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AHA Hypertension Guidelines 2017
AHA Hypertension Guidelines 2017
Introduction 4
Important Statistics 4
Diagnosing Hypertension 4
Measurement of BP 4
Patient Evaluation and History 4
Hypertensive Crises: Urgency vs Emergency 5
Laboratory Tests and Other Diagnostic Procedures 5
Out-of-Office Monitoring of BP 5
Masked and White Coat Hypertension 5
Treating Hypertension 5
Blood Pressure Goal for Patients With Hypertension 5
Drug Therapy 5
Lifestyle Therapy 9
Follow-up and Patient Adherence to Treatment 9
Hypertension in Patients With Comorbidities 9
Blood Pressure Components, Risk, and Comorbidities of Hypertension 10
Coexistence of Hypertension and Related Chronic Conditions 11
Prevalence and Lifetime Risk of Hypertension 12
Special Patient Groups 12
Primary Causes of Hypertension 12
Secondary Causes of Hypertension 12
Community Strategies to Improve Quality of Care: The Plan of Care for Hypertension 13
Improving Quality of Care for Patients: Performance Measures and Quality Improvement Strategies 14
References 15
Acknowledgments
American Academy of Physician Assistants, Association of Black Cardiologists, American College of Preventive Medicine, American Geriatrics
Society, American Pharmacists Association, American Society of Hypertension, American Society for Preventive Cardiology, National Medical
Association, Preventive Cardiovascular Nurses Association
TABLE 1. Classification of BP
TABLE 2. Hypertensive Crises: Emergencies and Urgencies (See Section 11.2 of 2017 Hypertension Guideline)
5
BP thresholds and recommendations for treatment and follow-up
Nonpharmacologic Nonpharmacologic
Reassess in Reassess in Nonpharmacologic
therapy and BP- therapy and BP-
1 year 3-6 mo therapy
lowering medication lowering medication
Reassess in Reassess in
3-6 mo 1 mo
(Class I) (Class I)
BP goal met?
No Yes
Consider
intensification
of therapy
Be aware that simultaneously administering CVD compared with placebo: compared with calcium channel blockers in
more than 1 renin-angiotensin system Diuretics black patients.43,44
blocker increases cardiovascular and ACE inhibitors ARBs may be better tolerated than ACE
renal risk.35-37 ARBs inhibitors in black patients, with less cough
When initiating antihypertensive drug and angioedema, but they offer no proven
Calcium channel blockers
therapy, use first-line agents that include advantage over ACE inhibitors in preventing
-Blockers10,40 stroke or CVD in this population, making
Thiazide diuretics
-Blockers were less effective than thiazide diuretics (especially chlorthalidone)
Calcium channel blockers
calcium channel blockers (36% or calcium channel blockers the best initial
Angiotensin-converting enzyme (ACE) lower risk) and thiazide diuretics choice for single-drug therapy.
inhibitors or angiotensin-receptor blockers (30% lower risk) in preventing
(ARBs)38,39 Table 5 lists primary and secondary oral
stroke in the general population. antihypertensive drugs.
Five drug classes have been shown to prevent ACE inhibitors were notably less effective
in preventing heart failure41,42 and stroke
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
9
The updated guideline recommends use of Stroke: Treatment recommendations require that focus on dietary modification, weight
BP-lowering medications in patients with recognition of stroke acuity, stroke type, and reduction, and exercise form the foundation
clinical CVD with an average BP greater therapeutic objectives. of treatment. The optimal antihypertensive
than 130/80 mm Hg. Intracerebral hemorrhage: Because of the drug therapy for patients with hypertension
The selection of medications for use in data linking high BP with poor clinical and metabolic syndrome has not been clearly
treating hypertension in patients with CVD outcomes75-77 and some suggestive data defined.87 Although caution is recommended
is guided by their use for other compelling for treatment in patients with modestly with thiazide diuretics in these patients
indications (eg, -blockers after myocardial high initial systolic BP levels,78,79 early because of their increased insulin resistance,
infarction). comprehensive lowering of systolic BP in dyslipidemia, and hyperuricemia and the
The updated guideline provides varying patients with markedly high systolic BP increased risk of conversion to overt diabetes
guidelines for other patients with specific levels (>220 mm Hg) might be sensible. mellitus, no data are currently available that
comorbidities: Acute ischemic stroke: Early initiation show a deterioration in cardiovascular or
ASCVD: Patients are already at risk and need or resumption of antihypertensive renal outcomes in patients treated with these
to have their BP controlled at 130/80 mm Hg treatment is indicated only for patients agents.87
(previously 140/90 mm Hg). The treatment who received a tissue-type plasminogen Atrial fibrillation: Hypertension is a risk factor
algorithm now includes an assessment of activator80,81 or patients with a systolic for atrial fibrillation and is present in more
ASCVD risk (the previous algorithm was BP higher than 220 mm Hg or diastolic than 80% of patients with atrial fibrillation,
based on BP values). BP higher than 120 mm Hg. making it by far the most common comorbid
Stable ischemic heart disease: Prescribe Rapidly reducing BP, even to lower condition, regardless of age.18 Control of
guideline-directed management and levels within the hypertensive hypertension is critical88,89 and may prevent
therapy. -Blockers and/or calcium channel range, can be detrimental. new-onset atrial fibrillation.88
blockers are effective antihypertensive and Restarting antihypertensive therapy
antianginal agents. Blood Pressure Components, Risk,
to improve long-term BP control is
Chronic heart failure: Antecedent reasonable after the first 24 hours for and Comorbidities of Hypertension
hypertension is present in 75% of patients.66 neurologically stable patients who Population Risk
High risk for CVD: Strong evidence supports have preexisting hypertension.82-84 According to reports published in 2010, high
treatment with antihypertensive medications Recurrent stroke: Elevated BP increases the BP is the leading cause of death and disability-
and more-intensive intervention. risk of a recurrent stroke, and guideline- adjusted life years worldwide.90,91 A follow-up
Heart failure with reduced ejection fraction: recommended antihypertensive drug study from the United States Nutrition Exami-
Prescribe guideline-directed management treatment to lower BP has been linked to a nation Survey found that more than 50% of
and therapy to hypertensive patients with reduction in 1-year recurrent stroke risk.85 deaths from coronary heart disease and stroke
occurred among people with hypertension. In
heart failure with reduced ejection fraction. Peripheral artery disease (PAD): the population-based Atherosclerosis Risk in
Nondihydropyridine calcium channel Hypertension is a major risk factor for PAD, Communities study, 25% of the cardiovascular
blockers are not recommended.67 and patients with hypertension and PAD events (like coronary heart disease, coronary
Heart failure with preserved ejection fraction: should be treated similarly to patients with revascularization, stroke, or heart failure) were
For patients with heart failure and persistent hypertension without PAD. attributable to hypertension.92 Figure 2 shows
hypertension after management of volume Diabetes mellitus: Combined with the percentage of these events attributable to
overload, prescribe ACE inhibitors or ARBs hypertension, diabetes mellitus greatly hypertension for different populations.93
and -blockers.68-73 increases the risk of damage from CVD, Observational Relationship
Chronic kidney disease: An ACE inhibitor (or resulting in a higher incidence of coronary Observational studies have shown graded asso-
an ARB if ACE inhibitor is not tolerated) is a heart disease, heart failure, peripheral artery ciations between higher systolic and diastolic
preferred drug for treatment of hypertension disease, stroke, and CVD mortality.86 BPs and increased CVD risk.6,94 One meta-
for those with chronic kidney disease stage Metabolic syndrome: Lifestyle modifications analysis revealed that 20 mm Hg higher
3, or for stage 1 or 2 with albuminuria (300
mg/d or higher, or 300 mg/g albumin-to-
creatinine ratio or higher or the equivalent
in the first morning void). Combining
an ARB with a direct renin inhibitor is
contraindicated because of a greater risk for
1. Black 36%
hyperkalemia and hypotension and lack of
demonstrated benefit.36 2. White 21%
Kidney transplantation: Hypertension is
common in patients who have received a 3. Women 32%
transplant because of preexisting kidney
disease, the effects of immunosuppressive
medications, and allograft pathology.74 4. Men 19%
High
Cholesterol
Alcohol Smoking
Overweight/
Low Obesity
Potassium
Physical
Inactivity
Premature Male
Birth Sex
Low Birth Low Socioeconomic
Weight Status
Family
Increased
Chronic Kidney History Age
Disease
FIGURE 3. Modifiable and fixed risk factors.
systolic BP and 10 mm Hg higher diastolic BP Cardiovascular Target Organ Damage hypertension involves improving medication
were each associated with a doubling in the Pulse wave velocity, carotid intima-media adherence, detection and correction of second-
risk of death from stroke, heart disease, or other thickness, and/or coronary artery calcium score ary hypertension, and addressing other patient
vascular disease.6 An observational study in provide noninvasive estimates of vascular characteristics.100-102
more than 1 million adult patients older than 30 target organ injury and atherosclerosis; how-
years found higher systolic and diastolic BPs ever, these are not routinely used as surrogate Cognitive Decline and Dementia
were associated with increased risk for CVD markers of hypertension.96 Left ventricular Vascular disease and its risk factors are present
incidence and angina, myocardial infarction, hypertrophy is commonly measured by electro- in a large number of patients with dementia,
heart failure, stroke, peripheral artery disease, cardiography, echocardiography, or magnetic including Alzheimers dementia.103-105 Hyper-
and abdominal aortic aneurysm, each evaluated resonance imaging. While electrocardiography tension is also the primary risk factor for small
separately.94 is considered a basic test in the routine evalu- vessel ischemic disease and cortical white
ation of hypertension, echocardiography and matter abnormalities.106-109 Systolic Hyperten-
Coexistence of Hypertension and magnetic resonance imaging are not universally sion in Europe (SYST-EUR)110 and Perindopril
Related Chronic Conditions recommended without other indications.97,98 Protection Against Recurrent Stroke (PROG-
RESS)111 both showed statistically significant
Recommendation: Screen for and manage other
Resistant Hypertension reductions in incident dementia.
modifiable CVD risk factors in adults with
A diagnosis of resistant hypertension is con-
hypertension.1 Sexual Dysfunction and Hypertension
ferred when a patient takes 3 antihypertensive
Many adult patients with hypertension have With the introduction of phosphodiesterase-5
medications with complementary mechanisms
other CVD risk factors, and a higher percentage inhibitors that can be administered with anti
of action (a diuretic should be one component)
of adults with CVD risk factors have hyperten- hypertensive medications, there is now effec-
but does not achieve control or when BP con-
sion. Observational studies demonstrate that tive therapy for erectile dysfunction that has
trol is achieved but requires 4 or more medica-
CVD risk factors frequently occur in combina- implications for systemic vascular disease.112
tions.99 Multiple studies indicate common risk
tion, with 3 or more risk factors present in 17% These drugs have also been shown to lower BP
factors for resistant hypertension include older
of patients.95 Figure 3 shows various modifiable and are recommended as a primary therapy for
age, obesity, chronic kidney disease, black race,
and fixed risk factors. pulmonary hypertension.113
and diabetes mellitus. Treatment of resistant
11
While the updated guideline means that more people
will be diagnosed with high BP, nearly all of these newly
categorized patients can treat their hypertension with
lifestyle changes instead of medication.
Patients Undergoing Surgical Procedures In the United States, black adults have also associated with a higher level of high-
Controlling BP to below 130/80 mm Hg or hypertension more often than Hispanic, white, density lipoprotein cholesterol and, within
target levels specified for an individual is Native American, and other adults defined by modest ranges of intake, a lower level of coro-
reasonable before major elective procedures race or ethnicity. In Hispanic adults, lower nary heart disease compared with abstinence.142
in either the inpatient or outpatient setting. If control rates result primarily from lack of While excessive sodium can increase
patients cannot take oral medications, they may awareness and treatment,123,124 whereas black hypertension, a higher level of potassium
be given intravenous medications (see Table 19 adults awareness and treatment are at least as tends to blunt the effect of sodium on BP,143
of the 2017 Hypertension Guideline) as neces- high as white adults, but their hypertension is and a lower sodium-potassium ratio correlates
sary to control BP. often more severe, and some medications are with a lower level of BP than that noted for
less effective in BP control.125 corresponding levels of sodium or potassium
on their own.144 Epidemiological studies
Prevalence and Lifetime Risk Pregnancy suggest that a lower sodium-potassium ratio
Recommendation: Women with hypertension
of Hypertension who become pregnant should be transitioned to
may reduce the risk of CVD compared with
While the updated guideline means that more the risk expected for corresponding levels of
methyldopa, nifedipine, and/or labetalol during either substance separately.145
people will be diagnosed with high BP, nearly
pregnancy.
all of these newly categorized patients can
Recommendation: Women with hypertension who Drugs and Other Substances That Impair
treat their hypertension with lifestyle changes
instead of medication. become pregnant should not be treated with ACE BP Control
inhibitors, ARBs, or direct renin inhibitors. Limit or discontinue use of substances that may
A much higher long-term population burden
Hypertension during pregnancy involves not raise BP, or consider prescribing alternative
of hypertension occurs as BP increases with
only women who already have hypertension agents.1 Many substancesover the counter,
age. A study of white male medical students
but also women who become hypertensive after prescription, or even food substancesaffect
showed that 6.5% had developed hypertension
pregnancy. Preeclampsia, a dangerous form of BP, so its important to always ask patients
by 45 years old and 37% had hypertension by
hypertension that some pregnant women devel- about the substances they are taking and their
age 65.114 Additionally, a multiethnic study
op, occurs in 3.8% of pregnancies and, along dietary patterns. Substances that can affect BP
showed that the 40-year risk for developing
with eclampsia, accounts for 9% of maternal include alcohol, amphetamines, antidepres-
hypertension for a 45 year old was 93% for
deaths in the United States.126 sants, antipsychotics, caffeine, decongestants,
black adults, 92% for Hispanic adults, 86% for
Managing BP during pregnancy is herbal supplements, immunosuppressants,
white adults, and 84% for Chinese adults.65
complicated because many medications, nonsteroidal anti-inflammatory drugs, oral
contraceptives, recreational drugs, systemic
Special Patient Groups including ACE inhibitors and ARBs, could
corticosteroids, and angiogenesis or tyrosine
Special attention is needed for specific harm the fetus. For women with hypertension
who become pregnant, transition them to kinase inhibitors. For more information, see
patient subgroups.
methyldopa, nifedipine, or labetalol127 during Table 14 of the 2017 Hypertension Guideline.
Race/Ethnicity pregnancy.128-132 -Blockers and calcium Genetic and Childhood Risk Factors
Recommendation: In black adults with hypertension channel blockers appear superior to other
Many genes or gene combinations influence
but without heart failure or chronic kidney disease, options for preventing preeclampsia.
BP.146,147 Factors that increase the likelihood of
initial treatment should include a thiazide-type hypertension in adults include genetic factors
diuretic or calcium channel blocker.43,115-117 Primary Causes of Hypertension and obesity in childhood, which increase the
Recommendation: Two or more antihypertensive Hypertension has many causes, including
likelihood of a high childhood BP leading to
medications are recommended to achieve a BP environmental factors, genetic and childhood
future hypertension148; premature birth, which
target of less than 130/80 mm Hg in most adults factors, and other secondary factors.
is associated with a 4 mm Hg higher systol-
with hypertension, especially in black adults.16,118,119
Environmental Risk Factors ic BP and 3 mm Hg higher diastolic BP in
Lifestyle changes are particularly important in Environmental risk factors for hypertension include adulthood149; and low birth weight from other
black and Hispanic adults for preventing hy- obesity, lack of physical activity, sodium intake, causes, which also contributes to higher BP in
pertension and as part of first-line or adjunctive and alcohol consumption. In fact, studies133,134 later life.150
therapy. However, patients in these ethnic have identified a direct relationship between
groups may struggle to adopt these changes body mass index and BP.135,136 Studies have
Secondary Causes of Hypertension
because of poor social support and financial also shown that even modest levels of physical Recommendation: Screening is recommended
considerations, which can limit access to basic activity can decrease the risk of hypertension.137 for certain indications and physical examination
necessities120 including healthy food, medical Excessive dietary sodium intake not only findings or in adults with resistant hypertension.
care, and medications. When working with affects BP but also is independently associated Referral to a physician with expertise in that
various ethnic groups, healthcare providers with an increased risk of stroke,138,139 CVD,140 particular form of condition/disease and
should also consider differences in learning and other adverse outcomes.141 In the United hypertension may be reasonable for diagnostic
styles and preferences, personal beliefs, values, States, alcohol consumption may account for confirmation and treatment.1
and culture.121,122 close to 10% of hypertension; however, it is
13
Information technologybased strategies to measures are often combined with quality- activity regimen; a sodium-reduced meal
promote hypertension control: More health improvement strategies, such as certification plan with options for breakfast, lunch, and
systems are developing registries to identify or financial incentives tied to higher- dinner; recommendations for sleep, rest, and
undiagnosed or undertreated hypertension. To quality care.182 relaxation; and suggestions for overcoming
reduce undiagnosed hypertension and improve Strategies and interventions aimed at barriers to healthful grocery shopping,
hypertension management, use a multipronged reducing the quality gap for a group of patients including reliable transportation to and from
approach, which may include identifying who are representative of those encountered appointments with health providers and
at-risk patients by applying hypertension in routine practice have been effective in
screening algorithms to electronic pharmacy visits.
improving the hypertension care and outcomes
health record databases, scheduling BP across a wide variety of clinic and community Access to health insurance and medication
measurements for at-risk patients, providing settings.183-189 assistance plans: Learn how patients
monthly feedback to physicians about at- Financial incentives: Reducing healthcare financially support and budget for their
risk patients who have yet to complete a BP and medication copayments has shown medical care and medications and then
measurement, and implementing electronic share advice on cost reductions, such as
improved outcomes for hypertension care
prompts for BP measurements whenever at- restructured payment plans. Ideally, patients
risk patients visit the clinic.179,180 in several US studies and in single studies
in Finland, Israel, and Brazil.190 The balance may change their thinking on medication
of evidence does not suggest that reducing adherence and treatment goals.
Improving Quality of Care for Patients:
medication copayments leads to an increase Social and community services: Patients with
Performance Measures and Quality
in overall healthcare expenditure. hypertension, particularly those with lower
Improvement Strategies incomes, can better meet treatment goals
Health literacy: Encourage patients to
Performance measures assess the effectiveness with the help of strong local partnerships.
of healthcare processes and whether desired change health behaviors, and provide
information such as a specific physical Integrate social and community services to
patient outcomes are achieved.181 Performance
reinforce clinical treatment goals.
15
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