Name: Hypertension Treatment Algorithm - Optometry Advisor
Published: 2021-09-29T17:20:00+00:00

Hypertension Treatment Algorithm H. PYLORI INFECTION TREATMENT GUIDELINE

HYPERTENSION TREATMENT ALGORITHM

							Adults ≥18yrs with hypertension

										▼
						Implement lifestyle modifications (continue throughout management)

										▼
				Set blood pressure (BP) goal and initiate BP-lowering medication based on age, diabetes, and chronic kidney disease (CKD)
		General population (no diabetes or CKD)													Diabetes or CKD present


	Age ≥60yrs				Age <60yrs							• All ages • With diabetes • No CKD					• All ages • CKD present w or w/o diabetes

	BP Goal <150/90mmHg				BP Goal <140/90mmHg							BP Goal <140/90mmHg					BP Goal <140/90mmHg



			Non-black	▼						▼	Black						▼	All races
			Initiate thiazide-type diuretic, ACEI, ARB, or CCB, alone or in combination^a						Initiate thiazide-type diuretic or CCB, alone or in combination					Initiate ACEI or ARB, alone or in combination with other class^a

				Select drug treatment titration strategy: A. Maximize first medication before adding second OR B. Add second medication class before maximizing first medication OR C. Start with two medication classes separately or as a fixed-dose combination

							At goal?^b						Yes
							At goal?^b

									No	▼
				• Reinforce medication and lifestyle adherence • Strategy A or B: Add and titrate thiazide-type diuretic, ACEI, ARB, or CCB (use class not previously selected)^a • Strategy C: Maximize dose of initial regimen

							At goal?						Yes
							At goal?

									No	▼
				• Reinforce medication and lifestyle adherence • Add and titrate thiazide-type diuretic, ACEI, ARB, or CCB (use class not previously selected)^a

							At goal?						Yes
							At goal?

									No	▼
			►	• Reinforce medication and lifestyle adherence • Add additional class (eg, β-blocker, aldosterone antagonist, or others not previously selected) and/or refer to hypertension specialist
			►
																	▼
				No			At goal?						Yes			►	Continue current therapy and monitoring^c
							At goal?									►


FIRST LINE THERAPY FOR COMPELLING INDICATIONS
Compelling indication								First-line Therapy
Heart failure								ACEI, ARB, angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, diuretic, BB (carvedilol, metoprolol succinate, bisoprolol)
Post myocardial infarction								BB^d (carvedilol, metoprolol, nadolol, bisoprolol, propranolol, timolol), ACEI, ARB
Diabetes								Thiazide diuretic, ACEI, ARB, CCB
Chronic kidney disease (CKD)								ACEI, ARB
Secondary stroke prevention								Thiazide diuretic, ACEI, ARB
LIFESTYLE MODIFICATIONS
Modification					Recommendation										Approximate SBP reduction
Weight loss					Aim for at least a 1kg reduction in body weight; best goal is ideal body weight										1mmHg/kg of weight loss
DASH diet (Dietary Approaches to Stop Hypertension)					Adopt a diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and total fat										3−11mmHg
Sodium reduction					Reduce dietary sodium intake by at least 1000mg/day; optimal goal is <1500mg/day										2−6mmHg
Potassium supplementation					Increase dietary potassium intake to 3500−5000mg/day. Four to five servings of fruits and vegetables will usually provide 1500−>3000mg of potassium										2−5mmHg
Physical activity					Increase physical activity:
					• Aerobic exercise: 90−150mins/wk										2−8mmHg
					• Dynamic resistance: 90−150mins/wk (6 exercises, 3 sets/exercise, 10 repetitions/set)										2−4mmHg
					• Isometric resistance: 3 sessions/wk for 8−10wks (4 x 2min hand grips, 1min rest in between)										4−5mmHg
Reduced alcohol consumption					Limit to no more than 2 drinks/day in men and 1 drink/day in women (1 drink = 12oz beer, 5oz wine, 1.5oz distilled spirit)										3−4mmHg
Tobacco Cessation					Provide behavioral interventions. May need to consider pharmacotherapy for cessation										—
STRATEGIES TO IMPROVE TREATMENT ADHERENCE
• Clinician empathy increases patient trust, motivation and adherence to therapy • Clinicians should consider patients’ cultural beliefs and individual attitudes in formulating a treatment plan • Simplifying medication regimens: — Dosing to once daily rather than multiple times per day may improve adherence — Use of fixed-dose combination agents rather than individual drug components
NOTES
Key: CVD = cardiovascular disease; ARB = angiotensin II receptor blocker; ACEI = angiotensin converting enzyme inhibitor; BB = beta blocker; CCB = calcium channel blocker ^a Avoid combination of ACEIs and ARBs. ^b Wait 1 month before titrating. ^c If BP goal not maintained, re-enter the algorithm where appropriate; individualize. ^d Avoid atenolol or BB with intrinsic sympathomimetic activity.
REFERENCES
James PA, Oparil S, et al. 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). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427. Whelton PK, 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. Journal of the American College of Cardiology. 2017. doi: 10.1016/j.jacc.2017.11.006 (Rev. 3/2018)

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