Hypertension

Hypertension BP Measurement Definitions BP Measurement Definition SBP First Korotkoff sound* DBP Fifth Korotkoff sound* Pulse pressure SBP minus DBP Mean arterial pressure DBP plus one third pulse pressure† Mid-BP Sum of SBP and DBP, divided by 2 *See Section 4 for a description of Korotkoff sounds. †Calculation assumes normal heart rate . BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure. CVD Risk Factors Common in Patients With Hypertension • • • • • • Modifiable Risk Factors* Current cigarette smoking, secondhand smoking Diabetes mellitus Dyslipidemia/hypercholesterolemia Overweight/obesity Physical inactivity/low fitness Unhealthy diet • • • • • • • Relatively Fixed Risk Factors† CKD Family history Increased age Low socioeconomic/educational status Male sex Obstructive sleep apnea Psychosocial stress *Factors that can be changed and, if changed, may reduce CVD risk. †Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive sleep apnea, cannot be changed (family history, increased age, male sex), or, if changed through the use of current intervention techniques, may not reduce CVD risk (psychosocial stress). CKD indicates chronic kidney disease; and CVD, cardiovascular disease. Definition of High BP COR I LOE Recommendation for Definition of High BP BP should be categorized as normal, elevated, or B-NR stage 1 or 2 hypertension to prevent and treat high BP. Categories of BP in Adults* BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated 120–129 mm Hg and <80 mm Hg 130–139 mm Hg ≥140 mm Hg or 80–89 mm Hg ≥90 mm Hg Hypertension Stage 1 Stage 2 or *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure. Prevalence of Hypertension Based on 2 SBP/DBP Thresholds*† Overall, crude Overall, age-sex adjusted SBP/DBP ≥130/80 mm Hg or Self-Reported Antihypertensive Medication† 46% Men Women (n=4717) (n=4906) 48% 43% 20–44 45–54 55–64 65–74 75+ 30% 50% 70% 77% 79% Non-Hispanic White Non-Hispanic Black Non-Hispanic Asian Hispanic 47% 59% 45% 44% Age group, y 19% 44% 63% 75% 85% Race-ethnicity§ 41% 56% 36% 42% SBP/DBP ≥140/90 mm Hg or SelfReported Antihypertensive Medication‡ 32% Men Women (n=4717) (n=4906) 31% 32% 11% 33% 53% 64% 71% 10% 27% 52% 63% 78% 31% 42% 29% 27% 30% 46% 27% 32% The prevalence estimates have been rounded to the nearest full percentage. *130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014. †BP cutpoints for definition of hypertension in the present guideline. ‡BP cutpoints for definition of hypertension in JNC 7. §Adjusted to the 2010 age-sex distribution of the U.S. adult population. BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health and Nutrition Examination Survey; and SBP, systolic blood pressure. Accurate Measurement of BP in the Office COR I Recommendation for Accurate Measurement of BP in the Office For diagnosis and management of high BP, proper C-EO methods are recommended for accurate measurement and documentation of BP. LOE Checklist for Accurate Measurement of BP Key Steps for Proper BP Measurements Step 1: Properly prepare the patient. Step 2: Use proper technique for BP measurements. Step 3: Take the proper measurements needed for diagnosis and treatment of elevated BP/hypertension. Step 4: Properly document accurate BP readings. Step 5: Average the readings. Step 6: Provide BP readings to patient. Selection Criteria for BP Cuff Size for Measurement of BP in Adults Arm Circumference 22–26 cm Usual Cuff Size 27–34 cm Adult 35–44 cm Large adult 45–52 cm Adult thigh Small adult Out-of-Office and Self-Monitoring of BP COR LOE I ASR Recommendation for Out-of-Office and SelfMonitoring of BP Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions. SR indicates systematic review. Corresponding Values of SBP/DBP for Clinic, HBPM, Daytime, Nighttime, and 24-Hour ABPM Measurements Clinic HBPM 120/80 Daytime ABPM 120/80 Nighttime ABPM 100/65 24-Hour ABPM 115/75 120/80 130/80 130/80 130/80 110/65 125/75 140/90 135/85 135/85 120/70 130/80 160/100 145/90 145/90 140/85 145/90 ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; DBP diastolic blood pressure; HBPM, home blood pressure monitoring; and SBP, systolic blood pressure. BP Patterns Based on Office and Out-of-Office Measurements Office/Clinic/Healthcare Setting Home/Nonhealthcare/ ABPM Setting Normotensive No hypertension No hypertension Sustained hypertension Hypertension Hypertension Masked hypertension No hypertension Hypertension White coat hypertension Hypertension No hypertension ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure. Detection of White Coat Hypertension or Masked Hypertension in Patients Not on Drug Therapy Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring. Secondary Forms of Hypertension COR I IIb Recommendations for Secondary Forms of Hypertension Screening for specific form(s) of secondary hypertension is recommended when the clinical C-EO indications and physical examination findings are present or in adults with resistant hypertension. LOE If an adult with sustained hypertension screens positive for a form of secondary hypertension, C-EO referral to a physician with expertise in that form of hypertension may be reasonable for diagnostic confirmation and treatment. Screening for Secondary Hypertension New-onset or uncontrolled hypertension in adults Conditions • Drug-resistant/induced hypertension • Abrupt onset of hypertension • Onset of hypertension at <30 y • Exacerbation of previously controlled hypertension • Disproportionate TOD for degree of hypertension • Accelerated/malignant hypertension • Onset of diastolic hypertension in older adults (age ≥65 y) • Unprovoked or excessive hypokalemia Yes Screen for secondary hypertension (Class I) (see Table 13) No Screening not indicated (No Benefit) Positive screening test Yes Refer to clinician with specific expertise (Class IIb) No Referral not necessary (No Benefit) Colors correspond to Class of Recommendation in Table 1 . TOD indicates target organ damage (e.g., cerebrovascular disease, hypertensive retinopathy, left ventricular hypertrophy, left ventricular dysfunction, heart failure, coronary artery disease, chronic kidney disease, albuminuria, peripheral artery disease). Causes of Secondary Hypertension With Clinical Indications Common causes Renal parenchymal disease Renovascular disease Primary aldosteronism Obstructive sleep apnea Drug or alcohol induced Uncommon causes Pheochromocytoma/paraganglioma Cushing’s syndrome Hypothyroidism Hyperthyroidism Aortic coarctation (undiagnosed or repaired) Primary hyperparathyroidism Congenital adrenal hyperplasia Mineralocorticoid excess syndromes other than primary aldosteronism Acromegaly Primary Aldosteronism COR I I I LOE Recommendations for Primary Aldosteronism C-EO 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). C-LD Use of the plasma aldosterone: renin activity ratio is recommended when adults are screened for primary aldosteronism. C-EO In adults with hypertension and a positive screening test for primary aldosteronism, referral to a hypertension specialist or endocrinologist is recommended for further evaluation and treatment. Renal Artery Stenosis COR I IIb LOE A Recommendations for Renal Artery Stenosis Medical therapy is recommended for adults with atherosclerotic renal artery stenosis. In adults with renal artery stenosis for whom medical management has failed (refractory hypertension, worsening renal function, and/or intractable HF) and those with nonatherosclerotic disease, including C-EO fibromuscular dysplasia, it may be reasonable to refer the patient for consideration of revascularization (percutaneous renal artery angioplasty and/or stent placement). Obstructive Sleep Apnea COR IIb LOE B-R Recommendation for Obstructive Sleep Apnea In adults with hypertension and obstructive sleep apnea, the effectiveness of continuous positive airway pressure (CPAP) to reduce BP is not well established. 2017 Hypertension Guideline Nonpharmacological Interventions Nonpharmacological Interventions COR LOE I A I A I A I A Recommendations for Nonpharmacological Interventions Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese. A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension. Sodium reduction is recommended for adults with elevated BP or hypertension. Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of CKD or use of drugs that reduce potassium excretion. Nonpharmacological Interventions (cont.) COR LOE I A I A Recommendations for Nonpharmacological Interventions Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension. Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively. *In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol). Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* Nonpharmacologi -cal Intervention Dose Approximate Impact on SBP Hypertension Normotension Weight/body fat Best goal is ideal body weight, but aim -5 mm Hg Weight loss -2/3 mm Hg for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight. DASH dietary Healthy diet Consume a diet rich in fruits, -11 mm Hg -3 mm Hg pattern vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. Reduced intake Dietary sodium Optimal goal is <1500 mg/d, but aim -5/6 mm Hg -2/3 mm Hg of dietary for at least a 1000-mg/d reduction in sodium most adults. Dietary Enhanced Aim for 3500–5000 mg/d, preferably -4/5 mm Hg -2 mm Hg potassium intake of by consumption of a diet rich in dietary potassium. potassium *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure. Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* (cont.) Nonpharmacologica Dose l Intervention Physical Aerobic ● 90–150 min/wk activity ● 65%–75% heart rate reserve Dynamic resistance ● 90–150 min/wk ● 50%–80% 1 rep maximum ● 6 exercises, 3 sets/exercise, 10 repetitions/set Isometric resistance ● 4 × 2 min (hand grip), 1 min rest between exercises, 30%–40% maximum voluntary contraction, 3 sessions/wk ● 8–10 wk Moderation Alcohol In individuals who drink alcohol, in alcohol consumption reduce alcohol† to: intake ● Men: ≤2 drinks daily ● Women: ≤1 drink daily Approximate Impact on SBP Hypertension Normotension -5/8 mm Hg -2/4 mm Hg -4 mm Hg -2 mm Hg -5 mm Hg -4 mm Hg -4 mm Hg -3 mm *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. †In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol). 2017 Hypertension Guideline Patient Evaluation Basic and Optional Laboratory Tests for Primary Hypertension Fasting blood glucose* Complete blood count Lipid profile Serum creatinine with eGFR* Serum sodium, potassium, calcium* Thyroid-stimulating hormone Urinalysis Electrocardiogram Optional testing Echocardiogram Uric acid Urinary albumin to creatinine ratio Basic testing *May be included in a comprehensive metabolic panel. eGFR indicates estimated glomerular filtration rate. 2017 Hypertension Guideline Treatment of High BP Follow-Up After Initial BP Evaluation COR LOE I B-R I B-R I B-R Recommendations for Follow-Up After Initial BP Elevation Adults with an elevated BP or stage 1 hypertension who have an estimated 10-year ASCVD risk less than 10% should be managed with nonpharmacological 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 nonpharmacological and antihypertensive drug therapy and have a repeat BP evaluation in 1 month. Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacological and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation in 1 month. Follow-Up After Initial BP Evaluation (cont.) COR LOE I B-R IIa C-EO Recommendations for Follow-Up After Initial BP Elevation For adults with a very high average BP (e.g., SBP ≥180 mm Hg or DBP ≥110 mm Hg), evaluation followed by prompt antihypertensive drug treatment is recommended. For adults with a normal BP, repeat evaluation every year is reasonable. BP Goal for Patients With Hypertension COR LOE I SBP: B-RSR IIb Recommendations for BP Goal for Patients With Hypertension For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher a BP target of less than 130/80 mm Hg is recommended. DBP: C-EO SBP: For adults with confirmed hypertension, without B-NR additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be DBP: reasonable. C-EO SR indicates systematic review. Blood Pressure (BP) Thresholds and Recommendations for Treatment and Follow-Up (continued on next slide) BP thresholds and recommendations for treatment and follow-up Normal BP (BP <120/80 mm Hg) Elevated BP (BP 120–129/<80 mm Hg) Promote optimal lifestyle habits Nonpharmacologic therapy (Class I) Stage 1 hypertension (BP 130–139/80-89 mm Hg) Clinical ASCVD or estimated 10-y CVD risk ≥10%* No Reassess in 1y (Class IIa) Reassess in 3–6 mo (Class I) Stage 2 hypertension (BP ≥ 140/90 mm Hg) Yes Nonpharmacologic therapy (Class I) Nonpharmacologic therapy and BP-lowering medication (Class I) Reassess in 3–6 mo (Class I) Reassess in 1 mo (Class I) Nonpharmacologic therapy and BP-lowering medication† (Class I) 1y (Class IIa) 3–6 mo (Class I) therapy (Class I) Reassess in 3–6 mo (Class I) BP-lowering medication (Class I) BP-lowering medication† (Class I) Reassess in 1 mo (Class I) BP goal met No Assess and optimize adherence to therapy Yes Reassess in 3–6 mo (Class I) Consider intensification of therapy Colors correspond to Class of Recommendation in Table 1. *Using the ACC/AHA Pooled Cohort Equations. Note that patients with DM or CKD are automatically placed in the highrisk category. For initiation of RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and renal function 2 to 4 weeks after initiating therapy. †Consider initiation of pharmacological therapy for stage 2 hypertension with 2 antihypertensive agents of 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 or with postural symptoms), identification of white coat hypertension or a white coat effect, documentation of adherence, monitoring of the response to therapy, reinforcement of the importance of adherence, reinforcement of the importance of treatment, and assistance with treatment to achieve BP target. General Principles of Drug Therapy COR III: Harm LOE A Recommendation for General Principle of Drug Therapy Simultaneous use of an ACE inhibitor, ARB, and/or renin inhibitor is potentially harmful and is not recommended to treat adults with hypertension. Choice of Initial Medication COR I LOE ASR Recommendation for Choice of Initial Medication For initiation of antihypertensive drug therapy, firstline agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs. SR indicates systematic review. Choice of Initial Monotherapy Versus Initial Combination Drug Therapy COR LOE I C-EO IIa C-EO Recommendations for Choice of Initial Monotherapy Versus Initial Combination Drug Therapy* Initiation of antihypertensive drug therapy with 2 first-line agents of different classes, either as separate agents or in a fixed-dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mm Hg above their BP target. Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target. 2017 Hypertension Guideline Hypertension in Patients With Comorbidities Stable Ischemic Heart Disease COR I LOE Recommendations for Treatment of Hypertension in Patients With Stable Ischemic Heart Disease (SIHD) SBP: In adults with SIHD and hypertension, a BP target of less than B-R 130/80 mm Hg is recommended. DBP: C-EO I Adults with SIHD and hypertension (BP ≥130/80 mm Hg) should SBP: be treated with medications (e.g., GDMT beta blockers, ACE B-R inhibitors, or ARBs) for compelling indications (e.g., previous MI, stable angina) as first-line therapy, with the addition of other drugs (e.g., dihydropyridine CCBs, thiazide diuretics, and/or DBP: mineralocorticoid receptor antagonists) as needed to further C-EO control hypertension. Heart Failure COR I LOE SBP: B-R DBP: C-EO Recommendation for Prevention of HF in Adults With Hypertension In adults at increased risk of HF, the optimal BP in those with hypertension should be less than 130/80 mm Hg. Heart Failure With Reduced Ejection Fraction COR I III: No Benefit LOE C-EO B-R Recommendations for Treatment of Hypertension in Patients With HFrEF Adults with HFrEF and hypertension should be prescribed GDMT titrated to attain a BP of less than 130/80 mm Hg. Nondihydropyridine CCBs are not recommended in the treatment of hypertension in adults with HFrEF. Heart Failure With Preserved Ejection Fraction COR I I LOE Recommendations for Treatment of Hypertension in Patients With HFpEF C-EO In adults with HFpEF who present with symptoms of volume overload, diuretics should be prescribed to control hypertension. C-LD Adults with HFpEF and persistent hypertension after management of volume overload should be prescribed ACE inhibitors or ARBs and beta blockers titrated to attain SBP of less than 130 mm Hg. Chronic Kidney Disease COR I LOE Recommendations for Treatment of Hypertension in Patients With CKD SBP: Adults with hypertension and CKD should be treated to a BP B-RSR goal of less than 130/80 mm Hg. DBP: C-EO IIa B-R IIb C-EO In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-creatinine ratio or the equivalent in the first morning void]), treatment with an ACE inhibitor is reasonable to slow kidney disease progression. In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-creatinine ratio in the first morning void]), treatment with an ARB may be reasonable if an ACE inhibitor is not tolerated. SR indicates systematic review. Management of Hypertension in Patients With CKD Treatment of hypertension in patients with CKD BP goal <130/80 mm Hg (Class I) Albuminuria (≥300 mg/d or ≥300 mg/g creatinine) Yes ACE inhibitor (Class IIa) No Usual “first-line” medication choices ACE inhibitor intolerant Yes ARB* (Class IIb) No ACE inhibitor* (Class IIa) •Colors correspond to Class of Recommendation in Table 1. •*CKD stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d or ≥300 mg/g creatinine. •ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP blood pressure; and CKD, chronic kidney disease. Hypertension After Renal Transplantation COR IIa LOE Recommendations for Treatment of Hypertension After Renal Transplantation SBP: After kidney transplantation, it is reasonable to treat patients with hypertension to a BP goal of less than 130/80 mm Hg. B-NR DBP: C-EO IIa B-R After kidney transplantation, it is reasonable to treat patients with hypertension with a calcium antagonist on the basis of improved GFR and kidney survival. Emergency Hypertension • Hypertension with end organ damage Acute Intracerebral Hemorrhage COR IIa III: Harm LOE Recommendations for Management of Hypertension in Patients With Acute Intracerebral Hemorrhage (ICH) In adults with ICH who present with SBP greater than 220 mm C-EO Hg, it is reasonable to use continuous intravenous drug infusion and close BP monitoring to lower SBP. A Immediate lowering of SBP to less than 140 mm Hg in adults with spontaneous 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. Management of Hypertension in Patients With Acute ICH Acute (<6 h from symptom onset) spontaneous ICH SBP 150–220 mm Hg SBP >220 mm Hg SBP lowering to <140 mm Hg (Class III:Harm) SBP lowering with continuous IV infusion and close BP monitoring (Class IIa) Colors correspond to Class of Recommendation in Table 1. BP indicates blood pressure; ICH, intracerebral hemorrhage; IV, intravenous; and SBP, systolic blood pressure. Acute Ischemic Stroke COR I I IIa LOE Recommendations for Management of Hypertension in Patients With Acute Ischemic Stroke Adults with acute ischemic stroke and elevated BP who are eligible for treatment with intravenous tissue plasminogen B-NR activator should have their BP slowly lowered to less than 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 intravenous tissue B-NR plasminogen activator and should be maintained below 180/105 mm Hg for at least the first 24 hours after initiating drug therapy. Starting or restarting antihypertensive therapy during hospitalization in patients with BP greater than 140/90 mm Hg B-NR who are neurologically stable is safe and reasonable to improve long-term BP control, unless contraindicated. Acute Ischemic Stroke (cont.) COR IIb III: No Benefit LOE Recommendations for Management of Hypertension in Patients With Acute Ischemic Stroke In patients with BP of 220/120 mm Hg or higher who did not receive intravenous alteplase or endovascular treatment and have no comorbid conditions requiring acute antihypertensive C-EO treatment, the benefit of initiating or reinitiating treatment of hypertension within the first 48 to 72 hours is uncertain. It might be reasonable to lower BP by 15% during the first 24 hours after onset of stroke. In patients with BP less than 220/120 mm Hg who did not receive intravenous thrombolysis or endovascular treatment and do not have a comorbid condition requiring acute A antihypertensive treatment, initiating or reinitiating treatment of hypertension within the first 48 to 72 hours after an acute ischemic stroke is not effective to prevent death or dependency. Management of Hypertension in Patients With Acute Ischemic Stroke Acute (<72 h from symptom onset) ischemic stroke and elevated BP Patient qualifies for IV thrombolysis therapy Yes Lower SBP to <185 mm Hg and DBP <110 mm Hg before initiation of IV thrombolysis (Class I) No BP ≤220/110 mm Hg BP >220/110 mm Hg Initiating or reinitiating treatment of hypertension within the first 48-72 hours after an acute ischemic stroke is ineffective to prevent death or dependency (Class III: No Benefit) Lower BP 15% during first 24 h (Class IIb) And Maintain BP <180/105 mm Hg for first 24 h after IV thrombosis (Class I) For preexisting hypertension, reinitiate antihypertensive drugs after neurological stability (Class IIa) Colors correspond to Class of Recommendation in Table 1. BP indicates blood pressure; DBP, diastolic blood pressure; IV, intravenous; and SBP, systolic blood pressure. Secondary Stroke Prevention COR LOE I A I A I B-R Recommendations for Treatment of Hypertension for Secondary Stroke Prevention Adults with previously treated hypertension who experience a stroke or transient ischemic attack (TIA) should be restarted on antihypertensive treatment after the first few days of the index event to reduce the risk of recurrent stroke and other vascular events. For adults who experience a stroke or TIA, treatment with a thiazide diuretic, ACE inhibitor, or ARB, or combination treatment consisting of a thiazide diuretic plus ACE inhibitor, is useful. Adults not previously treated for hypertension who experience a stroke or TIA and have an established BP of 140/90 mm Hg or higher should be prescribed antihypertensive treatment a few days after the index event to reduce the risk of recurrent stroke and other vascular events. Secondary Stroke Prevention (cont.) COR I IIb IIb IIb LOE B-NR Recommendations for Treatment of Hypertension for Secondary Stroke Prevention For adults who experience a stroke or TIA, selection of specific drugs should be individualized on the basis of patient comorbidities and agent pharmacological class. B-R For adults who experience a stroke or TIA, a BP goal of less than 130/80 mm Hg may be reasonable. B-R For adults with a lacunar stroke, a target SBP goal of less than 130 mm Hg may be reasonable. C-LD In adults previously untreated for hypertension who experience an ischemic stroke or TIA and have a SBP less than 140 mm Hg and a DBP less than 90 mm Hg, the usefulness of initiating antihypertensive treatment is not well established. Management of Hypertension in Patients With a Previous History of Stroke (Secondary Stroke Prevention) Stroke ≥72 h from symptom onset and stable neurological status or TIA Previous diagnosed or treated hypertension Yes Restart antihypertensive treatment (Class I) Aim for BP <140/90 mm Hg (Class IIb) No Established SBP ≥140 mm Hg or DBP ≥90 mm Hg Established SBP <140 mm Hg and DBP <90 mm Hg Initiate antihypertensive treatment (Class I) Usefulness of starting antihypertensive treatment is not well established (Class IIb) Aim for BP <130/80 mm Hg (Class IIb) Colors correspond to Class of Recommendation in Table 1. DBP indicates diastolic blood pressure; SBP, systolic blood pressure; and TIA, transient ischemic attack. Peripheral Arterial Disease COR I LOE B-NR Recommendation for Treatment of Hypertension in Patients With PAD Adults with hypertension and PAD should be treated similarly to patients with hypertension without PAD. Diabetes Mellitus COR I LOE SBP: In adults with DM and hypertension, antihypertensive drug B-RSR treatment should be initiated at a BP of 130/80 mm Hg or DBP: C-EO I IIb Recommendations for Treatment of Hypertension in Patients With DM higher with a treatment goal of less than 130/80 mm Hg. In adults with DM and hypertension, all first-line classes of ASR antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. In adults with DM and hypertension, ACE inhibitors or ARBs B-NR may be considered in the presence of albuminuria. SR indicates systematic review. Atrial Fibrillation COR IIa LOE B-R Recommendation for Treatment of Hypertension in Patients With AF Treatment of hypertension with an ARB can be useful for prevention of recurrence of AF. Valvular Heart Disease COR LOE Recommendations for Treatment of Hypertension in Patients With Valvular Heart Disease I In adults with asymptomatic aortic stenosis, hypertension should be treated with pharmacotherapy, starting at a low dose B-NR and gradually titrating upward as needed. IIa In patients with chronic aortic insufficiency, treatment of systolic hypertension with agents that do not slow the heart rate (i.e., C-LD avoid beta blockers) is reasonable. Aortic Disease COR I LOE Recommendation for Management of Hypertension in Patients With Aortic Disease Beta blockers are recommended as the preferred C-EO antihypertensive agents in patients with hypertension and thoracic aortic disease. 2017 Hypertension Guideline Special Patient Groups Racial and Ethnic Differences in Treatment COR I I LOE B-R Recommendations for Race and Ethnicity In black adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults C-LD with hypertension, especially in black adults with hypertension. Pregnancy COR I III: Harm LOE Recommendations for Treatment of Hypertension in Pregnancy Women with hypertension who become pregnant, or are planning to become pregnant, should be transitioned to C-LD methyldopa, nifedipine, and/or labetalol during pregnancy. C-LD Women with hypertension who become pregnant should not be treated with ACE inhibitors, ARBs, or direct renin inhibitors. 2017 Hypertension Guideline Other Considerations Resistant Hypertension: Diagnosis, Evaluation, and Treatment . BP indicates blood pressure; CKD, chronic kidney disease; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; NSAIDs, nonsteroidal antiinflammatory drugs; and SBP, systolic blood pressure. Adapted with permission from Calhoun et al. Hypertensive Crises: Emergencies and Urgencies COR I I I LOE Recommendations for Hypertensive Crises and Emergencies In adults with a hypertensive emergency, admission to an intensive care unit is recommended for continuous monitoring B-NR of BP and target organ damage and for parenteral administration of an appropriate agent. For adults with a compelling condition (i.e., aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma C-EO crisis), SBP should be reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection. For adults without a compelling condition, SBP should be reduced by no more than 25% within the first hour; then, if C-EO stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours. Diagnosis and Management of a Hypertensive Crisis SBP >180 mm Hg and/or DBP >120 mm Hg Target organ damage new/ progressive/worsening Yes Hypertensive emergency No Markedly elevated BP Admit to ICU (Class I) Reinstitute/intensify oral antihypertensive drug therapy and arrange follow-up Conditions: • Aortic dissection • Severe preeclampsia or eclampsia • Pheochromocytoma crisis Yes Reduce SBP to <140 mm Hg during first h* and to <120 mm Hg in aortic dissection† (Class I) No Reduce BP by max 25% over first h†, then to 160/100–110 mm Hg over next 2–6 h, then to normal over next 24–48 h (Class I) Colors correspond to Class of Recommendation in Table 1. *Use drug(s) specified in Table 19. †If other comorbidities are present, select a drug specified in Table 20. BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care unit; and SBP, systolic blood pressure. Cognitive Decline and Dementia COR IIa LOE B-R Recommendation for Prevention of Cognitive Decline and Dementia In adults with hypertension, BP lowering is reasonable to prevent cognitive decline and dementia. Patients Undergoing Surgical Procedures COR LOE Recommendations for Treatment of Hypertension in Patients Undergoing Surgical Procedures Preoperative I In patients with hypertension undergoing major surgery who have been on beta blockers chronically, beta blockers should B-NR be continued. IIa In patients with hypertension undergoing planned elective major surgery, it is reasonable to continue medical therapy for C-EO hypertension until surgery. IIb In patients with hypertension undergoing major surgery, discontinuation of ACE inhibitors or ARBs perioperatively may B-NR be considered. Patients Undergoing Surgical Procedures (cont.) COR IIb III: Harm III: Harm LOE Recommendations for Treatment of Hypertension in Patients Undergoing Surgical Procedures Preoperative In patients with planned elective major surgery and SBP of C-LD 180 mm Hg or higher or DBP of 110 mm Hg or higher, deferring surgery may be considered. For patients undergoing surgery, abrupt preoperative B-NR discontinuation of beta blockers or clonidine is potentially harmful. Beta blockers should not be started on the day of surgery in B-NR beta blocker–naïve patients. Intraoperative I Patients with intraoperative hypertension should be managed C-EO with intravenous medications until such time as oral medications can be resumed. 2017 Hypertension Guideline Strategies to Improve Hypertension Treatment and Control Antihypertensive Medication Adherence Strategies COR I IIa LOE B-R Recommendations for Antihypertensive Medication Adherence Strategies In adults with hypertension, dosing of antihypertensive medication once daily rather than multiple times daily is beneficial to improve adherence. Use of combination pills rather than free individual B-NR components can be useful to improve adherence to antihypertensive therapy. Strategies to Promote Lifestyle Modification COR I LOE Recommendation for Strategies to Promote Lifestyle Modification Effective behavioral and motivational strategies to achieve a healthy lifestyle (i.e., tobacco cessation, weight loss, C-EO moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension. Structured, Team-Based Care Interventions for Hypertension Control COR I LOE A Recommendation for Structured, Team-Based Care Interventions for Hypertension Control A team-based care approach is recommended for adults with hypertension. EHR and Patient Registries COR LOE Recommendations for EHR and Patient Registries I Use of the EHR and patient registries is beneficial for identification of patients with undiagnosed or undertreated B-NR hypertension. I Use of the EHR and patient registries is beneficial for guiding quality improvement efforts designed to improve hypertension B-NR control. Telehealth Interventions to Improve Hypertension Control COR IIa LOE A Recommendation for Telehealth Interventions to Improve Hypertension Control Telehealth strategies can be useful adjuncts to interventions shown to reduce BP for adults with hypertension. Performance Measures COR IIa LOE Recommendation for Performance Measures Use of performance measures in combination with other quality improvement strategies at patient-, provider-, and B-NR system-based levels is reasonable to facilitate optimal hypertension control. Quality Improvement Strategies COR IIa LOE Recommendation for Quality Improvement Strategies Use of quality improvement strategies at the health system, provider, and patient levels to improve identification and B-NR control of hypertension can be effective. Financial Incentives COR IIa IIa LOE B-R Recommendations for Financial Incentives Financial incentives paid to providers can be useful in achieving improvements in treatment and management of patient populations with hypertension. Health system financing strategies (e.g., insurance coverage and copayment benefit design) can be useful in facilitating B-NR improved medication adherence and BP control in patients with hypertension. 2017 Hypertension Guideline The Plan of Care for Hypertension The Plan of Care for Hypertension COR I LOE Recommendations for Financial Incentives Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals, C-EO encourages effective management of comorbid conditions, prompts timely follow-up with the healthcare team, and adheres to CVD GDMT. Clinician’s Sequential Flow Chart for the Management of Hypertension Clinician’s Sequential Flow Chart for the Management of Hypertension Measure office BP accurately Detect white coat hypertension or masked hypertension by using ABPM and HBPM Evaluate for secondary hypertension Identify target organ damage Introduce lifestyle interventions Identify and discuss treatment goals Use ASCVD risk estimation to guide BP threshold for drug therapy Align treatment options with comorbidities Account for age, race, ethnicity, sex, and special circumstances in antihypertensive treatment Initiate antihypertensive pharmacological therapy Insure appropriate follow-up Use team-based care Connect patient to clinician via telehealth Detect and reverse nonadherence Detect white coat effect or masked uncontrolled hypertension Use health information technology for remote monitoring and self-monitoring of BP ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure. 2017 Hypertension Guideline Summary of BP Thresholds and Goals for Pharmacological Therapy Plan of Care for Hypertension BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions Clinical Condition(s) General Clinical CVD or 10-year ASCVD risk ≥10% No clinical CVD and 10-year ASCVD risk <10% Older persons (≥65 years of age; noninstitutionalized, ambulatory, community-living adults) Specific comorbidities Diabetes mellitus Chronic kidney disease Chronic kidney disease after renal transplantation Heart failure Stable ischemic heart disease Secondary stroke prevention Secondary stroke prevention (lacunar) Peripheral arterial disease BP Threshold, mm Hg BP Goal, mm Hg ≥130/80 ≥140/90 ≥130 (SBP) <130/80 <130/80 <130 (SBP) ≥130/80 ≥130/80 ≥130/80 ≥130/80 ≥130/80 ≥140/90 ≥130/80 ≥130/80 <130/80 <130/80 <130/80 <130/80 <130/80 <130/80 <130/80 <130/80 ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.