Chapter I. clinical evaluation
Blood pressure measurement
• Rest for 5 or more minutes in a quiet, appropriate environment | |
• Avoid smoking, alcohol or caffeine before measurement | |
• Measure 2 or more times at 1- to 2-min intervals at a single visit | |
• Use a cuff with a bladder at least 40% of the arm circumference wide; 80% of arm circumference long (a standard bladder for adults: 13 cm wide; 22–24 cm long) | |
• Maintain the upper arm cuff at the heart level | |
• Inflate the cuff rapidly and deflate slowly at a speed of 2 mmHg per heart beat | |
• Identify the blood pressure as the systolic blood pressure at the first Korotkoff sound; the blood pressure as the diastolic blood pressure at the fifth Korotkoff sound | |
• Consider the blood pressure as the diastolic blood pressure at the fourth Korotkoff sound in pregnancy, arteriovenous shunt, and chronic aortic insufficiency | |
• Measure blood pressure in both arms on the initial visit; subsequently use the arm of higher pressure to measuring blood pressure | |
• Measure blood pressure in legs to exclude peripheral arterial disease, when pulses in the lower extremities are weak | |
• Repeating the measurement three or more times to estimate the average systolic and diastolic pressure in case of arrhythmia | |
• Measure blood pressure after 1- and 3-min standing in elderly persons and persons with diabetes and suspected orthostatic hypotension |
Measurement of the office or clinic blood pressure
Recommendations
|
Class
|
Level
|
References
|
• A mercury sphygmomanometer is recommended to be replaced by a non-mercury sphygmomanometer. |
IIa
|
C
| [1] |
Home blood pressure measurement
• Use an upper arm cuff | |
• Time of measurement should be | |
1. Morning: within 1 h after waking up, after urination, before taking antihypertensive drugs, before breakfast, after a 1–2 min rest in a seated position 2. Night: before retiring, after a 1–2 min rest in a seated position 3. Other conditions if necessary | |
• Frequency of measurement: one to three times per occasion | |
• Period of measurement: as long as possible; 1 week or more for the diagnosis of hypertension; over at least 5–7 days immediately preceding the visit during follow-up of treatment |
Category | Systolic blood pressure (mmHg) | Diastolic blood pressure (mmHg) |
---|---|---|
Clinic or office blood pressure | ≥140 | ≥90 |
Ambulatory blood pressure | ||
24-h | ≥130 | ≥80 |
Day | ≥135 | ≥85 |
Night | ≥120 | ≥70 |
Home blood pressure | ≥135 | ≥85 |
Automated office blood pressure | ≥135 | ≥85 |
Ambulatory blood pressure measurement
Automated office blood pressure measurement
Recommendations
|
Class
|
Level
|
References
|
•Automated office blood pressure can be measured to exclude white coat HTN. |
IIa
|
B
| [15] |
Central blood pressure measurement
Evaluation of the patient
Symptoms and signs
Medical history
Physical examination
Laboratory examinations
Recommendations
|
Class
|
Level
|
References
|
• It is recommended that the routine laboratory tests should be evaluated at the first visit and annually. |
IIa
|
C
|
Routine tests | |
12-leads electrocardiogram (ECG) | |
Urinalysis – proteinuria, hematuria, glucosuria | |
Hemoglobin, hematocrit | |
K+, creatinine, estimated glomerular filtration rate (eGFR)a, uric acid, | |
Fasting glucose, lipids [total cholesterol, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, triglyceride] | |
Chest X-ray | |
Microalbuminuria: albumin/creatinine (in random urine sample) | |
Recommended tests | |
75 g oral glucose tolerance test or hemoglobin A1c (if fasting glucose ≥100 mg/dL) | |
Echocardiogram | |
Carotid ultrasound: plaque | |
Ankle-brachial blood pressure index | |
Pulse wave velocity | |
Fundoscopy (mandatory in diabetes) | |
24-h urine protein excretion | |
Extended tests | |
Search for sub-clinical organ damage: brain, heart, kidney, vessels | |
Search for secondary causes of hypertension |
Cardiovascular risk factors and subclinical organ damage
Risk factors for cardiovascular disease | |
• Age (men ≥45 years old, female ≥55 years old)a | |
• Smoking | |
• Obesity (body mass index ≥25 kg/m2) or abdominal obesity (waist circumference men > 90 cm, women > 85 cm) | |
• Dyslipidemia [total cholesterol ≥220 mg/dL, low-density lipoprotein (LDL)-cholesterol ≥150 mg/dL, high-density lipoprotein (HDL)-cholesterol < 40 mg/dL, triglycerides ≥200 mg/dL] | |
• Pre-diabetes [impaired fasting glucose (100 ≤ fasting blood glucose < 126 mg/dL) or impaired glucose tolerance] | |
• Family history of premature cardiovascular disease (men < 55 years, women < 65 years) | |
• Diabetes mellitus [fasting blood glucose ≥126 mg/dL, postprandial 2-h glucose (oral glucose tolerance test) ≥200 mg/dL, or hemoglobin A1C ≥6.5%] | |
Subclinical organ damage | |
• Brain – periventricular white matter hyperintensity (PWMH), microbleeds, asymptomatic cerebral infarction | |
• Heart – left ventricular hypertrophy, angina pectoris, myocardial infarction, heart failure, | |
• Kidney – albuminuria, decreased estimated glomerular filtration rate (eGFR) (eGFR < 60 ml/min/1.73m2, chronic kidney disease) | |
• Blood vessels – atherosclerotic plaque, carotid-femoral pulse wave velocity > 10 m/sec, brachial-ankle pulse wave velocity > 18 m/sec, coronary calcification. | |
• Retina - stage 3 or 4 hypertensive retinopathy | |
Clinical cardiovascular or renal diseases | |
• Brain – Stroke, transient ischemic attack, vascular dementia | |
• Heart – angina, myocardial infarction, heart failure, atrial fibrillation | |
• Kidney – chronic kidney disease stage 3, 4, or 5. | |
• Blood vessels – aortic aneurysm, aortic dissection, peripheral vascular diseases |
Risk stratification system of hypertension
BP (mmHg) | Prehypertension (130–139/80–89) | Hypertension I (140–159/90–99) | Hypertension II (≥160/100) |
---|---|---|---|
Risk | |||
Risk factor 0 | Lowest risk group | Low added risk group | Moderate to high added risk group |
Risk factor 1–2 | Low to moderate added risk group | Moderate added risk group | High added risk group |
Risk factor ≥ 3, DM, sub-clinical organ damage | Moderate to high added risk group | High added risk group | High added risk group |
DMa, cardiovascular disease, chronic kidney disease | High added risk group | High added risk group | High added risk group |
Symptoms of and screening tools for secondary hypertension
Diseases | Clinical clues | Diagnoses | |||
---|---|---|---|---|---|
History | Physical diagnosis | Chemistry | Screening test | Additional test | |
Parenchymal renal diseases | Urinary tract infection or obstruction, analgesic abuse, familial history of polycystic kidney disease | Abdominal mass (polycystic kidney disease) | Proteinuria, hematuria, pyuria, reduced glomerular filtration rate (GFR) | Renal ultrasound (US) | Further studies for kidney diseases |
Renal artery stenosis | Fibromuscular dysplasia, premature hypertension (female), atherosclerotic diseases, sudden onset or worsening of hypertension, resistant hypertension, recurrent pulmonary edema | Abdominal bruit | Rapid worsening of renal function [spontaneous or after angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) treatment] | Kidney size difference > 1.5 cm, Duplex Doppler US, computed tomography (CT) | Magnetic resonance imaging, digital subtraction angiography |
Primary aldosteronism | Muscle weakness, premature hypertension, familial history of premature stroke (< 40 years) | Arrhythmia (severe hypokalemia) | Hypokalemia (spontaneously or after treatment by diuretics), incidental adrenal mass | Aldosterone-renin ratio (after correction of hypokalemia and excluding effect of ACE inhibitor or ARB) | Suppression test by saline infusion, fludrocortisone, and/or captopril); adrenal CT, adrenal vein sampling |
Pheochromo-cytoma | Paroxysmal hypertension, emergency visit by persistent hypertension with headache, sweat, and/or pallor, familial history | Café-au-lait lesion and neurofibromatosis neurofibroma | Incidental adrenal mass (extraadrenal mass in some cases) | Metanephrine and/or nor-metanephrine in 24-h urine | Abdominal and/or pelvic CT or magnetic resonance imaging (MRI); radioisotope scan using meta-iodobenzyl-guanidine |
Cushing syndrome | Rapid weight gain, polyuria, polydipsia, psychiatric problems | Central obesity, moon face, buffalo hump, abdominal striae, hirsutism | Hyperglycemia | Cortisol in 24-h urine | Dexamethasone suppression test |
Chapter II. Treatment of hypertension
Treatment of hypertension
Strategy for hypertension treatment
Initiation of hypertension treatment
Recommendations
|
Class
|
Level
|
References
|
• Generally, drug therapy is not recommended in prehypertension. |
III
|
A
| |
• In populations with elevated BP and in the prehypertensive range, instructions for lifestyle modifications should be provided for the prevention of HTN development and CVD. |
I
|
B
| |
• In the high risk HTN patients* with systolic BP over 130 mmHg by AOBP measurement, it is recommended to provide drug therapy along with lifestyle modifications. |
IIa
|
B
| [37] |
• In the population within the prehypertensive range, ambulatory BP monitoring or home BP measurement is recommended to exclude masked HTN. |
IIa
|
B
| [38] |
Recommendations
|
Class
|
Level
|
References
|
• In patients with grade 1 HTN at low risk, BP-lowering drug treatment is recommended if the patient remains hypertensive after a period of lifestyle intervention. |
I
|
B
| |
• In patients with grade 1 HTN and at moderate-to-high risk, prompt initiation of drug treatment is recommended along with lifestyle interventions. |
I
|
A
|
Recommendations
|
Class
|
Level
|
References
|
• BP-lowering drug treatment and lifestyle modifications are recommended for fit older patients (> 65 years but not > 80 years) when SBP is over 140 mmHg. |
IIa
|
B
| [54] |
• BP-lowering drug treatment and lifestyle modifications are recommended for frail older patients or older patients (> 80 years) when SBP is over 160 mmHg. |
I
|
A
|
Target blood pressure in the treatment of hypertension
Recommendations
|
Class
|
Level
|
References
|
• For hypertensive patients at low to moderate risk, target BP of 140/90 mmHg is recommended. |
I
|
A
| |
• For patients with CVD (over age 50 with CAD, PAD, aortic disease), congestive heart failure (CHF), or LVH, a target BP of 130/80 mmHg can be considered (SPRINT eligible population). |
IIa
|
B
| [37] |
• For high risk patients with 10-year CVD risk of > 15%, a target BP of 130/80 mmHg can be considered*. |
IIa
|
B
|
Conditions | Systolic BP (mmHg) | Diastolic BP (mmHg) |
---|---|---|
Uncomplicated, general | < 140 | < 90 |
Elderly | < 140 | < 90 |
DM | ||
Uncomplicated | < 140 | < 85 |
Complicateda | < 130 | < 80 |
High riskb | ≤ 130 | ≤ 80 |
Cardiovascular disease | ≤ 130 | ≤ 80 |
Cerebrovascular disease | < 140 | < 90 |
Chronic kidney disease | ||
No albuminuria | < 140 | < 90 |
Albuminuriac | < 130 | < 80 |
Recommendations
|
Class
|
Level
|
References
|
• It is recommended that SBP be lowered to below 140 mmHg in hypertensive patients with diabetes. |
I
|
A
| |
• It is recommended that DBP be lowered to below 85 mmHg in hypertensive patients with diabetes. |
I
|
B
| |
• In diabetic patients with CVD, a target BP < 130/80 mmHg can be considered. |
IIa
|
C
| [70] |
Recommendations
|
Class
|
Level
|
References
|
• If SBP drops to 110 mmHg and DBP falls to below 70 mmHg, the risk of mortality and the risk of developing CAD may increase. Lowering DBP to below 70 mmHg should be carefully considered in the elderly, in DM, and in multiple CAD without revascularization, and HTN patients with LVH. |
IIb
|
C
|
Non-pharmacologic therapy and lifestyle modifications
Lifestyle modification | BP reduction (systolic/diastolic BP, mm Hg) | Recommendation |
---|---|---|
Restriction of salt intake | -5.1/-2.7 | Less than 6 g of salt per day |
Body weight reduction | -1.1/-0.9 | Each reduction of 1 kg |
Moderation in drink | -3.9/-2.4 | Less than two glasses per day |
Exercise | -4.9/-3.7 | 30–50 min per day for more than 5 days in a week |
Diet control | -11.4/-5.5 | Vegetables-based healthy diet habit* |
Restriction of salt intake
Weight reduction
Moderation of alcohol consumption
Recommendations
|
Class
|
Level
|
References
|
• It is recommended to moderate alcohol consumption to less than 2 drinks per day. |
I
|
A
| [111] |
Exercise
Recommendations
|
Class
|
Level
|
References
|
• Regular aerobic exercise (e.g. at least 30 min of moderate dynamic exercise 5–7 days per week) is recommended. |
I
|
A
| |
• It is recommended that isometric exercise or isometric exercise, such as lifting a heavy weight, can be performed concurrently with aerobic exercise, but should be avoided as BP may temporarily rise when BP is not controlled. |
I
|
A
|
Smoking cessation
Healthy diet
Others
Pharmacological therapy for hypertension
Strategies for prescription of antihypertensive drugs
Recommendations
|
Class
|
Level
|
References
|
• In patients with BP higher than 160/100 mmHg or more than 20/10 mmHg above the target BP, two drugs can be prescribed in combination to maximize the antihypertensive effect and to achieve rapid BP control. |
IIa
|
C
| [129] |
Disease conditions | ACE inhibitors or Angiotensin receptor blockers | Beta-blockers | Calcium channel blockers | Diuretics |
---|---|---|---|---|
Congestive heart failure | ○ | ○ | ○ | |
Left ventricular hypertrophy | ○ | ○ | ||
Coronary artery disease | ○ | ○ | ○ | |
Chronic kidney disease | ○ | |||
Stroke | ○ | ○ | ○ | |
Elderly, isolated systolic hypertension | ○ | ○ | ○ | |
Post-myocardial infarction | ○ | ○ | ||
Prevention of atrial fibrillation | ○ | |||
Diabetes mellitus |
○
| ○ | ○ | ○ |
Absolute indications | Relative indications | Need cautions | Absolute contraindications | |
---|---|---|---|---|
Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers | Congestive heart failure, diabetic nephropathy | (Bilateral) Renal artery stenosis, hyperkalemia | Pregnancy, angioedema | |
Beta-blockers | Ischemic heart disease, myocardial infarction | Tachyarrhythmia | High blood glucose, peripheral artery disease | Asthma, severe and symptomatic bradyarrhythmia |
Calcium channel blockers | Elderly hypertension, isolate systolic hypertension, ischemic heart disease (non-DHP*) | Congestive heart failure | Severe and symptomatic bradyarrhythmia (non-DHP*) | |
Diuretics | Congestive heart failure, isolate systolic hypertension | High blood glucose | Gout, hypokalemia |
Classes of antihypertensive drugs
Recommendations
|
Class
|
Level
|
References
|
• Thiazide or thiazide-like diuretics can be used as first-line drugs with a preference for chlorthalidone or indapamide. |
IIa
|
B
| |
• Loop diuretics can be considered in patients with CHF, advanced CKD of stage IV or stage V. |
IIa
|
B
| [135] |
• In patients with resistant HTN, aldosterone antagonists such as spironolactone can be considered in the absence of hyperkalemia. |
IIa
|
B
|
Combination therapy
Resistant hypertension
Causes | Conditions |
---|---|
Inappropriate BP measurement | White coat hypertension Calcified vessel in the elderly (pseudohypertension) Wrong cuff use, using too small cuff |
Lifestyle factors | Severe weight gain, Heavy or binge drinking, Sleep apnea syndrome |
Volume overload | Excess salt intake, Volume expansion by renal diseases, Insufficient use of diuretics |
Medication | Poor compliance, Insufficient dose, or ineffective combination |
Drug interaction/adverse effects | Nonsteroidal anti-inflammatory drugs (NSAIDs) Oral pills, Corticosteroid, Herbal licorice |
Secondary hypertension |