Robert M. Carey, MD; Paul K. Whelton, MB, MD, MSc; for the 2017 ACC/AHA Hypertension Guideline Writing Committee *
Acknowledgment: The authors thank the members of the writing committee (see Appendix); the ACC and the AHA; Katherine Sheehan, PhD, ACC/AHA Director of Guideline Strategy and Operations; Naira Tahir, MPH, Associate Guideline Advisor; Abdul Abdulla, MD, Science and Medicine Advisor; Glenn N. Levine, MD, ACC/AHA Task Force Chair; and the following partnering professional organizations: American Academy of Physician Assistants, Association of Black Cardiologists, American College of Preventive Medicine, American Geriatrics Society, American Pharmacists Association, American Society of Hypertension, American Society for Preventive Cardiology, National Medical Association, and Preventive Cardiovascular Nurses Association.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-3203.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Requests for Single Reprints: Robert M. Carey, MD, University of Virginia Health System, PO Box 801414, Charlottesville, VA 22908-1414.
Current Author Addresses: Dr. Carey: University of Virginia Health System, PO Box 801414, Charlottesville, VA 22908-1414.
Dr. Whelton: Tulane University School of Public Health and Tropical Medicine and Tulane School of Medicine, 1440 Canal Street, New Orleans, LA 70112.
Author Contributions: Conception and design: R.M. Carey, P.K. Whelton.
Analysis and interpretation of the data: R.M. Carey, P.K. Whelton.
Drafting of the article: R.M. Carey.
Critical revision of the article for important intellectual content: R.M. Carey, P.K. Whelton.
Final approval of the article: R.M. Carey, P.K. Whelton.
Administrative, technical, or logistic support: P.K. Whelton.
Collection and assembly of data: P.K. Whelton.
In November 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) released a clinical practice guideline for the prevention, detection, evaluation, and treatment of high blood pressure (BP) in adults. This article summarizes the major recommendations.
In 2014, the ACC and the AHA appointed a multidisciplinary committee to update previous reports of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The committee reviewed literature and commissioned systematic reviews and meta-analyses on out-of-office BP monitoring, the optimal target for BP lowering, the comparative benefits and harms of different classes of antihypertensive agents, and the comparative benefits and harms of initiating therapy with a single antihypertensive agent or a combination of 2 agents.
This article summarizes key recommendations in the following areas: BP classification, BP measurement, screening for secondary hypertension, nonpharmacologic therapy, BP thresholds and cardiac risk estimation to guide drug treatment, treatment goals (general and for patients with diabetes mellitus, chronic kidney disease, and advanced age), choice of initial drug therapy, resistant hypertension, and strategies to improve hypertension control.
Table 1. Classification of BP*
Table 2. Recommendations for Measurement of BP*
Algorithm for detection of white coat hypertension or masked hypertension in patients not receiving antihypertensive drug therapy.
Colors correspond to class of recommendation in the Appendix Figure. (Reproduced with permission of the American College of Cardiology and the American Heart Association.) ABPM = ambulatory blood pressure monitoring; BP = blood pressure; HBPM = home blood pressure monitoring.
Algorithm for detection of white coat effect or masked uncontrolled hypertension in patients receiving drug therapy.
Colors correspond to class of recommendation in the Appendix Figure. (Reproduced with permission of the American College of Cardiology and the American Heart Association.) ABPM = ambulatory blood pressure monitoring; BP = blood pressure; CVD = cardiovascular disease; HBPM = home blood pressure monitoring.
Applying class of recommendation and level of evidence to clinical strategies, interventions, treatments, or diagnostic testing in patient care*.
COR and LOE are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. (Reproduced with permission of the American College of Cardiology and the American Heart Association.) COR = class (strength) of recommendation; EO = expert opinion; LD = limited data; LOE = level (quality) of evidence; NR = nonrandomized; R = randomized; RCT = randomized controlled trial.
* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).
† For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
‡ The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools and, for systematic reviews, the incorporation of an Evidence Review Committee.
Table 3. Screening for Secondary Hypertension*
Table 4. Recommendations for Nonpharmacologic and Pharmacologic Treatment and BP Goals*
BP thresholds and recommendations for treatment and follow-up.
Colors correspond to class of recommendation in the Appendix Figure. (Reproduced with permission of the American College of Cardiology and the American Heart Association.) ASCVD = atherosclerotic cardiovascular disease; BP = blood pressure; CVD = cardiovascular disease.
* Using the American College of Cardiology/American Heart Association Pooled Cohort Equations. Patients with diabetes mellitus or chronic kidney disease are automatically placed in the high-risk category. For initiation of use of a renin–angiotensin system inhibitor or diuretic therapy, clinicians should assess blood tests for electrolytes and renal function 2 to 4 wk after initiating therapy.
† Clinicians should consider initiation of pharmacologic therapy for stage 2 hypertension with 2 antihypertensive agents from different classes. Patients with stage 2 hypertension and BP ≥160/100 mm Hg should be promptly treated, carefully monitored, and subject to upward medication dose adjustment as necessary to control BP. Reassessment includes BP measurement, detection of orthostatic hypotension in selected patients (e.g., older patients or those with postural symptoms), identification of white coat hypertension or a white coat effect, documentation of adherence, monitoring of response to therapy, reinforcement of the importance of adherence, reinforcement of the importance of treatment, and assistance with treatment to achieve the BP target.
Table 5. Recommendations for Managing Resistant Hypertension and Improving Hypertension Management*
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Carey RM, Whelton PK, for the 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Ann Intern Med. 2018;168:351–358. [Epub ahead of print 23 January 2018]. doi: https://doi.org/10.7326/M17-3203
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Published: Ann Intern Med. 2018;168(5):351-358.
Published at www.annals.org on 23 January 2018
Cardiology, Coronary Risk Factors, Guidelines, Hypertension, Nephrology.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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