Hypertension—Clinician Algorithm

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For all adults 18 years of age and older, we suggest screening at all appropriate primary care visits, which include: new patient visits, periodic health exams, urgent office visits for neurological or cardiovascular related issues, medication renewal visits, and other visits where the primary care practitioner deems it an appropriate opportunity to monitor blood pressure. It is not necessary to measure blood pressure on every patient at every office visit if not clinically indicated.

CTFPHC Recommendations

  1. We recommend blood pressure measurement at all appropriate primary care visits.
  2. We recommend that blood pressure be measured according to the current techniques described in the Canadian Hypertension Education Program (CHEP) recommendations for office and out-of-office blood pressure measurementsi.
  3. For people who are found to have an elevated blood pressure during screening, the CHEP criteria for assessment and diagnosis of hypertension should be applied to determine whether the patient meets diagnostic criteria for hypertensionii.

Please note: These recommendations do not apply to those who have already received a confirmed diagnosis of hypertension.

Considerations for implementation

For primary care practitioners using electronic health records, flag a screening reminder for adults aged 18 years and older, especially for those who have not had their blood pressure measured.

Special considerations

The frequency and timing of blood pressure screening may vary between patients. The risks of high blood pressure, stroke, or heart disease changes over a person’s natural lifespan, increasing with age, comorbidities, and the presence of other risk factors. Therefore, screening frequency may increase accordingly, especially in patients with more than one vascular risk factor.

Having recent consistent normal blood pressure results may decrease the need for more frequent monitoring, while a tendency toward “high normal” blood pressure could indicate that more frequent monitoring is needed.

Adults identified as belonging to a high-risk ethnic group (e.g. South Asian, Aboriginal, African ancestry) may benefit from more frequent monitoring. Practitioners should remain alert for opportunities to screen infrequent visitors and others who have not been screened recently.

Screening and diagnosis

Initial blood pressure measurement

Results Action
SBP 130–139 and/or DBP 85–89 Follow up annually
SBP ≥ 140 and/or DBP ≥ 90 Schedule a follow-up visit
Patients demonstrating features of hypertensive urgency or emergencyiii Diagnosis of HTN

Follow-up visit #1

A history and physical examination should be performed and, if clinically indicated, diagnostic testsiv to search for target organ damagev and associated CV risk factors should be arranged within two visits.

Results Action
SBP 130–139 and/or DBP 85–89 Follow up annually
Meanvi SBP ≥ 140 and/or DBP ≥ 90 Schedule a follow-up visit within one month
Patients demonstrating features of hypertensive urgency or emergencyiii Diagnosis of HTN

Follow-up visit #2

Within one month of follow-up visit (#1).

Results Action
BP < 140/90 without target organ damagev or DM Follow up annually
BP 140–179/90–109 without target organ damagev or DM Schedule a follow-up visit or schedule a follow-up visit and conduct ABPM or schedule a follow-up visit and conduct HBPM
SBP ≥ 140 and/or DBP ≥ 90 with target organ damagev or DM, or SBP ≥ 180 and/or DBP ≥ 110 Diagnosis of HTN

Follow-up visit #3, without ABPM or HBPM

Results Action
BP < 140/90 Follow up annually
BP < 160/100 Schedule follow-up visits or conduct ABPM orconduct HBPM
SBP ≥ 160 or DBP ≥ 100 averaged across visits 1–3 Diagnosis of HTN

Follow-up visits #4 and 5, without ABPM or HBPM

Results Action
BP < 140/90 Follow up annually
SBP ≥ 140 or DBP ≥ 90 averaged across visits 1–5 Diagnosis of HTN

Follow-up visit and ABPM (if available)

Results Action
Mean awake BP < 135/85, or mean 24-hour BP < 130/80 Follow up annually
Mean awake SBP ≥ 135 or DBP ≥ 85, or mean 24-hour SBP ≥ 130 or DBP ≥ 80 Diagnosis of HTN

Follow-up visit and HBPM (if available)

Results Action
BP < 130/85 Follow up annually
Averagevii BP < 135/85 Repeat HBPM, or conduct 24-hour ABPM
Averagevii SBP ≥ 135 or DBP ≥ 85 Diagnosis of HTN

Notes

  1. See hypertension.ca.
  2. See hypertension.ca.
  3. Examples of hypertensive urgencies and emergencies:
    • Hypertensive encephalopathy
    • Acute aortic dissection
    • Acute left ventricular failure
    • Acute coronary syndrome
    • Acute kidney injury
    • Intracranial hemorrhage
    • Acute ischemic stroke
    • Eclampsia of pregnancy
  4. Diagnostic tests:
    • Urinalysis
    • Blood chemistry
    • Fasting blood glucose
    • Fasting cholesterol panel
    • Standard 12-lead ECG
    • Urinary albumin in diabetics
  5. Examples of target organ damage:
    • Cerebrovascular disease
    • Stroke
    • Dementia
    • Hypertensive retinopathy
    • Left ventricular dysfunction
    • Coronary artery disease
    • Renal disease
    • Peripheral artery disease
  6. If initial SBP ≥ 140 and/or DBP ≥ 90, two more readings should be taken using a validated device. The first reading should be discarded and the latter two averaged.
  7. Based on duplicate measures, morning and evening, for an initial seven-day period. First day home BP values should not be considered.
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