Hypertension Redefined: A Closer Look at the 2017 ACC/AHA Guidelines

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The new blood pressure guidelines emphasize the importance of healthy lifestyle, including a structured exercise program.
The new blood pressure guidelines emphasize the importance of healthy lifestyle, including a structured exercise program.

New guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) provide evidence-based recommendations for the prevention, identification, assessment, and treatment of hypertension in adult patients, including a new categorization for high blood pressure (BP) as well as lifestyle modification suggestions for the prevention and treatment of stage 1 and stage 2 hypertension.1

The committee, comprised members from the ACC/AHA, performed systematic reviews and meta-analyses of the recent literature regarding BP monitoring, optimal BP target, benefits vs harms of specific antihypertensive medications, monotherapy vs combination antihypertensive therapy, and the effect of lifestyle modification on hypertension risk and prognosis.

 

Based on the analyses, the ACC/AHA guideline renders the term “prehypertension” obsolete, and instead, replaces the term with “elevated BP.” The guideline states that elevated BP is defined as an average systolic BP of 120 mm Hg to 129 mm Hg and an average diastolic BP of <80 mm Hg. Stage 1 hypertension has now been expanded to be defined as an average systolic BP of 130 mm Hg to 139 mm Hg or average diastolic BP of 80 mm Hg to 89 mm Hg. In addition, the committee indicates that stage 2 hypertension should be categorized as a mean systolic BP of ≥140 mm Hg or a mean diastolic BP of ≥90 mm Hg, compared with previous recommendations of 160/100 mm Hg from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in 2003.

In addition, the new guidelines from the ACC/AHA suggest that clinicians should establish their BP estimates on a mean of at least 2 readings taken on at least 2 different occasions. Out-of-office BP measurements are also recommended to validate hypertension, identify white coat hypertension, and titrate medication.

Lifestyle modification in conjunction with antihypertensive medication is highlighted as a cornerstone of BP therapy in the new 2017 ACC/AHA guidelines. In patients with existing or increased risk for cardiovascular disease, lifestyle modification and drug therapy are recommended. Weight loss in overweight or obese adults, a class 1 recommendation, is expected to reduce BP approximately 1 mm Hg per kilogram of weight loss. The Dietary Approaches to Stop Hypertension diet as well as sodium reduction are also recommended for patients with elevated hypertension or stage 1 and 2 hypertension.1,2 In addition, supplementation with dietary potassium, initiation of a structured and consistent exercise program, and the avoidance or reduction in alcohol consumption are additional lifestyle modifications that appear to provide effective BP lowering based on the committee's findings.1,2

The guidelines recommend that high-risk patients with stage 1 hypertension with preexisting cardiovascular disease and a mean BP of ≥130/80 mm Hg should undergo drug treatment. The BP threshold for drug treatment in patients without preexisting cardiovascular disease is ≥140/90 mm Hg.

Although the guideline appears to provide feasible evidence-based approaches for managing BP, an accompanying editorial by Timothy J. Wilt, MD, suggests the guidelines fail to compare the benefits vs harms of certain interventions, the associated costs, and the variation in each patient's preferences.2

The guidelines also recommend a team-based care approach for patients with hypertension as well as the use of patient registries and electronic health record data for “recognizing uncontrolled hypertension and guiding initiatives for quality improvement in hypertension control.”1,3

References

  1. Carey RM, Whelton PK; for the 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension guideline [published online January 23, 2018]. Ann Intern Med. doi:10.7326/M17-3203
  2. Wilt TJ, Kansagara D, Qaseem A; for the Clinical Guidelines Committee of the American College of Physicians. Hypertension limbo: balancing benefits, harms, and patient preferences before we lower the bar on blood pressure [published online January 23, 2018]. Ann Intern Med. doi:10.7326/M17-3293
  3. Carey RM, Whelton PK. The 2017 American College of Cardiology/American Heart Association Hypertension guideline: a resource for practicing clinicians [published online January 23, 2018]. Ann Intern Med. doi:10.7326/M18-0025
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