What are the discharge instructions for a patient with elevated blood pressure?

Discharge Instructions for Elevated Blood Pressure

Patients with elevated blood pressure should be discharged with clear instructions targeting a blood pressure goal of <130/80 mmHg through lifestyle modifications and appropriate medication management, with follow-up within 1 month to assess treatment effectiveness. 1

Blood Pressure Goals and Classification

• Target blood pressure: <130/80 mmHg for most adults 1
• Special populations:
  • Patients with moderate-to-severe CKD: Target systolic BP 120-129 mmHg 1
  • Patients with history of stroke/TIA: Target systolic BP 120-129 mmHg 1
  • Older adults (≥65 years): Target systolic BP 130-140 mmHg if tolerated 2

Lifestyle Modifications

Provide written instructions for the following lifestyle changes:

• Dietary recommendations:

  • DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy)
  • Sodium restriction (<2000 mg/day)
  • Increased potassium intake (unless contraindicated)
  • Reduction in alcohol consumption (≤1 drink/day for women, ≤2 drinks/day for men)

• Physical activity:

  • Regular aerobic exercise (150 minutes/week of moderate-intensity activity)
  • Strength training 2-3 times per week

• Weight management:

  • Target BMI <25 kg/m²
  • For overweight/obese patients, aim for 5-10% weight loss initially

• Smoking cessation if applicable

Expected BP reduction with lifestyle modifications: 2

Modification	Approximate Reduction in Systolic BP
Weight loss	5-20 mmHg per 10 kg lost
DASH diet	8-14 mmHg
Sodium reduction	2-8 mmHg
Physical activity	4-9 mmHg
Moderate alcohol consumption	2-4 mmHg

Home Blood Pressure Monitoring Instructions

• Device selection: 1

  • Recommend automated validated devices
  • Ensure appropriate cuff size (bladder should encircle 80% of arm)

• Measurement protocol: 1

  • Sit quietly for 5 minutes before measurement
  • Avoid caffeine, exercise, and smoking for at least 30 minutes prior
  • Empty bladder before measurement
  • Sit with back supported, feet flat on floor
  • Position arm at heart level
  • Take 2-3 readings, 1 minute apart, morning and evening
  • Record all readings with date and time

• Recording:

  • Provide BP log or recommend mobile app for tracking
  • Instruct patient to bring log to follow-up appointments

Medication Management

• For newly diagnosed hypertension:

  • Start with a single agent if BP is <20/10 mmHg above target
  • Start with two agents if BP is ≥20/10 mmHg above target 2
  • First-line options include:
    • ACE inhibitors or ARBs (e.g., lisinopril)
    • Calcium channel blockers (e.g., amlodipine)
    • Thiazide or thiazide-like diuretics (e.g., chlorthalidone)

• For patients already on medication:

  • Continue current regimen with adjustments as needed
  • Provide clear instructions on dosage changes if applicable
  • Emphasize importance of medication adherence

• Medication-specific instructions:

  • ACE inhibitors/ARBs: Monitor for cough, dizziness; avoid pregnancy 3
  • Calcium channel blockers: Watch for peripheral edema 4
  • Diuretics: Take earlier in the day to avoid nighttime urination

Follow-Up Instructions

• Timing: 1, 2

  • For BP 130-139/80-89 mmHg: Follow-up within 1 month
  • For BP 140-159/90-99 mmHg: Follow-up within 2-4 weeks
  • For BP ≥160/100 mmHg: Follow-up within 1-2 weeks

• Laboratory monitoring:

  • For patients on ACE inhibitors, ARBs, or diuretics: Check serum creatinine, eGFR, and potassium within 2-4 weeks of starting therapy 2
  • Annual monitoring of renal function and electrolytes for all patients on antihypertensive medications

Warning Signs Requiring Immediate Medical Attention

Instruct patients to seek immediate medical care for:

• Severe headache with BP >180/120 mmHg
• Chest pain or shortness of breath
• Neurological symptoms (vision changes, weakness, confusion)
• Severe dizziness or fainting

Special Considerations

• Diabetic patients:

  • Monitor for hypoglycemia when starting ACE inhibitors 3
  • Target BP <130/80 mmHg 2

• Elderly patients:

  • Start medications at lower doses and titrate more slowly
  • Monitor for orthostatic hypotension (check standing BP) 2
  • Be vigilant about medication side effects

• Patients with CKD:

  • Prefer ACE inhibitors or ARBs as first-line therapy
  • Monitor renal function and potassium closely 1
  • Consider SGLT2 inhibitors for additional benefits 1

• Patients with heart failure:

  • Medications with BP-lowering effects recommended: ACE inhibitors/ARBs, beta-blockers, MRAs, and SGLT2 inhibitors 1

Common Pitfalls to Avoid

• White coat hypertension: Home BP monitoring helps identify this phenomenon
• Medication non-adherence: Discuss barriers to adherence and simplify regimen when possible
• Inadequate follow-up: Emphasize importance of keeping appointments
• Improper BP measurement technique: Provide detailed instructions for home monitoring
• Failure to address lifestyle factors: Emphasize non-pharmacological approaches alongside medications

Remember that consistent blood pressure control is more important than rapid normalization. Gradual, sustainable changes lead to better long-term outcomes and reduced cardiovascular risk.