Hypertension

#Hypertension, new, uncontrolled
Confirmed based on two appropriately measured readings >2 weeks apart. Stage 1 (130-139/80-89) vs Stage 2 (140+/90+). Goal (ACC, 2017) <130/80 especially if ASCVD (or risk>10%), CKD, DM [goal <140/80 if labile HTN, side effects, age >75 with many cormorbidities or DBP<55] [goal individualized if frail or limited life expectancy]. ASCVD risk ***.
- initial workup: CBC, BMP, LFTs, lipids, TSH, UA, A1c, EKG; if DM/CKD, add urine albumin/creatinine.
- low threshold for ambulatory 24h monitor for episodic, resistant or white coat HTN
- reviewed consequences of untreated HTN (eg, 10mm decrease--> decrease of 20% MACE, 28% HF, 13% mortality)
- encouraged lifestyle modifications:
-- weight loss: 1mmHg/kg
-- decrease EtOH 1(F) or 2(M)/day: 4mm
-- reduce sodium to <2.4g: 2-8mm
-- DASH diet: 6mm alone; 14mm if combined with low sodium
-- aerobic exercise 30mins/day: 4-9mm
- given Stage 2 HTN and/or patient preference, will also start first line pharmacologic therapy:
-- amlodipine 2.5mg qd
-- chlorthalidone 12.5mg qd (mortality benefit vs HCTZ; thiazides effective even in CKD4)
-- ACE/ARB
-- note: metaanalyses show decreased side effect profile with multiple low dose (eg 1/4 of max dose) antihypertensives compared to single agents at full doses; thiazide and ACE/ARB can balance K
-- consider spironolactone/eplereonone as 4th line or if hypoK
-- no BBs indicated unless symptomatic CAD or HRrEF (then choose metoprolol succinate or carvedilol)
- pt advised to buy home upper arm-cuff BP monitor to bring to next visit for calibration and teaching
- defer workup for secondary hypertension
- decision aids:
-- https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=zx1768
-- https://www.healthdecision.org/tool#/tool/hypertension
-- https://statindecisionaid.mayoclinic.org/index.php/statin/index