Diagnosis and Management of Hypertension (HTN) in Primary Care
Publication Date: April 1, 2020
Last Updated: March 14, 2022
Recommendations
Screening, Diagnosis, and Monitoring
a. Screening
1. We recommend screening adults for elevated blood pressure periodically. (Strong for)
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b. Measurement Techniques
2. We suggest using attended or unattended, fully automated office blood pressure measurement (programmed to wait five minutes and record the average of three measurements separated by at least 30 seconds).
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3. When fully automated blood pressure measurement is not available, we suggest measurement of blood pressure using standard technique and a properly calibrated and validated sphygmomanometer. (Weak for)
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4. We suggest using out-of-office blood pressure monitoring methods (ambulatory 24-hour monitoring or home blood pressure measurements) to inform the diagnosis and management of hypertension. (Weak for)
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c. Monitoring
5. Among patients treated for hypertension, we suggest offering home blood pressure self-monitoring with co-interventions for lowering systolic and diastolic blood pressure. (Weak for)
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Treatment Goals and General Approaches to Hypertension Management
a. Blood Pressure Goals
6. For all patients, including those with type 2 diabetes, we suggest treating to a systolic blood pressure goal of <130 mm Hg. (Weak for)
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7. For patients 60 years and over, we recommend treating to a systolic blood pressure goal of <150 mm Hg with added benefit to lowering systolic blood pressure further for those between 130 mm Hg and 150 mm Hg. (Strong for)
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8. For patients 60 years and over with type 2 diabetes, we recommend treating to a systolic blood pressure goal of <140 mm Hg with added benefit to lowering systolic blood pressure further for those between 130 mm Hg and 140 mm Hg. (Strong for)
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9. For patients 30 years and over, we recommend treating to a diastolic blood pressure goal of <90 mm Hg. (Strong for)
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10. We recommend offering pharmacist-led medication management as an option for patients with hypertension. (Strong for)
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11. We suggest offering nurse-led interventions as an option for patients treated for hypertension. (Weak for)
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12. We suggest offering registered dietitian-led nutrition interventions as an option for patients with hypertension who are or are not on medication. (Weak for)
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13. We suggest technology-based interventions (e.g., e-counseling, electronic transmission of data, telemonitoring, mobile applications) for improving control of hypertension. (Weak for)
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Non-Pharmacological Treatment
a. Weight Reduction
14. We suggest advising patients with hypertension and overweight/obesity to lose weight to improve blood pressure. (Weak for)
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15. For patients with hypertension and overweight/obesity, we suggest offering a diet directed at weight loss for the treatment of hypertension. (Weak for)
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16. For the treatment of hypertension, there is insufficient evidence for or against offering weight loss medications for patients with obesity and hypertension. ()
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17. For the treatment of hypertension, there is insufficient evidence to suggest for or against bariatric surgery for patients with obesity and hypertension. ()
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b. Exercise/ Physical Activity
18. We suggest offering individual or group-based exercise for the treatment of hypertension to reduce blood pressure. (Weak for)
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19. We recommend a target for aerobic exercise of at least 120 minutes per week for reduction in blood pressure. (Strong for)
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c. Dietary Modifications
20. We recommend a dietitian-led Dietary Approaches to Stop Hypertension Diet for the treatment or prevention of hypertension for patients with hypertension or interested patients with other cardiovascular risk factors. (Strong for)
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21. In patients with hypertension, we recommend that sodium intake be limited to no more than 2,300 mg/day (100 mmol/day), with referral to a dietitian or other support as appropriate. (Strong for)
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22. In patients with additional cardiovascular risk factors, such as dyslipidemia, we suggest considering a dietitian-led Mediterranean Diet as an alternative to the Dietary Approaches to Stop Hypertension Diet. (Weak for)
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Pharmacological Treatment
a. For Hypertension
23. We recommend offering a thiazide-type diuretic, calcium channel blocker, or either an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker as primary pharmacologic therapy for hypertension for reduction in composite cardiovascular outcomes. (Strong for)
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24. In African American patients with hypertension, we recommend against using an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker as monotherapy. (Strong against)
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25. In hypertensive patients 65 years and over, we suggest a thiazidetype diuretic for reduction in composite cardiovascular outcomes. (Weak for)
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26. We recommend against more than one of the following three drug classes together in the same patient: angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or direct renin inhibitors. (Strong against)
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27. For the treatment of hypertension, there is insufficient evidence to recommend for or against initiating combination therapy over initiating monotherapy with the sequential addition of another medication. ()
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b. For Resistant Hypertension
28. For patients with resistant hypertension (defined as those who are not adequately controlled with maximally tolerated dose of triple therapy [i.e., a thiazide-type diuretic, calcium channel blockers, and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker]), we suggest adding spironolactone in those patients without contraindications. (Weak for)
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Recommendation Grading
Overview
Title
Diagnosis and Management of Hypertension (HTN) in Primary Care
Authoring Organization
Veterans Health Administration / Department of Defense
Publication Month/Year
April 1, 2020
Last Updated Month/Year
February 5, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Assist in managing or co-managing patients with HTN.
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient
Intended Users
Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D006973 - Hypertension
Keywords
hypertension, high blood pressure, drug management
Source Citation
Tschanz CMP, Cushman WC, Harrell CTE, Berlowitz DR, Sall JL. Synopsis of the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: The Diagnosis and Management of Hypertension in the Primary Care Setting. Ann Intern Med. 2020 Dec 1;173(11):904-913. doi: 10.7326/M20-3798. Epub 2020 Sep 1. PMID: 32866417.