Hypertension+Algorithm

The algorithms below were created by Vijay Bhandari in 2009 for a noon conference on evidence-based treatments for hypertension in different clinical settings.
=Hypertension Treatment Algorithm #1 (for uncomplicated hypertension)=


 * Goal BP <140/90
 * If CAD risk equivalent or [|Framingham]10-year CV risk >10%, consider BP goal <130/80
 * CAD risk equivalents include CVA, carotid artery disease, PVD, and AAA
 * For algorithms below, titrate doses up q2-4 weeks to meet BP goal. If still not at goal, go to the next number and add that medication. You do not need to maximize doses of each medication, as combinations of medications are often more effective than single medications, even at higher doses.


 * 1) **Chlorthalidone** (or **HCTZ** if planning combo pill) 12.5 -> 25
 * 2) Add **lisinopril** 10 -> 20 -> 40. Titrate q2-4 weeks to BP goal.
 * 3) Add **amlodipine** (DHP CCB) 5 -> 10. Titrate q2-4 weeks to BP goal
 * or **nifedipine** XL (DHP CCB) 30 -> 60 -> 120
 * or **diltiazem** ER (nonDHP CCB) 180 -> 300 -> 420
 * or **verapamil** SR (nonDHP CCB) 120 -> 240 -> 360
 * 1) Consider:
 * **spironolactone** 25 -> 50 (avoid if Cr>2 or K>5)
 * **metoprolol** succinate 50 -> 100 -> 200 or metoprolol tartrate 25 -> 50 -> 100 BID (avoid if using diltiazem or verapamil)
 * other subclass of **calcium channel blocker** not already used
 * **hydralazine** 20 -> 50 -> 100 bid
 * **clonodine** 0.2 -> 0.2 -> 0.3 -> 0.4 bid
 * **clonodine** patch 0.1 -> 0.2 -> 0.3

=Hypertension Treatment Algorithm #2 (for patients with DM and/or CKD, especially with proteinuria)=


 * Goal BP <130/80
 * If proteinuria >1g/day, consider BP goal <125/75
 * For algorithms below, titrate doses up q2-4 weeks to meet BP goal. If still not at goal, go to the next number and add that medication.


 * 1) **Lisinopril** 10 -> 20 -> 40. Titrate q2-4 weeks to BP goal. **If patient has albuminuria >500mg/d, even if BP at goal, consider uptitrating lisinopril to 80 or adding losartan 25.**
 * 2) Add **chlorthalidone** (or **HCTZ** if planning combo pill) 12.5 -> 25
 * consider **furosemide** 10 -> 20 -> 40 bid or **torsemide** 2.5 - 5 -> 10 if GFR <30
 * 1) Add **diltiazem** ER (nonDHP CCB) 180 -> 300 -> 420 or **verapamil** SR (nonDHP CCB) 120 -> 240 -> 360
 * or **amlodipine** 5 -> 10
 * or **nifedipine** XL (DHP CCB) 30 -> 60 -> 120
 * 1) Condider adding:
 * **spironolactone** 25 -> 50 (avoid if Cr>2 or K>5)
 * **metoprolol succinate** 50 -> 100 -> 200 or metoprolol tartrate 25 -> 50 -> 100 BID (avoid if using diltiazem or verapamil)
 * other subclass of **calcium channel blocker** not already used
 * **hydralazine** 20 -> 50 -> 100 bid
 * **clonodine** 0.2 -> 0.2 -> 0.3 -> 0.4 bid
 * **clonodine** patch 0.1 -> 0.2 -> 0.3

=Hypertension Treatment Algorithm #3 (for patients with CAD and stable angina or h/o MI and normal LV systolic function)=


 * Goal BP <130/80
 * If patient meets above criteria and has comorbid diabetes and/or proteinuric CKD, then clinical judgment should determine which algorithm to follow. In general, a more recent MI (within 3 years) or exercise-limiting anginal symptoms would warrant stronger consideration of this algorithm.
 * For algorithms below, titrate doses up q2-4 weeks to meet BP goal. If still not at goal, go to the next number and add that medication.


 * 1) **Metoprolol succinate** 50 -> 100 -> 200 or metoprolol tartrate 25 -> 50 -> 100 BID. Titrate to HR goal 55-70 as BP tolerates.
 * if at this point angina remains inadequately controlled at 2-4 weeks, add **amlodipine** 5 -> 10 or **nifedipine** XL 30 -> 60 -> 120.
 * 1) Add **lisinopril** 5 or 10
 * if at this point angina remains inadequately controlled at 2-4 weeks, add **amlodipine** 5 -> 10 or **nifedipine** XL 30 -> 60 -> 120.
 * 1) Increase **lisinopril** to 10 -> 20 -> 40
 * 2) Add **chlorthalidone** (or **HCTZ** if planning combo pill) 12.5 -> 25
 * 3) Add **amlodipine** 5 -> 10 or **nifedipine** XL (DHP CCB) 30 -> 60 -> 120
 * 4) Condider adding:
 * **spironolactone** 25 -> 50 (avoid if Cr>2 or K>5)
 * **hydralazine** 20 -> 50 -> 100 bid

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