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New Recommendations for Treatment of Hypertension
Hypertension, the world’s most common and modifiable cardiovascular risk factor, has been the focus of multiple clinical practice guidelines.
In hopes to address the ongoing controversies and to account for new evidence from recent trials that focused on hypertension, the American College of Cardiology and the American Heart Association (ACC/AHA) have now produced the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.
Notable Changes to Treatment Targets
One noteworthy change in the 2017 guideline relates to the definition of hypertension and treatment targets.
This guideline now categorizes:
- Normal
Systolic BP [SBP] <120 mm Hg
Diastolic BP [DBP] <80 mm Hg
- Elevated
Systolic BP [SBP] 120-129 mm Hg
Diastolic BP [DBP] <80 mm Hg
- Stage 1 hypertension
Systolic BP [SBP] 130-139 mm Hg
Diastolic BP [DBP] 80-89 mm Hg
- Stage 2 hypertension
Systolic BP [SBP] ≥140 mm Hg
Diastolic BP [DBP] ≥90 mm Hg
Clinically speaking, lowering the diagnostic thresholds for “hypertension” beyond previous guidelines will significantly increase the number of individuals with this diagnosis.
Heightening Thresholds and Goals for Hypertension
The 2017 ACC/AHA guideline also proposes more aggressive thresholds and goals for treatment relative to prior guidelines. Treatment recommendations are now based on an individual’s underlying cardiovascular disease (CVD) risk.
For those with known CVD or diabetes:
The guideline recommends intervention (both lifestyle and pharmacological treatment) for stage 1 hypertension (SBP ≥130 mm Hg or DBP ≥80 mm Hg).
For all others:
The guideline proposes use of BP-lowering medications in stage 1 hypertension only if a patient’s estimated 10-year atherosclerotic CVD (ASCVD) risk is 10% or higher.
For those with lower ASCVD risk:
Lifestyle modification is recommended until the individual reaches stage 2 hypertension (140/90 mm Hg), above which drug therapy is recommended.
In terms of treatment targets, for high-risk adults with known CVD or a 10-year ASCVD risk estimate greater than 10%, the BP targets are less than 130/80 mm Hg. For adults without CVD and an estimated 10-year ASCVD risk estimate less than 10%, BP less than 130/80 mm Hg is still targeted. These recommendations are the same for patients of all ages.
Smart Steps Forward for Hypertension Management
The 2017 guideline strategy of tailoring treatment to a combination of both BP and underlying 10-year estimated risk of ASCVD is a big step forward for hypertension management. This change reflects epidemiologic data showing that both underlying risk and change in BP while receiving treatment determine one’s absolute benefit from BP lowering.
Monitoring Changes:
The new guideline also provides a much more intensive recommendation concerning out-of-office and self-monitored BP. This guideline reiterates previous recommendations concerning office BP measurement and detection of white-coat hypertension. There is clearly strong evidence to suggest that knowing the BP of an individual outside the clinic setting is more predictive of outcomes than their clinic BP and brings the US guidelines more in line with those used already in Europe.
Medication Changes:
Strong recommendations concerning first-line medications and use of monotherapy compared with multidrug therapy are also a part of the new guideline. For first-line drugs, this guideline reiterates previous assessment that initiation of antihypertensive drug therapy can include:
- Thiazide diuretics
- Calcium channel blockers
- Angiotensin-converting enzyme inhibitors
- Angiotensin II receptor blockers
This guideline also recommends initiation of two first-line agents of different classes in adults when their BP is more than 20/10 mm Hg above their BP target, a strategy with increasing clinical evidence.
Bryan Heart remains at the forefront of heart care and is dedicated to monitoring and adapting to the latest clinical practice guidelines to ensure our patients receive the best possible care.
If you have questions regarding new recommendations for treatment of hypertension, or would like to refer a patient, call 402-483-3333.
Additional resources:
www.onlinejacc.org/content/early/2017/11/04/j.jacc.2017.11.006
