Hypertension Practice Standard Summary

The Hypertension (HTN) Practice Standard supports the diagnosis and treatment of hypertensive conditions. These conditions include hypertension, prehypertension, hypotension, tachycardia, and bradycardia.

Background

The HTN Practice Standard will launch if all of the following criteria are met:

Patient is greater than or equal to 18 years old
Based on the patient’s Chief Complaint, the diagnoses presented for the provider’s consideration by machine learning relate to essential (primary) hypertension, elevated blood-pressure reading without diagnosis of hypertension, other secondary hypertension, encounter for screening for cardiovascular disorders, or secondary hypertension, unspecified

Clinical Content

Medical Interview Summary

The HTN Practice Standard starts by asking every patient about recent blood pressure and heart rate readings, related medication use (aspirin, statins), and if the patient has had a past EKG as part of a hypertension evaluation. All patients also get asked about red flag symptoms suggesting end organ damage, symptoms that may be seen with tachycardia, bradycardia, or hypotension, and are asked about current pregnancy if female. Details regarding these red flag symptoms can be found under the “Virtual Care Management Pearls” section below.

These questions intend to identify patients who may warrant a referral to in person care, including urgent care, emergency department, or obstetrics. In those cases, the provider will see a recommendation for the appropriate referral.

If the conditions above requiring in person care are not identified, the interview will proceed by asking for additional hypertensive history and risk factors. Risk factors include obesity, family history of hypertension, unhealthy diet, amount of physical activity, tobacco usage, alcohol usage, and history of heart attack, stroke, or sleep apnea. At the end of the automated questions, a diagnosis will be presented for the provider’s consideration, along with relevant medication(s), and documentation to support the provider’s medical decision making. In addition, referrals and lab suggestions will be displayed. Based on the diagnosis selected by the provider, some care plans will be entered in for the patient’s education. The provider can choose to use the suggestions provided, or change them based on their clinical decision making.

Virtual Care Management Pearls

Hypertension care guidance and definitions
- Hypertension care and recommendations are aligned with JNC8 guidelines
- This includes the definition of stages of blood pressure elevation and blood pressure goals based on additional factors including age, race, and the presence of diabetes, CKD, or proteinuria
- Blood pressure and heart rate definitions:
- Related care and recommendations for consideration
  - Screening blood pressure checks are recommended at age and risk appropriate intervals for patients who report normal blood pressure values and do not have a history of hypertension or antihypertensive medication use
  - ASCVD risk assessment is recommended (not automated in the Hypertension Practice Standard)
  - Encourage support for lifestyle modifications
  - Refer to diet or lifestyle coach as needed

Diagnoses resulting in a referral for additional in-person care
- Hypertensive Emergency
  - Hypertensive Emergency: SBP ≥ 180 or DBP ≥ 120
  - Referral: Emergency department
- Symptomatic hypotension
  - Hypotension: SBP <90 or DBP <60
  - Any of the following symptoms: chest pain, shortness of breath, palpitations, severe headache, dizziness, lightheadedness, recent syncope
  - Referral: Emergency department
- Asymptomatic hypotension
  - Hypotension: SBP <90 or DBP <60
  - None of the following symptoms: chest pain, shortness of breath, palpitations, severe headache, dizziness, lightheadedness, recent syncope
  - Referral: In person PCP
- Secondary hypertension
  - Emergent
    - Stage 1 or Stage 2 Hypertension: SBP 140-179 or DBP 90-119
    - Any of the following symptoms / situations suggesting a secondary cause of hypertension: constant sweating, tremors/shakes, flank pain, low potassium, muscle weakness, currently taking >3 hypertension medications
    - Not pregnant
    - Referral: Emergency department
  - Nonemergent
    - Stage 1 or Stage 2 Hypertension: SBP 140-179 or DBP 90-119
    - No secondary hypertension symptoms / situations above
    - Age < 30 years old
    - Not pregnant
    - Has not previously received a medical hypertension evaluation
    - None of the following hypertension risk factors: obesity, history of MI or CVA or sleep apnea, family history of hypertension, inadequate exercise, unhealthy diet, excessive alcohol use, smoker
    - Referral: In person PCP
- Symptomatic tachycardia
  - Tachycardia: Heart rate > 100
  - Any of the following symptoms: chest pain, palpitations, dizziness, lightheadedness, recent syncope, fever
  - Referral: Emergency department
- Symptomatic bradycardia
  - Bradycardia: Heart rate <60
  - Any of the following symptoms: dizziness, lightheadedness, recent syncope
  - Referral: Emergency department
- Hypertensive crisis
  - Stage 1 or Stage 2 Hypertension: SBP 140-179 or DBP 90-119
  - Any of the following symptoms: chest pain, shortness of breath, severe headache, vision changes, claudication
  - Referral: Emergency department
- Normal or Prehypertension with urgent or emergent symptoms:
  - Normal or Prehypertension: SBP 90 -139 and DBP 60-89
  - Any of the following symptoms: Chest pain, shortness of breath, severe headache, vision changes, claudication
  - Referral: Emergency department for chest pain
  - Referral: Urgent care for shortness of breath, severe headache, vision changes, or claudication
- Gestational hypertension with pregnancy
  - Stage 1 or Stage 2 Hypertension: SBP 140-179 or SBP 90-119
  - Pregnant
  - Referral: Ob/Gyn (urgent)
- Normal or Prehypertension with pregnancy
  - Normal or Prehypertension: SBP 90 -139 and DBP 60-89
  - Pregnant
  - Referral: Ob/Gyn (routine)

Prehypertension and hypertension diagnoses
- Combinations of the following are used to categorize treatment per JNC8 guidelines, as outlined in the “Medication Guidelines” section below
  - Prehypertension blood pressure values
  - Stage 1 Hypertension blood pressure values
  - Stage 2 Hypertension blood pressure values
  - Age
  - Presence of DM
  - Presence of CKD or proteinuria
  - Race (Black/African American vs other)
  - ASCVD risk assessment

Medication Guidelines

Prehypertension
- Blood Pressure: 120-139 / 80-89

Stage 1 Hypertension
- Blood Pressure: 140-159 / 90-99

Stage 2 Hypertension:
- Blood Pressure: 160-179 / 100-119

Follow-up Recommendations Identified for Discussed with the Patient

Normal blood pressure without a history of hypertension or antihypertensive medication use (Screening)
- Age 18-39, BP <120/80, no risk factors
  - Recheck blood pressure every 3-5 years
- Age ≥40, BP <120/80, no risk factors
  - Recheck blood pressure annually
- Age ≥18, BP <120/80, with risk factors
  - Recheck blood pressure annually
- Age ≥18, BP ≥120/80, no risk factors
  - Recheck blood pressure annually
- Age ≥18, BP ≥120/80, with risk factors
  - Recheck blood pressure every 6 months
Normal blood pressure, currently taking antihypertensive medication
- Home blood pressure checks once daily at different times of day if possible
- Return visit every 3 months
- 3 months of medication refill each visit
Prehypertension
- Refer to coaching for lifestyle modifications
- Home blood pressure checks once daily at different times of day if possible
- Return visit in 6 month
Stage 1 or Stage 2 Hypertension
- Refer to coaching for lifestyle modifications
- Refer to In person PCP or urgent care for EKG, if EKG has not been done
- Home blood pressure checks once daily at different times of day if possible
- Uncontrolled hypertension or new hypertension diagnosis:
  - Return visit in 2 weeks after:
    - First medication refill
    - Initiation of new medication
    - Adjustment of medication
  - Return visit every 2 weeks until blood pressure is at goal
- Controlled hypertension:
  - Return visit every 3 months
  - 3 months of medication refill each visit
Hypertensive Emergency
- Referral: Emergency department
Symptomatic hypotension
- Referral: Emergency department
Asymptomatic hypotension
- Referral: In person PCP
Secondary hypertension
- Emergent, reviewed in “Virtual Care Management Pearls” section above
  - Referral: Emergency department
- Nonemergent, reviewed in “Virtual Care Management Pearls” section above
  - Referral: In person PCP
Symptomatic tachycardia
- Referral: Emergency department
Symptomatic bradycardia
- Referral: Emergency department
Hypertensive crisis
- Referral: Emergency department
Normal or Prehypertension with urgent or emergent symptoms:
- Referral: Emergency department for chest pain
- Referral: Urgent care for shortness of breath, headache, vision changes, or claudication
Pregnancy
- Normal or prehypertension blood pressure values
  - Referral: Ob/Gyn (routine)
- Gestational hypertension with Stage 1 or Stage 2 Hypertension blood pressure values
  - Referral: Ob/Gyn (urgent)

ICD-10 Codes Provided

Associated Available TextExpanders (if needed)

Please see your institution's Text Snippet document on available options.

Chat and Documentation Suggestions

In addition to presenting diagnostic and treatment suggestions for consideration by the provider, the Hypertension Practice Standard presents chat and documentation suggestions to the provider for consideration based on previous machine learning. The suggestions are tied to the selection of a diagnosis suggested for consideration by the provider. For example, if the Practice Standard suggests Hypertensive Emergency (I16.1) as the ICD-10 diagnosis AND the provider selects Hypertensive Emergency (I16.1) as the ICD-10 diagnosis, the chat and documentation suggestions for consideration will relate primarily to hypertensive emergency management.

Citations

Chen, R., Suchard, M. A., & Krumholtz, H. M. (2021). Comparative First-Line Effectiveness and Safety of ACE (Angiotensin-Converting Enzyme) Inhibitors and Angiotensin Receptor Blockers: A Multinational Cohort Study. AHA, 78(3), 591-603. https://doi.org/10.1161/HYPERTENSIONAHA.120.16667
Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention, phase II. The Trials of Hypertension Prevention Collaborative Research Group. (1997). Archives of internal medicine, 157(6), 657–667.
Elmer, P. J., Obarzanek, E., Vollmer, W. M., Simons-Morton, D., Stevens, V. J., Young, D. R., Lin, P. H., Champagne, C., Harsha, D. W., Svetkey, L. P., Ard, J., Brantley, P. J., Proschan, M. A., Erlinger, T. P., Appel, L. J., & PREMIER Collaborative Research Group (2006). Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Annals of internal medicine, 144(7), 485–495. https://doi.org/10.7326/0003-4819-144-7-200604040-00007
James, P. A., MD, Oparil, S., MD, & Carter, B. L., PharmD (2014). 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311(5), 507-520. https://doi.org/10.1001/jama.2013.284427
Qaseem, A., MD, PHD, MHA, Wilt, T. J., MD, MPH, & Rich, R., MD (2015). Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. ACP. https://doi.org/10.7326/M16-1785
U.S. Preventive Services Task Force (2021, April 27). Hypertension in Adults: Screening. Retrieved October 6, 2022, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening#:~:text=Recommendation%20Summary&text=The%20USPSTF%20recommends%20screening%20for,diagnostic%20confirmation%20before%20starting%20treatment .