Hypertension and cardiovascular disease: clinical guidance and resources

Screening and treatment of depression following acute coronary syndrome

(Developed by the AAFP, March 2019)

The guideline, Screening and Treatment of Depression Following Acute Coronary Syndrome, was developed by the American Academy of Family Physicians and approved by the Board of Directors in March 2019. The guideline was published in the American Family Physician on June 14, 2019.

Key Recommendations

• A standardized depression screening tool (e.g. BDI-II, HADS, GDS, PHQ) should be used to screen for depression in patients who have recently experienced an acute coronary syndrome (ACS) event.
• In patients who screen positive for depression, further assessment should be performed to confirm the diagnosis of depression.
• Antidepressant medication, preferably SSRIs/SNRIs, and/or CBT should be prescribed to improve symptoms of depression in patients who have a history of ACS and have been diagnosed with depression. Tricyclic antidepressants (TCAs) have multiple adverse events, including potential cardiotoxicity and should not be used in patients with heart disease.

See the full recommendation for further details.

(Endorsed, March 2019)

The guideline on Diagnosis of Venous Thromboembolism was developed by the American Society of Hematology and was endorsed by the American Academy of Family Physicians.

Key recommendations

Pulmonary embolism (PE)

• For individuals with a low or intermediate pretest probability or prevalence, clinicians should use a D-dimer strategy to rule out PE followed by VQ scan or CTPA in patients requiring additional testing. D-dimer testing alone should not be used to rule in a PE.
• For individuals with a high pretest probability or prevalence (≥50%), clinicians should start with CTPA to diagnose PE. If CTPA is not available, a VQ scan be used with appropriate follow up testing.
• D-dimer testing alone should not be used to diagnose PE and should not be used as a subsequent test after CT scan in individuals with a high pretest probability/prevalence.
• For individuals who have a positive D-dimer or likely pretest probability, a CTPA should be performed. D-dimer testing can be used to exclude recurrent PE in individuals with unlikely pretest probability.
• Use of an age-adjusted D-dimer cutoff in outpatients older than 50 years is safe and improves diagnostic yield. Age-adjusted cutoff = Age (years) x 10 µg/L (using D-dimer assays with a cutoff of 500 µg/L).

Lower extremity deep vein thrombosis (DVT)

• For individuals with a low pretest probability or prevalence, clinicians should use a D-dimer strategy to rule out DVT followed by proximal lower extremity ultrasound or whole-leg ultrasound in patients requiring additional testing.
• For individuals with low pretest probability or prevalence (≤10%), positive D-dimer alone should not be used to diagnose DVT and additional testing following negative proximal or whole-leg ultrasound should not be conducted.
• For individuals with an intermediate pretest probability or prevalence (~25%), whole-leg ultrasound or proximal lower extremity ultrasound should be used. Serial proximal ultrasound testing is needed after a negative proximal ultrasound. No serial testing is needed after a negative whole leg ultrasound.
• For individuals with suspected DVT and high pretest probability or prevalence (≥50%), whole-leg ultrasound or proximal lower extremity ultrasound should be used. Serial ultrasound should be used if initial ultrasound is negative and no alternative diagnosis is identified.

Upper extremity DVT

• For individuals with low prevalence/unlikely pretest probability, D-dimer testing should be used to exclude upper extremity DVT, followed by duplex ultrasound if positive.
• For individuals with high prevalence/likely pretest probability, either D-dimer testing followed by duplex ultrasound/serial duplex ultrasound, or duplex ultrasound/serial duplex ultrasound alone can be used for assessing patients suspected of having upper extremity DVT.
• A positive D-dimer alone should not be used to diagnose upper extremity DVT.

See the full recommendation for more information.

Management of high blood pressure in adults

(Developed by the AAFP, July 2022)

The 2022 Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP, was developed by the American Academy of Family Physicians and approved by the Board of Directors in July 2022. The guideline was then published in the American Family Physician.

Key recommendations

• Treat adults who have hypertension to a standard blood pressure target (less than 140/90 mm Hg) to reduce the risk of all-cause and cardiovascular mortality (strong recommendation; high-quality evidence).
  • Treating to a lower blood pressure target (less than 135/85 mm Hg) does not provide additional benefit at preventing mortality; however, a lower blood pressure target could be considered based on patient preferences and value.
• Consider treating adults who have hypertension to a lower blood pressure target (less than 135/85 mm Hg) to reduce risk of myocardial infarction (weak recommendation; moderate-quality evidence).
  • Although treatment to a standard blood pressure target (less than 140/90 mm Hg) reduced the risk of myocardial infarction, there was a small additional benefit observed with a lower blood pressure target. There was no observed additional benefit in preventing stroke with the lower blood pressure target.

See the full recommendation for more information.

Treatment of hypertension in adults over age 60

(Jointly Developed, January 2017; reaffirmed, 2022)

The guideline, Treatment of Hypertension in Adults Over Age 60 to Higher vs. Lower Targets, was developed by the American College of Physicians and the American Academy of Family Physicians.

Key recommendations

• Adults over age 60 with persistent systolic blood pressure ≥150 mm Hg should be treated to achieve a target systolic blood pressure of <150 mm Hg.
• Adults 60 years or older with a history of stroke or TIA may be treated to a lower target blood pressure of <140 mm Hg to reduce the risk of recurrent stroke.
• Adults over age 60 with a high cardiovascular risk may be treated to a lower target blood pressure of <140 mm Hg.
• Treatment goals should be based on a periodic discussion of the benefits and harms of specific blood pressure targets.

The AAFP continues its endorsement of the JNC8 guideline for the management of high blood pressure in adults. These recommendations are consistent with JNC8 and should be used to augment its guidance.

See the full recommendation for more information.

High blood pressure in children and adolescents

(Affirmation of Value*, February 2018)

The guideline, Screening and Management of High Blood Pressure in Children and Adolescents was developed by the American Academy of Pediatrics and categorized as Affirmation of Value by the American Academy of Family Physicians.

Key recommendations:

• Children and adolescents three years of age or older should have their blood pressured measured annually. Blood pressure checks should be performed at every health care encounter for children and adolescents who are obese, take medications that raise blood pressure, have renal disease, diabetes or a history of aortic arch obstruction or coarctation.
• Hypertension should be diagnosed in children and adolescents who have auscultatory-confirmed blood pressure readings greater than the 95^th percentile, based on sex, age, and height tables, at three different visits.
• Children and adolescents being evaluated for high BP should have a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history recorded and a physical examination to identify findings suggestive of secondary causes of hypertension. Electrocardiography should not be used for initial evaluation.
• Children and adolescents who have been diagnosed with hypertension should be counseled regarding lifestyle modifications including diet and physical activity.
• Children and adolescents who fail lifestyle modifications should be prescribed pharmacologic therapy. Treatment options may include an ACE inhibitor, ARB inhibitor, long-acting calcium channel blocker, or thiazide diuretic.
• Treatment goals for children and adolescents who have been diagnosed with hypertension should be a reduction in blood pressure to less than the 90^th percentile and less than 130/80 in adolescents aged 13 years or older.

See the full guideline for more recommendations, blood pressure tables, and treatment algorithms.

*The AAFP uses the category of “Affirmation of Value” to support clinical practice guidelines that provide valuable guidance, but do not meet our criteria for full endorsement. The primary reasons for not endorsing this guideline included:

• There was a lack of transparency in the methodology used for study evaluation.
• While recommendations based on expert opinion were identified, it was unclear how those recommendations were developed.
• The management of conflicts of interest was not well described.
• There was inadequate discussion of the potential harms of medications for long-term use in children.

The USPSTF recommends one-time screening with ultrasonography in men aged 65 to 75 who have ever smoked. The USPSTF recommends clinicians selectively offer screening with ultrasonography in men aged 65 to 75 who have never smoked rather than routinely screening all men in this group. The USPSTF recommends against routine screening with ultrasonography in women who have never smoked and have no family history.

See the full recommendation for more information.

Physicians should decide on an individual basis whether to initiate low-dose aspirin for the primary prevention of CVD in adults aged 40 to 59 who have a 10% or greater 10-year CVD risk. The USPSTF recommends against initiating low-dose aspirin for the primary prevention of CVD in adults 60 and older.

See the full recommendation for more information.

The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for atrial fibrillation.

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The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adding the ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP) level, or coronary artery calcium (CAC) score to traditional risk assessment for CVD in asymptomatic adults to prevent CVD events.

See the full recommendation for more information

The USPSTF recommends against screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at low risk of CVD events. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at intermediate or high risk of CVD events.

See the full recommendation for more information.

The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population.

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The AAFP recommends against genomics profiling to assess risk for cardiovascular disease. The net health benefit from the use of any genomic tests for the assessment of cardiovascular disease risk is negligible and there is no evidence that they lead to improved patient management or increased risk reduction.

Read the full clinical considerations

The AAFP recommends against routine testing for Factor V Leiden and/or prothrombin 2012G> (PT) in asymptomatic adult family members of patients with venous thromboembolism, for the purpose of considering primary prophylactic anticoagulation. This recommendation does not extend to patients with other risk factors for thrombosis such as contraception use.

Read the full clinical considerations.

The USPSTF recommends offering or referring adults with CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity.

See the full recommendation for more information.

The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement.

See the full recommendation for more information.

The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents.

See the full recommendation for more information.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for PAD and CVD risk with the ABI in asymptomatic adults.

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Proper ICD-10 coding of hypertension helps demonstrate the severity of the patient's illness, which can affect payment under value-based models.

This FPM Journal article walks through several patient scenarios to demonstrate proper diagnosis and procedure coding for suspected hypertension, primary or secondary hypertension, hypertensive crisis, and hypertension present with heart or kidney disease.

Five family medicine practices teamed up to improve patient outcomes by focusing on three specific hypertension measures. Read how they did it in this FPM Journal article.

Relying on in-office blood pressure readings to manage hypertension may not give an accurate picture of a patient’s condition. A growing body of evidence points toward 24-hour ambulatory monitoring as a better approach. Read more in this FPM Journal article.

The USPSTF recommends screening for and treating lipid disorders in adults aged 40 to 75 who have a 10-year cardiovascular risk of more than 10%, and recommends selectively offering treatment to those who have a 10-year cardiovascular risk of 7.5% to 10%.

See the full recommendation for more information.

The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger.

See the full recommendation for more information.

Management of blood cholesterol

(Affirmation of Value, December 2020)

The “VA/DOD Clinical Practice Guideline for the Management of Dyslipidemia for Cardiovascular Risk Reduction” was developed by the US Department of Veteran Affairs and the Department of Defense and categorized as Affirmation of Value by the American Academy of Family Physicians.

Key recommendations

• All adults should receive counseling on healthy diet and lifestyle to reduce risk of cardiovascular disease (CVD).
• CVD risk screening should include a lipid profile and a risk calculation*.
• Routine screening for dyslipidemia outside of the context of a cardiovascular risk assessment is not recommended.
• Individuals with an increased 10-year risk for cardiovascular disease (greater than 12%) should be counseled on healthy diet and lifestyle modifications to reduce risk. Additionally, shared decision making should be conducted to determine options for moderate intensity statins for primary prevention, if desired by the individual.
• Individuals with established atherosclerotic cardiovascular disease (ASCVD) should be treated with a moderate-dose statin following a shared decision-making discussion of benefits and harms. Routine use of non-statin lipid lowering drugs are not recommended.
• Routine monitoring of lipid level goals as part of secondary prevention is not recommended for individuals with established ASCVD.
• Individuals may be offered a high-dose statin only in select instances (e.g., ACS, multiple uncontrolled risk factors or recurrent CVD events on moderate-dose statin) following a discussion of the additional harms, small additional benefits, and patient preferences.

The AAFP uses the category of “Affirmation of Value” to support clinical practice guidelines that provide valuable guidance, but do not meet our criteria for full endorsement. The primary reasons for not endorsing this guideline included:

*While risk-based recommendations allow for more patient-centered discussions and treatment decisions, many calculators used to assess risk include race/ethnicity as a factor. The AAFP recognizes that these calculators are limited by their reliance on race as a risk factor and issues a strong call for research for methods to accurately assess risk based on social determinants of health and racism instead of race. The AAFP opposes the use of race as a proxy for biology or genetics in clinical evaluation and management and the following policy opposing the inappropriate use of race in clinical decision making: Race Based Medicine

• The guideline possessed small methodological flaws and issued several recommendations without strong evidence.
• Screening recommendations were not completely aligned with current AAFP-supported USPSTF recommendations for dyslipidemia.

See the full recommendation for more information.