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”
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)
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)
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
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”
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)
Additional Hypertension Classifications
‘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 Hgand
Patient has failed to improve with 3 months of lifestyle modification
‘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 while not on antihypertensive medications or
If patient is on antihypertensive therapy with office SPB of 120 to 129 and DBP is <80, and they have high risk comorbidities such as CKD, >10% risk of stroke, or signs of hypertension related end organ damage
Acute severe hypertension
Severe hypertension: SBP ≥180 mmHg or DBP ≥120 mmHg with end organ damage (e.g., pulmonary edema, cardiac ischemia, neurologic deficits, acute renal failure, aortic dissection, and eclampsia is termed hypertensive emergency. This is a medical emergency that requires hospital care.
If no evidence of end organ damage termed hypertensive urgency can manage in ambulatory setting with close follow up
Blood pressure should not be decreased abruptly to prevent cerebral hypoperfusion
Resistant hypertension
Uncontrolled BP despite treatment ≥3 antihypertensive agents of different classes (one of which is usually a diuretic)
The ACC/AHA task force also recommends the following as cut offs for hypertension whenusing at home BP measurements: >110/>65 mmHg for nighttime mean and >125/>75 mmHg for 24hr mean.
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
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
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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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