2017 ACC/AHA Hypertension Guidelines

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2017 ACC/AHA Hypertension Guidelines
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Guidelines for Lifestyle modification:

Nonpharmacological Interventions

Class I

"1. Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese.(Level of Evidence: A) "

"2. A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension.(Level of Evidence: A) "

"3. Sodium reduction is recommended for adults with elevated BP or hypertension.(Level of Evidence: A) "

"4. Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of chronic kidney disease (CKD) or use of drugs that reduce potassium excretion.(Level of Evidence: A) "

"5. Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension.(Level of Evidence: A) "

"6. Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively.(Level of Evidence: A) "

In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol)

Strategies to Promote Lifestyle Modification

Class I

"1. Effective behavioral and motivational strategies to achieve a healthy lifestyle (i.e., tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension.(Level of Evidence: C-EO) "

Structured, Team-Based Care Interventions for Hypertension Control

Class I

"1. A team-based care approach is recommended for adults with hypertension.(Level of Evidence: A) "

Electronic Health Record (EHR) and Patient Registries

Class I

"1. Use of the EHR and patient registries is beneficial for identification of patients with undiagnosed or undertreated hypertension.(Level of Evidence: B-NR) "

"2. Use of the EHR and patient registries is beneficial for guiding quality improvement efforts designed to improve hypertension control .(Level of Evidence: B-NR) "

Telehealth Interventions to Improve Hypertension Control

Class IIa

"1. Telehealth strategies can be useful adjuncts to interventions shown to reduce BP for adults with hypertension.(Level of Evidence: A) "

"2. Use of performance measures in combination with other quality improvement strategies at patient-, provider-, and system-based levels is reasonable to facilitate optimal hypertension control.(Level of Evidence: B-NR) "

Quality Improvement Strategies

Class IIa

"1. Use of quality improvement strategies at the health system, provider, and patient levels to improve identification and control of hypertension can be effective.(Level of Evidence: B-R) "

Quality Improvement Strategies

Class IIa

"1. Financial incentives paid to providers can be useful in achieving improvements in treatment and management of patient populations with hypertension.(Level of Evidence: B-R) "

"1. Health system financing strategies (e.g., insurance coverage and copayment benefit design) can be useful in facilitating improved medication adherence and BP control in patients with hypertension.(Level of Evidence: B-NR) "

The Plan of Care for Hypertension

Class I

"1. Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals, encourages effective management of comorbid conditions, prompts timely follow-up with the healthcare team, and adheres to CVD guideline-directed medical therapy (GDMT).(Level of Evidence: C-EO) "

Guidelines for Medical therapy:

General Principles of Drug Therapy

Class III: Harm

"1. Simultaneous use of an ACE inhibitor, ARB, and/or renin inhibitor is potentially harmful and is not recommended to treat adults with hypertension.(Level of Evidence: A) "

Treatment Threshold and the Use of Cardiovascular Disease (CVD) Risk Estimation to Guide Drug Treatment of Hypertension

Class I

"1. Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher, and for primary prevention in adults with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average SBP 130 mm Hg or higher or an average DBP 80 mm Hg or higher.(Level of Evidence: SBP: A, DBP: C-EO) "

"2. Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher.(Level of Evidence: C-LD) "

Blood Pressure (BP) Goal for Patients With Hypertension

Class I

"1. For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mm Hg is recommended.(Level of Evidence: SBP: B-R, DPB: C-EO) "

Class IIb

"1. For adults with confirmed hypertension, without additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable. (Level of Evidence: SBP: B-NR, DPB: C-EO) "

Choice of Initial Medication

Class I

"1. For initiation of antihypertensive drug therapy, first-line agents include thiazide diuretics, calcium channel blockers (CCBs), and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs).(Level of Evidence: A) "

Choice of Initial Monotherapy Versus Initial Combination Drug Therapy

Class I

"1. Initiation of antihypertensive drug therapy with 2 first-line agents of different classes, either as separate agents or in a fixed-dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mm Hg above their BP target.(Level of Evidence: C-EO) "

Class IIa

"1. Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target. (Level of Evidence: C-EO) "

Follow-Up After Initiating Antihypertensive Drug Therapy

Class I

"1. Adults initiating a new or adjusted drug regimen for hypertension should have a follow-up evaluation of adherence and response to treatment at monthly intervals until control is achieved.(Level of Evidence: B-R) "

Monitoring Strategies to Improve Control of Blood Pressure (BP) in Patients on Drug Therapy for High BP

Class I

"1. Follow-up and monitoring after initiation of drug therapy for hypertension control should include systematic strategies to help improve BP, including use of HBPM, team-based care, and telehealth strategies.(Level of Evidence: A) "

Stable Ischemic Heart Disease (SIHD)

Class I

"1. In adults with SIHD and hypertension, a blood pressure (BP) target of less than 130/80 mm Hg is recommended.(Level of Evidence: SBP: B-R DPB: C-EO) "

"2. Adults with SIHD and hypertension (BP ≥130/80 mm Hg) should be treated with medications (e.g., guideline-directed medical therapy (GDMT) beta blockers, ACE inhibitors, or ARBs) for compelling indications (e.g., previous MI, stable angina) as first-line therapy, with the addition of other drugs (e.g., dihydropyridine CCBs, thiazide diuretics, and/or mineralocorticoid receptor antagonists) as needed to further control hypertension.(Level of Evidence: SBP: B-R DPB: C-EO) "

"3. In adults with SIHD with angina and persistent uncontrolled hypertension, the addition of dihydropyridine CCBs to GDMT beta blockers is recommended.(Level of Evidence: B-NR) "

Class IIa

"1. In adults who have had a MI or acute coronary syndrome, it is reasonable to continue GDMT beta blockers beyond 3 years as long-term therapy for hypertension. (Level of Evidence: B-NR) "

Class IIb

"1. Beta blockers and/or CCBs might be considered to control hypertension in patients with CAD (without HFrEF) who had an MI more than 3 years ago and have angina. (Level of Evidence: C-EO) "

Heart Failure

Class I

"1. In adults at increased risk of HF, the optimal BP in those with hypertension should be less than 130/80 mm Hg.(Level of Evidence: SBP: B-R DPB: C-EO) "

Heart Failure With Reduced Ejection Fraction

Class I

"1. Adults with HFrEF and hypertension should be prescribed guideline-directed medical therapy (GDMT) titrated to attain a BP of less than 130/80 mm Hg.(Level of Evidence: C-EO) "

Class III: No Benefit

"1.Nondihydropyridine CCBs are not recommended in the treatment of hypertension in adults with HFrEF.(Level of Evidence: B-R) "

Heart Failure With Preserved Ejection Fraction

Class I

"1. In adults with HFpEF who present with symptoms of volume overload, diuretics should be prescribed to control hypertension.(Level of Evidence: C-EO) "

"2. Adults with HFpEF and persistent hypertension after management of volume overload should be prescribed ACE inhibitors or ARBs and beta blockers titrated to attain SBP of less than 130 mm Hg.(Level of Evidence: C-LD) "

Recommendations for Treatment of Hypertension in Patients With CKD

Class I

"1. Adults with hypertension and CKD should be treated to a BP goal of less than 130/80 mm Hg.(Level of Evidence: SBP:B-R, DBP:C-EO) "

Class IIa

"1. In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-creatinine ratio or the equivalent in the first morning void), treatment with an ACE inhibitor is reasonable to slow kidney disease progression. (Level of Evidence: B-R) "

Class IIb

"1. In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-creatinine ratio in the first morning void), treatment with an ARB may be reasonable if an ACE inhibitor is not tolerated. (Level of Evidence: C-EO) "

Recommendations for Treatment of Hypertension After Renal Transplantation

Class IIa

"1. After kidney transplantation, it is reasonable to treat patients with hypertension to a BP goal of less than 130/80 mm Hg. (Level of Evidence: SBP:B-NR, DBP:C-EO) "

"2. After kidney transplantation, it is reasonable to treat patients with hypertension with a calcium antagonist on the basis of improved GFR and kidney survival. (Level of Evidence: B-R) "

Acute Intracerebral Haemorrhage (ICH)

Class IIa

"1. In adults with ICH who present with SBP greater than 220 mm Hg, it is reasonable to use continuous intravenous drug infusion and close blood pressure (BP) monitoring to lower systolic blood pressure (SBP).(Level of Evidence: C-EO) "

Class III: Harm

"1.Immediate lowering of SBP to less than 140 mm Hg in adults with spontaneous ICH who present within 6 hours of the acute event and have an SBP between 150 mm Hg and 220 mm Hg is not of benefit to reduce death or severe disability and can be potentially harmful.(Level of Evidence: A) "

Acute Ischemic Stroke

Class I

"1. Adults with acute ischemic stroke and elevated blood pressure (BP) who are eligible for treatment with intravenous tissue plasminogen activator should have their BP slowly lowered to less than 185/110 mm Hg before thrombolytic therapy is initiated.(Level of Evidence: B-NR) "

"2. In adults with an acute ischemic stroke, BP should be less than 185/110 mm Hg before administration of intravenous tissue plasminogen activator and should be maintained below 180/105 mm Hg for at least the first 24 hours after initiating drug therapy.(Level of Evidence: B-NR) "

Class IIa

"1. Starting or restarting antihypertensive therapy during hospitalization in patients with BP greater than 140/90 mm Hg who are neurologically stable is safe and reasonable to improve long-term BP control, unless contraindicated.(Level of Evidence: B-NR) "

Class IIb

"1. In patients with BP of 220/120 mm Hg or higher who did not receive intravenous alteplase or endovascular treatment and have no comorbid conditions requiring acute antihypertensive treatment, the benefit of initiating or reinitiating treatment of hypertension within the first 48 to 72 hours is uncertain. It might be reasonable to lower BP by 15% during the first 24 hours after onset of stroke.(Level of Evidence: C-EO) "

Class III: No Benefit

"1.In patients with BP less than 220/120 mm Hg who did not receive intravenous thrombolysis or endovascular treatment and do not have a comorbid condition requiring acute antihypertensive treatment, initiating or reinitiating treatment of hypertension within the first 48 to 72 hours after an acute ischemic stroke is not effective to prevent death or dependency.(Level of Evidence: A) "

Secondary Stroke Prevention

Class I

"1. Adults with previously treated hypertension who experience a stroke or transient ischemic attack (TIA) should be restarted on antihypertensive treatment after the first few days of the index event to reduce the risk of recurrent stroke and other vascular events.(Level of Evidence: A) "

"2. For adults who experience a stroke or TIA, treatment with a thiazide diuretic, ACE inhibitor, or ARB, or combination treatment consisting of a thiazide diuretic plus ACE inhibitor, is useful.(Level of Evidence: A) "

"3. Adults not previously treated for hypertension who experience a stroke or TIA and have an established BP of 140/90 mm Hg or higher should be prescribed antihypertensive treatment a few days after the index event to reduce the risk of recurrent stroke and other vascular events.(Level of Evidence: B-R) "

"4. For adults who experience a stroke or TIA, selection of specific drugs should be individualized on the basis of patient comorbidities and agent pharmacological class.(Level of Evidence: B-R) "

Class IIb

"1. For adults who experience a stroke or TIA, a BP goal of less than 130/80 mm Hg may be reasonable.(Level of Evidence: B-R) "

"2. For adults with a lacunar stroke, a target SBP goal of less than 130 mm Hg may be reasonable.(Level of Evidence: B-R) "

"3. In adults previously untreated for hypertension who experience an ischemic stroke or TIA and have a SBP less than 140 mm Hg and a DBP less than 90 mm Hg, the usefulness of initiating antihypertensive treatment is not well established.(Level of Evidence: C-LD) "

Peripheral Arterial Disease (PAD)

Class I

"1. Adults with hypertension and PAD should be treated similarly to patients with hypertension without PAD.(Level of Evidence: B-NR) "

Diabetes Mellitus

Class I

"1. In adults with DM and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mm Hg or higher with a treatment goal of less than 130/80 mm Hg.(Level of Evidence: SBP:B-R, DBP:C-EO) "

"2. In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective.(Level of Evidence: A) "

Class IIb

"1. In adults with DM and hypertension, ACE inhibitors or ARBs may be considered in the presence of albuminuria.(Level of Evidence: B-NR) "

Atrial Fibrillation (AF)

Class IIa

"1. Treatment of hypertension with an ARB can be useful for prevention of recurrence of AF.(Level of Evidence: B-R) "

Valvular Heart Disease (VHD)

Class I

"1. In adults with asymptomatic aortic stenosis, hypertension should be treated with pharmacotherapy, starting at a low dose and gradually titrating upward as needed.(Level of Evidence: B-NR) "

Class IIa

"1. In patients with chronic aortic insufficiency, treatment of systolic hypertension with agents that do not slow the heart rate (i.e., avoid beta blockers) is reasonable.(Level of Evidence: C-LD) "

Aortic Disease

Class I

"1. Beta blockers are recommended as the preferred antihypertensive agents in patients with hypertension and thoracic aortic disease.(Level of Evidence: C-EO) "

Racial and Ethnic Differences in Treatment

Class I

"1. In black adults with hypertension but without heart failure (HF) or chronic kidney disease (CKD), including those with diabetes mellitus (DM), initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blockers (CCB).(Level of Evidence: B-R) "

"2. Two or more antihypertensive medications are recommended to achieve a blood pressure target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension.(Level of Evidence: C-LD) "

Pregnancy

Class I

"1. Women with hypertension who become pregnant, or are planning to become pregnant, should be transitioned to methyldopa, nifedipine, and/or labetalol during pregnancy .(Level of Evidence: C-LD) "

Class III: Harm

"1.Women with hypertension who become pregnant should not be treated with ACE inhibitors, ARBs, or direct renin inhibitors.(Level of Evidence: C-LD) "

Older Persons

Class I

"1. Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community dwelling adults (≥65 years of age) with an average SBP of 130 mm Hg or higher.(Level of Evidence: A) "

Class IIa

"1. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs.(Level of Evidence: C-EO) "

Hypertensive Crises—Emergencies and Urgencies

Class I

"1. In adults with a hypertensive emergency, admission to an intensive care unit is recommended for continuous monitoring of BP and target organ damage and for parenteral administration of an appropriate agent.(Level of Evidence: B-NR) "

"2. For adults with a compelling condition (i.e., aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma crisis), SBP should be reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection.(Level of Evidence: C-EO) "

"3. For adults without a compelling condition, SBP should be reduced by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours.(Level of Evidence: C-EO) "

Cognitive Decline and Dementia

Class IIa

"1. In adults with hypertension, BP lowering is reasonable to prevent cognitive decline and dementia.(Level of Evidence: B-R) "

Patients Undergoing Surgical Procedures

Class I

"1. In patients with hypertension undergoing major surgery who have been on beta blockers chronically, beta blockers should be continued.(Level of Evidence: B-NR) "

Class IIa

"1. In patients with hypertension undergoing planned elective major surgery, it is reasonable to continue medical therapy for hypertension until surgery.(Level of Evidence: C-EO) "

Class IIb

"1. In patients with hypertension undergoing major surgery, discontinuation of ACE inhibitors or ARBs perioperatively may be considered.(Level of Evidence: B-NR) "

"2. In patients with planned elective major surgery and SBP of 180 mm Hg or higher or DBP of 110 mm Hg or higher, deferring surgery may be considered.(Level of Evidence: C-LD) "

Class III: Harm

"1.For patients undergoing surgery, abrupt preoperative discontinuation of beta blockers or clonidine is potentially harmful.(Level of Evidence: B-NR) "

"2.Beta blockers should not be started on the day of surgery in beta blocker– naïve patients.(Level of Evidence: B-NR) "

Intraoperative

Class I

"1. Patients with intraoperative hypertension should be managed with intravenous medications until such time as oral medications can be resumed.(Level of Evidence: C-EO) "

Antihypertensive Medication Adherence Strategies

Class I

"1. In adults with hypertension, dosing of antihypertensive medication once daily rather than multiple times daily is beneficial to improve adherence.(Level of Evidence: B-R) "

Class IIa

"1. Use of combination pills rather than free individual components can be useful to improve adherence to antihypertensive therapy.(Level of Evidence: B-NR) "