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cardio.htn.core.v1PRODUCTION
cardio.htn.core.v1

Hypertension (chronic management)

cardiologychronicadult
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Encounter flow

9/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Outpatient HTN per ACC/AHA 2017; acute crisis (>180/120 + end-organ) routes to hypertensive-emergency engine

Inputs
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Advance rule
Set
Advance when

patient is in chronic management context per ACC/AHA 2017 §4

Patient inputs (13)

AHA/ACC 2017 §7.1 PREVENT calculator + drug class tolerability

Treatment target driver per ACC/AHA 2017 Class I; SPRINT (Wright NEJM 2015)

Diastolic component per ACC/AHA 2017 §4 staging criteria

eGFR for ACEi/ARB titration per KDIGO 2021; CKD modifier

Baseline before ACEi/ARB/MRA per ACC/AHA 2017 §8; spironolactone for resistant HTN (PATHWAY-2, Williams Lancet 2015)

OSA reversible HTN driver per ESC/ESH 2023 §8.2 — STOP-BANG screening

Pregnancy → labetalol/methyldopa/nifedipine ER per ACOG 2019; AVOID ACEi/ARB (ACC/AHA 2017 Class III)

Drug-induced HTN (NSAID, decongestants, COCs, stimulants) per ESC/ESH 2023 Table 21; existing regimen

DM target <130/80 per ADA 2026; ACEi/ARB preference per ACC/AHA 2017 Class I

CKD/HTN overlap → ACEi/ARB Class I per KDIGO 2021

Concurrent ASCVD risk → AHA/ACC PREVENT calculator 2023

Hyperthyroidism reversible HTN driver per ESC/ESH 2023 §8.2 secondary causes

LVH, arrhythmia screen in HTN end-organ per ACC/AHA 2017 Class I

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningbp_above_180_120_with_end_organ
    BP ≥180/120 with end-organ damage (chest pain, dyspnea/pulm edema, neuro deficit, AKI, retinopathy) per ACC/AHA 2017 §11
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebp_above_180_120_no_end_organ
    BP ≥180/120 without acute target-organ damage — "severe hypertension" (2025 AHA/ACC HBP retires the term "hypertensive urgency")
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_htn
    Pregnancy confirmed in patient on ACEi/ARB/MRA — ACC/AHA 2017 Class III
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateresistant_htn_pattern
    BP not at goal on ≥3 agents incl. diuretic at max-tolerated doses with adherence verified per ACC/AHA 2017 §9.1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehyperkalemia_on_RAASi
    K+ ≥5.5 on ACEi/ARB/MRA combination per ACC/AHA 2017 §8
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateaki_after_RAASi_initiation
    Cr rise >30% after ACEi/ARB/diuretic initiation per KDIGO 2021
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

2025 AHA/ACC HTN — 4-tier stepwise add-on titration
axis: htn_2025_aha_stepwisestep 1 - Step 1 — Lifestyle + initial monotherapy or low-dose dual per ACC/AHA 2017 §8
Selected step "Step 1 — Lifestyle + initial monotherapy or low-dose dual per ACC/AHA 2017 §8" — Stage 1 HTN (130–139/80–89) with elevated CV risk OR Stage 2 (≥140/90) per ACC/AHA 2017 §4
  • amlodipine
    first line
    DHP_CCB
    2.5–5 mg • PO • once daily; titrate to 10 mg
    triggers: no_compelling_indication, isolated_systolic_HTN_elderly, Black_patient
    2025 AHA — first-line; ALLHAT/ACCOMPLISH; well tolerated
    rxcui 17767
  • lisinopril
    first line
    ACE_inhibitor
    5–10 mg • PO • once daily; titrate to 40 mg
    triggers: DM, CKD_with_proteinuria, HFrEF, post_MI
    Compelling indications — RAAS-preferred per ACC/AHA 2017 Class I; HOPE (Yusuf NEJM 2000)
    rxcui 29046
  • losartan
    first line
    ARB
    50 mg • PO • once daily; titrate to 100 mg
    triggers: ACEi_intolerant_cough, DM, CKD_with_proteinuria
    LIFE trial (Dahlöf Lancet 2002) — alternative if ACEi cough or angioedema; ACC/AHA 2017 Class I
    rxcui 52175
  • chlorthalidone
    first line
    thiazide_like_diuretic
    12.5 mg • PO • once daily; titrate to 25 mg
    triggers: no_compelling_indication, volume_predominant_phenotype
    2025 AHA prefers chlorthalidone over HCTZ — ALLHAT
    rxcui 2409

outpatient playbook — drug actions (6)

  1. 1. first-line single agent (ACEi or ARB or DHP-CCB or thiazide-like) per ACC/AHA 2017 §8
    rxcui 17767
    Amlodipine 5 mg OR lisinopril 10 mg OR losartan 50 mg OR chlorthalidone 12.5 mg per ACC/AHA 2017 Table 15 • PO • once daily
    trigger: Stage 1 with elevated risk OR Stage 2 single-drug start per ACC/AHA 2017 §8
    Choose by compelling indication per ACC/AHA 2017 Table 15: RAASi for DM/CKD/HFrEF; CCB for ISH/Black (ALLHAT JAMA 2002); thiazide-like for volume
  2. 2. two-drug combo at start if BP ≥20/10 above goal per ESC/ESH 2023 §7.2
    rxcui 29046
    Lisinopril 10 mg + amlodipine 5 mg (ACCOMPLISH preferred) OR + chlorthalidone 12.5 mg • PO • once daily
    trigger: BP ≥150/90 at presentation per ESC/ESH 2023 §7.2
    Combo at start improves time-to-goal per ESC/ESH 2023 Class I; ACCOMPLISH (Jamerson NEJM 2008)
  3. 3. add third agent — thiazide-like if not already on one per ACC/AHA 2017 §8
    rxcui 2409
    Chlorthalidone 12.5–25 mg (or HCTZ 25 mg) per ACC/AHA 2017 • PO • once daily
    trigger: BP not at goal on RAASi + CCB at 4–6 weeks per ACC/AHA 2017 §8
    Standard 3-drug ladder; ALLHAT (JAMA 2002)
  4. 4. spironolactone (resistant HTN) per PATHWAY-2 (Williams Lancet 2015)
    rxcui 9997
    12.5–25 mg titrated to 50 mg • PO • once daily
    trigger: BP not at goal on RAASi + CCB + thiazide at max-tolerated doses per ACC/AHA 2017 §9.1
    PATHWAY-2 Class I — first add-on for resistant HTN
  5. 5. beta-blocker for compelling indication per 2025 AHA/ACC HBP
    rxcui 221124
    Metoprolol succinate 25 mg titrated to 200 mg OR carvedilol 6.25 BID titrated to 25 BID • PO • daily / BID
    trigger: CAD / HFrEF / AF / post-MI per 2025 AHA/ACC HBP
    Compelling indication only; not first-line for uncomplicated HTN per 2025 AHA/ACC HBP (PMID 40811516) — LIFE losartan>atenolol HR 0.87 (0.77–0.98)
  6. 6. pregnancy-safe agent per 2025 AHA/ACC HBP pregnancy section
    rxcui 6185
    Labetalol 200–400 mg BID OR nifedipine ER 30–60 mg daily OR methyldopa 250 mg BID-TID • PO • BID-TID
    trigger: Pregnancy or planning pregnancy
    2025 AHA/ACC (PMID 40811516); AVOID ACEi/ARB/direct-renin-inhibitor/MRA/atenolol/nitroprusside in pregnancy (Class III)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Office BP ≥130/80 (US) or ≥140/90 (ESC) — confirmed; Home / ABPM elevated per ACC/AHA 2017 §5; Known HTN — titration / monitoring visit per ACC/AHA 2017 §9.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hypertension (chronic management)** (cardio.htn.core.v1).
Scope: Outpatient HTN per ACC/AHA 2017; acute crisis (>180/120 + end-organ) routes to hypertensive-emergency engine

No severity triggers fired against current inputs.

Plan

Regimen axis: **2025 AHA/ACC HTN — 4-tier stepwise add-on titration** — step "Step 1 — Lifestyle + initial monotherapy or low-dose dual per ACC/AHA 2017 §8".
1. amlodipine 2.5–5 mg PO once daily; titrate to 10 mg (DHP_CCB, first line) — 2025 AHA — first-line; ALLHAT/ACCOMPLISH; well tolerated
2. lisinopril 5–10 mg PO once daily; titrate to 40 mg (ACE_inhibitor, first line) — Compelling indications — RAAS-preferred per ACC/AHA 2017 Class I; HOPE (Yusuf NEJM 2000)
3. losartan 50 mg PO once daily; titrate to 100 mg (ARB, first line) — LIFE trial (Dahlöf Lancet 2002) — alternative if ACEi cough or angioedema; ACC/AHA 2017 Class I
4. chlorthalidone 12.5 mg PO once daily; titrate to 25 mg (thiazide_like_diuretic, first line) — 2025 AHA prefers chlorthalidone over HCTZ — ALLHAT

Setting playbook (outpatient) — Confirm diagnosis with out-of-office BP per ACC/AHA 2017 §5, achieve BP <130/80 (or syndrome-specific target per SPRINT Wright NEJM 2015), reduce ASCVD risk via medications + lifestyle, and screen for secondary HTN when warranted per ESC/ESH 2023 §8
5. first-line single agent (ACEi or ARB or DHP-CCB or thiazide-like) per ACC/AHA 2017 §8 Amlodipine 5 mg OR lisinopril 10 mg OR losartan 50 mg OR chlorthalidone 12.5 mg per ACC/AHA 2017 Table 15 PO once daily — Stage 1 with elevated risk OR Stage 2 single-drug start per ACC/AHA 2017 §8 (Choose by compelling indication per ACC/AHA 2017 Table 15: RAASi for DM/CKD/HFrEF; CCB for ISH/Black (ALLHAT JAMA 2002); thiazide-like for volume)
6. two-drug combo at start if BP ≥20/10 above goal per ESC/ESH 2023 §7.2 Lisinopril 10 mg + amlodipine 5 mg (ACCOMPLISH preferred) OR + chlorthalidone 12.5 mg PO once daily — BP ≥150/90 at presentation per ESC/ESH 2023 §7.2 (Combo at start improves time-to-goal per ESC/ESH 2023 Class I; ACCOMPLISH (Jamerson NEJM 2008))
7. add third agent — thiazide-like if not already on one per ACC/AHA 2017 §8 Chlorthalidone 12.5–25 mg (or HCTZ 25 mg) per ACC/AHA 2017 PO once daily — BP not at goal on RAASi + CCB at 4–6 weeks per ACC/AHA 2017 §8 (Standard 3-drug ladder; ALLHAT (JAMA 2002))
8. spironolactone (resistant HTN) per PATHWAY-2 (Williams Lancet 2015) 12.5–25 mg titrated to 50 mg PO once daily — BP not at goal on RAASi + CCB + thiazide at max-tolerated doses per ACC/AHA 2017 §9.1 (PATHWAY-2 Class I — first add-on for resistant HTN)
9. beta-blocker for compelling indication per 2025 AHA/ACC HBP Metoprolol succinate 25 mg titrated to 200 mg OR carvedilol 6.25 BID titrated to 25 BID PO daily / BID — CAD / HFrEF / AF / post-MI per 2025 AHA/ACC HBP (Compelling indication only; not first-line for uncomplicated HTN per 2025 AHA/ACC HBP (PMID 40811516) — LIFE losartan>atenolol HR 0.87 (0.77–0.98))
10. pregnancy-safe agent per 2025 AHA/ACC HBP pregnancy section Labetalol 200–400 mg BID OR nifedipine ER 30–60 mg daily OR methyldopa 250 mg BID-TID PO BID-TID — Pregnancy or planning pregnancy (2025 AHA/ACC (PMID 40811516); AVOID ACEi/ARB/direct-renin-inhibitor/MRA/atenolol/nitroprusside in pregnancy (Class III))

Non-pharmacologic actions:
- DASH diet, sodium <1500 mg/d, weight loss to BMI <25, alcohol <2 drinks/d (men) <1 (women) per ACC/AHA 2017 §6.2 Class I
- Aerobic exercise 150 min/week + resistance training 2x/week per ACC/AHA 2017 §6.2 Class I
- Smoking cessation pharmacotherapy + counselling per ACC/AHA 2017 §6.2
- OSA evaluation if STOP-BANG ≥3 per ESC/ESH 2023 §8.2
- Home BP monitor with validated device + technique training per ESC/ESH 2023 §4
- Renal denervation referral for resistant HTN refractory to spironolactone (Class IIb 2025 AHA/ACC HBP — RADIANCE-HTN/SPYRAL); SYMPLICITY HTN-3 (Bhatt NEJM 2014)
- Vaccinations (flu, pneumococcal, COVID, RSV) per AHA 2024 prevention guidance

AVOID / contraindication checks:
- ACEi_ARB_avoid_pregnancy — ACC/AHA 2017 Class III
- ACEi_ARB_avoid_bilateral_RAS — ACC/AHA 2017 Class III
- Thiazide_avoid_severe_hypoNa — ESC/ESH 2023 §7.3
- MRA_avoid_K_above_5_or_eGFR_below_30 — PATHWAY 2 (Williams Lancet 2015) exclusion
- Nondhpccb_avoid_with_BB_brady — ESC/ESH 2023 §7.4
- Beta_blocker_avoid_decompensated_HF — ACC/AHA 2017 Table 15

Monitoring

Regimen monitoring:
- BMP 2 weeks after ACEi/ARB/thiazide/MRA initiation per ACC/AHA 2017 §8
- BMP q3–6 months on RAAS/diuretic/MRA combo per ACC/AHA 2017 §8
- Home BP 2x morning + 2x evening x 7 days pre-visit per ESC/ESH 2023 §4
- Urine ACR annually if DM or CKD per KDIGO 2021
- eGFR annually per KDIGO 2021
- Lipid panel annually per ACC/AHA 2019 lipid guideline
- Orthostatic BP in elderly or diabetic per ACC/AHA 2017 §5; SPRINT (Wright NEJM 2015)

Setting (outpatient) monitoring:
- BP at every visit; home BP series before each visit per ACC/AHA 2017 §5 Class I
- BMP 1–2 weeks after ACEi/ARB/diuretic/MRA start or dose change; then q3–6 months per ACC/AHA 2017 §8
- Annual lipid + A1c + urine ACR + eGFR per ACC/AHA 2017 §6; KDIGO 2021
- Annual ECG; echo if LVH/HF suspicion per ESC/ESH 2023 §5

Follow-up plan: Visit cadence by control + comorbidity per ACC/AHA 2017 §9; ASCVD prevention bundle
- Close-out criterion: follow-up scheduled per ACC/AHA 2017 §9

Monitoring phase: Home BP series per ACC/AHA 2017 §5; BMP at 1–2 wks after ACEi/ARB/diuretic change; lipid + A1c per ASCVD plan

Disposition

Current setting: outpatient — Confirm diagnosis with out-of-office BP per ACC/AHA 2017 §5, achieve BP <130/80 (or syndrome-specific target per SPRINT Wright NEJM 2015), reduce ASCVD risk via medications + lifestyle, and screen for secondary HTN when warranted per ESC/ESH 2023 §8

Disposition criteria:
- At goal (<130/80) → q3–12 month visits per ACC/AHA 2017 §9
- Not at goal → q4–6 week titration visits per ACC/AHA 2017 §9
- Resistant → HTN specialist referral per ACC/AHA 2017 §9.1; PATHWAY-2 (Williams Lancet 2015)

Escalation triggers (move to higher acuity):
- BP ≥180/120 with end-organ damage → ED for hypertensive emergency per ACC/AHA 2017 §11
- Persistent BP >150/90 on triple therapy → secondary HTN workup (ARR, plasma metanephrines, RAS imaging, OSA, urinary cortisol) per ESC/ESH 2023 §8
- New AKI / hyperkalemia → hold RAAS/MRA, BMP recheck per KDIGO 2021
- Pregnancy planned/confirmed → switch off ACEi/ARB/MRA per ACOG 2019; ACC/AHA 2017 Class III

Patient Action Plan

**Hypertension home BP monitoring + escalation plan per ACC/AHA 2017 §5**
Personalised values: target_BP, home_meds, baseline_eGFR, pregnancy_status.

**At goal — average home BP <130/80 (or personalised target) per ACC/AHA 2017 §8** (green):
Triggers:
- 7-day morning + evening home BP average <130/80 per ACC/AHA 2017 §5
- No symptoms of orthostasis, fatigue, or new headache per ACC/AHA 2017 §5
Actions:
- Continue all current medications per ACC/AHA 2017 §9
- Continue DASH diet, low-sodium intake, exercise per ACC/AHA 2017 §6.2
- Bring home BP log to next visit per ESC/ESH 2023 §4
- Annual labs (BMP, lipid, A1c, urine ACR) per ACC/AHA 2017 §6

**Caution — average home BP 130–159/80–99 OR new mild symptoms per ACC/AHA 2017 staging** (yellow):
Triggers:
- 7-day average 130–159/80–99 per ACC/AHA 2017 Stage 1–2 thresholds
- Occasional readings ≥160/100 but not sustained per ESC/ESH 2023 §4
- Mild new headache, fatigue, or peripheral edema per ACC/AHA 2017 §8 ADR monitoring
Actions:
- Check technique (cuff size, position, rest 5 min, no caffeine/cigarette in 30 min) per ACC/AHA 2017 §5
- Review medication adherence (missed doses?) per AHA 2020
- Reduce salt; avoid NSAIDs and decongestants per ACC/AHA 2017 §6.2
- Call provider within 1 week for titration per ACC/AHA 2017 §9
Contact provider when:
- Home BP average >150/95 for ≥3 days per ACC/AHA 2017 §9
- Side effects (cough, dizziness, swelling, AKI symptoms) per ACC/AHA 2017 §8
- Pregnancy planned or suspected per ACOG 2019

**Medical alert — BP ≥180/120 OR end-organ symptoms per ACC/AHA 2017 §11** (red):
Triggers:
- BP ≥180/120 on home device on ≥2 readings 5 min apart per ACC/AHA 2017 §11
- Severe headache, vision change, chest pain, dyspnea, weakness, slurred speech, confusion per ACC/AHA 2017 §11 end-organ signs
- New shortness of breath, swelling, oliguria per ACC/AHA 2017 §11
- Pregnancy + BP ≥160/110 OR severe-features symptoms per ACOG 2019
Actions:
- Call 911 / go to ED immediately if any end-organ symptom per ACC/AHA 2017 §11
- If asymptomatic and BP >180/120: take home meds as prescribed, recheck in 30 min, call provider same day per ACC/AHA 2017 §11
- Do NOT self-administer extra doses unless action plan specifically allows per ACC/AHA 2017
- Bring all medication bottles to ED for reconciliation per AHA 2020
Contact provider when:
- Any red zone trigger — call now, do not wait for office hours per ACC/AHA 2017 §11

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] BP ≥180/120 with end-organ damage (chest pain, dyspnea/pulm edema, neuro deficit, AKI, retinopathy) per ACC/AHA 2017 §11
- [SEVERE] BP ≥180/120 without acute target-organ damage — "severe hypertension" (2025 AHA/ACC HBP retires the term "hypertensive urgency")
- [SEVERE] Pregnancy confirmed in patient on ACEi/ARB/MRA — ACC/AHA 2017 Class III

Citations

- 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM HBP Guideline (retires 2017) + ESC 2024 + KDIGO 2021 BP in CKD + ADA 2026 [PMID:40811516](https://pubmed.ncbi.nlm.nih.gov/40811516/)
- Cited evidence (PMID 40811497) [PMID:40811497](https://pubmed.ncbi.nlm.nih.gov/40811497/)
- Cited evidence (PMID 26551272) [PMID:26551272](https://pubmed.ncbi.nlm.nih.gov/26551272/)
- Cited evidence (PMID 39555827) [PMID:39555827](https://pubmed.ncbi.nlm.nih.gov/39555827/)
- Cited evidence (PMID 38945140) [PMID:38945140](https://pubmed.ncbi.nlm.nih.gov/38945140/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM HBP Guideline (retires 2017) + ESC 2024 + KDIGO 2021 BP in CKD + ADA 2026 — PMID:40811516
  • Cited evidence (PMID 40811497) — PMID:40811497
  • Cited evidence (PMID 26551272) — PMID:26551272
  • Cited evidence (PMID 39555827) — PMID:39555827
  • Cited evidence (PMID 38945140) — PMID:38945140