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    Hypertension

    high blood pressure

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    Assessment & Plan (short)

    #Hypertension, new, uncontrolled
    Confirmed based on two appropriately measured readings >2 weeks apart. Goal BP ***.  ASCVD risk ***.
    - Initial workup: CBC, BMP, LFTs, lipids, TSH, UA, A1c, EKG
    - Diet and lifestyle modifications:
    - Meds:

    Assessment & Plan (long)

    #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

    Description

    New hypertension

    Organ systems
    • Cardiovascular
    Medical field
    • Internal medicine
    Setting
    • Outpatient
    Related dotphrases
    Hypertension (Resistant)
    Author
    Patrick Sanger
    Page info

    Originally created: June 13, 2020 by Patrick Sanger

    [xyz-ips snippet="lastupdated"] [xyz-ips snippet="sectioneditor"] [post-views]

    Number of revisions: [xyz-ips snippet="numrevisions"]

    References
    [xyz-ips snippet="easyfootnote"]
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