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Hypertension in the clinic

Management of hypertension in the clinic (chalk talk) - Dr. Hayes 07/30/24

Evaluating Blood Pressure

  • First step is confirming the patient actually has elevated blood pressure
  • Many factors can falsely elevate BP readings:
  • Wrong cuff size
  • Patient smoking/drinking coffee beforehand
  • Full bladder (can raise BP 10-15 points)
  • Not resting for 5 minutes before measurement (can raise BP 10-20 points)
  • Patient talking during measurement
  • Best practice:
  • Have patient rest 5 minutes before measurement
  • Take BP as last vital sign
  • Patient should not talk during measurement
  • Use proper cuff size
  • Consider having patient empty bladder first
  • Implementing these changes led to 8 point drop in systolic and 6 point drop in diastolic BP on average
  • Ambulatory BP monitoring gives the most accurate picture of true BP
  • Home BP measurements are useful but home devices may not be as accurate

Initial Evaluation

  • For new hypertension diagnosis, always order:
  • Basic metabolic panel - to check renal function, electrolytes
  • EKG - to look for signs of end organ damage
  • Look for signs of secondary hypertension:
  • Low potassium may indicate hyperaldosteronism
  • EKG changes may indicate underlying heart/lung issues

When to Treat

  • No specific BP threshold necessitates emergency treatment if asymptomatic
  • Symptoms + very high BP (generally >180/110) may indicate hypertensive emergency
  • For hypertensive emergencies, lower BP gradually by 25% initially
  • Rapid BP lowering in chronic hypertension patients can cause stroke-like symptoms
  • For asymptomatic elevated BP, treatment can be initiated over days to weeks

Treatment

  • Three main drug classes proven to reduce cardiovascular events:
    • Thiazide diuretics (chlorthalidone preferred over HCTZ)
    • ACE inhibitors
    • Calcium channel blockers (dihydropyridines like amlodipine)
  • Choose based on patient characteristics/comorbidities
  • Beta blockers not recommended as first-line (may increase heart failure risk)
  • Start with 2 drugs if BP >20/10 mmHg above goal
  • Goal BP:
  • Generally 130/80 for high risk patients (e.g. diabetics)
  • 140/90 may be acceptable for low risk patients
  • Consider screening for secondary causes if BP uncontrolled on 3+ meds including a diuretic

Other Considerations

  • Low salt diet lowers BP but no direct evidence it reduces CV events
  • Nocturnal BP control important - consider nighttime dosing of meds
  • Once started, BP meds usually need to be continued long-term
  • There is no BP that is "too low" as long as organs are perfused and patient is asymptomatic
  • Diastolic BP may be more important than systolic for CV risk

References

  • The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major Cardiovascular Events in Hypertensive Patients Randomized to Doxazosin vs Chlorthalidone: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2000;283(15):1967–1975. doi:10.1001/jama.283.15.1967
Last update: April 22, 2026