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Hypertension

Hypertension Clinical Guideline

Mid November 2017, the American College of  Cardiology (ACC), the American Heart Association (AHA), American Academy of Physician Assistants (AAPA), Association of Black Cardiologists (ABC), American College of Preventive Medicine (ACPM), American Geriatrics Society (AGS), American Pharmacists Association (APhA), American Society of Hypertension (ASH), American Society for Preventive Cardiology (ASPC), National Medical Association (NMA) and Preventive Cardiovascular Nurses Association (PCNA) released a Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.

This guideline is an update of the National Heart, Lung, and Blood Institute (NHLBI) publication, “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure." This guideline compliments the ACC/AHA’s set of guidelines revolving around the management/prevention of cardiovascular disease (Cardiovascular Risk Reduction Clinical Practice Guidelines). However, it does not address the use of BP lowering medications for the purposes of prevention of recurrent cardiovascular events in patients with stable ischemic heart disease (SIHD) or chronic heart failure (HF) in the absence of hypertension; these topics are the focus of other ACC/AHA guidelines. The complete version of this guideline can be found at http://hyper.ahajournals.org/. Highlights of this guideline include:

  • Through a meta-analysis of 61 prospective studies, the risk of cardiovascular disease increased in a log-linear fashion from systolic blood pressure levels >115mmHg to >180mmHg and from diastolic blood pressures of >75mmHg to>105mmHg.  In that analysis, 20mmHg higher systolic blood pressure and 10mmHg higher diastolic blood pressure were each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. 

  • Blood Pressure should be categorized as “Normal”(<120mmHg systolic or <80mmHg diastolic), “Elevated” (120-129mmHg systolic and <80mmHg diastolic), “Stage 1 Hypertension” (130-139mmHg systolic or 80-89mmHg diastolic), “Stage 2 Hypertension” (≥140mmHg systolic or ≥90mmHg diastolic) (See table 6. Categories of BP in Adults). This classification system is most valuable in untreated adults as an aid in decisions about prevention or treatment of high blood pressure. (COR: I; LOE: B-NR)

  • For diagnosis and management of high blood pressure, proper methods are recommended for accurate measurement and documentation of blood pressure (See table 8. Checklist for Accurate Measurement of BP). (COR: I; LOE: C-EO)

  • Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for the titration of BP-lowering medications, in conjunction with telehealth counseling or clinical interventions. (COR: I; LOE: ASR ) (SR=systematic review)

  • For initiation of antihypertensive drug therapy, first-line agents include thiazide diuretics, CCB’s, and ACE inhibitors or ARB’s. (COR: I; LOE: ASR)(SR=systematic review)

  • 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 20/10mmHg above their BP target. (COR: I; C-EO)

  • 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. (COR: I; LOE: B-R)

  • 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. (COR: I; LOE: A)

  • Treatment of hypertension with a SBP treatment goal of less than 130mmHg is recommended for non-institutionalized ambulatory community dwelling adults (≥65 years of age) with an average SBP of 130mmHg or higher. (COR: I; LOE:A)

You may also reference:

Paramount’s Medical Advisory Council (MAC) adopted 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  on February 13, 2018.