To better: Define, Diagnose, Measure, and Manage Hypertension

Hypertension is poorly managed, only 48.3 % are controlled nationwide

Where do we go wrong?

The Problem

Hypertension is a common, dangerous, expensive, time consuming, ailment. Depending on the cutoff Blood Pressure definition (140/90 or 130/90), Hypertension (HTN) affects 30 to 46% of the population.  It causes 18% of the heart attacks, 35% of the strokes, 39% of heart failure in men and 59% of heart failure in women and 23% of renal failure. It contributes to 500,000 deaths each year from cardiovascular disease. It costs $76 Billion dollars of the $351 Billion we spend yearly on cardiovascular disease. It consumes 42 million office visits per year. Despite its high prevalence, significant morbidity and mortality, and excessive cost, it is poorly managed. Only 48.3% are controlled.

Usual care

If the Blood Pressure (BP) is above goal in the office (130/80 or 140/90), patients come back for 2 more office visits. If the BP remains elevated, the diagnosis of Primary or Essential HTN is made, and doctors recommend lifestyle changes. After that fails, most providers start a diuretic (Are they the same? NO). If that fails, one of four classes of drugs (ACE, ARB, CCB, diuretics) are added in any order using a trial and error methodology. Meds are adjusted every few months. They are increased to maximally tolerated doses, following specialty guidelines. HTN is treated as a singular disease and there is no systematic workup for potential secondary causes. This approach fails in over half the patients. Only 48.3% are controlled to goal BP.

Where do we go wrong?


The definition is inappropriate. A high BP reading is not Hypertension. Everyone has a high reading during the day. It must be consistently elevated and the more time out of the day it is elevated, the worse it is for your brain, heart, and kidneys.  HTN is dynamic. It should be defined over a time frame. BP Load refers to the amount of time your BP is above the recommended goal BP. Your BP should be elevated less than 30% of the time.


Office based blood pressure is unreliable. If your BP is high in the office and high at home, you have hypertension. If your Blood Pressure is high in the office but normal at home, you have white coat hypertension that may not need treatment. If you were normal in the office but high at home, you would be misdiagnosed as normal when you in fact have dangerously high blood pressure.  Blood pressure varies by time of day with the highest readings usually occurring between 8:00 AM and noon and 4:00 PM and 8:00 PM and dipping when you sleep. It is best to monitor your blood pressure twice a day at a fixed time of your choosing between 8AM and noon and 4:00 PM in 8:00 PM three days a week (M,W,Saturday) or (T,T,Sunday) and report those numbers to your doctor.


The diagnosis is suspect. Presently, if your blood pressure is elevated on three occasions in the office and lifestyle changes do not control it, you would be diagnosed with "Hypertension" and started on a medication. This default diagnosis was originally called Essential Hypertension but is now called Primary Hypertension. Primary Hypertension means the doctor ruled out all secondary causes of Hypertension and this is not the case. There are more than 50 secondary causes of Hypertension with treatments that vary from medication to angioplasty to surgery. A systematic approach to diagnosis is preferred.


If the definition is inappropriate. The measurement is unreliable, and the diagnosis is suspect you have no change at management. Over the past 50 years hypertension has been managed with a trial-and-error approach. "Try this, let's see what happens" and the result with guidelines and everything available to modern medicine is worse than a coin flip. Less than half of patients are controlled.

Is there a better way?

  • The A4M method

    A4M uses home blood pressure load monitoring to define hypertension. We use peak diurnal home BP readings to approximate the highest BP levels over a 10-day timeframe. We use renin, aldosterone, and cortisol levels to help diagnosis the root cause of HTN. We use a proprietary drug sequencing algorithm to recommend a minimum number of drugs to control hypertension. We use templated Virtual Visits (VV) to reduce provider management time. We provide performance monitoring to determine best practice, relative drug costs, time management, disease distribution rates, drug side effect rates, event rates and outcomes. As the database grows machine learning will refine the algorithms for improved efficacy and further cost reductions.