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

The new ACC/AHA Hypertension Guidelines, presented at AHA Scientific Sessions in Anaheim, CA, now define hypertension as readings above 130/80 mmHg. The change from the old definition of >140/90 reflects the risk of complications associated with BP levels above 130/80 mmHg. This update also eliminated the category of prehypertension. People with those readings now will be categorized as having either Elevated or Stage I hypertension, to emphasize the risk associated with milder stages of elevated BP. According to the new definition, nearly half of the US adult population have hypertension, as opposed to 1 in 3 with the previous definition.

BP categories in the new guideline are:

• Normal : Less than 120/80 mmHg;
• Elevated : SBP between 120-129 and DBP less than 80;
• Stage 1 : SBP between 130-139 or DBP between 80-89;
• Stage 2 : SBP at least 140 or DBP at least 90 mmHg;
• Hypertensive crisis : SBP >180 and/or DBP >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.

By lowering the definition of hypertension, the guidelines recommend earlier intervention to prevent further BP increases and the complications of hypertension. High BP should be treated earlier with lifestyle changes and in some patients with medication. Once stage I hypertension has been identified, the type of treatment depends on the ASCVD risk of the patient. Medication, in addition to lifestyle changes, is only prescribed in those who have had a CVD event, or if they are at high ASCVD risk according to a risk score. Individuals at low risk should only be prescribed lifestyle intervention to lower BP. This approach ensures that treatment is focused on patients most likely to experience events.

The new guidelines stress the importance of using proper technique to measure BP. BP levels should be based on an average of two to three readings on at least two different occasions. Moreover, the guidelines stress the importance of home BP monitoring using validated devices and appropriate training of healthcare providers to reveal white-coat hypertension. Home readings can also identify masked hypertension, when pressure is normal in a medical setting but elevated at home.

Physicians should also recognize that many people will need two or more types of medications to control their BP, and that people may take their pills more consistently if multiple medications are combined into a single pill. Moreover, identifying socioeconomic status and psychosocial stress as risk factors for high BP is important and they should be considered in a patient’s plan of care.

During a dedicated media briefing on the new guidelines the question was raised why the SPRINT target of SBP <120 mmHg was not used. Considering that this guideline is meant to be applied to the general population, the committee members answered that it is wise to be more prudent at this time, until there is more randomized data available on different BP targets. Other trials however, even if they didn’t specifically address the question of the effect of using different targets, suggest that a lower BP is better. Naturally, RCTs offer the best evidence available. In case of SPRINT, it should be acknowledged that the trial population as well as the measuring methods were a little different. Thus, to extrapolate findings to an entire nation, the committee believes that the new target of 130/80 mmHg achieves an appropriate balance between efficacy and safety.

The new guidelines were developed by the American Heart Association, American College of Cardiology and nine other health professional organizations. They were written by a panel of 21 scientists and health experts who reviewed more than 900 published studies. The guidelines underwent a careful systematic review and approval process. Each recommendation is classified by the strength (class) of the recommendation followed by the level of evidence supporting the recommendation.

Watch a webcast with dr. Paul Whelton (chairman guideline committee) via this link

Disclosures

- Our reporting is based on the information provided at the AHA 2017 congress -

Find the 2017 Hypertension Guideline: Executive Summary online at Hypertension Read a corresponding analysis of the new guidelines by Muntner et al. published in JACC