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Audrey White


  • 47% of adults in the US have HTN, yet only 24% of adults with HTN have adequate BP control (2021)
  • HTN is associated with ↑CVD risk and is the most prevalent modifiable risk factor for CVD


  • ACC/AHA 2017: BP ≥ 130/80 or taking antihypertensive mediation
  • Resistant HTN: uncontrolled BP despite taking 3 antihypertensive medications (including a diuretic) OR ≥ 4 total medications
  • Whitecoat HTN: elevated office BP but normal readings when measured with ambulatory or home blood pressure monitoring (ABPM/HBPM)
Hypertension by ABPM/HBPM
Yes No
Hypertension by office blood pressure
Yes Sustained hypertension White coat hypertension
No Masked hypertension Sustained normotension


  • Screen all adults >18. Less frequent screening (q3-5 yrs) is appropriate for adults 18-39 without risk factors and previously normal BP. More frequent screening (q6-12mo) for adults ≥40 or with risk factors (USPSTF Grade A)
  • Risk factors: older age, black race, family history, excess weight/obesity, lifestyle habits (lack of physical activity, stress, tobacco use, alcohol use), dietary factors (high salt or high fat diet)
  • Consider screening for masked HTN with ABPM/HBPM if SBP 120-129 mmHg in office + risk factors (ACC/AHA 2017) Diagnosis
  • Proper measurement: Avoid caffeine/smoking 30 min prior and empty bladder. Have pt sit quietly at rest for 5 min with legs uncrossed. Place proper sized cuff on exposed arm, supported at heart level.
  • Hypertension by office BP (≥130/80) and hypertension out of office confirmed by ABPM or HBPM, as follows:
    • Daytime mean: SBP ≥ 130 or DBP ≥ 80
    • Nighttime mean: SBP ≥ 110 or DBP ≥ 65
    • 24 hr mean: SBP ≥ 125 or DBP ≥ 75
  • If ABPM not possible, 2-3 outpt measurements at 1-4 week intervals are required to confirm diagnosis
  • A diagnosis can be made without confirmatory readings in these circumstances
    • HTN urgency or emergency: SBP ≥ 180 or DBP ≥ 120
    • Initial SBP ≥ 160 or DBP ≥ 100 and evidence of end-organ damage (LV hypertrophy, HTN retinopathy, ischemic CVD, CKD)


  • Perform in all pts with newly diagnosed HTN
    • BMP, fasting glucose, CBC, lipid profile, UA, TSH, EKG
    • Calculate 10 yr ASCVD risk
  • Distinguish between primary (90% incidence) vs. secondary HTN (10%)
  • Suspect 1º (essential) HTN: gradual onset, family hx, associated risk factors
  • Suspect 2º: unusual presentation (new diagnosis in young/elderly, abrupt, exacerbation in previously controlled HTN), drug-resistant, or the presence of clinical clue (abdominal bruit in renovascular HTN, hypokalemia in hyperaldosteronism)
  • Assess for end organ damage: retinopathy (eye exam), CVD/LV hypertrophy, HF (TTE), CKD (urine Alb:Cr), PAD (ABI)
Common 2° Causes Suggestive Features Diagnostic Testing
Drug or alcohol induced History of substance use (cocaine, caffeine, nicotine, medications) UDS, BP improvement after withdrawal of suspected agent
Medication induced Steroids, OCP, sympathomimetic, SNRI/TCA, atypical antipsychotics BP improvement after withdrawal of suspected substance
OSA Apneic events, somnolence, obesity, ↑ neck circumference Polysomnography
Primary hyperaldosteronism Hypokalemia, metabolic alkalosis Plasma aldosterone/renin levels*
Primary kidney disease Hypervolemia, ↑ Cr, abnormal UA, family history of kidney disease UA, urine Alb:Cr ratio, renal US
Renovascular disease (RAS or FMD) Abdominal bruit, ↑ Cr after ACE-I or ARB, young age, severe HTN with onset >55, flash pulmonary edema Doppler renal US
*Not reliable if taking MRA. Adjust diagnostic threshold level if taking ACEi/ARB.


ACA-AHA guidelines (2017) (based on SPRINT trial)
Elevated BP SBP 120-129 mmHg AND DBP <80 mmHg Lifestyle modifications. Reassess in 3-6 months
Stage 1 SBP 130-139 mmHg OR DBP 80-89 mmHg Lifestyle modification. If CVD, T2D, CKD, age ≥ 65 or ASCVD risk ≥ 10%, add anti-HTN medication. Reassess monthly until BP goal is met, then measure q3-6 mo
Stage 2 SBP ≥140 mmHg OR DBP ≥90 mmHg Lifestyle modification and 1-2 anti-HTN medications. Reassess monthly until BP goal is met, then measure q3-6 mo.

Therapy goals

  • Adults over 60 years: target BP varies by guideline. Consider CVD risk and co-morbidities (e.g., stroke) to decide target BP.
  • White coat HTN: lifestyle modification & CVD risk reduction
  • Masked HTN: treatment guided by out-of-office BP measurements
  • Diastolic HTN: treat to prevent LVH and HFpEF
  • BP target:
    • <130/80 mmHg: general population
    • <140/90 (less aggressive goal): frail pts with orthostatic hypotension, limited life expectancy
  • If not meeting goals, combination therapy > doubling a single agent. Preferred combinations
    • ACEi/ARB + CCB
    • ACEi/ARB + CCB + thiazide
    • ACEi/ARB + CCB + MRA
    • Do NOT combine BB and non-dihydropyridine CCB

Non-pharmacological lifestyle interventions: indicated for all pts regardless of stage

  • 8-14 mmHg ↓: DASH diet (fresh produce, whole grains, low-fat dairy)
  • 5-10 mmHg ↓: weight loss (10kg or 22lbs), expect 1 mmHg for every 1kg reduction in body weight
  • 3-9 mmHg ↓: Na+ restriction (1.5g/d), aerobic exercise for 90-150 min/week, increased intake of K+ rich foods
  • 2-4 mmHg ↓: moderate EtOH (2 drinks/day for men; 1 drink/day for women)
  • Medication changes: consider transitioning offending medications
  • Tobacco cessation: smoking increases risk of masked HTN, renovascular HTN, severe hypertensive retinopathy, and arterial stiffness

Pharmacologic therapy

  • Initial monotherapy: ACEi/ARB, dihydropyridine CCB, or thiazides
  • Degree of BP reduction (not type of medication) is the major determinant of CVD risk reduction
  • There is controversial evidence in using race to determine therapy. Some studies suggest the benefit of CCB or thiazides in black pts
Antihypertensive Drug Class and Side Effects
Drug Class Common Drugs Side effects/ comments
Thiazide diuretics HCTZ 12.5-50 mg
Chlorthalidone 12.5-25 mg (preferred agent based on RCT, but ↑ risk electrolyte abnormalities)
HypoNa, hypoMg, hypoK, ↑ uric acid, hypovolemia, orthostatic hypotension
Contraindicated in pregnancy
Angiotensin-converting enzyme inhibitor (ACEi) Lisinopril, benazepril, fosinopril, quinapril (all 5-40 mg daily)
Ramipril, 2.5-20 mg in 1-2 doses
Angioedema (more common in AA), AKI, hyperK, cough
Contraindicated in pregnancy
Angiotensin receptor blocker (ARB) Losartan 25 - 100 mg in 1-2 doses
Candesartan 8 - 32 mg in 1-2 doses
Irbesartan 150 - 300 mg
Valsartan 80 - 320 mg
AKI, hyperkalemia, angioedema (less frequent than ACE-I). Less side effects than ACEi
Contraindicated in pregnancy
Calcium channel blocker (CCB) Dihydropyridine: Amlodipine 2.5-10 mg 1-2 doses Nifedipine 30-120 mg in 1-2 doses
Nondihydropyridine: Diltiazem ER 120-360 mg
Verapamil ER 100-480 mg
Dihydropyridine: peripheral edema, worsening proteinuria
Nondihydropyridine: constipation, heart block if used with BB
Amlodipine is safe but not first line for HFrEF. Other CCBs may worsen outcomes in HFrEF.
Mineralocorticoid receptor antagonist (MRA) Spironolactone 12.5 - 50 mg
Eplerenone 25 - 50 mg
Good choice for resistant HTN
AKI, hyperkalemia
Spironolactone—gynecomastia and secondary sexual side effects
Beta blocker (BB) Atenolol 25- 100mg in 1-2 doses
Carvedilol 6.25-25 mg BID
Metoprolol succinate 25 - 200 mg QD
Nebivolol 5 - 10 mg
Labetalol 100 - 300 bid
Reserve for CHF/CAD/arrhythmia
Hyperglycemia, fatigue, ↓ HR
β 1-selective (atenolol, bisoprolol, metoprolol) may be safer in pts with COPD, asthma, diabetes
Vasodilators Hydralazine 25-100mg in 2–4 doses
Minoxidil 5-10mg in 3-4 doses
Reserve for HTN resistant to optimized 4 drug regimen
Reflex tachycardia, fluid retention, SLE-like reaction
Centrally- acting agents (alpha 2 agonists) Clonidine 0.1-0.6 mg QD, (Weekly transdermal patch 0.1-0.3mg is preferred to avoid non-adherence and subsequent reflex HTN)
Methyldopa 250-500 mg QD
Reserve for resistant HTN
Rebound HTN and withdrawal
Loop diuretics Furosemide 20-160 mg QD
Torsemide 10 – 100 mg QD
Bumetanide 0.5 – 3.0 mg QD
Reserve for HTN and volume overload states
AKI, hypovolemia, hypoK, hypoMg
Conditions and Recommended Drug Classes
Conditions Drug Class
Heart failure ACE-I/ARB or ARNI + BB + MRA + diuretics
Diabetes All first line agents, ACEi/ARB if presence of albuminuria
Recurrent stroke prevention ACEi/ARB, thiazide
Pregnancy nifedipine, labetalol, methyldopa

Additional information

  • Refer to Nephrology or HTN specialist when HTN resistant to >3 meds and negative secondary work-up
  • VA Specific Guidance:
  • Agents that require PADR: quinapril, candesartan, irbesartan, olmesartan, telmisartan, labetalol, nebivolol, nifedipine SA, eplerenone, clonidine patch
  • Walmart: $4/mo for amlodipine, atenolol, benazepril, clonidine, carvedilol, enalapril, furosemide, hydralazine, HCTZ, Irbesartan, isosorbide mononitrate, lisinopril, lisinopril/HCTZ, losartan, losartan/HCTZ, metoprolol, ramipril
  • Validated BP cuffs:
  • How to get BP cuff at the VA: Prosthetics consult BP Cuff TVHS. *Must answer all questions in the consult, including blood pressure cuff size