Prehypertension Blood pressure 120/80 mmHg to 139/89 mmHg

No risk factors

Monitor annually. Recheck blood pressure in three to six months.

One or more risk factors

Modify risk factors.

Blood pressure at goal No target organ disease Stage 1 hypertension Blood pressure 140/90 mmHg to 159/99 mmHg Thiazide diuretic Blood pressure not at goal

Evaluate every three to six months.

Add ACE inhibitor, ARB, beta blocker, CCB, or combination.

CHF

Diuretic, beta blocker, ACE inhibitor, ARB, or aldosterone antagonist Beta blocker, ACE inhibitor, or aldosterone antagonist Diuretic, ACE inhibitor, ARB, beta blocker, or CCB Evaluate blood pressure after two weeks. If at goal, continue monitoring every one to three months. If not at goal, increase dose of medication or add a second drug and continue to monitor until at goal; consider secondary causes of hypertension or referral if not achieving goal.

Post-MI Target organ disease present Diabetes

Chronic renal failure or insufciency

ACE inhibitor or ARB

Stage 2 hypertension Blood pressure 160/100 mmHg to 180/119 mmHg

No target organ disease

Target organ disease present

Combination drug with thiazide diuretic and ACE inhibitor, ARB, beta blocker, or CCB; if organ disease is present, start with a drug specic to the organ affected (see stage 1).

Monitor every two weeks and increase or add medications until the blood pressure goal is reached. Add according to target organ disease as indicated. If blood pressure is unresponsive or not at goal with three medications, consider secondary causes and referral to specialist.

Hypertensive urgencies or emergencies Blood pressure 180/120 mmHg or higher

Urgent: severe headache, dyspnea, epistaxis, or severe anxiety

Treat with combination therapy and treat the presenting symptom (e.g., pain medication for severe pain); recheck in 24 hours, consider referral or emergent care, and monitor for target organ disease.

Emergent: hypertensive encephalopathy, intracerebral hemorrhage, acute MI, left-ventricular failure, pulmonary edema, dissecting aortic aneurysm, or acute renal failure

Immediate referral to emergency room

ACEangiotension-converting enzyme; ARBangiotension receptor blocker; CCBcalcium channel blocker; CHFcongestive heart failure; MImyocardial infarction

Figure 1. Hypertension Algorithm

Note. Based on information from National Institutes of Health, 2004; Primary Care Update, 2003.