Managing Hypertension

Guides JNC/ACC hypertension management with staging, treatment algorithms, and monitoring schedules.

Why This Skill Exists

Hypertension affects approximately 116 million U.S. adults and is the leading modifiable risk factor for cardiovascular disease, stroke, heart failure, and chronic kidney disease. The 2017 ACC/AHA guideline redefined hypertension thresholds (≥130/80 mmHg), replacing the prior JNC 8 threshold of ≥140/90 mmHg, which significantly expanded the population requiring intervention. Uncontrolled hypertension accounts for an estimated 500,000 deaths annually in the United States.

Primary care clinicians manage the overwhelming majority of hypertensive patients, yet control rates remain below 50% nationally. Common errors include reliance on single office readings, failure to rule out white-coat hypertension, inadequate titration intervals, and missed secondary causes. This skill enforces the ACC/AHA stepwise approach to diagnosis, staging, treatment selection, and monitoring to drive blood pressure to target with minimal adverse effects.

Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the patient's most recent office BP (average of ≥2 readings, seated, ≥1 minute apart)? Default: [REQUIRED]
2. Has ambulatory blood pressure monitoring (ABPM) or home BP monitoring (HBPM) been performed? Default: no
3. What is the patient's 10-year ASCVD risk score (Pooled Cohort Equations)? Default: calculate
4. Does the patient have established clinical ASCVD, heart failure, CKD, or diabetes? Default: no
5. What antihypertensives is the patient currently taking with doses? Default: none
6. Has secondary hypertension been considered or ruled out? Default: not yet assessed
7. What is the patient's baseline creatinine, potassium, and eGFR? Default: pending labs
8. Is the patient pregnant or planning pregnancy? Default: no

Documents to Request

• Office BP log with at least 2 readings per visit over 2-3 visits
• ABPM or HBPM data if available (≥12 readings over ≥4 days)
• Current medication list including NSAIDs, decongestants, oral contraceptives
• Baseline metabolic panel (BMP) with creatinine, potassium, sodium, glucose
• Lipid panel and fasting glucose or A1c for ASCVD risk calculation
• ECG (12-lead) for LVH assessment if not done within past year
• Urinalysis with albumin-to-creatinine ratio
• Prior echocardiogram report if history of LVH or heart failure

Step 1: Accurate Diagnosis and Staging

Confirm hypertension diagnosis per 2017 ACC/AHA criteria:

Confirm with out-of-office readings if feasible. ABPM is the gold standard; HBPM (average of morning and evening readings over 7 days, discard day 1) is acceptable. White-coat hypertension: office BP elevated but ABPM daytime average <135/85.

Step 2: Secondary Hypertension Screening

Screen for secondary causes when any of the following are present:

• Age of onset <30 or >55 with no prior history
• Resistant hypertension (uncontrolled on ≥3 drugs including a diuretic at optimal dose)
• Sudden loss of BP control in previously well-managed patient
• Hypokalemia (K+ <3.5) not explained by diuretics
• Renal bruit or asymmetric kidney size

Step 3: First-Line Pharmacotherapy

Select initial therapy per ACC/AHA compelling indications:

Starting doses: Lisinopril 10mg daily, amlodipine 5mg daily, chlorthalidone 12.5mg daily. Titrate at 4-week intervals.

Step 4: Combination Therapy and Titration

If BP remains above target on single agent at adequate dose:

1. Dual therapy: Combine agents from two different classes; preferred combinations:

   • ACEi/ARB + CCB (e.g., lisinopril 20mg + amlodipine 5mg)
   • ACEi/ARB + thiazide-type diuretic (e.g., losartan 100mg + HCTZ 25mg)
   • Avoid: ACEi + ARB combination (hyperkalemia, renal risk per ONTARGET trial)

2. Triple therapy: Add third class if dual therapy insufficient after 4 weeks at max tolerated doses

   • Standard triple: ACEi/ARB + CCB + thiazide-type diuretic

3. Resistant hypertension (uncontrolled on ≥3 drugs including diuretic):

   • Confirm adherence (pill counts, pharmacy refill data)
   • Optimize diuretic (switch HCTZ to chlorthalidone 25mg or indapamide 1.25mg)
   • Add spironolactone 25-50mg (per PATHWAY-2 trial) as fourth agent
   • Check for secondary causes if not previously done

Step 5: Monitoring and Follow-Up Schedule

BP targets per ACC/AHA 2017:

• General: <130/80 mmHg (if can be achieved without undue treatment burden)
• Age ≥65, non-institutionalized: <130 systolic (per SPRINT trial); individualize if frail
• CKD: <130/80 mmHg
• Diabetes: <130/80 mmHg

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is BP staging documented with the method of measurement (office, ABPM, HBPM)?
2. Has ASCVD risk been calculated and documented to justify treatment threshold?
3. Are medication selections aligned with compelling indications and contraindications?
4. Is the titration plan documented with specific dose escalation timeline and lab monitoring?
5. Has secondary hypertension been considered with screening rationale documented?

Quality Audit

• BP measured correctly: seated ≥5 minutes, supported arm at heart level, appropriate cuff size
• At least 2 readings averaged, ≥1 minute apart
• BP stage documented per 2017 ACC/AHA classification
• Out-of-office confirmation obtained or plan documented
• 10-year ASCVD risk calculated and recorded
• Secondary hypertension screening considered and documented
• First-line agent selected per compelling indications
• ACEi/ARB contraindicated medications checked (pregnancy, bilateral RAS, angioedema history)
• BMP checked within 2 weeks of ACEi/ARB/diuretic initiation
• Creatinine rise ≤30% from baseline on ACEi/ARB (>30% = hold and investigate)
• Lifestyle modifications counseled: DASH diet, sodium <2300mg/day, exercise 150 min/week, weight loss, alcohol moderation
• Follow-up interval documented per titration phase
• Adherence assessment performed at each visit
• Home BP monitoring instructions provided with target values

Guidelines

• Never start ACEi and ARB simultaneously—dual RAAS blockade increases hyperkalemia and acute kidney injury risk
• Always check potassium and creatinine within 1-2 weeks of starting or uptitrating ACEi, ARB, or diuretic
• White-coat hypertension affects 15-30% of patients with elevated office BP; confirm with out-of-office readings before initiating pharmacotherapy
• Chlorthalidone is preferred over HCTZ due to longer half-life, proven cardiovascular outcomes (ALLHAT), and superior 24-hour BP control
• ACEi/ARB must be discontinued immediately if pregnancy is confirmed or planned—teratogenic effects include renal agenesis and oligohydramnios
• Beta-blockers are NOT first-line for uncomplicated hypertension per ACC/AHA 2017; reserve for compelling indications (post-MI, HFrEF, rate control)
• Orthostatic hypotension must be assessed in elderly patients at each visit: check standing BP at 1 and 3 minutes after rising
• Document all BP readings in a structured log to enable trend analysis across visits