Sandbox: Hypertension

Template:Hypertension - ACC -2017 Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

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

Accurate Measurement of Blood Pressure (BP) in the Office

Class I

"1. For diagnosis and management of high BP, proper methods are recommended for accurate measurement and documentation of BP.(Level of Evidence: C-EO) "

Out-of-Office and Self-Monitoring of Blood Pressure (BP)

Class I

"1. Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.(Level of Evidence: A) "

Masked and White Coat Hypertension

Class IIa

"1. In adults with an untreated Systolic Blood Pressure (SBP) greater than 130 mm Hg but less than 160 mm Hg or Diastolic Blood Pressure (DBP) greater than 80 mm Hg but less than 100 mm Hg, it is reasonable to screen for the presence of white coat hypertension by using either daytime Ambulatory blood pressure monitoring (ABPM) or Home blood pressure monitoring (HBPM) before diagnosis of hypertension. (Level of Evidence: B-NR) "

"2. In adults with white coat hypertension, periodic monitoring with either ABPM or HBPM is reasonable to detect transition to sustained hypertension. (Level of Evidence: C-LD) "

"3. In adults being treated for hypertension with office BP readings not at goal and HBPM readings suggestive of a significant white coat effect, confirmation by ABPM can be useful. (Level of Evidence: C-LD) "

"4. In adults with untreated office BPs that are consistently between 120 mm Hg and 129 mm Hg for SBP or between 75 mm Hg and 79 mm Hg for DBP, screening for masked hypertension with HBPM (or ABPM) is reasonable . (Level of Evidence: B-NR) "

Class IIb

"1. In adults on multiple-drug therapies for hypertension and office BPs within 10 mm Hg above goal, it may be reasonable to screen for white coat effect with HBPM. (Level of Evidence: C-LD) "

"2. It may be reasonable to screen for masked uncontrolled hypertension with HBPM in adults being treated for hypertension and office readings at goal, in the presence of target organ damage or increased overall CVD risk. (Level of Evidence: C-EO) "

"3. In adults being treated for hypertension with elevated HBPM readings suggestive of masked uncontrolled hypertension, confirmation of the diagnosis by ABPM might be reasonable before intensification of antihypertensive drug treatment. (Level of Evidence: C-EO) "

Secondary Forms of Hyperpertension

Class I

"1. Screening for specific form(s) of secondary hypertension is recommended when the clinical indications and physical examination findings are present or in adults with resistant hypertension.(Level of Evidence: C-EO) "

Class IIb

"1. If an adult with sustained hypertension screens positive for a form of secondary hypertension, referral to a physician with expertise in that form of hypertension may be reasonable for diagnostic confirmation and treatment. (Level of Evidence: C-EO) "

Primary Aldosteronism

Class I

"1. In adults with hypertension, screening for primary aldosteronism is recommended in the presence of any of the following concurrent conditions: resistant hypertension, hypokalemia (spontaneous or substantial, if diuretic induced), incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke at a young age (<40 years).(Level of Evidence: C-EO) "

"2. Use of the plasma aldosterone: renin activity ratio is recommended when adults are screened for primary aldosteronism.(Level of Evidence: C-LD) "

"3. In adults with hypertension and a positive screening test for primary aldosteronism, referral to a hypertension specialist or endocrinologist is recommended for further evaluation and treatment.(Level of Evidence: C-EO) "

Renal Artery Stenosis

Class I

"1. Medical therapy is recommended for adults with atherosclerotic renal artery stenosis.(Level of Evidence: A) "

Class IIb

"1. In adults with renal artery stenosis for whom medical management has failed (refractory hypertension, worsening renal function, and/or intractable HF) and those with nonatherosclerotic disease, including fibromuscular dysplasia, it may be reasonable to refer the patient for consideration of revascularization (percutaneous renal artery angioplasty and/or stent placement). (Level of Evidence: C-EO) "

Obstructive Sleep Apnea

Class IIb

"1. In adults with hypertension and obstructive sleep apnea, the effectiveness of continuous positive airway pressure (CPAP) to reduce BP is not well established. (Level of Evidence: B-R) "

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)

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) "

Follow-Up After Initial BP Evaluation

Class I

"1. Adults with an elevated BP or stage 1 hypertension who have an estimated 10-year ASCVD risk less than 10% should be managed with nonpharmacological therapy and have a repeat BP evaluation within 3 to 6 months.(Level of Evidence: B-R) "

"2. Adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of 10% or higher should be managed initially with a combination of nonpharmacological and antihypertensive drug therapy and have a repeat BP evaluation in 1 month.(Level of Evidence: B-R) "

"3. Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacological and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation.(Level of Evidence: B-R) "

"4. For adults with a very high average BP (e.g., SBP ≥180 mm Hg or DBP ≥110 mm Hg), evaluation followed by prompt antihypertensive drug treatment is recommended.(Level of Evidence: B-R) "

Class IIa

"1. For adults with a normal BP, repeat evaluation every year is reasonable. (Level of Evidence: C-EO) "

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) "

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) "