High Blood Pressure: ACC/AHA Releases Updated Guideline
Am Fam Physician. 2018 Mar 15;97(6):413-415.
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Key Points for Practice
• Accurate measurement of blood pressure is essential to categorize blood pressure, stratify cardiovascular risk, and guide management.
• A target blood pressure of less than 130/80 mm Hg is recommended for adults with confirmed hypertension and cardiovascular disease, or a 10-year atherosclerotic cardiovascular disease risk of 10% or more.
• Adults with elevated blood pressure or stage 1 hypertension whose estimated 10-year risk of atherosclerotic cardiovascular disease is less than 10% should be treated with nonpharmacologic interventions.
From the AFP Editors
Meta-analyses of observational studies have shown that elevated blood pressure (BP) and hypertension are associated with an increased risk of cardiovascular disease (CVD), end-stage renal disease, subclinical atherosclerosis, and all-cause mortality. A person's risk of hypertension is influenced by various genetic and environmental factors, such as being overweight or obese; diet; alcohol intake; and fitness level. The American College of Cardiology (ACC) and American Heart Association (AHA) recently updated their guideline on the prevention, detection, evaluation, and treatment of high BP in adults. The ACC/AHA recommendations were based on a systematic review that addressed the following questions:
Is there evidence that home BP monitoring (HBPM) and/or ambulatory BP monitoring (ABPM) are superior to office-based BP measurement by a health care professional for preventing adverse outcomes and achieving better BP control?
What is the optimal BP target for antihypertensive therapy in adults?
In adults with hypertension, do various antihypertensive drug classes differ in their comparative benefits and harms?
In adults with hypertension, does initiating treatment with antihypertensive pharmacologic monotherapy vs. combination therapy differ in comparative benefits and harms on specific health outcomes?
Estimates of the prevalence of hypertension are greatly influenced by the choice of cutoffs used to categorize elevated BP and hypertension, the methods used to establish the diagnosis, and the population studied. The prevalence of hypertension among U.S. adults is substantially higher when the definitions in this guideline are used vs. the definitions in the Seventh Report of the Joint National Committee, but nonpharmacologic therapy would be recommended for most patients with newly diagnosed hypertension based on the current guideline.
To prevent and treat hypertension, BP should first be categorized as normal (less than 120 mm Hg systolic and less than 80 mm Hg diastolic), elevated (120 to 129 mm Hg systolic and less than 80 mm Hg diastolic), stage 1 hypertension (130 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic), or stage 2 hypertension (at least 140 mm Hg systolic or at least 90 mm Hg diastolic). Patients whose systolic and diastolic BPs are in different categories should be assigned to the higher category (i.e., a patient with a BP of 128/82 mm Hg should be diagnosed with stage 1 hypertension).
BP Measurement and Out-of-Office Monitoring
Although BP measurement in the office setting is relatively easy, errors are common and can result in a misleading estimation of a patient's true BP. Accurate measurement and recording are essential to categorize BP, ascertain BP-related CVD risk, and guide management of hypertension. Most systematic errors in BP measurement can be avoided by having the patient sit quietly for five minutes before a reading is taken, supporting the limb used to measure BP, ensuring the BP cuff is at heart level, using the correct cuff size, and deflating the cuff slowly. Because individual BP measurements tend to vary, a single reading is inadequate for clinical decision making. Using the average of two or three measurements taken on two or more separate occasions will minimize random error and provide a more accurate basis for estimation of BP. Out-of-office BP measurement in conjunction with telehealth counseling or clinical interventions is recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication. ABPM is generally accepted as the best out-of-office method, but HBPM is often a more practical approach.
White Coat and Masked Hypertension
White coat hypertension is characterized by elevated BP measurements in the office setting but normal readings on ABPM or HBPM. In contrast, masked hypertension is characterized by normal office readings but ABPM/HBPM readings that are consistently above normal. The risk of CVD and all-cause mortality in persons with masked hypertension is similar to that in those with sustained hypertension, and about twice as high as in persons with normal BP. Some studies have identified a small increase in the risk of CVD complications and all-cause mortality in patients with white coat hypertension.
The prevalence of white coat hypertension ranges from 13% to as high as 35% in some popu
Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.
This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.
A collection of Practice Guidelines published in AFP is available at http://www.aafp.org/afp/practguide.
Copyright © 2018 by the American Academy of Family Physicians.
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