High blood pressure should be treated earlier with lifestyle changes and in some patients with medication – at 130/80 mm Hg rather than 140/90 – based on new ACC and American Heart Association (AHA) guidelines for the detection, prevention, management and treatment of high blood pressure.

The new guidelines – the first comprehensive set since 2003 – lower the definition of high blood pressure to account for complications that can occur at lower numbers and to allow for earlier intervention. The new definition will result in nearly half of the U.S. adult population (46 percent) having high blood pressure, with the greatest impact expected among younger people. Additionally, the prevalence of high blood pressure is expected to triple among men under age 45, and double among women under 45, the guideline authors note. However, only a small increase is expected in the number of adults requiring antihypertensive medication.

"You've already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure," said Paul K. Whelton, MB, MD, MSc, FACC, lead author of the guidelines. "We want to be straight with people – if you already have a doubling of risk, you need to know about it. It doesn't mean you need medication, but it's a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches."

Blood pressure categories in the new guideline are:

• Normal: Less than 120/80 mm Hg;
• Elevated: Systolic between 120-129 and diastolic less than 80;
• Stage 1: Systolic between 130-139 or diastolic between 80-89;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

The guidelines eliminate the category of prehypertension, categorizing patients as having either Elevated (120-129 and less than 80) or Stage I hypertension (130-139 or 80-89). While previous guidelines classified 140/90 mm Hg as Stage 1 hypertension, this level is classified as Stage 2 hypertension under the new guidelines. In addition, the guidelines stress the importance of using proper technique to measure blood pressure; recommend use of home blood pressure monitoring using validated devices; and highlight the value of appropriate training of health care providers to reveal "white-coat hypertension." Other changes include:

• Only prescribing medication for Stage I hypertension if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease or calculation of atherosclerotic risk (using the same risk calculator used in evaluating high cholesterol).
• Recognizing that many people will need two or more types of medications to control their blood pressure, and that people may take their pills more consistently if multiple medications are combined into a single pill.
• Identifying socioeconomic status and psychosocial stress as risk factors for high blood pressure that should be considered in a patient's plan of care.

In a corresponding analysis of the guidelines' impact, Paul Muntner, PhD, et al., suggests "the 2017 ACC/AHA hypertension guideline has the potential to increase hypertension awareness, encourage lifestyle modification and focus antihypertensive medication initiation and intensification on US adults with high CVD risk."

The new ACC/AHA guidelines were developed with nine other health professional organizations and were written by a panel of 21 scientists and health experts who reviewed more than 900 published studies. They are the successor to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7), issued in 2003 and overseen by the National Heart, Lung, and Blood Institute (NHLBI). In 2013, the NHLBI asked the AHA and ACC to continue the management of guideline preparation for hypertension and other cardiovascular risk. The guidelines were published in the Journal of the American College of Cardiology and Hypertension. For a wide array of ACC-developed tools, resources and commentary for both clinicians and patients, visit the ACC's High Blood Pressure Guidelines Hub.

Keywords: AHA17, AHA Annual Scientific Sessions, Antihypertensive Agents, Blood Pressure Monitoring, Ambulatory, White Coat Hypertension, Blood Pressure, Risk Factors, Prehypertension, National Heart, Lung, and Blood Institute (U.S.), Prevalence, Cardiovascular Diseases, Stress, Psychological, Hypertension, Stroke, Systole, Hypercholesterolemia, Myocardial Infarction, Diabetes Mellitus, Renal Insufficiency, Chronic, Hospitalization, Social Class, Life Style, Health Personnel, Cholesterol

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