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## Complete Summary

#### GUIDELINE TITLE

Medical management of adults with hypertension.

#### BIBLIOGRAPHIC SOURCE(S)

Michigan Quality Improvement Consortium. Medical management of adults
with hypertension. Southfield (MI): Michigan Quality Improvement
Consortium; 2007 Aug. 1 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement
Consortium. Medical management of adults with hypertension. Southfield
(MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hypertension

#### GUIDELINE CATEGORY

Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Health Plans\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To achieve significant, measurable improvements in the management of
    hypertension through the development and implementation of common
    evidence-based clinical practice guidelines

-   To design concise guidelines that are focused on key management
    components of essential hypertension to improve outcomes

#### TARGET POPULATION

Adult patients [\>]{.underline}18 years of age who are:

-   Not pregnant

-   Diagnosed with hypertension

    -   Prehypertension (120-139/80-89)

    -   Hypertension:

        -   Stage 1 (140-159/90-99)

        -   Stage 2 ([\>]{.underline}160/[\>]{.underline}100)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Assessment of lifestyle, cardiovascular risk factors, concomitant
    disorders, causes of hypertension, target organ damage, and
    cardiovascular disease

2.  Physical examination including 2 or more blood pressure (BP)
    measurements using regularly calibrated equipment with appropriate
    sized cuff and separated by at least 2 minutes, verification in
    contralateral arm, funduscopic exam, neck exam (bruits), heart and
    lung exam, abdominal exam for bruits or aortic aneurysm, and
    extremity pulses

3.  Laboratory tests including potassium, creatinine, glucose,
    hematocrit, calcium, urinalysis, lipid panel, and electrocardiogram
    (EKG)

**Management/Treatment**

1.  Patient education and nonpharmacologic interventions including
    lifestyle modifications and self BP monitoring

2.  Pharmacologic intervention including

    -   Thiazide-type diuretics

    -   Two-drug combination (thiazide-type diuretic plus
        angiotensin-converting enzyme inhibitor \[ACEI\], beta blocker
        or calcium channel blocker \[extended/sustained release or long
        acting\])

    -   Angiotensin receptor blocker (ARB) if angiotensin converting
        enzyme inhibitor not tolerated

3.  Post therapy BP monitoring and adjustment of therapy

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Michigan Quality Improvement Consortium (MQIC) project leader
conducts a search of current literature in support of the guideline
topic. Computer database searches are used to identify published
studies, existing protocols and/or national guidelines on the selected
topic developed by organizations such as the American Diabetes
Association, American Heart Association, American Academy of Pediatrics,
etc. If available, clinical practice guidelines from participating MQIC
health plans and Michigan health systems are also used to develop a
framework for the new guideline.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence for the Most Significant Recommendations**

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational studies

D.  Opinion of expert panel

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Using information obtained from literature searches and available health
plan guidelines on the designated topic, the Michigan Quality
Improvement Consortium (MQIC) project leader prepares a draft guideline
to be reviewed by the medical directors\' committee at one of their
scheduled meetings. Priority is given to recommendations with \[A\] and
\[B\] levels of evidence (see \"Rating Scheme for the Strength of the
Evidence\" field).

The initial draft guideline is reviewed, evaluated, and revised by the
committee resulting in draft two of the guideline. Additionally, the
Michigan Academy of Family Physicians participates in guideline
development at the onset of the process and throughout the guideline
development procedure. The MQIC guideline feedback form and draft two of
the guideline are distributed to the medical directors, as well as the
MQIC measurement and implementation group members, for review and
comments.  Feedback from members is collected by the MQIC project leader
and prepared for review by the medical directors\' committee at their
next scheduled meeting. The review, evaluation, and revision process
with several iterations of the guideline may be repeated over several
meetings before consensus is reached on a final draft guideline.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

When consensus is reached on the final draft guideline, the medical
directors approve the guideline for external distribution to
practitioners with review and comments requested via the Michigan
Quality Improvement Consortium (MQIC) health plans (project leader
distributes final draft to medical directors\' committee, measurement
and implementation groups to solicit feedback).

The MQIC project leader also forwards the approved guideline draft to
appropriate state medical specialty societies for their input. After all
feedback is received from external reviews, it is presented for
discussion at the next scheduled committee meeting. Based on feedback,
subsequent guideline review, evaluation, and revision may be required
prior to final guideline approval.

The MQIC Medical Directors approved this updated guideline in August
2007.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The level of evidence grades (A-D) are provided for the most significant
recommendations and are defined at the end of the \"Major
Recommendations\" field.

**Initial Assessment**

-   The objectives of the initial evaluation are to assess lifestyle,
    cardiovascular risk factors, and concomitant disorders, reveal
    identifiable causes of hypertension, and check for target organ
    damage and cardiovascular disease.

-   Physical examination: 2 or more blood pressure (BP) measurements
    using regularly calibrated equipment with the appropriate sized cuff
    and separated by at least 2 minutes, verification in contralateral
    arm, funduscopic exam, neck exam (bruits), heart and lung exam,
    abdominal exam for bruits or aortic aneurysm, and extremity pulses
    **\[A\]**

-   Laboratory tests prior to initiating therapy: potassium, creatinine,
    glucose, hematocrit, calcium, urinalysis, lipid panel, and
    electrocardiogram (EKG) **\[D\]**

**Patient Education and Nonpharmacologic Interventions**

-   Lifestyle modification: weight reduction (body mass index \[BMI\]
    goal \<25), reduction of dietary sodium to less than 2.4 g/day, DASH
    diet **\[A\]** (i.e., diet high in fruits and vegetables, reduced
    saturated and total fat), aerobic physical activity
    [\>]{.underline}30 minutes most days of the week, tobacco avoidance,
    increased dietary potassium and calcium, moderation of alcohol
    consumption^1^ **\[A\]**

-   Use of self BP monitoring. Home measurement device should be checked
    regularly for accuracy. Mean self measured BP \>135/85 is generally
    considered to be hypertensive

^1^Moderate alcohol consumption is defined as up to two drinks per day
for men, one drink per day for women and older people.

**Goals of Therapy**

-   Adjust therapy to achieve target BP [\<]{.underline}140/90 (\<130/80
    for patients with diabetes or kidney disease)

**Pharmacologic Interventions**

-   Prehypertension (120-139/80-89): none unless compelling indication
    (e.g., diabetes, renal failure, congestive heart failure \[CHF\],
    post-myocardial infarction \[MI\], stroke, arteriosclerotic
    cardiovascular disease)

-   Hypertension, Stage 1 (140-159/90-99): thiazide-type diuretics alone
    or in combination with angiotensin-converting enzyme inhibitor
    (ACEI), beta blocker, or calcium channel blocker (extended/sustained
    release or long acting)^2^. Angiotensin receptor blocker (ARB) if
    ACEI not tolerated

-   Hypertension, Stage 2 ([\>]{.underline}160/[\>]{.underline}100):
    two-drug combination (thiazide-type diuretic plus ACEI, beta
    blocker, or calcium channel blocker \[extended/sustained release or
    long acting\]^2^; use ARB if ACEI not tolerated)

-   ACEI (ARB if ACEI not tolerated) are recommended in patients with
    diabetes or heart failure **\[A\]**.

-   Beta-blockers are recommended in patients with ischemic heart
    disease or heart failure.

-   3 or more drugs may be necessary for some patients to achieve goal
    BP.

^2^Avoid use of short-acting nonsustained release calcium channel
blockers **\[A\]**.

**Monitoring and Adjustment of Therapy \[D\]**

-   Prehypertension without medication: annual BP check with lifestyle
    modification counseling

-   Hypertension, Stage 1: initiate therapy and recheck at monthly
    intervals until goal is reached.

-   Hypertension, Stage 2: initiate therapy and recheck weekly or more
    often if indicated. Symptomatic Stage 2 may require hospital
    monitoring and treatment.

-   Modify antihypertensive therapy as needed if adverse effects become
    intolerable

-   Once BP controlled with medication: recheck every 3 to 6 months.

-   Serum potassium and creatinine should be monitored at least 1 to 2
    times/year for patients on medication.

**Definitions**:

**Levels of Evidence for the Most Significant Recommendations**

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational studies

D.  Opinion of expert panel

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is provided for the most significant
recommendations (See \"Major Recommendations\" field).

The guideline is based on several sources including, Hypertension
Diagnosis and Treatment, Institute for Clinical Systems Improvement,
2006
([www.icsi.org](http://www.icsi.org/guidelines_and_more/gl_os_prot/)).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Through a collaborative approach to developing and implementing common
clinical practice guidelines and performance measures for hypertension,
Michigan health plans will achieve consistent delivery of evidence-based
services and better health outcomes. This approach also will augment the
practice environment for physicians by reducing the administrative
burdens imposed by compliance with diverse health plan guidelines and
associated requirements.

#### POTENTIAL HARMS

-   Adverse effects of antihypertensive medications

-   The use of short-acting nonsustained release calcium channel
    blockers should be avoided in patients with stage 1 and 2
    hypertension.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline lists core management steps. Individual patient
considerations and advances in medical science may supersede or modify
these recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Approved Michigan Quality Improvement Consortium (MQIC) guidelines are
disseminated through email, U.S. mail, and websites.

The MQIC project leader prepares approved guidelines for distribution.
Portable Document Format (PDF) versions of the guidelines are used for
distribution.

The MQIC project leader distributes approved guidelines to MQIC
membership via email.

The MQIC project leader submits request to website vendor to post
approved guidelines to MQIC website
([www.mqic.org](http://www.mqic.org/)).

The MQIC project leader completes a statewide mailing of the
comprehensive set of approved guidelines and educational tools annually.
The guidelines and tools are distributed in February of each year to
physicians in the following medical specialties:

-   Family Practice

-   General Practice

-   Internal Medicine

-   Other Specialists for which the guideline is applicable (e.g.
    endocrinologists, allergists, pediatricians, cardiologists, etc.)

The statewide mailing list is derived from the Blue Cross Blue Shield of
Michigan (BCBSM) provider database. Approximately 95% of the state\'s
M.D.\'s and 96% of the state\'s D.O.\'s are included in the database.

The MQIC project leader submits request to the National Guideline
Clearinghouse (NGC) to post approved guidelines to NGC website
([www.guideline.gov](http://www.guideline.gov/)).

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Michigan Quality Improvement Consortium. Medical management of adults
with hypertension. Southfield (MI): Michigan Quality Improvement
Consortium; 2007 Aug. 1 p.

#### ADAPTATION

The guideline is based on several sources including, Hypertension
Diagnosis and Treatment, Institute for Clinical Systems Improvement,
2006
([www.icsi.org](http://www.icsi.org/guidelines_and_more/gl_os_prot/)).

#### DATE RELEASED

2003 Aug (revised 2007 Aug)

#### GUIDELINE DEVELOPER(S)

Michigan Quality Improvement Consortium - Professional Association

#### SOURCE(S) OF FUNDING

Michigan Quality Improvement Consortium

#### GUIDELINE COMMITTEE

Michigan Quality Improvement Consortium Medical Director\'s Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Physician representatives from participating Michigan Quality
Improvement Consortium health plans, Michigan State Medical Society,
Michigan Osteopathic Association, Michigan Association of Health Plans,
Michigan Department of Community Health, and Michigan Peer Review
Organization

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Standard disclosure is requested from all individuals participating in
the Michigan Quality Improvement Consortium (MQIC) guideline development
process, including those parties who are solicited for guideline
feedback (e.g. health plans, medical specialty societies). Additionally,
members of the MQIC Medical Directors\' Committee are asked to disclose
all commercial relationships.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement
Consortium. Medical management of adults with hypertension. Southfield
(MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Michigan Quality Improvement Consortium Web
site](http://www.mqic.org/pdf/MQIC 2007 Hypertension Guideline.pdf).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on April 14, 2004. The
information was verified by the guideline developer on July 27, 2004.
This NGC summary was updated by ECRI on November 28, 2005. The updated
information was verified by the guideline developer on December 19,
2005. This NGC summary was updated by ECRI Institute on March 4, 2008.
The updated information was verified by the guideline developer on March
12, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be
reproduced with the citation developed by the Michigan Quality
Improvement Consortium.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
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Readers with questions regarding guideline content are directed to
contact the guideline developer.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008