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Clinical challenges in diagnosing and managing adult hypertension

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ABSTRACTAlthough there is still no consensus on how to diagnose hypertension, opinion is moving toward incorporating out-of-office blood pressure measurements into the process. The SPRINT trial poses potential opportunities and challenges. Simplified antihypertensive drug regimens incorporating single pill combinations are very effective.

KEY POINTS

  • Diagnosing hypertension continues to require a sufficient number of well-performed office blood pressure measurements for most patients.
  • First-tier drug choices are angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (but not both together), calcium channel blockers, and thiazide-type diuretics. Add-ons to achieve blood pressure targets should come from first-tier classes not used initially.
  • Simple implementation principles can achieve high control rates across a fractured healthcare delivery landscape. Equitable care can reduce racial disparities in hypertension control.


 

References

Hypertension is a primary care specialty. Most of the 70,000,000 adult Americans with hypertension are cared for by primary care providers. Medications are readily available that achieve high control rates when used in combination. Primary care providers are uniquely positioned to lead team-oriented approaches to improve medication adherence and provide equitable care that addresses racial disparity in hypertension control.

This review focuses on some of the challenges that primary care providers face, including diagnosis of hypertension, medication options, controversy regarding the goal systolic blood pressure in the elderly, and population care strategies in our fractured healthcare system.

USING OUT-OF-OFFICE AND AUTOMATED MEASUREMENTS FOR DIAGNOSIS

A systematic review performed for the US Preventive Services Task Force concluded that the evidence supports ambulatory monitoring to confirm blood pressure in the office in all but the most severe cases of office-based blood pressure elevation in order to avoid misdiagnosis and overtreatment.1 Elevated ambulatory pressure is the best predictor of cardiovascular events in prospective cohort studies.1 A new hypertension diagnostic algorithm for Canada2 is similar to an earlier American Heart Association algorithm3 in recommending diagnostic confirmation by out-of-office measures including home blood pressure, ambulatory pressure, or automated office blood pressures. With automated blood pressure measurement, the clinician or medical assistant initiates preprogrammed oscillometric devices to take sequential blood pressure measurements after the assistant leaves the examining room. Thresholds for the diagnosis of hypertension are1,2:

  • Office measurements: ≥ 140/90 mm Hg
  • Automated office measurements (mean): ≥ 135/ 85 mm Hg
  • Home blood pressure measurements: ≥ 135/85 mm Hg
  • Ambulatory monitoring (mean of daytime readings): ≥ 135/85 mm Hg
  • Ambulatory monitoring (mean 24-hour reading): ≥ 130/80 mm Hg.

However, evidence supporting the use of ambulatory monitoring, home measurements, and automated office measurements has significant limitations. There is no evidence from prospective randomized controlled trials that withholding treatment on the basis of these measurements when office blood pressures are elevated leads to cardiovascular outcomes equivalent to normotensive outcomes. Also, the Centers for Medicare and Medicaid Services do not reimburse for ambulatory blood pressure monitoring, which would lead to inconsistent implementation and more disparity in healthcare. Moreover, when ambulatory monitoring is used to diagnose hypertension, how to determine response to treatment has not been defined.

Table 1 summarizes recommendations for the use of out-of-office measurements to diagnose hypertension.1–4 System-wide efforts can reduce the need for out-of-office confirmation; these include improving competence in measuring office blood pressure through peer validator spot-checking in the normal workflow, performance feedback reporting of repeat measurements when the first is elevated, and extensive use of walk-in measurements to reduce the white-coat effect.5,6 Two well-performed office measurements performed on each of two or three visits over at least a month will continue to be the diagnostic standard for most patients. Small errors in technique introduce inaccuracies in blood pressure readings, which, if falsely high, can lead to unnecessary treatment or, conversely, if falsely low can lead to inadequate treatment. Table 2 lists several common measurement errors that need to be consistently avoided.7–9

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