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Hypertension guidelines: Treat patients, not numbers

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Release date: January 1, 2019
Expiration date: December 31, 2019
Estimated time of completion: 1 hour

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ABSTRACT

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.

KEY POINTS

  • The 2017 ACC/AHA guidelines lowered the definition of hypertension to 130/80 mm Hg or higher, thereby in-creasing the number of US adults with hypertension from 31.9% to 45.6%.
  • For patients with known cardiovascular disease or a 10-year risk of an atherosclerotic cardiovascular disease event of 10% or higher, drug treatment “is recommended” if the average blood pressure is 130/80 mm Hg or higher. For those without cardiovascular disease and at lower risk, drug treatment is recommended if the aver-age blood pressure is 140/90 mm Hg or higher.
  • A treatment goal of less than 130/80 mm Hg “is recommended” for patients with hypertension and known car-diovascular disease or a 10-year risk of an atherosclerotic cardiovascular disease event of 10% or higher, and “may be reasonable” for those without additional markers of increased cardiovascular risk.
  • Intensive blood pressure control has the potential to significantly reduce rates of morbidity and death associated with cardiovascular disease, at the price of causing more adverse effects.


 

References

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.

HOW THE GOALS EVOLVED

JNC 7, 2003: 140/90 or 130/80

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:

  • < 140/90 mm Hg for most patients
  • < 130/80 mm Hg for those with diabetes or chronic kidney disease.
Blood pressure guidelines, 2003–2017
JNC 7 defined hypertension as 140/90 mm Hg or higher, and introduced the classification of prehypertension for patients with a systolic blood pressure of 120 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg. It advocated managing systolic hypertension in patients over age 50. It also recommended lifestyle changes such as the Dietary Approaches to Stop Hypertension (DASH) diet, moderate alcohol consumption, weight loss, and a physical activity plan.

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

ACC/AHA/CDC 2014: 140/90

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).

JNC 8 2014: 140/90 or 150/90

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:

  • < 140/90 mm Hg for patients under age 60
  • < 150/90 mm Hg for patients age 60 and older.
JNC 7 and JNC 8 guidelines compared
Table 2 shows the differences in recommendations between JNC 7 and JNC 8.

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.

ASH/ISH 2014: 140/90 or 150/90

Also in 2014, the ASH and the International Society of Hypertension released their own report.6 Their goals:

  • < 140/90 mm Hg for most patients
  • < 150/90 mm Hg for patients age 80 and older.

AHA/ACC/ASH 2015: Goals in subgroups

In 2015, the AHA, ACC, and ASH released a joint scientific statement outlining hypertension goals for specific patient populations7:

  • < 150/90 mm Hg for those age 80 and older
  • < 140/90 mm Hg for those with coronary artery disease
  • < 130/80 mm Hg for those with comorbidities such as diabetes and cardiovascular disease.

ADA 2016: Goals for patients with diabetes

In 2016, the American Diabetes Association (ADA) set the following blood pressure goals for patients with diabetes8:

  • < 140/90 mm Hg for adults with diabetes
  • < 130/80 mm Hg for younger adults with diabetes and adults with a high risk of cardiovascular disease
  • 120–160/80–105 mm Hg for pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy.

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