, monthly) until: Blood pressure is at goal Treatment regimen is optimized (see Sidebar 6) Comorbid conditions and/or other patient preferences direct otherwise No Follow up annually or more frequently as dictated by comorbid conditions (to include lab monitoring, if indicated) Yes Implement SDM to assess patient values and preferences; assess the need for and implement lifestyle modification Is the patient willing to engage in pharmacotherapy? Patient refuses pharmacotherapy; consider nurse-led and dietitian-led interventions to improve blood pressure control Patient appropriate for HTN treatment The Diagnosis and Management of Hypertension in the Primary Care Setting Module A: Screening and Diagnosis VA/DoD CLINICAL PRACTICE GUIDELINES March 2020 VA/DoD CLINICAL PRACTICE GUIDELINES March 2020 Sidebar 6: Optimize Treatment Assess adherence Consider evaluating for interfering substances (some prescription medications, NSAIDs, alcohol, recreational drugs) Consider evaluating and addressing contributing lifestyle factors Optimize treatment (refer to Appendix F, Table F-1 in the full CPG) Titrate initial drug Add another agent from a different class Reevaluate diagnosis (resistant HTN, secondary causes of HTN) Consider specialty consultation for patients with resistant HTN Consider co-interventions to enhance management of HTN and improve blood pressure (pharmacist-led, nurse-led, dietitian-led) DASH Diet Protocol Nutrient Recommended Intake Saturated fat 6% of total calories Total fat 27% of total calories Carbohydrate 55% of total calories Dietary fiber 30 grams/day Protein 18% of total calories Cholesterol 150 mg/day Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/prevent weight gain Mediterranean Diet Protocol Food Item Goal Recommended Items Olive oil 4 tbsp per day Tree nuts and peanuts 3 servings per week Fresh fruits including natural fruit juices 3 servings per day Vegetables 2 servings per day Seafood (primarily fatty fish) 3 servings per week Legumes 3 servings per week Sofritoa 2 servings per week White meat In place of red meat Wine with meals 7 glasses per week, for those who drinkb Discouraged Items Soda drinks <1 drink per day Commercial baked goods, sweets, pastriesc <3 servings per week Spread fats <1 serving per day Red and processed meats <1 serving per day Guidance Conducting Home Blood Pressure Measurement Preparation Have an empty bladder; rest quietly, without talking or texting, in seated position with back supported for at least five minutes Position Sit with back supported; keep both feet flat on the floor Cuff should be on bare arm; directly above the bend of the arm, pulled taut Center of the bladder of the cuff (commonly marked on the cuff) should be placed over the arterials pulsation of the patient s bare upper arm The arm with the cuff should be supported on a flat surface Number of readings Take 2 readings at least 1 minute apart in the morning before any antihypertensive medications and 2 readings at least 1 minute apart in the evening before bed for a total of 4 readings Duration of monitoring Preferred monitoring period is 7 days; a minimum period of 3 days may be sufficient, ideally in the period immediately before the next appointment Analyzing readings For each monitoring period, average all of the readings If the first day of readings is excluded, as sometimes recommended, the minimum of preferred periods of HBPM should be 4 and 8 days, respectively Guidance Conducting Office Blood Pressure Measurement Properly prepare the patient Have the patient relax, sitting in a chair with feet flat on floor and back supported for 3 5 minutes without talking or moving around before recording the first reading Avoid caffeine, exercise, and smoking for 30 minutes before measurement Ensure that the patient has emptied his/her bladder The patient nor the observer should talk during rest period or the measurement Remove clothing covering the location of cuff placement Sitting on an examining table does not fulfill these criteria Use proper technique (attended or unattended, fully AOBP measurement is preferred) Use a validated upper-arm cuff measurement device that has been calibrated Support the patient s arm (e.g.