Act Rapidly

Uncontrolled High Blood Pressure Needs to be Met With Immediate Action

High blood pressure is the most prevalent and modifiable risk factor for the development of cardiovascular diseases including:

Coronary artery disease
Heart failure
Atrial fibrillation
Stroke
Dementia
Chronic kidney disease
All-cause mortality

The prevalence of hypertension by age group per NHANES 2017 to 2020 is:

28.5% among those 20 to 44 years of age
58.6% among those 45 to 64 years of age
76.5% among those ≥65 years of age

Medication therapy to lower blood pressure added to lifestyle interventions is recommended:

for all adults with average BP ≥140/90 mm Hg
for selected adults with average BP ≥130/80 mm Hg who have clinical CVD, previous stroke, diabetes, chronic kidney disease, or increased 10-year predicted cardiovascular risk of ≥7.5% defined by PREVENT™

Reduce Therapeutic Inertia

Therapeutic inertia—failing to start or intensify treatment when BP is high—is a common problem. It is also a leading factor contributing to suboptimal BP control rates, along with the failure of patients to schedule or return for follow up appointments. Both can leave your patient with serious unmanaged risk and can be addressed with an evidence-based treatment protocol.

“For women, high blood pressure has a bigger impact on death from heart disease and stroke than any other risk factor. For men, only cigarette smoking has a higher impact.”
—AHA Statistical Update

Extend Lives: Act Rapidly to Manage Pressure

Start or continue lifestyle interventions
Reassess in 1 year

When average office BP 120-129 mm Hg systolic and <80 mm Hg diastolic for 2 or more measurements on 2 or more office visits:

Start or continue lifestyle interventions aimed at lowering blood pressure and preventing elevated BP and hypertension
Reassess in 3-6 months
Consider out-of-office BP measurement using 24-hour ambulatory blood pressure monitoring (ABPM) or self-measured blood pressure (SMBP) to exclude masked hypertension

When average office BP ≥130-139 mm Hg systolic or 80-89 mm Hg diastolic:

For all patients, start or continue lifestyle interventions aimed at lowering blood pressure
For patients who have clinical cardiovascular disease, previous stroke, diabetes, chronic kidney disease, or 10-year predicted cardiovascular risk of ≥7.5% defined by PREVENT™, start anti-hypertensive medications
For patients without existing CVD or elevated risk, initiate medication if average BP remains ≥130-139 mm Hg systolic or 80-89 mm Hg diastolic after 3-6 months of lifestyle intervention

For patients receiving medication:

Initiate first-line therapy with thiazide-type diuretics, long-acting dihydropyridine CCBs, and ACEi or ARBs
Follow up in 2-4 weeks to check electrolytes through a basic metabolic panel and renal function when starting a diuretic, ACE or ARB
Follow up every month, using the treatment algorithm to guide therapy until BP is <130/80 mm Hg and it may be reasonable to encourage efforts to reach <120/80 mmHg
If control is not reached with a single first-line drug, consider adding an agent from another class to reach goal
Consider out-of-office BP measurement using 24-hour ABPM or SMBP to confirm a diagnosis or titrate medications until BP goal is reached

When average office BP ≥140 mm Hg systolic or >90 mm Hg diastolic:

Start or continue lifestyle modification
Initiate first-line therapy with thiazide-type diuretics, long-acting dihydropyridine CCBs, and ACEi or ARBs
Start anti-hypertensive medications, prescribing 2 first-line agents from different classes, ideally in a single-pill combination
Follow up in 2-4 weeks to check electrolytes through a basic metabolic panel and renal function when starting a diuretic, ACE or ARB or mineralocorticoid receptor antagonist
Follow up every month until BP is controlled to <130/80mmHg and, it may be reasonable to encourage efforts to reach <120/80 mmHg
Consider out-of-office BP measurement using 24-hour ABPM or SMBP

Reassess using SMBP to identify white-coat effect and determine a patient’s adherence and response to therapy.

Once BP goal is met, reassess in 3-6 months.

Practice Assessment: How Rapidly Do You Act?

Notify the provider if a patient has high BP? Flag high BPs in the electronic health record (EHR)? Use a hypertension treatment protocol? Identify patients with uncontrolled BP using an EHR report? Identify contributing factors of clinical inertia?

Taking Action is Not Enough—We Must Partner With Patients to Achieve Control

If measurements are valid, action is quick and effective, and your practice follows up with patients to monitor their progress, you can help patients achieve and maintain control. This reduces serious risk of CVD and associated comorbidities.

Up Next: Partner With Patients

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Act Rapidly

Act Rapidly

Uncontrolled High Blood Pressure Needs to be Met With Immediate Action

Reduce Therapeutic Inertia

Extend Lives: Act Rapidly to Manage Pressure

Practice Assessment: How Rapidly Do You Act?

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Taking Action is Not Enough—We Must Partner With Patients to Achieve Control

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