• University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2009 Feb. 15 p.

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2003 Apr. 13 p. [8 references]

Note from the National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the full text for additional information, including detailed information on selection of drugs, dosing, possible side effects, and cost of medications and considerations for pregnant patients. The levels of evidence (A, B, C, D) and grades of recommendations (I-III) are defined at the end of the "Major Recommendations" field.

Diagnosis

• Although a single, carefully taken blood pressure (BP) reading may predict future cardiovascular risk, for clinical purposes this risk is better identified by taking the mean BP level from recordings over several visits.
• Home and ambulatory blood pressure monitoring helps improve BP control, and identifies "white coat" and "masked" hypertension [IIA].
• If home BP monitoring is used, careful calibration of the BP monitor and thorough patient education are essential.
• Individuals with mean BP > 135/80 should be screened for diabetes [IB].

Treatment

• For patients without diabetes or end organ damage, target of BP therapy is <140/90 mmHg [IA].
• For patients with diabetes or end organ damage (e.g., renal insufficiency, retinopathy, congestive heart failure [CHF], coronary artery disease [CAD], peripheral vascular obstructive disease [PVOD], cerebrovascular disease), aggressive treatment of hypertension (HTN) provides significant improvements in clinical outcomes [IA]. Systolic goals have not been specifically defined. A target systolic blood pressure of 135 mmHg or less [ID] and diastolic BP goal of 80 mmHg or less [IB] is recommended based on trials to date.
• Treatment of systolic blood pressure (SBP) over 160 mmHg is important in reducing cerebrovascular accident (CVA) and congestive heart failure risk [IA].
• Lifestyle modifications to lower BP are important adjuncts to drug therapy [IA].
• Begin therapy with a thiazide diuretic for almost all patients. Add second and third agents as needed to achieve effective BP reduction goals [IA].
  • Angiotensin-converting enzyme (ACE) inhibitors and long-acting dihydropyridine calcium channel blockers are the first choice additional agents.
  • Specific illnesses may guide the choice of agent(s), e.g.,:
    • ACE inhibitors (angiotensin II receptor antagonists [ARBs] for those unable to tolerate ACE inhibitors) for patients with renal disease or diabetes with microalbuminuria or left ventricular (LV) dysfunction
    • Beta-blockers for those with coronary artery disease or congestive heart failure
• Over 70% of individuals require two or more drugs to achieve BP goals. A fixed combination therapy may be cost-effective. Once a day medications increase compliance and are preferred.

Definitions:

Levels of Evidence

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational trials
4. Opinion of expert panel

Strength of Recommendation

I = Generally should be performed

II = May be reasonable to perform

III = Generally should not be performed

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Conclusions were based on prospective randomized clinical trials if available, to the exclusion of other data; if randomized controlled trials were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size.

• University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2009 Feb. 15 p.

Not applicable: The guideline was not adapted from another source.

1997 (revised 2009 Feb)

University of Michigan Health System - Academic Institution

University of Michigan Health System

Hypertension Guideline Team

Team Leader: Masahito Jimbo, MD, Family Medicine

Team Members: William E. Barrie, MD, General Medicine; Michael P Dorsch, PharmD, Pharmacy; R Van Harrison, PhD, Medical Education; Kenneth A. Jamerson, MD, Cardiovascular Medicine

Guidelines Oversight Team: Connie Standiford, MD; William Chavey, MD; Van Harrison, PhD

The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed. Disclosure of a relationship is not intended to suggest bias in the information presented, but is made to provide readers with information that might be of potential importance to their evaluation of the information.

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2003 Apr. 13 p. [8 references]

This NGC summary was completed by ECRI on March 19, 2003. The information was verified by the guideline developer on April 23, 2003. This NGC summary was updated by ECRI on September 13, 2005. The updated information was verified by the guideline developer on September 20, 2005. This NGC summary was updated by ECRI Institute on August 18, 2009. The updated information was verified by the guideline developer on September 11, 2009.

This NGC summary is based on the original guideline, which is copyrighted by the University of Michigan Health System (UMHS).