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HYPERTENSION

PROTOCOL
NEW PATIENT or NEW ONSET :

FIRST VISIT:

Assess lifestyle and other CV risk factors HTN, TBC, Obesity(BMI>30),


sedentary life style, Dyslipidemia, DM, Microalbuminuria or estimated
GFR<60, Age (men>55, women>65), family history of early CVD (men<55,
women <65).

Assess presence/absence of end organ damage or concomitant disorders.


Document all of this information thoroughly.

Baseline Tests: EKG, UA/Microalbuminuria, CMP, CBC, FASTING LIPIDS.


Consider TSH if suspecting thyroid causes or URIC ACID level if Hx of gout and
planning on using thiazide diuretics. It is imperative to evaluate kidney
function and end organ damage prior to starting medication.

Start pharmacotherapy according to compelling vs. non-compelling


recommendations (JNC-VIII).

Provide your patient with an informative handout on blood pressure.


http://familydoctor.org/online/famdocen/home/alphabetsearch/h.html

If suspecting secondary HTN, do full work up for suspected causes, especially


in young children with HTN, the elderly with sudden onset of HTN and on HTN
not responding to conventional therapy.

FOLLOW UP VISIT:

The initial visit should be followed by a second visit in 2-3weeks (sooner if


needed) to assess therapy efficacy / side effects. Thereafter, visits should be
monthly until therapy goal is reached.

Once HTN is controlled, the next visit should be in 3 months. If HTN is still at
goal, subsequent visits should be every 6 months for all patients(or 3-6
months if co-morbidities present).

Once under control, medication should be prescribed for 1 month with 5


refills. This will prompt the patient to return in 6 months before running out of
medications. The patient should always return before being out of
medication, since checking blood pressure without medications will not
provide useful information.

Pertinent labs (CBC, CMP, Fasting Lipids, etc) - should be checked every 6
months if men > 55 y/o and women > 65 y/o OR every 12 months if men <
55 y/o and women < 65 y/o.

If a patient cannot return for a 6 month appointment, we should provide a 1


time refill of the medication and inform that no further refills will be provided
until the patient is seen in clinic. This will ensure a return follow up without
leaving the patient without medication.

Do not abandon your patient. Develop a reminder system for follow up visits.
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HYPERTENSION
PROTOCOL
RED ALERTS:

HYPERTENSIVE EMERGENCY: BP above or equal to 180/120mmHg (either SBP or


DBP) with symptoms or end organ damage. Under most circumstances, treating a
hypertensive emergency in the pre-hospital setting is unwise, since rapid lowering
of BP can critically decrease end-organ perfusion. If symptoms or end organ
damage are present, call 911 and send to the ER.

HYPERTENSIVE URGENCY: BP above or equal to 180/120mmHg (either SBP or DBP)


without symptoms or end organ damage. Goal is to lower BP around
160/100mmHg over hours or 1-2 days. If asymptomatic, can be treated in the office.
Get UA and CMP on arrival to confirm there is no protein in urine and stable Cr. If
you feel the need for immediate additional laboratory or radiologic data send the
patient to the ER with an assigned driver or ambulance. Follow up should be within
2-3 days.

REMINDERS:

Review classification and management of blood pressure in adults.


Review life style modifications to manage hypertension.
Review algorithm for pharmacologic treatment and compelling indications
(JNC-VIII).
DM or CKD: goalis BP < 130/80mmHg. Primary goal should be achieving
Systolic BP goal.
CKD: Definition GFR less than 60ml/min (Cr > 1.5mg/dL in men or >
1.3mg/dL in women),
ACEI or ARB for renal protection in DM.
If using an ACEI or ARB up to 35% increase in serum creatinine is acceptable
and not a reason to withhold treatment unless hyperkalemia develops.
Avoid BB with COPD or heart block.
Do not give ACEI /ARB in females with the potential to get pregnant or with
history of angioedema.
Avoid Aldosterone antagonists or K + sparing diuretics in patients with K +> 5
mEq/L.
Avoid thiazides with gout or hyponatremia.
DASH (Dietary Approach to Stop HTN) diet, for those who are overweight or
obese by BMI.
Treat hyperlipidemia aggressively.
ASA 81mg/day only when blood pressure is controlled and if no contra-
indications such as an active ulcer, bleeding disorders or anticoagulation
therapy.
Do not forget possible Secondary Hypertension Identifiable causes: OSA,
drug-induced, chronic kidney disease, primary aldosteronism, renovascular
disease, chronic steroid/Cushings, pheochromocytoma, coarctation of the
aorta, thyroid/parathyroid disease.

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