Toolkit for Implementing the Chronic Care Model in an Academic Environment: Residents, Staff, and Patients Working as a Team

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Toolkit for Implementing the Chronic Care Model in an Academic Environment

Hypertension Algorithm for Diabetes in Adults Goal BP <130/80 (Text Description)

The Hypertension Algorithm begins with a text box that reads:

Assess Blood Pressure
Evaluate meds/Reinforce lifestyle modification

Two arrows lead from it. The one to the left is labeled "BP <130/80 mmHg" and points to a box that reads:

Follow-up BP each visit
If microalbuminuria or nephropathy present (Table 1)

The arrow to the right is labeled "BP >130/80 mmHg" and points to a box that reads:

If DM1 ACE inhibitor (ACEi) therapy is first choice
If DM2 start ARB agent is first choice
If microalbuminuria or nephropathy present (Table 1)
If African-American—Consider starting ACE or ARB in combination with diuretic
If SBP >145mm Hg and/or DBP >90mmHg consider starting with combination antihypertensive therapy

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Reassess therapy in 1 week—titrate to at least ½ max dose (on average >3 medications will be needed to achieve blood pressure goals

Two arrows lead from this box to two boxes below it. The arrow to the left is labeled "BP <130/80 mmHg" and leads to a small box that reads:

Continue Therapy
BP Check Every Visit

The arrow to the right is labeled "BP >130/80 mmHg" and points to a box that reads:

Add Diuretic OR Calcium Channel Blocker (CCB) OR Beta Blocker
If Diuretic Chosen: (Preferred if no other compelling indciations)

Creatinine <1.8mg/dl Creatinine >1.8md/dl
Thiazide diuretic* Loop Diuretic
(*Max. dose 25md Hydrochlorothiazide or equivalent)

If Beta Blocker Chosen: (Strongly recommended if history of MI)
—Choose beta blocker without intrinsic sympathomimetic activity

If CCB Chosen:

If Diltiazem or Verapamil Chosen:

Pulse and conduction effects should be considered if combined with B blocker

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Reassess therapy in 1 week/Titrate to at least ½ max dose or add additional agent

Two arrows lead from this box to two boxes below it. The arrow to the left is labeled "BP <130/80 mmHg" and points to the small box that reads:

Continue Therapy
BP Check Every Visit

The arrow to the right is labeled "BP >130/80 mmHg" and points to a box that reads:

Add: Medication not chosen from above
OR/Consider discontinuation IF SBP doesn't drop by 10 or DBP doesn't drop by 5
OR/ Go to Alternative Treatment**

Two arrows lead from this box. The arrow to the left is labeled "BP <130/80 mmHg" and points to the small box that reads:

Continue Therapy
BP Check Every Visit

The arrow to the right is labeled "BP >130/80 mmHg" and points back up to the box that reads:

Add Diuretic OR Calcium Channel Blocker (CCB) OR Beta Blocker
If Diuretic Chosen: (Preferred if no other compelling indciations)

Creatinine <1.8mg/dl Creatinine >1.8md/dl
Thiazide diuretic* Loop Diuretic
(*Max. dose 25md Hydrochlorothiazide or equivalent)

If Beta Blocker Chosen: (Strongly recommended if history of MI)
—Choose beta blocker without intrinsic sympathomimetic activity

If CCB Chosen:

If Diltiazem or Verapamil Chosen:

Pulse and conduction effects should be considered if combined with B blocker

___________________________________________________________________________________________

Reassess therapy in 1 week/Titrate to at least ½ max dose or add additional agent

Table 1

Microalbuminuria/Proteinuria

In Type 2 patient, an ACEi or angiotensin receptor blocker (ARB) should be used first line.
In Type 1 patients, an ACEi is recommended to reduce protein excretion.
Concsider the use of verapamil or ditiazem in patient with proteinuria unable to tolerate ACEi or ARBs.

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