ACC/AHA Blood Pressure Treatment Guideline: Lifestyle Modification and Drug Therapy

SUMMARY:

Treatment of hypertension should involve non-pharmacologic therapy (also called lifestyle modification) alone or in concert with antihypertensive drug therapy.  The ACC/AHA Blood Pressure Guidelines address both areas. In addition, the AHA scientific statement (2019) on BP measurement concluded that validated oscillometric devices allow for accurate BP measurement in the outpatient setting and “may provide a more accurate measurement of BP than auscultation”

Table of Contents  

Current ACC/AHA Definitions

(See ‘Related ObG Entry’ below)

  • Normal
    • Systolic <120 mmHg and diastolic <80 mmHg
  • Elevated
    • Systolic 120 to 129 mmHg and diastolic <80 mmHg
  • Hypertension
    • Stage 1: Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg
    • Stage 2: Systolic ≥140 mmHg or diastolic ≥90 mmHg
  • ‘White Coat’ hypertension
    • Elevated BP in the office but not outside the office
    • Checking for ‘White Coat’ hypertension using either daytime Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM) is “reasonable” if
      • Office SBP is >130 but <160 mm Hg or
      • Office diastolic BP (DBP) >80 but <100 mm Hg
  • ‘Masked’ hypertension
    • Elevated BP out-of-office but not in-office
    • Checking for ‘masked’ hypertension with daytime ABPM or HBPM is “reasonable if”
      • Office SPB is 120 to 129 and DBP is <80
  • Hypertensive emergency (formerly called ‘malignant hypertension’)
    • Severe hypertension: SBP ≥180 mmHg or DBP ≥120 mmHg
    • Consider this a medical emergency which may need ICU care
  • Resistant hypertension
    • Uncontrolled BP despite treatment ≥3 antihypertensive agents (one of which is usually a diuretic)

Lab Work-Up

  • Basic
    • Fasting blood glucose | Sodium | Potassium | Calcium
      • Can be part of comprehensive metabolic panel
    • Serum creatinine with eGFR
    • CBC
    • Lipid profile
    • TSH
    • Urinalysis
    • Electrocardiogram
  • Optional testing
    • Echocardiogram
    • Uric acid
    • Urinary albumin/creatinine ratio

BP Treatment Summary

  • <120 mmHg and <80 mmHg → NORMAL BP
    • Healthy lifestyle choices  
    • Yearly check-ups 
  • 120 – 129 mmHg and <80 mmHg → ELEVATED BP
    • Lifestyle changes  
    • Reassess in 3 to 6 months  
  • 130 – 139 mmHg or 80-89 mmHg → HIGH BP – STAGE 1  
    • 10-year heart disease and stroke risk assessment <10% risk 
      • Lifestyle changes  
      • Re-assess in 3 to 6 months 
    • 10-year heart disease and stroke risk assessment ≥10% risk 
      • Lifestyle changes  
      • Medication  
      • Monthly follow-up until BP is under control 
  • ≥140 mmHg or ≥90 mmHg → HIGH BP – STAGE 2 
    • Lifestyle changes  
    • Consider initiation of therapy with 2 different classes of medications 
    • Monthly follow-up until BP is under control
    • If BP ≥160/100 mm Hg: Treat promptly, monitor carefully and adjust medication dose upward as necessary to achieve control  

NOTE: Calculate 10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (see ‘Learn More – Primary Sources’ below)

Lifestyle Modification (Non-pharmacological Interventions) 

  • Weight loss 
    • Goal: Optimum goal is ideal body weight but can expect 1mm Hg for every 1kg reduction 
  • Diet 
    • DASH diet: Fruits and vegetables, whole grains, low-fat dairy products, reduced saturated and total fat 
    • Other diets with supportive evidence 
      • Low in calories from carbohydrates  
      • High-protein diets  
      • Vegetarian diets  
      • Mediterranean dietary pattern  
    • Sodium: Goal <1500 mg/d, but aim for at least a 1000-mg/d reduction 
    • Potassium: Goal 3500 to 5000 mg/d, preferably through diet 
  • Exercise – Recommend structured exercise program  
    • Aerobic: 90–150 min/wk; 65%–75% heart rate reserve 
    • Dynamic resistance and Isometric resistance also shown to lower BP  
  • Alcohol Reduction (drink = 12 oz regular beer [5% alc] / 5 oz wine [12% alc] / 1.5 oz distilled spirits [40% alc])  
    • Women: ≤ 1 drink per day  
    • Men: ≤ 2 drink per day 

First Line Pharmacological Treatment

Dosages based on ACC/AHA guidelines and may differ from FDA labeling

Thiazide or thiazide-type diuretics

  • Chlorthalidone: 12.5–25 mg/d
    • Preferred due to prolonged half-life and evidence of reduced adverse CVD outcomes
    • Monitor for: Hyponatremia & hypokalemia | Uric acid & calcium levels
    • Caution: Ask about history of acute gout unless patient is on uric acid–lowering therapy
  • Hydrochlorothiazide: 25–50 mg/d
  • Indapamide: 1.25–2.5 mg/d
  • Metolazone: 2.5–5 mg/d

ACE (angiotensin-converting-enzyme) inhibitors

  • Benazepril: 10–40 mg/d (divided in to 1 or 2 doses)
  • Captopril: 12.5–150 mg/d (divided in to 2 or 3 doses)
  • Enalapril: 5–40 mg/d (divided in to 1 or 2 doses)
  • Fosinopril 10–40 mg/d
  • Lisinopril: 10–40 mg/d
  • Moexipril 7.5–30 mg/d (divided in to 1 or 2 doses)
  • Perindopril: 4–16 mg/d
  • Quinapril: 10–80 mg/d (divided in to 1 or 2 doses)
  • Ramipril: 2.5–20 mg/d (divided in to 1 or 2 doses)
  • Trandolapril: 1–4 mg/d

Caution: Do not combine with ARBs or direct renin inhibitor | Increased risk of hyperkalemia (watch for patients with CKD, on K+ supplements or sparing meds) | Risk for acute renal failure in patients with severe bilateral renal artery stenosis | Do not use in pregnancy | Do not use if patient has history of angioedema with ACE inhibitors

ARBs (Angiotensin II Receptor Blockers)

  • Azilsartan: 40–80 mg/d
  • Candesartan: 8–32 mg/d
  • Eprosartan: 600–800 mg/d (divided in to 1 or 2 doses)
  • Irbesartan: 150–300 mg/d
  • Losartan: 50–100 mg/d (divided in to 1 or 2 doses)
  • Olmesartan: 20–40 mg/d
  • Telmisartan: 20–80 mg/d
  • Valsartan: 80–320 mg/d

Caution: Do not combine with ACE or direct renin inhibitor | Increased risk of hyperkalemia (watch for patients with CKD, on K+ supplements or sparing meds) | Risk for acute renal failure in patients with severe bilateral renal artery stenosis | Do not use in pregnancy | Do not use if patient has history of angioedema with ARBs | Note: Patient with history of angioedema due to ACE inhibitor can start ARBs six weeks after ACE inhibitor has been stopped

CCB (Calcium Channel Blocker): Dihydropyridines

  • Amlodipine: 2.5–10 mg/d
  • Felodipine: 2.5–10 mg/d
  • Isradipine: 5–10 mg/d (divided in to 2 doses)
  • Nicardipine SR: 60–120 (divided in to 2 doses)
  • Nifedipine LA: 30–90 mg/d
  • Nisoldipine: 17–34 mg/d

Caution: Avoid use in patients with heart failure/reduced ejection fraction (HFrEF) – amlodipine or felodipine may be used if required | Dose-related pedal edema is more common in women

CCB: Nondihydropyridines

  • Diltiazem ER: 120–360 mg/d
  • Verapamil IR: 120–360 mg/d (divided in to 3 doses)
  • Verapamil SR: 120–360 mg/d (divided in to 1 or 2 doses)
  • Verapamil-delayed onset ER: 100–300 mg/d (1 dose in the evening)

Caution: Avoid routine use with beta blockers due to increased risk of bradycardia and heart block| Avoid in patients with HFrEF | Note drug interactions with diltiazem and verapamil (CYP3A4 major substrate and moderate inhibitor)

Second Line Pharmacological Treatment

Complete list with dosing available in the guideline link (see ‘Learn More – Primary Sources’ below)

  • Second line treatment includes the following classes of medications
    • Diuretics: Loop | Potassium sparing | Aldosterone antagonists
    • Beta-blockers: Cardioselective | cardioselective and vasodilatory | noncardioselective | intrinsic sympathomimetic activity | combined alpha- and beta-receptor
    • Direct renin inhibitor
    • Alpha-1 blockers
    • Central alpha2 agonist and other centrally acting drugs
    • Direct vasodilators
  • While some are generally less effective than first-line class drugs, some may be preferred in certain clinical settings such as symptomatic heart failure  

KEY POINTS:

Target BP and Treatment Strategy

 BP Target Goals

  • Known CVD or 10-year ASCVD event risk >10%
    • <130/80 mm Hg “is recommended”
  • No additional markers for CVD risk
    • <130/80 mm Hg “may be reasonable”  

Monotherapy vs Combination Therapy

  • Stage 1 hypertension
    • Start with a single agent Initiation of antihypertensive drug therapy and titrate dose or add another medication to achieve target  
  • Stage 2 hypertension and an average BP more than 20/10 mm Hg above BP target
    • Start with a combination of 2 first-line agents of different classes
    • Can be either separate or fixed-dose combination

Treatment of white coat and masked hypertension (ACC/AHA)

  • No data on the risks and benefits of treating white coat and masked hypertension
  • Consistent evidence that masked hypertension and masked uncontrolled hypertension are associated with adverse outcomes related to elevated BP compared to normotensive individuals
  • More recent evidence (see ‘Related ObG Topic’ below) that there may associated risk with white coat hypertension and research authors suggest lifestyle modification and monitoring to what for possible transition to sustained hypertension

Special Populations

During Pregnancy

  • Transition to
    • Methyldopa | Nifedipine | Labetalol (see ‘Related ObG Entry’ below)
  • Caution: Do not treat with
    • ACE inhibitors | ARBs | Direct renin inhibitors

Race / Ethnicity

  • Black adults with hypertension but no heart failure or chronic kidney disease
    • Begin initial treatment with a thiazide-type diuretic or CCB
    • Target of <130/80 using two or more antihypertensives if needed is recommended for most adults, but “especially in black adults with hypertension”

Diabetic Patients with Hypertension

  • Initiate treatment at ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg
  • All first-line classes of antihypertensive are useful and effective
  • “ACE inhibitors or ARBs may be considered in the presence of albuminuria”

Learn More – Primary Sources  

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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association

ASCVD Heart Risk Calculator

ACC/AHA Blood Pressure Guideline: Current Classification System and Treatment Targets

SUMMARY:  

The latest USPSTF released its recommendation regarding screening for hypertension in adults (2021). Based on current evidence demonstrating high certainty regarding net benefit, the task force reaffirms and “recommends screening for hypertension in adults 18 years or older with office blood pressure measurement. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. (A recommendation)”.

The ACC/AHA task force report represents the work of several professional bodies based upon hundreds of studies.  There are notable changes from previous practice guidelines, especially related to screening and detection.  The ACC/AHA task force recommends the following classification system:

<120 mmHg and <80 mmHg: NORMAL BP

  • Healthy lifestyle choices  
  • Yearly check-ups 

120 – 129 mmHg and <80 mmHg: ELEVATED BP

  • Healthy lifestyle changes  
  • Reassess in 3 to 6 months  

130 – 139 mmHg or 80-89 mmHg: HIGH BP – STAGE 1  

  • 10-year heart disease and stroke risk assessment <10% risk 
    • Lifestyle changes  
    • Re-assess in 3 to 6 months 
  • 10-year heart disease and stroke risk assessment ≥10% risk 
    • Lifestyle changes  
    • Medication  
    • Monthly follow-up until BP is under control 

≥140 mmHg or ≥90 mmHg: HIGH BP – STAGE 2 

  • Lifestyle changes  
  • Consider initiation of therapy with 2 different classes of medications 
  • Monthly follow-up until BP is under control
  • If BP ≥160/100 mm Hg: Treat promptly, monitor carefully and adjust medication dose upward as necessary to achieve control  

NOTE: Calculate 10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (see ‘Learn More – Primary Sources’ below)

KEY POINTS:  

Risk Factors   

  • Genetic predisposition  
    • Complex polygenic disorder  
    • Rarely single gene disorder (e.g. Liddle’s or Gordon’s syndrome) 
  • Environmental Risk Factors  
    • Overweight and Obesity 
    • Sodium Intake 
    • Potassium  
      • Higher levels appear to blunt sodium effect on BP  
      • Lower sodium/potassium ratio may reduce risk of CVD  
    • Physical fitness  
      • Even modest levels of physical activity is associated with a decrease in the risk of incident hypertension  
    • Alcohol 
      • In US, may account for 10% of BP burden  
      • Also associated with higher HDL and at modest intake range, lower risk for CHD when compared to abstinence 

Non-pharmacological Interventions 

  • Weight loss 
    • Goal: Optimum goal is ideal body weight but can expect 1mm Hg for every 1kg reduction 
  • Diet 
    • DASH diet: Fruits and vegetables, whole grains, low-fat dairy products, reduced saturated and total fat 
    • Other diets with supportive evidence 
      • Low in calories from carbohydrates  
      • High-protein diets  
      • Vegetarian diets  
      • Mediterranean dietary pattern  
    • Sodium: Goal <1500 mg/d, but aim for at least a 1000-mg/d reduction 
    • Potassium: Goal 3500 to 5000 mg/d, preferably through diet 
  • Exercise – Recommend structured exercise program  
    • Aerobic: 90–150 min/wk; 65%–75% heart rate reserve 
    • Dynamic resistance and Isometric resistance also shown to lower BP  
  • Alcohol Reduction (drink = 12 oz regular beer [5% alc] / 5 oz wine [12% alc] / 1.5 oz distilled spirits [40% alc])  
    • Women: ≤ 1 drink per day  
    • Men: ≤ 2 drink per day 

Taking a BP 

  • Prep 
    • Avoid caffeine, exercise, smoking at least 30 minutes before  
    • Empty bladder 
    • No talking while measurement is taken 
    • Remove clothing covering cuff placement 
    • Patient should sit on chair, feet on floor and back supported for > 5 min before taking pressure (not lying or sitting on an exam table) 
  • Technique 
    • Validated device 
    • Support arm 
    • Middle of cuff on upper arm at level of atrium (midpoint of the sternum) 
    • Cuff size: Bladder should encircle 80% of the arm  
    • Can use either stethoscope diaphragm or bell 
  • Taking the measurement 
    • First visit: Record BP in both arms and use arm with higher reading for subsequent measurements  
    • Separate measurement by 1 to 2 minutes 
    • To estimate systolic BP, use radial pulse obliteration and then inflate cuff 20-30 mmHg higher  
    • Deflate cuff pressure 2 mmHg per second and listen for Korotkoff sounds  
      • Systolic BP: First Korotkoff sound 
      • Diastolic BP: Disappearance of all Korotkoff sounds  
      • Use nearest even number  
    • Note time of most recent BP medication before taking measurements  
  • Average the readings to estimate BP 
    • Use average of ≥ 2 readings obtained on ≥ 2 occasions  

Note: The AHA has released a scientific statement that validated oscillometric devices allow accurate BP measurement in the outpatient setting, while reducing human errors associated with the auscultation. The AHA document further states that

Fully automated oscillometric devices capable of taking multiple readings even without an observer being present may provide a more accurate measurement of BP than auscultation. 

Target BP Goal  

  • Known CVD or 10-year heart disease and stroke risk assessment ≥ 10% risk 
    • 130/80 
  • Without additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable 

Adults ≥ 65 years 

  • Treat to same goal of 130/80 as younger adults  
  • Recommendation differs with ACP and AAFP guidance that suggests a goal of 150/90 

Pregnancy Recommendations

  • Women with hypertension who become pregnant, or are planning a pregnancy should be transitioned to methyldopa, nifedipine, and/or labetalol during pregnancy
  • Do not treat women with hypertension in pregnancy with ACE inhibitors, ARBs, or direct renin inhibitors

Oral Contraceptives and NSAIDs

  • Oral contraceptives and NSAIDs are listed as commonly used medications that may cause elevated BP
  • The ACC/AHA guideline recommends the following

 OCPs

Use low-dose (e.g., 20–30 mcg ethinyl estradiol) agents or a progestin-only form of contraception, or consider alternative forms of birth control where appropriate (e.g., barrier, abstinence, IUD)

Avoid use in women with uncontrolled hypertension

NSAIDs

Avoid systemic NSAIDs when possible

Consider alternative analgesics (e.g., acetaminophen, tramadol, topical NSAIDs), depending on indication and risk

Learn More – Primary Sources:

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults – A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement

10-year risk calculator using ASCVD algorithm

AHA AMA: BP Treatment Algorithm 

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association

2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures