Jaccjacc.cardiosource.com

BLOOD PRESSURE (BP) GOAL
NNT CVA or MI2 = 36
≤ 139 / 89 mm Hg – All Adult Hypertension
Pregnancy Potential: Avoid ACE-Inhibitors1 Add amlodipine 5 mg X ½ daily  5 mg X 1 daily  10 mg daily SPIRONOLACTONE OR BETA-BLOCKER
IF on thiazide AND eGFR ≥ 60 mL/min/1.73m2 AND K < 4.5
Add spironolactone 12.5 mg daily  25 mg daily Add atenolol 25 mg daily  50 mg daily (Keep heart rate > 55) • Consider medication non-adherence.
• Consider interfering agents (e.g., NSAIDs, excess alcohol).
• Consider white coat effect. Consider BP checks by medical assistant (e.g., two checks with 2 readings each, 1 week apart).
• Consider discontinuing lisinopril / HCTZ and changing to chlorthalidone 25 mg plus lisinopril 40 mg daily. Consider additional agents (hydralazine, terazosin, reserpine, minoxidil).
• Consider stopping atenolol and adding diltiazem to amlodipine, keeping heart rate > 55.
• Avoid using clonidine, verapamil, or diltiazem together with a beta blocker.
These heart-rate slowing drug combinations may cause symptomatic bradycardia over time.
• Consider secondary etiologies.
• Consider consultation with a hypertension specialist.
1. ACE-Inhibitors are contraindicated in pregnancy and not recommended in most child-bearing age women.
2. NNT = number needed to treat to prevent one event, maintaining hypertension control for at least 5 years. 2013 Kaiser Permanente Medical Care Program. Used with per Organizations ma manente Medical Care Program „ Medication up-titrations are recommended at 2-4 week intervals (for most patients) until control is achieved. Consider follow-up labs when up-titrating or adding lisinopril/HCTZ, chlorthalidone, HCTZ, or spironolactione.
„ Use lipid lowering therapy according to Dyslipidemia Management in Adults guideline: http://cl.kp.org/pkc/national/cmi/programs/dyslipidemia/guideline/index.html „ If pregnant, refer to OB/GYN for hypertension management. If on ACE-Is or ARBs, discontinue immediately.
LIFESTYLE CHANGES ARE RECOMMENDED FOR ALL PATIENTS:
Š Sodium restriction (≤ 2.4 gm sodium daily).
Š Weight reduction if BMI ≥ 25 kg/m2.
Š Exercise at a moderate pace to achieve 150 mins / week (i.e., 30 min / 5 days/wk).
Š Limit daily alcohol to no more than 1 drink (women) or 2 drinks (men).
Š Smoking cessation is strongly recommended; counsel tobacco users on the health risks of smoking, RECOMMENDATIONS FOR PATIENTS WITH ACE-I INTOLERANCE:
1. HCTZ 25 mg, then 50 mg to achieve BP goal.
2. Add losartan 25 mg, then 50 mg, then 100 mg to achieve BP goal.
3. Add amlodopine 2.5 mg, then 5 mg, then 10 mg to achieve BP goal.
Table 2: Dosage Range for Selected Antihypertensive Medications1
DRUG CLASS
GENERIC (OTHER NAMES)
USUAL DOSAGE RANGE
ACE-I-THIAZIDE COMBINATION PILL
THIAZIDE-TYPE DIURETICS
THIAZIDE-TYPE DIURETICS
THIAZIDE-TYPE DIURETICS
ACE INHIBITORS (ACE-I)
ACE INHIBITORS (ACE-I)
ACE INHIBITORS (ACE-I)
ANGIOTENSIN II RECEPTOR
BLOCKER (ARB)
LONG-ACTING DIHYDROPYRIDINE
CALCIUM CHANNEL BLOCKERS (CCB)
LONG-ACTING DIHYDROPYRIDINE
CALCIUM CHANNEL BLOCKERS (CCB)
LONG-ACTING DIHYDROPYRIDINE
CALCIUM CHANNEL BLOCKERS (CCB)
ALDOSTERONE RECEPTOR BLOCKER
BETA-BLOCKERS (BB)
BETA-BLOCKERS (BB)
BETA-BLOCKERS (BB)
BETA-BLOCKERS (BB)
ACE-I-THIAZIDE COMBINATION PILL
ALPHA BLOCKERS
ALPHA BLOCKERS
ALPHA BLOCKERS
DIRECT VASODILATORS
DIRECT VASODILATORS
ALPHA-2 AGONISTS
PERIPHERAL ADRENERGIC INHIBITOR
1 Availability of medications may vary depending on regional formularies.
2013 Kaiser Permanente Medical Care Program. Used with per Organizations ma manente Medical Care Program

Source: http://jaccjacc.cardiosource.com/acc_documents/2013_KP_National_Hypertension_Algorithm.pdf