Guideline for the diagnosis and ... - Heart Foundation

1 Guideline for the diagnosis and management of hypertension in adults2016 Suggested citation: National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults 2016. Melbourne: National Heart Foundation of Australia, 978-1-74345-110-6 2016 National Heart Foundation of Australia ABN 98 008 419 761 This work is copyright. No part of this publication may be reproduced in any form or language without prior written permission from the National Heart Foundation of Australia (national office). Enquiries concerning permissions should be directed to image: wavebreakmedia, This document has been produced by the National Heart Foundation of Australia for the information of health professionals. The statements and recommendations it contains are, unless labelled as expert opinion , based on independent review of the available evidence.

2 Interpretation of this document by those without appropriate medical and/or clinical training is not recommended, other than at the request of, or in consultation with, a relevant health professional. While care has been taken in preparing the content of this material, the Heart Foundation and its employees cannot accept any liability, including for any loss or damage, resulting from the reliance on the content, or for its accuracy, currency and completeness. The information is obtained and developed from a variety of sources including, but not limited to, collaborations with third parties and information provided by third parties under licence. It is not an endorsement of any organisation, product or service. This material may be found in third parties programs or materials (including, but not limited to, show bags or advertising kits).

3 This does not imply an endorsement or recommendation by the National Heart Foundation of Australia for such third parties organisations, products or services, including their materials or information. Any use of National Heart Foundation of Australia materials or information by another person or organisation is at the user s own risk. PRO-167 The Guideline for the diagnosis and management of hypertension in adults has been endorsed by the following Heart Foundation of Australia Guideline for the diagnosis and management of hypertension in adults 2016iAcknowledgementsNational Heart Foundation of Australia National Blood Pressure and Vascular Disease Advisory CommitteeProfessor Craig Anderson, MBBS, PhD, FRACP, FAFPHM, FAMHSP rofessor Leonard Arnolda, PhD, MBBS, FRACP, FCSANZ, ChairMs Diane Cowley, BN, GDip Midwifery (NZ), MPH, MHA&IS, MNPDr John Dowden, FRCP (Edin), FRACGP, MRCGP, MICGPDr Genevieve Gabb, MBBS (Hons), FRACP, Grad Dip ClinEpiProfessor Jonathan Golledge, MB BChir, BA, MA, MChir, FRCS, FRACS, NHMRC FellowProfessor Graeme Hankey MBBS, MD, FRCP (Lond), FRCP (Edin)

4 , FRACPDr Faline Howes, BMedSci, MBBS (Hons), MPH, FRACGPMr Les Leckie, Community/Consumer RepresentativeProfessor Arduino Mangoni, PhD, FRCP (Lond, Glas, Edin), FRACPP rofessor Vlado Perkovic, MBBS, PhD, FRACP, FASNP rofessor Markus Schlaich MD, FAHA, FESC, NHMRC Senior Research FellowProfessor Nicholas Zwar, MBBS, MPH, PhD, FRACGPN ational Heart Foundation of AustraliaDr Tanya Medley, BAppSci (Hons), PhDMs Jinty Wilson, MBAThe National Heart Foundation of Australia gratefully acknowledges the generous contribution of the following authors and reviewers of the Guideline for the diagnosis and management of hypertension in adults for the diagnosis and management of hypertension in adults 2016 National Heart Foundation of Australiaii Abbreviations and acronyms ABI Ankle brachial indexABPM Ambulatory blood pressure monitoringACCESS Acute Candesartan Cilexetil Evaluation in Stroke SurvivorsACCOMPLISH Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic HypertensionACCORD Action to Control Cardiovascular Risk in DiabetesACE Angiotensin converting enzymeACR Albumin/creatinine ratioALTITUDE Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal EndpointsAMSTAR A

5 Measurement Tool to Assess Systematic ReviewsARB Angiotensin receptor blockerBMI Body mass indexBPLTTC Blood Pressure Lowering Treatment Trialists CollaborationCHHIPS Controlling Hypertension and Hypotension Immediately Post-StrokeCNS Central nervous systemCPAP Continuous positive airway pressureCR Controlled releaseCT Computerised tomographyCVD Cardiovascular diseaseDASH Dietary Approaches to Stop HypertensionECG ElectrocardiographESC European Society of CardiologyESH European Society of HypertensionGFR Glomerular filtration rateGRADE Grading of Recommendations Assessment, Development and EvaluationHAPPy Hypertension Adherence Program in PharmacyHBPM Home blood pressure monitoringHDL High-density lipoproteinHOPE Heart Outcomes Prevention EvaluationHYVET Hypertension in the Very Elderly TrialJNC Joint National Committee (on Prevention Detection Evaluation and Treatment of High Blood Pressure)

6 KDIGO Kidney Disease Improving Global OutcomesLDL Low-density lipoproteinmmHg Millimetres of mercuryNBPVDAC National Blood Pressure and Vascular Disease Advisory CommitteeNHMRC National Health and Medical Research CouncilNICE National Institute of Clinical ExcellenceNSAID Non-steroidal anti-inflammatory drugsNVDPA National Vascular Disease Prevention AllianceONTARGET Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint TrialPCR Protein/creatinine ratio PICO Patient, Intervention, Comparison, OutcomePROGRESS Perindopril Protection Against Recurrent Stroke StudyRACGP Royal Australian College of General PractitionersSCAST Scandinavian Candesartan Acute Stroke TrialSNAP Smoking, Nutrition, Alcohol, Physical activitySNRIs Serotonin and norepinephrine reuptake inhibitorsSOMANZ The Society of Obstetric Medicine of Australia and New ZealandSPRINT Systolic Blood Pressure Intervention TrialSPS3 Secondary Prevention of Small Subcortical StrokesTGA Therapeutic Goods AdministrationTIA Transient ischaemic attackVA NEPHRON-D Veteran Affairs Nephropathy in Diabetes, Combined Angiotensin Inhibition for the Treatment of Diabetic NephropathyWHO World Health OrganizationNational Heart Foundation of Australia Guideline for the diagnosis and management of hypertension in adults 2016iiiContentsACKNOWLEDGEMENTS.

7 IABBREVIATIONS AND ACRONYMS ..iiI. SUMMARY OF RECOMMENDATIONS .. S NEW IN THIS EDITION? ..51 INTRODUCTION .. Scope of the Guideline .. Related guidelines .. Methodology ..10 Disclaimer .. Epidemiology of blood pressure ..102 DEFINITION AND CLASSIFICATION OF HYPERTENSION .. Hypertensive urgencies and emergencies ..123 HYPERTENSION AND ABSOLUTE CVD RISK ASSESSMENTS .. When and who to assess for absolute CVD risk ..134 EVALUATION AND diagnosis OF HYPERTENSION .. Blood pressure measurement ..15 Blood pressure measuring devices .. Blood pressure measurement in the clinic .. Blood pressure measurement outside of the clinic .. Medical history ..21 Complementary medicines .. Physical examination and laboratory investigations .. Additional diagnostic tests for selected patients ..255.

8 LIFESTYLE ADVICE FOR CONFIRMED HYPERTENSION .. Physical activity .. Weight control .. Dietary modification .. Salt restriction .. Dietary fat .. Smoking cessation .. Moderate alcohol consumption .. Relaxation therapies ..30 Guideline for the diagnosis and management of hypertension in adults 2016 National Heart Foundation of Australiaiv 6. ANTIHYPERTENSIVE THERAPY FOR CONFIRMED HYPERTENSION .. Treatment thresholds for antihypertensive drug therapy .. Treatment targets using antihypertensive drug therapy .. Choice of antihypertensive drugs ..337 DOSES AND SAFETY OF ANTIHYPERTENSIVE DRUGS ..398 INITIATING TREATMENT WITH COMBINATION THERAPY ..439 TREATMENT STRATEGIES AND TREATMENT TARGETS FOR SELECTED CO-MORBIDITIES .. Stroke and TIA ..44 Drug choice ..44 Treatment targets ..45 Acute stroke.

9 Chronic kidney disease ..46 Drug choice ..46 Treatment targets .. Diabetes ..48 Drug choice ..48 Treatment targets .. Myocardial infarction ..49 Drug choice ..49 Treatment targets .. Chronic Heart failure ..50 Drug choice ..50 Treatment targets .. Peripheral arterial disease ..51 Drug choice and treatment targets ..5110 TREATMENT STRATEGIES FOR ASSOCIATED CONDITIONS .. White-coat and masked hypertension .. Older persons ..52 Drug choice ..52 Treatment targets .. Pregnancy .. Blood pressure variability .. Treatment-resistant hypertension .. Obstructive sleep apnoea ..56 National Heart Foundation of Australia Guideline for the diagnosis and management of hypertension in adults 2016v11 STRATEGIES TO MAXIMISE ADHERENCE ..5812 MANAGING OTHER CARDIOVASCULAR RISK FACTORS.

10 Lipid-lowering drugs .. Antiplatelet therapy ..5913 MONITORING RESPONSES TO DRUG TREATMENT .. Follow-up of patients with hypertension .. Withdrawing drug therapy ..6014 PATIENTS PERSPECTIVES ..6115 REFERENCES ..62 APPENDIX 1 ..74 Tables, figures and boxesTable Grading of Recommendations Assessment, Development and Evaluation ( grade ) ..7 Table National Health and Medical Research Council levels of evidence ..8 Table Classification of clinic blood pressure levels in adults ..12 Box Treatment decision aid ..14 Table Measurement and evaluation of clinic blood pressure ..16 Table Clinical indications for out-of-clinic blood pressure measurements ..18 Table Criteria for diagnosis of hypertension using different methods of blood pressure measurement ..19 Table Recommendations on methods of blood pressure measurement.