Generated Summary
The document is a clinical practice guideline from the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, focusing on the prevention, detection, evaluation, and management of high blood pressure in adults. This guideline is based on systematic methods to evaluate and classify evidence. The guideline emphasizes a patient-centered approach, addressing lifestyle modifications, pharmacological treatments, and the importance of controlling blood pressure to reduce cardiovascular disease (CVD) risk. It incorporates new information from studies of office-based blood pressure–related risk of CVD, ambulatory blood pressure monitoring, home blood pressure monitoring, telemedicine, and other areas. The recommendations are intended for use in the United States and have a global impact, aiming to improve patient care and align with patients’ interests. Management in accordance with guideline recommendations is effective when followed by practitioners and patients, with shared decision-making between clinicians and patients.
Key Findings & Statistics
- Observational studies have demonstrated graded associations between higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) and increased CVD risk. A 20 mm Hg higher SBP and a 10 mm Hg higher DBP were each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease.
- In a separate observational study including >1 million adult patients ≥30 years of age, higher SBP and DBP were associated with increased risk of CVD incidence and angina, myocardial infarction (MI), heart failure (HF), stroke, peripheral artery disease (PAD), and abdominal aortic aneurysm, each evaluated separately.
- For adults 45 years of age without hypertension, the 40-year risk of developing hypertension was 93% for African-American, 92% for Hispanic, 86% for white, and 84% for Chinese adults.
- The prevalence of hypertension among U.S. adults is substantially higher when the definition in the present guideline is used versus the JNC 7 definition (46% versus 32%).
- Adding self-report of previously diagnosed hypertension yields a 5% to 10% higher estimate of prevalence.
- In the U.S. general adult population, hypertension awareness, treatment, and control have been steadily improving since the 1960s (S3.4-1-S3.4-4), with NHANES 2009 to 2012 prevalence estimates for men and women, respectively, being 80.2% and 85.4% for awareness, 70.9% and 80.6% for treatment (88.4% and 94.4% in those who were aware), 69.5% and 68.5% for control in those being treated, and 49.3% and 55.2% for overall control in adults with hypertension.
- In patients with clinical CVD and an average BP ≥130/80 mm Hg and for primary prevention of CVD in adults with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of ≥10%, a BP target of less than 130/80 mm Hg is recommended.
Other Important Findings
- For the purposes of secondary prevention, clinical CVD is defined as CHD, congestive HF, and stroke. Several meta-analyses of RCTs support the value of using BP-lowering medications, in addition to nonpharmacological treatment, in patients with established CVD in the absence of hypertension.
- The recommended BP classification system is most valuable in untreated adults as an aid in decisions about prevention or treatment of high BP.
- For black adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB.
- Patients with primary aldosteronism have a 3.7-fold increase in HF, a 4.2-fold increase in stroke, a 6.5-fold increase in MI, a 12.1-fold increase in atrial fibrillation (AF), increased left ventricular hypertrophy (LVH) and diastolic dysfunction, increased stiffness of large arteries, widespread tissue fibrosis, increased remodeling of resistance vessels, and increased kidney damage as compared with patients with primary hypertension matched for BP level.
- The DASH diet has produced overall reductions in SBP of approximately 11 mm Hg and 3 mm Hg, respectively, and the diet was especially effective in blacks.
Limitations Noted in the Document
- The choice of specific risk calculators for estimation of risk and risk threshold has been an important source of variability, ambiguity, and controversy.
- The guidelines do not address the recommendations for treatment of hypertension occurring with acute coronary syndromes.
- BP measurement in office settings is prone to errors, leading to misleading estimations of an individual’s true BP level.
- The extent to which guideline recommendations for use of BP averages from ≥2 occasions is followed in practice is unclear.
- The data for prediction of CVD risk are stronger with ABPM than with office measurements.
- The overlap between HBPM and both daytime and 24-hour ABPM in diagnosing white coat hypertension is only 60% to 70%, and the data for prediction of CVD risk are stronger with ABPM than with office measurements.
Conclusion
The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline offers comprehensive recommendations for the prevention, detection, evaluation, and management of high blood pressure in adults, reflecting the importance of blood pressure control in reducing cardiovascular risk. The emphasis on individualizing treatment strategies based on CVD risk assessment, patient characteristics, and comorbidities represents a shift towards more precise and effective patient care. The recommendation for a BP target of less than 130/80 mm Hg for most adults, particularly those with established CVD or high ASCVD risk, underscores the importance of aggressive blood pressure management. The guideline also highlights the value of lifestyle modifications, such as the DASH diet, weight loss, and increased physical activity, in managing hypertension. The inclusion of strategies like team-based care and the use of EHRs and patient registries aims to improve the quality of care and address barriers to effective treatment. However, there are limitations that need to be addressed. Despite the advancements, there are still gaps in knowledge, particularly regarding the optimal BP targets in specific populations and the best approaches for implementation. Continued research and innovation in the field are essential to further refine these guidelines and improve outcomes. Adherence to these guidelines, particularly with a focus on patient-centered care and appropriate use of antihypertensive medications, has the potential to significantly impact individual and population-level cardiovascular health.