitoring of blood pressure should be encouraged in patients with elevated blood
pressure.
Accurate, reproducible blood pressure measurement is important to allow comparisons between blood pres-
sure values and to correctly classify blood pressure (Pickering, 2005 [Guideline]). Incorrectly classifying
a hypertensive patient as normotensive fails to identify their increased risk for vascular events and kidney
disease. Incorrectly classifying a patient with normal blood pressure as hypertensive can result in unneces-
sary worry, time costs, medical costs and exposure to treatment-related harm.
In the health care setting, blood pressure may be measured manually using the auscultatory technique with a
sphygmomanometer and stethoscope. Mercury sphygmomanometers are no longer permitted in health care
settings. Anaeroid sphygmomanometers use a lever and bellows system in place of the mercury column but
must be calibrated regularly to maintain accuracy. "Hybrid" sphygmomanometers use an electronic pressure
gauge, but blood pressure is still determined by auscultation (Ogedegbe, 2010 [Reference]).
Oscillometric sphygmomanometers use a pressure transducer to determine the mean arterial pressure in
the upper arm at the brachial artery. Systolic and diastolic blood pressure are then calculated based on an
algorithm. Devices that measure blood pressure at alternative sites like the wrist or finger are not suffi-
ciently accurate and are not recommended. Blood pressure measured using a standardized technique with a
validated oscillometric device can be used instead of manual auscultation and may reduce white-coat effect
and other errors (Myers, 2011 [High Quality Evidence]; Myers, 2010 [Low Quality Evidence]). Some oscil-
lometric devices can be automated to measure blood pressure multiple times at varying intervals and may
also be programmed to incorporate a waiting period before the first measurement. Less expensive devices
meant for home use are widely available, but many have not been independently validated for accuracy
against a reference standard. A list of devices and results of validation testing can be found at http://www.
dableducational.org.
Blood pressure may vary substantially and is affected by emotions, pain, eating, voiding, caffeine, nicotine,
drugs, body position, mental activity and physical activity. Therefore, if an elevated blood pressure reading
has been obtained, the blood pressure level should be confirmed on a different day. Confirmation may be
based on 1) one or more follow-up visits with at least two blood pressure readings at each visit, 2) 24-hour
ambulatory blood pressure monitoring or 3) home blood pressure monitoring using a validated device.
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 Hypertension Diagnosis and Treatment
Algorithm Annotations Fifteenth Edition/November 2014

Confirmation of elevated blood pressure using repeated office blood pressure measurement alone is common
in current clinical practice. Repeating office blood pressure measurement is subject to the following limita-
tions compared with out-of-office methods: 1) lower diagnostic accuracy (Hodgkinson, 2011 [Systematic
Review]), 2) lower prognostic value for predicting future cardiovascular events (National Clinical Guideline
Centre [UK], 2011 [Guideline]) and 3) failure to capture blood pressure variations over time. One explana-
tion for lower diagnostic and predictive value is that 15-30% of individuals have higher blood pressure in
the medical setting and in the presence of medical personnel, a phenomenon named the white-coat effect
or isolated clinic hypertension (McManus, 2012 [Guideline]).
A second method of confirming elevated blood pressure that is gaining increasing acceptance is ambulatory
blood pressure measurement (ABPM). ABPM devices are small, portable machines connected to a blood
pressure cuff worn by patients. ABPM devices record blood pressure using oscillometry at regular intervals
while patients go about their normal activities including sleep. Measurements are typically taken at 20-to-30-
minute intervals over 24 to 48 hours. Results may be reported for 24 hours, day (awake) and night (sleep)
(Ogedegbe, 2010 [Reference]). As noted above, ABPM has better diagnostic accuracy (Hodgkinson, 2011
[Systematic Review]) and predicts subsequent cardiovascular events and target organ damage more reliably
than office blood pressure measurements (National Clinical Guideline Centre [UK], 2011 [Guideline]).
Limitations of ABPM include cost, availability, discomfort and sleep disturbance.
A third method of confirming elevated blood pressure is home blood pressure monitoring (HBPM) with
an automated oscillometric device that records pressure from the brachial artery. Although the evidence is
less extensive than for ABMP, HPBM identifies patients with normal out-of-office blood pressure readings,
and home readings are a stronger predictor of subsequent cardiovascular events than are office readings.
(Fagard, 2005 [Meta-analysis]; Ohkubo, 1998 [Low Quality Evidence]; Niiranen, 2010 [Low Quality
Evidence]; Asayama, 2006 [Low Quality Evidence])
Self-monitoring may improve adherence to treatment and has been associated with small improvements in
BP control, even in the absence of additional self-management support interventions (Uhlig, 2013 [System-
atic Review]).
For patients with non-hypertensive levels of blood pressure upon initial screening or confirmatory testing,
re-screening should occur at intervals based on the risk for incident hypertension. Incident hypertension
increases markedly with age, blood pressure level and body mass index, and is highest in African Ameri-
cans. Depending on a number of risk factors, re-screening at one- to two-year intervals is recommended. In
non-African American individuals ages 18-40 with normal BMI (< 25 kg/m2) and normal blood pressure
(< 120/80 mmHg), even less frequent re-screening can be considered due to the low risk of incident hyper-
tension.
Return to Algorithm

3. Complete Initial Assessment: Accurately Stage and Complete Risk

Assessment
Recommendations:
It is important to accurately stage newly confirmed hypertension and assess risk for
cardiovascular disease and other target organ damage.
A complete review of all medications (prescription and over-the-counter) is very impor-
tant.
Return to Algorithm

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 Hypertension Diagnosis and Treatment
Algorithm Annotations Fifteenth Edition/November 2014

The goal of the clinical evaluation in newly confirmed hypertension is to determine whether the patient has
primary or secondary hypertension, target organ damage, and other cardiovascular risk factors.
The absolute risk of cardiovascular events or other complications of hypertension increases progressively
with the level of blood pressure, the number of non-hypertensive cardiovascular risk factors, and the severity
and extent of target organ damage. Using the 2013 ACC/AHA Pooled Cardiovascular Risk Equation, a
10-year coronary heart disease risk level can be estimated for an individual based on age, sex, race, total
and high-density lipoprotein-cholesterol levels, systolic blood pressure level, smoking status, diabetes status
and whether the individual uses antihypertensive medications (Goff, 2013 [Low Quality Evidence]). This
method of risk assessment makes clear the need not only to control blood pressure but also to control all
cardiovascular risk factors to maximize risk reduction.
Specific approaches to the diagnosis and management of dyslipidemia are reviewed in the ICSI Lipid
Management in Adults guideline.
Accurately Stage Hypertension
This treatment guideline is designed to be used in new or previously diagnosed hypertensive patients
in conjunction with the ICSI Preventive Services for Adults guideline.
Hypertension Stages Systolic Diastolic
(BP mmHg) (BP mmHg)
Prehypertension 120-139 or 80-89

Stage 1 hypertension 140-159 or 90-99

Stage 2 hypertension > 160 or > 100

Modified from the Seventh Report of the Joint National Committee on Prevention, Detection, Evalua-
tion, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.
When systolic and diastolic pressure falls into different categories, the higher category should be selected
in classifying the individual's blood pressure status.
Medical History
The history should focus on modifiable lifestyle factors including weight change, dietary intake of sodium
and cholesterol, level of physical activity, psychosocial stressors and patterns of alcohol, recreational
drug and tobacco use.
Determine all medications being used including herbal supplements, over-the-counter, prescription
and recreational drugs as many agents may temporarily elevate blood pressure and/or adversely affect
blood pressure control (Aw, 2005 [Meta-analysis]; Priya, 2000 [Low Quality Evidence]).
Determine if there is a family history of hypertension, cardiovascular disease, cerebrovascular disease,
diabetes mellitus and dyslipidemia in first- or second-degree relatives, and document if there is.
Assess for symptoms and signs of target organ damage and secondary hypertension via a directed history
and focused examination.
Physical examination
The initial physical examination should include the following in order to accurately stage hypertension,
assess target organ damage and search for signs of secondary causes of hypertension:
Two or more blood pressure measurements separated by at least one minute with the patient
seated with back supported, feet flat on the floor and upper arm supported at the level of the
mid-sternum.
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 Hypertension Diagnosis and Treatment
Algorithm Annotations Fifteenth Edition/November 2014

Measurement of height, weight and calculation of body mass index.

Funduscopic examination for hypertensive retinopathy (i.e., arteriolar narrowing, focal arte-
riolar constrictions, arteriovenous crossing changes, hemorrhages and exudates, disc edema).
While the reproducibility of office funduscopic findings is poor, there are clinical findings (in
particular, retinal hemorrhages, papilledema) that guide important clinical decisions.
Examination of the neck for distended veins or an enlarged thyroid gland
Examination of the heart for abnormalities in rate and rhythm, increased size, precordial heave,
clicks, murmurs, and third and fourth heart sounds
Examination of the lungs for rales and evidence of bronchospasm
Examination of the abdomen for renal or abdominal aortic bruits, enlarged kidneys, masses and
abnormal aortic pulsation
Examination of the extremities for diminished or absent peripheral arterial pulsations, bruits
and edema
Neurological assessment
Initial laboratory studies
Initial lab screen should include 12-lead electrocardiogram, urinalysis, fasting blood glucose or A1c,
serum sodium, potassium, creatinine (with estimated or measured glomerular filtration rate), calcium
and lipid profile (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein choles-
terol and triglycerides). Additional laboratory and diagnostic studies may be required in individuals
with suspected secondary hypertension and/or evidence of target organ damage. Other tests may be
ordered at the discretion of the clinician such as complete blood count, chest x-ray, uric acid or TSH
(Chobanian, 2003 [Guideline]).
Cardiovascular Risk Factors/Target Organ Damage as Supported by Latest Evidence
Major risk factors
Hypertension
Elevated LDL cholesterol
Family history of premature cardiovascular disease (men younger than 55 or women younger than 65)
Physical inactivity
Tobacco usage, particularly cigarettes
Target organ damage
Heart
Left ventricular hypertrophy
Angina/prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Dementia
Chronic kidney disease
Estimated GFR less than 60 mL/min
Microalbuminuria
Peripheral arterial disease
Retinopathy
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 Hypertension Diagnosis and Treatment
Algorithm Annotations Fifteenth Edition/November 2014

4. Is Secondary Cause Suspected?

Secondary causes account for only a small percentage of all cases of hypertension, but their detection can
be important to determine appropriate intervention. Some lifestyle risk factors like obesity and excessive
alcohol use may also contribute to hypertension and treatment resistence but are not usually classified as
secondary causes.
Features suggestive of secondary hypertension include abrupt onset of symptomatic hypertension, hyperten-
sive crisis, sudden loss of blood pressure control after previous stability on drug therapy and drug resistence
hypertension.
Differential diagnosis and typical approach to evaluations are shown below.

Diagnosis Signs/Symptoms Options for Further

Evaluation
Chronic kidney disease Variable, may be Estimated GFR, urinalysis
absent
Renalvascular hypertension Unexplained Consult with specialist
hypertension in
younger women,
abdominal bruit
Sleep apnea Excessive daytime History, sleep study
sleepiness, obesity,
snoring
Primary aldosteronism Unprovoked Plasma renin/aldosterone
hypokalemia ratio
24-hour urine aldosterone
Drug-induced (prescription, Variable history Medication review, urine
over-the-counter, toxin screen
supplements or illicit drugs)
Aortic coarctation Unequal blood Aortic imaging, consult
pressure in right and local experts for preferred
left arms, delayed or test
absent femoral pulses
Cushing syndrome Hyperglycemia, Dexamethasone
truncal obesity suppression test, 24-hour
urine free cortisol
Pheochromocytoma Paroxysmal 24-hour urine
symptoms metanephrines and
normetanephrines, plasma-
free metanephrines
Thyroid/parathyroid disease Variable, TSH, serum PTH
hypercalcemia

Care should be taken to ensure advanced testing is correctly chosen and done properly to avert the need for
repeat studies. This may require discussion with or referral to a specialist.
Return to Algorithm

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 Hypertension Diagnosis and Treatment
Algorithm Annotations Fifteenth Edition/November 2014

5. Order Additional Workup/Consider Referral

If screening tests for secondary hypertension are positive, consider appropriate referral for additional workup
and treatment.
If you suspect a diagnosis of secondary hypertension, it is recommended that you obtain a consultation early
in order to confirm the most efficient and cost-effective approach to patient evaluation and management
(Chobanian, 2003 [Guideline]; Gifford Jr, 1989 [Guideline]).
Return to Algorithm

6. See the ICSI Hypertension Diagnosis and Treatment Work Group

Endorsement of JNC 8 Management Recommendations
Return to Algorithm

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