Purpose: To review the evidence and provide clinical recommendations for appropriate blood pressure treatment targets for adults with hypertension.

Methods: This guideline is based on a systematic review of randomized controlled trials (RCTs) from database inception to May 2019. The target audience for the guideline includes all primary care clinicians, including family physicians, and the target patient population includes adults who have hypertension with or without cardiovascular disease (CVD). The panel defined patients as having hypertension when their blood pressures routinely measured higher than 140/90 mm Hg. This guideline was developed using a modified version of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, a transparent approach to evaluating the certainty of the evidence and determining the strength of recommendations.

Recommendation 1: The American Academy of Family Physicians (AAFP) strongly recommends clinicians treat adults who have hypertension to a standard blood pressure target (less than 140/90 mm Hg) to reduce the risk of all cause and cardiovascular mortality (strong recommendation; high-quality evidence). Treating to a lower blood pressure target (less than 135/85 mm Hg) did not provide additional benefit at preventing mortality; however, a lower blood pressure target could be considered based on clinical assessment and patient preferences and values.

Recommendation 2: The AAFP recommends clinicians consider treating adults who have hypertension to a lower blood pressure target (less than 135/85 mm Hg) to reduce risk of myocardial infarction (weak recommendation; moderate-quality evidence). Although treatment to a standard blood pressure target (less than 140/90 mm Hg) reduced the risk of myocardial infarction, there was a small additional benefit observed with a lower blood pressure target. There was no observed additional benefit in preventing stroke with the lower blood pressure target.

Guideline Scope and Purpose

The purpose of this guideline is to provide recommendations relevant to primary care for blood pressure treatment targets. This guideline will not discuss specific pharmacologic or other hypertension treatments. The target audience includes family physicians and other primary care clinicians. The target patient population is adults with hypertension, with or without CVD.

Introduction

Hypertension is a highly prevalent condition that results in significant morbidity and mortality. Defined as systolic blood pressure 140 mm Hg and higher or diastolic blood pressure 90 mm Hg and higher, hypertension affects approximately 32% of adults in the United States¹ and is a leading cause of death worldwide.² In the United States, hypertension annually costs between $131 billion and $198 billion, including costs of medications, health care services, and loss of productivity from premature death.³

Risk factors for hypertension include having obesity or overweight,⁴ alcohol use,⁵ increasing age,⁶ a family history of hypertension,⁷ exposure to systemic racism,⁸ diabetes mellitus,⁶ and physical inactivity.⁶ Uncontrolled hypertension is associated with CVD, renal disease, cerebrovascular disease, and death.⁹ Typical interventions for aiding patients in reducing blood pressure include lifestyle modifications (i.e., weight loss, dietary changes, and increased physical activity) and antihypertensive medications. The most common pharmacologic treatments for reducing blood pressure include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, thiazide diuretics, calcium channel blockers, and beta blockers. Selection of medications should include cost, ease of use, adverse effect profile, and comorbid conditions.

Accurate measurement of blood pressure is essential to the diagnosis and management of hypertension. Ambulatory and home blood pressure measurements can be useful in diagnosis and monitoring. Although the optimal method for blood pressure measurement remains unclear and under investigation, diagnosis requires two or more blood pressure readings on two or more occasions that meet the criteria for hypertension.

The goal of treatment is to reduce morbidity and mortality while minimizing risk of harms from medical intervention. Significant debate exists as to the ideal blood pressure targets for treatment of hypertension, and clinicians and patients are faced with conflicting recommendations from different organizations. The AAFP endorsed the Eighth Joint National Committee (JNC 8) guidelines for the management of hypertension in 2014 and reaffirmed it in 2019 as part of its five-year review process.10 Additionally, the AAFP developed a joint guideline with the American College of Physicians in 2017 that provided evidence-based recommendations for blood pressure treatment targets in adults older than 60 years.¹¹ However, both guidelines are now considered out of date, and, given the availability of new evidence, updated guidance from the AAFP was identified as a need. Multiple other guidelines have been published with differing recommendations.^12–16 Due to differences in methodologic rigor, insufficient consideration of harms, and the management of conflicts of interest, the AAFP has not endorsed these guidelines, leaving uncertainty for family physicians and other primary care clinicians when managing hypertension.¹⁷ Identifying evidence-based blood pressure treatment targets using shared decision-making that incorporates patient risks and values will improve patient-oriented outcomes while minimizing harms.