2017 Guideline for High Blood Pressure in Adults

Authors:
Whelton PK, Carey RM, Aronow WS, et al.
Citation:
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017;Nov 13:[Epub ahead of print].

The following are key points to remember from the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:

Part 1: General Approach, Screening, and Follow-up

  1. 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.
  2. It is critical that health care providers follow the standards for accurate BP measurement. BP should be categorized as normal, elevated, or stages 1 or 2 hypertension to prevent and treat high BP. Normal BP is defined as <120/<80 mm Hg; elevated BP 120-129/<80 mm Hg; hypertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥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, in conjunction with clinical interventions and telehealth counseling. Corresponding BPs based on site/methods are: office/clinic  140/90, HBPM 135/85, daytime ABPM 135/85, night-time ABPM 120/70, and 24-hour ABPM 130/80 mm Hg. In adults with an untreated systolic BP (SBP) >130 but <160 mm Hg or diastolic BP (DBP) >80 but <100 mm Hg, it is reasonable to screen for the presence of white coat hypertension using either daytime ABPM or HBPM 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 daytime ABPM or HBPM is reasonable.
  3. 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 2010, hypertension was the leading cause of death and disability-adjusted life-years worldwide, and a greater contributor to events in women and African Americans compared with whites.  Often overlooked, the risk for CVD increases in a log-linear fashion; from SBP levels <115 mm Hg to >180 mm Hg, and from DBP levels <75 mm Hg to >105 mm Hg. A 20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. 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. SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, SBP; this is not true for DBP.
  4. 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.
  5. 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). Physicians are advised to refer patients screening positive for these conditions to a clinician with specific expertise in the condition.
  6. 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. Men should be limited to no more than 2 and women no more than 1 standard alcohol drink(s) per day. 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 may decrease SBP by approximately 11 mm Hg.
  7. The benefit of pharmacologic treatment for BP reduction is related to atherosclerotic CVD (ASCVD) risk. For a given magnitude reduction of BP, fewer individuals with high ASCVD risk would need to be treated to prevent a CVD event (i.e., lower number needed to treat) such as in older persons, those with coronary disease, diabetes, hyperlipidemia, smokers, and CKD. 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.
  8. Follow-up: 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.

Part 2:  Principles of Drug Therapy and Special Populations

  1. Principles of drug therapy: 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. 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.

    Spironolactone or eplerenone is preferred for the treatment of primary aldosteronism and in resistant hypertension. 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.
  2. 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, diuretics should be used to control 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.
  3. CKD: BP goal should be <130/80 mm Hg. In those with stage 3 or higher CKD or stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated.
  4. Adults with stroke and cerebral vascular disease are complex. To accommodate the variety of important issues pertaining to BP management in the stroke patient, treatment recommendations require recognition of stroke acuity, stroke type, and therapeutic objectives, which along with ideal antihypertensive therapeutic class have not been fully studied in clinical trials. In adults with acute intracranial hemorrhage and SBP >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 acute ischemic stroke, BP 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. Starting or restarting antihypertensive therapy during the hospitalization when patients with ischemic stroke are stable with BP >140/90 mm Hg is reasonable. 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.

    Secondary prevention following a stroke or transient ischemic attack (TIA) should begin by restarting treatment after the first few days of the index event to reduce recurrence. Treatment with ACE inhibitor or ARB with thiazide diuretic is useful. Those not previously treated for hypertension and 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.
  5. Diabetes mellitus (DM) and hypertension: Antihypertensive drug treatment should be initiated at a 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.
  6. Metabolic syndrome: Lifestyle modification with an emphasis on improving insulin sensitivity by means of dietary modification, weight reduction, and exercise is the foundation of treatment of the metabolic syndrome. 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.
  7. Valvular heart disease: Asymptomatic aortic stenosis with 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).
  8. Aortic disease: Beta-blockers are recommended as the preferred antihypertensive drug class in patients with hypertension and thoracic aortic disease.
  9. Race/ethnicity: In African American adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults, especially in African American adults, with hypertension.
  10. Age-related issues: Treatment of hypertension is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age), with an average SBP ≥130 mm Hg with SBP treatment goal of <130 mm Hg. For older adults (≥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.
  11. Preoperative surgical procedures: 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. For patients with planned 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. Intraoperative hypertension should be managed with intravenous medication until oral medications can be resumed.
  12. For discussion regarding hypertensive crises with and without comorbidities, refer to Section 11.2: Hypertensive Crises–Emergencies and Urgencies in the Guideline.
  13. 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.

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