From the Guidelines
Patients with hypertension should undergo comprehensive screening, including out-of-office blood pressure measurement with ABPM and/or HBPM, serum creatinine, eGFR, and urine ACR, as well as a 12-lead ECG, to identify potential complications and comorbidities. The most recent and highest quality study, the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, recommends measuring BP out-of-office using ABPM and/or HBPM, or repeated office BP measurements on more than one visit, for individuals with increased CVD risk and screening office BP of 120–139/70–89 mmHg. Some key points to consider when screening patients with hypertension include:
- Measuring serum creatinine, eGFR, and urine ACR in all patients with hypertension, and repeating these measurements at least annually if moderate-to-severe CKD is diagnosed 1
- Performing a 12-lead ECG for all patients with hypertension, and considering echocardiography in patients with hypertension and ECG abnormalities, or signs or symptoms of cardiac disease 1
- Screening for secondary hypertension in patients with resistant hypertension, sudden onset of hypertension, or hypertension at a young age, which may include tests for renal artery stenosis, primary aldosteronism, pheochromocytoma, or thyroid dysfunction 1
- Regular monitoring of blood pressure at home, with readings taken twice daily, morning and evening, to help identify target organ damage and guide treatment decisions 1 It is essential to prioritize these screenings to identify potential complications and comorbidities, guide treatment decisions, and prevent complications such as cardiovascular disease, stroke, and kidney failure, ultimately improving outcomes in hypertensive patients.
From the FDA Drug Label
Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake
- Screening recommendations:
- Lipid control
- Diabetes management
- Antithrombotic therapy
- Smoking cessation
- Exercise
- Limited sodium intake The FDA drug label does not provide specific screening recommendations for patients with hypertension. However, it suggests that control of high blood pressure should be part of comprehensive cardiovascular risk management, which includes the above factors 2.
From the Research
Screening Recommendations for Patients with Hypertension
- Patients with hypertension should be targeted for chronic kidney disease (CKD) screening, as CKD is a major public health problem and hypertension is present in more than 80% of patients with CKD 3, 4.
- The US Preventative Services Task Force does not have a screening recommendation for CKD, but evidence suggests that screening can prevent progression and is cost-effective 3.
- Populations at risk for CKD, such as those with hypertension, diabetes, and age greater than 50 years, should be targeted for screening 3.
- CKD is diagnosed and risk stratified with estimated glomerular filtration rate utilizing serum creatinine and measuring urine albumin-to-creatinine ratio 3.
Treatment and Management of Hypertension in CKD Patients
- The National Kidney Foundation clinical practice guidelines recommend a blood pressure goal of <130 mmHg systolic and <80 mmHg diastolic for all CKD patients 4.
- Treatment of hypertension is imperative, and a combination of non-pharmacologic and pharmacologic interventions may be necessary to achieve blood pressure goals 4.
- Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are recommended as first-line pharmacologic interventions for patients with diabetes or non-diabetics with more than 200 mg protein/gram creatinine on a random urine sample 4.
- The combination of ACEIs/ARBs and calcium channel blockers (CCBs) has been shown to have superior benefits on metabolic, renal, and cardiovascular outcomes in hypertensive patients 5.
Gaps in Current Practice
- Despite guideline recommendations, ACEIs and ARBs are insufficiently prescribed for patients with hypertension associated with CKD and proteinuria 6.
- The prescription rate of ACEIs/ARBs is lower in patients aged <75 years with CKD stage G1-G5 compared to patients aged ≥75 years with CKD stage G1-G3 6.