The 2017 guideline is an update of the “Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7), published in 2003. The 2017 guideline is a comprehensive guideline incorporating new information from studies regarding blood pressure (BP)-related risk of cardiovascular disease (CVD), ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), BP thresholds to initiate antihypertensive drug treatment, BP goals of treatment, strategies to improve hypertension treatment and control, and various other important issues.
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Normal, elevated, stage 1 hypertension, stage 2 hypertension.
Elevated BP is in the 120-129/>80 mm Hg, hypertension stage 1 is defined as 130-139 or 80-89 mm Hg. Hypertension stage 2 is defined as ≥140 or ≥90 mm Hg. Prior to labeling a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP.
Out-of-office and self-monitoring of BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, Corresponding BPs based on site/methods are: office/clinic 140/90, home 135/85.
It is reasonable to screen for the presence of white coat hypertension using either home BP or morning ambulatory BPM prior to diagnosis of hypertension. In adults with elevated office BP (120-129/<80) but not meeting the criteria for hypertension, screening for masked hypertension with home BP or daytime ABPM is reasonable.
For an adult 45 years of age without hypertension, the 40-year risk for developing hypertension is 93% for African Americans, 92% for Hispanics, 86% for whites, and 84% for Chinese adults.
In persons ≥30 years of age, higher SBP and DBP are associated with increased risk for CVD, angina, myocardial infarction (MI), heart failure (HF), stroke, peripheral arterial disease, and abdominal aortic aneurysm.
It is important to screen for and manage other CVD risk factors in adults with hypertension: smoking, diabetes, dyslipidemia, excessive weight, low fitness, unhealthy diet, psychosocial stress, and sleep apnea.
Basic testing for primary hypertension includes fasting blood glucose, complete blood cell count, lipids, basic metabolic panel, thyroid stimulating hormone, urinalysis, electrocardiogram with optional echocardiogram, uric acid, and urinary albumin-to-creatinine ratio.
Screening for secondary causes of hypertension is necessary for new-onset or uncontrolled hypertension in adults including drug-resistant (≥3 drugs), abrupt onset, age <30 years, excessive target organ damage (cerebral vascular disease, retinopathy, left ventricular hypertrophy, HF with preserved ejection fraction [HFpEF] and HF with reserved EF [HFrEF], coronary artery disease [CAD], chronic kidney disease [CKD], peripheral artery disease, albuminuria) or for onset of diastolic hypertension in older adults or in the presence of unprovoked or excessive hypokalemia.
Screening includes testing for CKD, renovascular disease, primary aldosteronism, obstructive sleep apnea, drug-induced hypertension (nonsteroidal anti-inflammatory drugs, steroids/androgens, decongestants, caffeine, monoamine oxidase inhibitors), and alcohol-induced hypertension. If more specific clinical characteristics are present, screening for uncommon causes of secondary hypertension is indicated (pheochromocytoma, Cushing’s syndrome, congenital adrenal hyperplasia, hypothyroidism, hyperthyroidism, and aortic coarctation).
All patients with an elevated BP (>120/>80 mmHg should be prescribed nonpharmacologic interventions to reduce BP include: weight loss for overweight or obese patients with a heart healthy diet, sodium restriction, and potassium supplementation within the diet; and increased physical activity with a structured exercise program.
The usual impact of each lifestyle change is a 4-5 mm Hg decrease in SBP and 2-4 mm Hg decrease in DBP; but diet low in sodium, saturated fat, and total fat and increase in fruits, vegetables, and grains (the Dash Diet) may decrease SBP by approximately 11 mm Hg.
Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP ≥130 mm Hg or a DBP ≥80 mm Hg, or for primary prevention in adults with no history of CVD but with an estimated 10-year ASCVD risk of ≥10% and SBP ≥130 mm Hg or DBP ≥80 mm Hg.
Use of BP-lowering medication is also recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and a SBP ≥140 mm Hg or a DBP ≥90 mm Hg.
The prevalence of hypertension is lower in women compared with men until about the fifth decade, but is higher later in life. While no randomized controlled trials have been powered to assess outcome specifically in women (e.g., SPRINT), other than special recommendations for management of hypertension during pregnancy, there is no evidence that the BP threshold for initiating drug treatment, the treatment target, the choice of initial antihypertensive medication, or the combination of medications for lowering BP differs for women compared with men.
For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of <130/80 mm Hg is recommended. For adults with confirmed hypertension, but without additional markers of increased CVD risk, a BP target of <130/80 mm Hg is recommended as reasonable.
In low-risk adults with elevated BP or stage 1 hypertension with low ASCVD risk, BP should be repeated after 3-6 months of nonpharmacologic therapy.
Adults with stage 1 hypertension and high ASCVD risk (≥10% 10-year ASCVD risk) should be managed with both nonpharmacologic and antihypertensive drug therapy with repeat BP in 1 month.
Adults with stage 2 hypertension should be evaluated by a primary care provider within 1 month of initial diagnosis, and be treated with a combination of nonpharmacologic therapy and 2 antihypertensive drugs of different classes with repeat BP evaluation in 1 month.
For adults with a very high average BP (e.g., ≥160 mm Hg or DBP ≥100 mm Hg), prompt evaluation and drug treatment followed by careful monitoring and upward dose adjustment is recommended.
Chlorthalidone (12.5-25 mg) is the preferred diuretic because of long half-life and proven reduction of CVD risk. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors should not be used in combination.
Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors should not be used in combination. ACE inhibitors and ARBs increase the risk of hyperkalemia in CKD and with supplemental K+ or K+-sparing drugs. ACE inhibitors and ARBs should be discontinued during pregnancy. Calcium channel blocker (CCB) dihydropyridines cause edema. Non-dihydropyridine CCBs are associated with bradycardia and heart block and should be avoided in HFrEF. Loop diuretics are preferred in HF and when glomerular filtration rate (GFR) is <30 ml/min. Amiloride and triamterene can be used with thiazides in adults with low serum K+, but should be avoided with GFR <45 ml/min.
First step to treating resistant hypertension is the assurance of compliance with low salt diet and medication. First line drugs for hypertension are an ACEi or ARBs, CCB, and chlorthalidone. Spironolactone or eplerenone is the preferred additional drug in resistant hypertension, and the treatment of primary aldosteronism. Beta-blockers are not first-line therapy except in CAD and HFrEF. Abrupt cessation of beta-blockers should be avoided.
Bisoprolol and metoprolol succinate are preferred in hypertension with HFrEF and bisoprolol when needed for hypertension in the setting of bronchospastic airway disease. Beta-blockers with both alpha- and beta-receptor activity such as carvedilol are preferred in HFrEF.
Alpha-1 blockers are associated with orthostatic hypotension; this drug class may be considered in men with symptoms of benign prostatic hyperplasia. Central acting alpha-1 agonists should be avoided, and are reserved as last-line due to side effects and the need to avoid sudden discontinuation. Direct-acting vasodilators are associated with sodium and water retention and must be used with a diuretic and beta-blocker.
Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, CCBs, and ACE inhibitors or ARBs.
Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target. Improved adherence can be achieved with once-daily drug dosing, rather than multiple dosing, and with combination therapy rather than administration of the free individual components.
For adults with confirmed hypertension and known stable CVD or ≥10% 10-year ASCVD risk, a BP target of <130/80 mm Hg is recommended. The strategy is to first follow standard treatment guidelines for CAD, HFrEF, previous MI, and stable angina, with the addition of other drugs as needed to further control BP.
In HFpEF with symptoms of volume overload, loop or thiazide with adequate potassium should be used for diuresis and treatment of hypertension, following which ACE inhibitors or ARBs and beta-blockers should be titrated to SBP <130 mm Hg. Treatment of hypertension with an ARB can be useful for prevention of recurrence of atrial fibrillation.
The blood pressure goal for patients with chronic kidney disease should be <130/80 mm Hg.
Treat patients with stage 3 or higher chronic kidney disease (CKD), or stage 1 or 2 CKD with albuminuria (>300 mg/day) with an ACE inhibitor to slow the progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated.
These patients require recognition of stroke acuity, stroke type and therapeutic objectives, which have not been fully studied in clinical trials.
For adults with acute intracranial hemorrhage and systolic blood pressure > 220 mm Hg, it may be reasonable to use continuous intravenous drug infusion with close BP monitoring to lower SBP. Immediate lowering of SBP to <140 mm Hg from 150-220 mm Hg is not of benefit to reduce death, and may cause harm.
In patients with acute ischemic stroke, blood pressure should be lowered slowly to <185/110 mm Hg prior to thrombolytic therapy and maintained to <180/105 mm Hg for at least the first 24 hours after initiating drug therapy.
It is reasonable to start or restart antihypertensive therapy for patients who are hospitalized for ischemic stroke when their blood pressure is stable at >140/90 mm Hg . In those who do not undergo reperfusion therapy with thrombolytics or endovascular treatment, if the BP is ≥220/120 mm Hg, the benefit of lowering BP is not clear, but it is reasonable to consider lowering BP by 15% during the first 24 hours post onset of stroke. However, initiating or restarting treatment when BP is <220/120 mm Hg within the first 48-72 hours post-acute ischemic stroke is not effective.
In patients who have suffered a stroke or transient ischemic attack, you should you start treatment after the first few days of the index event to reduce recurrence.
In patients who have suffered a stroke or transient ischemic attack but who have never have been previously treated for hypertension, those who have a BP ≥140/90 mm Hg should begin antihypertensive therapy a few days after the index event. Selection of drugs should be based on comorbidities. A goal of <130/80 mm Hg may be reasonable for those with a stroke, TIA, or lacunar stroke. For those with an ischemic stroke and no previous treatment for hypertension, there is no evidence of treatment benefit if the BP is <140/90 mm Hg.
You should initiative antihypertensive drug treatment in patients with diabetes mellitus when BP ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg. In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs may be considered in the presence of albuminuria.
The optimal antihypertensive drug therapy for patients with hypertension in the setting of the metabolic syndrome has not been clearly defined. Chlorthalidone was at least as effective for reducing CV events as the other antihypertensive agents in the ALLHAT study. Traditional beta-blockers should be avoided unless used for ischemic heart disease.
In patients with asymptomatic aortic stenosis hypertension should be treated with pharmacotherapy, starting at a low dose, and gradually titrated upward as needed.
In patients with chronic aortic insufficiency, treatment of systolic hypertension is reasonable with agents that do not slow the heart rate (e.g., avoid beta-blockers).
In patients with aortic disease, beta-blockers are recommended as the preferred antihypertensive drug class in patients with hypertension and thoracic aortic disease.
African-American patients with hypertension, but without heart failure or chronic kidney disease, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications (ACEi or ARB and CCB) are recommended to achieve a BP target of <130/80 mm Hg in most adults, especially in African American adults, with hypertension.
The treatment goal for elderly patients (≥65 years of age) who are ambulatory and community-dwelling is recommended at <130 mm Hg.
In an elderly person (≥65 years of age) with hypertension and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. BP lowering is reasonable to prevent cognitive decline and dementia.
Beta-blockers should be continued in persons with hypertension undergoing major surgery, as should other antihypertensive drug therapy until surgery. Discontinuation of ACE inhibitors and ARBs perioperatively may be considered.
In patients planning elective major surgery and SBP ≥180 mm Hg or DBP ≥110 mm Hg, deferring surgery may be considered.
Abrupt preoperative discontinuation of beta-blockers or clonidine may be harmful in patients with hypertension. Intraoperative hypertension should be managed with intravenous medication until oral medications can be resumed.
Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals; effective management of comorbid conditions; timely follow-up with the healthcare team; and adheres to CVD evidence-based guidelines.
Effective behavioral and motivational strategies are recommended to promote lifestyle modification.
A structured team-based approach including a physician, nurse, and pharmacist collaborative model is recommended, along with integrating home-based monitoring and telehealth interventions.
Outcome may be improved with quality improvement strategies at the health system, provider, and patient level. Financial incentives paid to providers can be useful.
Rubenfire M. 2017 Guideline for High Blood Pressure in Adults. November 13, 2017. Available here.