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AHA/ACC Issues New Hypertension Guideline

Hypertension; ePub 2017 Nov 13; Whelton, et al

The American Heart Association and the American College of Cardiology (AHA/ACC) has issued a new guideline for the prevention, detection, evaluation, and management of high blood pressure (BP) in adults. The new guideline recommends use of a systolic blood pressure (SBP) ≥130 mm Hg or a diastolic BP (DBP) ≥80 mm Hg to designate the presence of hypertension. Previous guidelines had recommended SBP ≥140 mm Hg or DBP ≥90 mm Hg. Other guideline highlights include:

  • Prevalence of hypertension is estimated to be ~14% higher using the proposed SBP and DBP cut-points for the definition of hypertension compared to those recommended in the 2003 JNC 7 guideline (46% vs 32%).
  • Nonpharmacological management is recommended for adults with BP 130-140 mm Hg/ 80-90 mm Hg who have a 10-year cardiovascular (CV) risk < 10%.
  • Individuals with BP 130-140 mm Hg/ 80-90 mm Hg who have a 10-year CV risk >10% should begin pharmacological management in addition to nonpharmacological therapy.
  • 4 drug classes are recommended as options for initial choice of antihypertensive drug therapy (thiazide diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers) in adults who do not have a compelling need for a specific BP lowering medication from another class to manage other illness.
  • All patients with BP >140/90 mm Hg should receive pharmacological therapy.

Citation:

Whelton PK, Carey RM, Aronow WS, et al. 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. [Published online ahead of print November 13, 2017]. Hypertension. doi:10.1161/HYP.0000000000000065.

Commentary:

This guideline represents a radical shift in the treatment of high blood pressure, recommending a systolic blood pressure of <130 mm Hg, rather than the previously recommended BP <140, as the target blood pressure to achieve when using pharmacologic management. The recommendation is based on data from the SPRINT trial, which randomized 9,361 persons with a systolic blood pressure of 130 mm Hg or higher and increased cardiovascular risk (10-year risk >15%), but without diabetes, to a systolic blood-pressure target of <120 mm Hg or a target of < 140 mm Hg.1 Results after 3.26 years of follow-up showed a significantly lower rate of the primary composite outcome (MI, other ACS, stroke, heart failure, or death from cardiovascular causes) in the intensive-treatment group than in the standard-treatment group (hazard ratio, 0.75; P<0.001). All-cause mortality was also significantly lower in the intensive-treatment group (hazard ratio, 0.73; P=0.003). This recommendation is certain to engender a good deal of controversy. One controversal question is whether it is sensible to extrapolate from the results seen in this high-risk group to then lower target BP for all groups. Another area of discussion is in regard to the intensive treatment group having higher rates of serious adverse events, including hypotension, syncope, electrolyte abnormalities, and acute kidney injury/failure. There will be debate over whether these side effects are offset by the benefit when applied to both high- and lower-risk groups. For now, though, it can be noted that neither of the 2 main organizations representing the majority of primary care physicians—the American Academy of Family Physicians and the American College of Physicians—have endorsed these new guidelines. —Neil Skolnik, MD

  1. The SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-2116. doi:10.1056/NEJMoa1511939.

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