What are the 2017 ACC/AHA and ACP/AAFP guidelines on hypertension (high blood pressure)?

Updated: Feb 22, 2019
  • Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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2017 ACC/AHA guidelines

The 2017 ACC/AHA guidelines eliminated the classification of prehypertension and divided hypertension into two levels [1, 2] : (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg.

In adults at increased risk of heart failure (HF), the optimal BP in those with hypertension should be less than 130/80 mm Hg.

Adults with HFrEF (HF with reduced ejection fraction) and hypertension should be prescribed GDMT (guideline-directed management and therapy) titrated to attain a BP of less than 130/80 mm Hg.

Nondihydropyridine calcium channel blockers (CCBs) are not recommended in the treatment of hypertension in adults with HFrEF.

Adults with hypertension and chronic kidney disease (CKD) should be treated to a BP goal of less than 130/80 mm Hg.

After kidney transplantation, it is reasonable to treat patients with hypertension to a BP goal of less than 130/80 mm Hg. After kidney transplantation, it is reasonable to treat patients with hypertension with a calcium antagonist on the basis of improved glomerular filtration rate (GFR) and kidney survival.

Immediate lowering of SBP to lower than 140 mm Hg in adults with spontaneous intracerebral hemorrhage (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.

Adults with acute ischemic stroke and elevated BP who are eligible for treatment with intravenous (IV) tissue plasminogen activator (tPA) should have their BP slowly lowered to below 185/110 mm Hg before thrombolytic therapy is initiated.

In adults with an acute ischemic stroke, BP should be less than 185/110 mm Hg before administration of IV tPA and should be maintained below 180/105 mm Hg for at least the first 24 hours after initiating drug therapy.

For adults who experience a stroke or transient ischemic attack (TIA), treatment with a thiazide diuretic, ACEI, or angiotensin receptor blocker (ARB), or combination treatment consisting of a thiazide diuretic plus ACEI, is useful.

In adults with an untreated SBP greater than 130 mm Hg but less than 160 mm Hg or a 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 ABPM (ambulatory BP monitoring) or HBPM (home BPM) before diagnosis of hypertension.

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 home BPM (or ABPM) is reasonable.

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).

Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than two and one standard drinks per day, respectively.

Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension.

Women with hypertension who become pregnant should not be treated with ACEIs, ARBs, or direct renin inhibitors.

Use of BP-lowering medications is recommended for secondary prevention of recurrent cardiovascular disease (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 of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher.

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 below 10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher.

Adults with an elevated BP or stage 1 hypertension who have an estimated 10-year ASCVD risk below 10% should be managed with nonpharmacologic therapy and have a repeat BP evaluation within 3 to 6 months.

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 nonpharmacologic and antihypertensive drug therapy and have a repeat BP evaluation in 1 month.

For adults with a very high average BP (eg, SBP ≥180 mm Hg or DBP ≥110 mm Hg), evaluation followed by prompt antihypertensive drug treatment is recommended.

Simultaneous use of an ACE, ARB, and/or renin inhibitor is potentially harmful and is not recommended to treat adults with hypertension.

2017 ACP/AAFP guidelines

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released their guidelines regarding hypertension in adults aged 60 years, including the following [72] :

  • Clinicians should initiate treatment in patients aged 60 years or older who have persistent SBP at or above 150 mm Hg to achieve a target of less than 150 mm Hg to reduce the risk for stroke, cardiac events, and death.
  • If patients 60 years or older have a history of stroke or transient ischemic attack or have high cardiovascular risk, physicians should consider starting or increasing drug therapy to achieve an SBP of less than 140 mm Hg to reduce the risk for stroke and cardiac events.
  • Consider initiating or intensifying pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk based on individualized assessment, to achieve a target SBP of less than 140 mm Hg to reduce the risk for stroke and cardiac events. Factors include comorbidity, medication burden, risk of adverse events, and cost. Generally, increased cardiovascular risk includes known cardiovascular disease, diabetes, or chronic kidney disease with a glomerular filtration rate of less than 45 mL/min/1.73 m 2.

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