Commentary

2017 ACC/AHA hypertension guidelines: Toward tighter control
Under the new definition (≥ 130/80 mm Hg), 46% of US adults have hypertension.
Wesam Aleyadeh, MD
Ministry of Health, Amman, Jordan
Erika Hutt-Centeno, MD
Department of Internal Medicine, Cleveland Clinic; Clinical Instructor, Cleveland Clinic Lerner College of Case Western Reserve University, Cleveland, OH
Haitham M. Ahmed, MD, MPH
Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
Nishant P. Shah, MD
Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic
Address: Nishant Shah, MD, J3-6, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; shahn2@ccf.org
Release date: January 1, 2019
Expiration date: December 31, 2019
Estimated time of completion: 1 hour
The updated 2017 American College of Cardiology and American Heart Association (ACC/AHA) guidelines for managing hypertension advocate tighter blood pressure control than previous guidelines. This review summarizes the evidence behind the guidelines, discusses the risks and benefits of stricter blood pressure control, and provides our insights on blood pressure management in clinical practice.
When treating high blood pressure, how low should we try to go? Debate continues about optimal blood pressure goals after publication of guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) in 2017 that set or permitted a treatment goal of less than 130 mm Hg, depending on the population.1
In this article, we summarize the evolution of hypertension guidelines and the evidence behind them.
The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),2 published in 2003, specified treatment goals of:
JNC 7 provided much-needed clarity and uniformity to managing hypertension. Since then, various scientific groups have published their own guidelines (Table 1).1–9
In 2014, the ACC, AHA, and US Centers for Disease Control and Prevention (CDC) published an evidence-based algorithm for hypertension management.3 As in JNC 7, they suggested a blood pressure goal of less than 140/90 mm Hg, lifestyle modification, and polytherapy, eg, a thiazide diuretic for stage 1 hypertension (< 160/100 mm Hg) and combination therapy with a thiazide diuretic and an angiotensin-converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), or calcium channel blocker for stage 2 hypertension (≥ 160/100 mm Hg).
Soon after, the much-anticipated report of the panel members appointed to the eighth JNC (JNC 8) was published.4 Previous JNC reports were written and published under the auspices of the National Heart, Lung, and Blood Institute, but while the JNC 8 report was being prepared, this government body announced it would no longer publish guidelines.
In contrast to JNC 7, the JNC 8 panel based its recommendations on a systematic review of randomized clinical trials. However, the process and methodology were controversial, especially as the panel excluded some important clinical trials from the analysis.
JNC 8 relaxed the targets in several subgroups, such as patients over age 60 and those with diabetes and chronic kidney disease, due to a lack of definitive evidence on the impact of blood pressure targets lower than 140/90 mm Hg in these groups. Thus, their goals were:
Of note, a minority of the JNC 8 panel disagreed with the new targets and provided evidence for keeping the systolic blood pressure target below 140 mm Hg for patients 60 and older.5 Further, the JNC 8 report was not endorsed by several important societies, ie, the AHA, ACC, National Heart, Lung, and Blood Institute, and American Society of Hypertension (ASH). These issues compromised the acceptance and applicability of the guidelines.
Also in 2014, the ASH and the International Society of Hypertension released their own report.6 Their goals:
In 2015, the AHA, ACC, and ASH released a joint scientific statement outlining hypertension goals for specific patient populations7:
In 2016, the American Diabetes Association (ADA) set the following blood pressure goals for patients with diabetes8:
Under the new definition (≥ 130/80 mm Hg), 46% of US adults have hypertension.
Goal: systolic pressure below 130 mm Hg if the patient can take multiple medications and be followed closely.