Clinical Context

Hypertension is not only 1 of the most common chronic diseases of adulthood, but it is a leading cause of disability and mortality worldwide. The current recommendations include a brief review of the effect of hypertension in the United States.

Hypertension is the number 1 modifiable risk factor for cardiovascular disease in the United States, and it trails only cigarette smoking as the leading modifiable risk factor for all-cause mortality. Research shows that more than half of cases of cardiovascular death are associated with hypertension, and approximately one quarter of all cardiovascular events are attributable to hypertension. The effects of hypertension in promoting cardiovascular disease appear more prominent among women vs men and among blacks vs whites.

In 2014, the American Heart Association (AHA) and American College of Cardiology (ACC) convened a 21-member panel to develop new guidelines for the diagnosis and management of hypertension. The recommendations from this panel are summarized here.

Study Synopsis and Perspective

The ACC and the AHA have released a new guideline on hypertension with a new definition that calls 130 to 139 mm Hg systolic and or 80 to 89 mm Hg stage 1 hypertension.

Officially called the 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 document includes new recommendations on the definition of hypertension and systolic and diastolic blood pressure (BP) thresholds for initiation of treatment with antihypertensive medications, and an aggressive new BP treatment target.

The guidelines were released here at the AHA 2017 Scientific Sessions and published simultaneously in the Journal of the American College of Cardiology,^[1] and in the AHA journal Hypertension.^[2]

"The goal was to provide a comprehensive guideline for diagnosis, prevention, evaluation, treatment, and very important, strategies to improve control rates during treatment," Dr Paul Whelton (Tulane University School of Public Health and Tropical Medicine, New Orleans, LA), chair of the 2017 Hypertension Practice Guidelines, said at a press conference.

Dr Whelton pointed to 5 main areas of emphasis in the new guideline:

• A strong emphasis on BP measurement, both on accuracy of BP measurements and on using the average of measures taken over several visits, as well as an emphasis on out-of-office BP measurements, "which is relatively new for a [BP] guideline," Dr Whelton noted.
• A new BP classification system, updating the previous "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure" (JNC7) guidelines. "We thought the evidence supported a slightly new classification system," Dr Whelton said.
• A new approach to decision-making for treatment that incorporates underlying cardiovascular risk.
• Lower targets for BP during the management of hypertension.
• Strategies to improve BP control during treatment, with an emphasis on lifestyle approaches.

The definition of normal BP has not changed from the previous document, Dr Whelton noted, but the new guidelines eliminate the classification of prehypertension and divide those BP levels previously called prehypertension into elevated BP, with a systolic pressure between 120 and 129 and diastolic pressure less than 80 mm Hg, and stage 1 hypertension, which they now define as a systolic pressure 130 to 139 or a diastolic pressure of 80 to 89 mm Hg.

The writing committee did not like the term prehypertension for patients particularly in that higher range, Dr Whelton said, "because we felt at that stage somebody is already at substantial increased risk -- double the risk for a heart attack compared with somebody in a normal [BP] range -- so we think stage 1 hypertension is the appropriate term, and that will capture the risk for adults and for clinicians much better."

BP Classification by JNC7 and 2017 ACC/AHA Hypertension Guidelines

Dr Whelton was also senior author on an accompanying study meant to look at the theoretical effects of the definitions and treatment goals in the new guideline vs those set out in the previous JNC7 guideline.^[3]

The study, with first author Dr Paul Munter (School of Public Health, University of Birmingham, Alabama), concludes that compared with the JNC7 guideline, the 2017 ACC/AHA guideline "results in a substantial increase in the prevalence of hypertension, but a small increase in the percentage of US adults recommended antihypertensive medication," adding that the 2017 ACC/AHA guidelines recommend that a substantial proportion of US adults receiving antihypertensive medication be treated with more intensive BP lowering.

Prevalence of Hypertension According to JNC7 and 2017 ACC/AHA Guidelines

The reason that prevalence will increase substantially but patients receiving treatment will only increase moderately is that the recommendations for stage 1 hypertension treatment are guided by the patients' underlying cardiovascular risk: only those with clinical cardiovascular disease or an estimated risk of 10% or more of atherosclerotic cardiovascular disease would be offered treatment, and the remainder should be given advice on lifestyle modification.

Dr Robert M. Carey (University of Virginia School of Medicine), vice-chair of the writing committee, discussed the committee's recommendations for treatment of hypertension: "Lifestyle modification is the cornerstone of the treatment of hypertension, and we expect that this guideline will cause our society and our physician community to really pay attention much more to lifestyle recommendations," Carey said during the briefing.

Specific recommendations include advice to lose weight, follow a Dietary Approaches to Stop Hypertension (DASH) pattern diet, reduce sodium to less than 1500 mg/day and increase potassium intake to 3500 mg/day through dietary intake, increase physical activity to a minimum of 30 minutes of exercise 3 times per week, and limit alcohol intake to 2 drinks or less per day for men and 1 or less for women.

Dr Carey noted that they are recommending the ACC/AHA Pooled Cohort Equations to estimate the 10-year atherosclerotic cardiovascular disease risk, taking into account age, race, sex, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, treatment with aspirin or a statin, systolic BP, treatment for hypertension, history of diabetes, and current smoking.

Finally, he pointed to new goals for treatment of hypertension: "This has decreased since the last guideline," he noted. "The last guideline recommended less than 140/90 mm Hg; our guideline recommends a target of 130/80 mm Hg."

Dr Whelton discussed the rationale for this more intensive BP goal of less than 130/80 mm Hg in older adults. "It's largely based on the fact that a large number of older adults have been enrolled in [BP]-lowering treatment trials, especially in more recent trials," he said.

In those studies, notably the Systolic Blood Pressure Intervention Trial (SPRINT) and Action to Control Cardiovascular Risk in Diabetes (ACCORD) trials, antihypertensive treatment reduced cardiovascular disease morbidity and mortality without any increased risk for falls or orthostatic hypotension.

Thorough Review

Moderating the press briefing on the new guideline were Dr Stephen Hauser (Lewis Katz School of Medicine at Temple University, Philadelphia, PA), former president of the AHA, who was standing in for current president Dr John J Warner (UT Southwestern University Hospitals, Dallas), and Dr Mary Walsh (St Vincent Heart Center of Indiana, Carmel), president of the ACC.

"We saw the need to update these guidelines to reflect the real threats of high [BP] and establish a protocol that could improve the cardiovascular health of all Americans," Dr Hauser said.

"This guideline is the product of 3 years of thorough review by a panel of 21 experts who reviewed over 900 sources," he added. "The guidelines further underwent multiple rounds of peer review and were reviewed by the writing group of [the] 41-member scientific advisory coordinating committee, which I'm a part of, and I did read them; all partner organizations; and the guidelines executive committee."

"We update guidelines based on evidence and continually monitor new research," Dr Walsh commented. "The [AHA] and the [ACC] were given primary stewardship of the cardiovascular treatment guidelines from the US government in 2013. Shortly thereafter, the organizations began laying the groundwork for the new guideline, which has been in development now for 3 years.

"Other groups have published high [BP] recommendations in the past 4 years, but they were not comprehensive, and they were not endorsed widely," she added. These guidelines, she said, "have been a collaborative effort by 11 organizations."

Other partner organizations include the American Academy of Physician Assistants, the American College of Preventive Medicine, the American Geriatrics Society, the American Pharmacists Association, the American Society of Hypertension, the American Society of Preventive Cardiology, the Association of Black Cardiologists, the National Medical Association, and the Preventive Cardiovascular Nurses Association.

Clinical Implications

• The threshold to diagnose hypertension has been lowered in the current recommendations from the broadly accepted level of 140/90 mm Hg or more to a level of 130/80 mm Hg or above.
• First-line agents for hypertension include diuretics, calcium channel blockers, and ACE inhibitors or ARBs.
• Implications for the Healthcare Team: The current recommendations have profound implications for the way hypertension is diagnosed and followed over time. There is an emphasis on BP monitoring outside the clinical setting.

CME Test