Copyright ©1998 ∞/Badger Medical, PA

CATEGORY: SPECIAL NEEDS AND SERVICES

TOPIC: HYPERTENSION (J-G-02F)

PURPOSE: TO GUIDE THERAPY FOR JAIL PATIENTS WHO HAVE

HYPERTENSION

1.0 References.

1.1 Major Outcomes in High-Risk Hypertensive Patients Randomized to

Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs

Diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent

Heart Attack Trial (ALLHAT)

JAMA, Dec 2002; 288: 2981 - 2997.

1.2 The Seventh Report of the Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure The National

Heart, Lung, and Blood Institute (NHLBI) - National Institutes of Health

Volume 3 • Number 5233 • May 2003

1.3 Treatment Guidelines from the Medical Letter, Drugs for Hypertension.

Volume 7, Issue 77) January 2009.

1.4 NCCHC Clinical Guideline for Health Care in Correctional Settings, High

Blood Pressure. National Commission on Correctional Health Care. August

2008.

1.5 Management of Hypertension in the Outpatient Setting. Dominic Sica, MD.

Primary Care: Clinics in Office Practice. 35 (2008) 451-473.

1.6 First Do No Harm: Severe Asymptomatic Hypertension in the Emergency

Department, A 2008 Clinical Review. EMedHome

(http://www.emedhome.com/features_article.cfm), November 2008.

2.0 Definitions

2.1 Abbreviations

2.1.1 SBP = Systolic Blood Pressure

2.1.2 DBP = Diastolic Blood Pressure

2.2 Normal Blood Pressure: SBP < 120mmHg and DBP < 80 mmHg.

2.3 Pre-hypertension: SBP between 120-139 mmHg or DBP between 80-89 mmHg.

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2.4 Stage 1 Hypertension: SBP between 140-159 mmHg or DBP between 90-99

mmHg.

2.5 Stage 2 Hypertension: SBP >160 mmHg or DBP> 100 mmHg.

2.6 Hypertensive Emergency refers to markedly elevated blood pressure in the setting

of an acute life threatening event that is exacerbated by the hypertension.

Examples of such life-threatening events include acute myocardial infarction,

intracranial hemorrhage and acute pulmonary edema.

2.7 Hypertensive Urgency refers to markedly elevated blood pressure in a patient with

known severe medical problems that could be exacerbated by hypertension.

Examples include coronary artery disease, congestive heart failure or renal

insufficiency.

2.8 Treatment Resistant Hypertension refers to patients who have failed to achieve

good blood pressure control despite full doses of three antihypertensive

medications from three different classes.

3.0 Screening.

3.1 All jail patients will routinely receive a blood pressure check at the following

times:

3.1.1 As part of the Initial Health Screening.

3.1.2 With each visit to the medical clinic.

3.1.3 As part of the Yearly Health Evaluation.

3.2 Verification of findings. Patients found to have an elevated blood pressure should

have the blood pressure rechecked to verify the accuracy of the reading as follows:

3.2.1 All automatic blood pressure machine readings greater than 160/110

should be verified by manual blood pressure readings.

3.2.2 If the blood pressure reading is greater than 160/110, the blood pressure

should be immediately retaken in the opposite arm and then rechecked

again in 2-24 hours. If confirmed, the patient should be referred for

treatment of Stage 2 Hypertension (3.3.1).

3.2.3 If the blood pressure is greater than 140/90 but less than 160/100, the

blood pressure should be rechecked in two weeks and one month. If

confirmed, the patient should be referred for treatment of Stage 1

Hypertension (3.3.2).

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3.2.4 If the blood pressure is greater than 130/85 but less than 140/90, the blood

pressure should be rechecked in six months.

3.3 Referral for treatment. Patients found to have hypertension will be referred for

treatment according to the following schedule:

3.3.1 If the patient has Stage 2 hypertension, the patient should be seen in the

next scheduled medical clinic. If the patient cannot be seen in the medical

clinic within 48 hours, the on-call practitioner should be called so that

therapy can begin within 48 hours. The patient will then be seen in the

medical clinic as scheduled.

3.3.2 If the patient has Stage 1 Hypertension, the patient should be scheduled

into the medical clinic as a non-urgent case.

3.3.3 If the patient has pre-hypertension, the patient should be informed by the

nursing staff of this and counseled on lifestyle changes, such as weight

loss, exercise, and smoking cessation. The patient does not have to be

seen in medical clinic, but the blood pressure should be repeated in six

months.

4.0 Clinical Evaluation.

4.1 All patients with hypertension should receive history and physical examination

looking for evidence of end organ damage caused by hypertension.

4.2 Laboratory studies, EKGs and other testing may be considered depending on the

age of the patient, the severity of the hypertension, co-morbid conditions and

whether the patient has had previous evaluations.

5.0 Therapy of uncomplicated hypertension.

5.1 Pre-hypertension. The patient should be counseled regarding life style

modification, including smoking cessation, weight loss, and exercise. No

antihypertensive medication need be prescribed except with a compelling

indication, such as the presence of co morbid conditions.

5.2 Stage 1 Hypertension. The patient should be counseled regarding lifestyle

modification and started on a thiazide diuretic.

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5.3 Stage 2 Hypertension. The patient should be counseled on lifestyle modification

and started on a thiazide diuretic plus a second appropriate anti-hypertensive from

a different class.

5.3.1 In most cases, an ACE inhibitor is the preferred choice for a second

antihypertensive drug with the following exceptions:

5.3.2 If the patient has heart disease, a beta blocker may be considered as the

second antihypertensive drug.

5.3.3 Pregnant women and women who may become pregnant should not

receive ACE inhibitors. A calcium channel blocker or a beta blocker

would be acceptable choices.

5.3.4 A calcium channel blocker may be a more appropriate second

antihypertensive for African-American patients.

6.0 Frequency of follow-up visits for patients treated for uncomplicated hypertension.

6.1 Patients with good control of their blood pressure (SBP<139 and DBP<89) should

have their blood pressure rechecked at six months. If their blood pressure remains

stable, further routine follow up should take place yearly.

6.2 Patients with fair control of their hypertension (SBP 140-159 or DBP 90-99)

should be rechecked every three months. Their medication should be maximized

and then, if necessary, a second medication added until good control is reached.

6.3 Patients with poor control of their blood pressure (SBP>160 or DBP >100) should

be followed monthly. Medication doses should be maximized until the patient

achieves good control. If the patient does not achieve good control with

maximum doses of two agents, a third agent may be added until good control is

reached.

7.0 Complicated Hypertension

7.1 Treatment of Resistant Hypertension. Resistant hypertension refers to patients

who have failed to achieve good blood pressure control despite full doses of three

antihypertensive medications from three classes. Such patients should be referred

to the medical director of the facility for an investigation into the cause of the

treatment resistance.

5.5 Hypertensive Urgency. Hypertensive Urgency refers to markedly elevated blood

pressure in a patient with known severe medical problems that could be

exacerbated by hypertension. Examples include coronary artery disease,

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congestive heart failure or renal insufficiency. Such patients usually do not

require hospitalization, but they should receive appropriate combination oral

antihypertensive therapy immediately.

5.6 Hypertensive Emergency. Hypertensive emergency refers to markedly elevated

blood pressure in the setting of an acute life-threatening even that is exacerbated

by the hypertension. Examples of such life-threatening events include acute

myocardial infarction, stroke and acute pulmonary edema. Such patients should

be immediately transferred by ambulance to the local emergency department

______________________________________

Signature of Medical Director

REV.