Presented by Summary of Recommendations from the 2017 - - PowerPoint PPT Presentation

December 20, 2017 Presented by Jointly provided by: Summary of Recommendations from the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management

• f High Blood Pressure in Adults

Summary of Recommendations from the 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

Jointly provided by Tulane University Paul K. Whelton, MB, MD, MSc Clinical Professor and Show Chwan Health System Endowed Chair in Global Public Health Tulane University School of Public Health and Tropical Medicine Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA Professor of Medicine Tulane University School of Medicine Tulane Heart and Vascular Institute

Presenters’ Disclosures Keith C. Ferdinand, MD has disclosed the following affiliations. Any real or apparent COIs related to the presentation have been resolved. Disclosures

• Consultant- Amgen, Sanofi,

Boehringer Ingelheim, Novartis, Quantum Genomics Paul K. Whelton, MB, MD has disclosed the following affiliations. Any real or apparent COIs related to the presentation have been resolved. Disclosures

• Chair, 2017 ACC/AHA BP Guideline

Writing Committee

• Chair, SPRINT, ALLHAT, TOHP and

TONE trials

AMA and Tulane University Disclosures

The following AMA members have documented that they have nothing to disclose and no COIs to resolve:

• Michael Rakotz, MD, FAHA, FAAFP, Activity Director and Moderator; Una Charley; Delane Heldt, PMP; and

Alison Smith, MPH, BA, BSN, RN The following Tulane faculty have disclosed/documented the following. Any real or apparent COIs have been resolved:

• Chayan Chakraborti, MD, FACP, FHM, Tulane Faculty Liaison – Honorarium: ACP
• Myra Kleinpeter, MD, MPH, Chair, Tulane CCE (CME) Advisory Committee – Grants: Amgen, Glaxo Smith Kline,

Astra Zeneca; Speakers Bureau: Gilead Sciences, Fresenius Medical Care, OPKO; Stocks: BD, Abbvie, P&G; Board Member: Orleans Parish Medical Society, New Orleans East Hospital

• N. Kevin Krane, MD, FACP, Vice Dean of Academic Affairs – Nothing to disclose

The following Tulane CCE/CME staff have documented that they have nothing to disclose and no COIs to resolve:

• Melinda Epperson, PhD, Director, Tulane CCE; Caroline Lind, MPH, MBA; Sarah Refvem, MPH; Pamala

Schmidt; and Roblynn Sliwinski

Objectives Slide The presenters will:

• Define new levels of blood pressure (BP) classification
• Describe how to accurately measure BP (office and out-of-office)
• Define non-pharmacological treatment for hypertension
• Recognize when to use pharmacologic treatment and understand

treatment targets

• Review BP treatment targets for people with comorbid conditions

(diabetes, CKD, CVD, CHF)

• Review treatment of special populations with high BP (African Americans,
• lder persons)

• Dr. Whelton’s Slides
• 1. Introduction - Background and Science/Evidence of Guideline
• 2. Classification of Blood Pressure and Impact on Prevalence
• 3. Blood Pressure Measurement (in and out-of-office)
• 4. Treatment of Hypertension
• 5. Special populations:

Focus on Older Adults, Diabetes, CKD

• 6. Importance of Team-Based Care, Plan of Care and shared Decision Making

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 Paul K. Whelton, MB, MD, MSc

Show Chwan Chair of Global Public Health Tulane University School of Public Health and Tropical Medicine Tulane University School of Medicine

• Conflicts of interest: None
• Disclosures:
• Chair, 2017 ACC/AHA BP Guideline Writing Committee
• Chair, SPRINT, ALLHAT, TOHP and TONE trials

Tulane University School of Medicine - December 20, 2017

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Current status

BP Clinical Practice Guidelines (CPGs)

• Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High BP, 1977
• Consensus report, with six recommendations
• Stepped-care treatment for adults with DBP ≥105 mm Hg
• No recommendations for lifestyle change or drug treatment based on SBP
• Seventh Report of JNC on Prevention, Detection, Evaluation, and Treatment of High BP, 2003
• Structured, comprehensive guideline; recommendations supported by more/better evidence
• Detailed BP classification system; focus on SBP but included DBP recommendations
• Lifestyle modification recommended as initial treatment for high BP
• Antihypertensive drug therapy when SBP/DBP exceeded 140/90 mm Hg (130/80 for DM or CKD)
• Several subsequent US BP clinical practice guidelines
• Most focused on aspects of antihypertensive drug treatment
• In 2013, NHLBI transferred responsibility for CVD prevention CPGs to ACC and AHA

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

• Initiative lead by
• American College of Cardiology
• American Heart Association
• Nine additional partners
• American Academy of Physician Assistants
• American College of Preventive Medicine
• American Geriatrics Society
• American Pharmacists Association
• American Society of Hypertension
• American Society of Preventive Cardiology
• Association of Black Cardiologists
• National Medical Association
• Preventive Cardiovascular Nurses Association
• Writing committee
• Multidisciplinary (21 members)
• No relationships with industry
• Independent External Review Committee (10 members)
• Systematic review/meta-analyses for selected questions
• Processes standardized
• ACC/AHA Guideline Task Force processes
• 15 easy to navigate self contained sections
• 106 recommendations supported by 448 evidence tables
• Each recommendation characterized by:
• Class (strength) of Recommendation (COR)
• Level of evidence (LOE)
• Extensive peer review (internal & external)
• Approved by 11 partner professional societies

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

Paul K. Whelton, MB, MD, MSc, FAHA, Chair Robert M. Carey, MD, FAHA, Vice Chair Wilbert S. Aronow, MD, FACC, FAHA Bruce Ovbiagele, MD, MSc, MAS, MBA FAHA Donald E. Casey, Jr, MD, MPH, MBA, FAHA Sidney C. Smith, Jr, MD, MACC, FAHA Karen J. Collins, MBA Crystal C. Spencer, JD Cheryl Dennison Himmelfarb, RN, ANP, PhD Randall S. Stafford, MD, PhD Sondra M. DePalma, MHS, PA-C, CLS, AACC Sandra J. Taler, MD, FAHA Samuel Gidding, MD, FACC, FAHA Randal J. Thomas, MD, MS, FACC, FAHA Kenneth A. Jamerson, MD Kim A. Williams, Sr, MD, MACC, FAHA Daniel W. Jones, MD, FAHA Jeff D. Williamson, MD, MHS Eric J. MacLaughlin, PharmD Jackson T. Wright, Jr, MD, PhD Paul Muntner, PhD

Writing Committee

Whelton PK et al. Hypertension. 10.1161/HYP.0000000000000065. [Epub ahead of print]. Whelton PK et al. J Am Coll Cardiol. 2017; doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

Class (Strength) of Recommendation

I Strong: Benefit >>> Risk IIa Moderate: Benefit >> Risk IIb Weak: Benefit ≥ Risk III: No Benefit Moderate: Benefit = Risk III: Harm Strong: Risk > Benefit

Level (Quality) of Evidence

A

High quality evidence from >1 RCT or meta-analysis

B-R

Moderate quality evidence from ≥1 RCT or meta-analysis (Randomized)

B-NR

Moderate quality evidence from ≥ 1 well designed/executed non-randomized, observational or registry studies or meta- analyses of such studies (Nonrandomized)

C-LD

Moderate quality evidence from randomized, observational

• r registry studies, meta-analyses of such studies, or

physiological/mechanistic studies in humans (Limited Data)

C-EO

Consensus of expert opinion (Expert Opinion)

Whelton PK et al. Hypertension. 10.1161/HYP.0000000000000065. [Epub ahead of print]. Whelton PK et al. J Am Coll Cardiol. 2017; doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

• New BP classification system
• BP measurement (including accuracy, use of averages, and out of office measurements)
• New approach to treatment decisions for management of hypertension

(CVD risk estimation in addition to average BP)

• Lower targets for BP during treatment of hypertension
• Strategies to improve BP control during treatment of hypertension

Selected Highlights

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

BP Classification (JNC 7 and ACC/AHA Guidelines)

SBP DBP <120 and <80 120–129 and <80 130–139

• r

80–89 140–159

• r

90-99 ≥160

• r

≥100 JNC7 Normal BP Prehypertension Prehypertension Stage 1 hypertension Stage 2 hypertension 2017 ACC/AHA Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Stage 2 hypertension

• Blood Pressure should be based on an average of ≥2 careful readings on ≥2 occasions
• Adults with SBP or DBP in two categories should be designated to the higher BP category

Whelton PK et al. Hypertension. 10.1161/HYP.0000000000000065. [Epub ahead of print]. Whelton PK et al. J Am Coll Cardiol. 2017; doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].

Key Points Specific Instructions

Step 1: Properly prepare the patient.

• Have patient relax, sitting in a chair (feet on floor, back supported) for >5 min.
• Avoid caffeine, exercise, and smoking for at least 30 min before measurement.
• Ensure bladder emptied.
• No talking during rest period or measurement.
• Remove clothing covering location of cuff placement.
• Measurements while patient sitting or lying on exam table do not fulfill criteria.

Step 2: Use proper technique for BP measurements.

• Use validated BP measurement device that is calibrated periodically.
• Support patient’s arm (e.g., resting on a desk).
• Position middle of cuff on patient’s upper arm at mid-sternum (right atrium).
• Use correct cuff size, such that the bladder encircles 80% of the arm.
• Either stethoscope diaphragm or bell may be used for auscultatory readings.

Step 3: Take the proper measurements needed for diagnosis and treatment of elevated BP/hypertension.

• At first visit, record BP in both arms. Subsequently, use arm with higher reading.
• Separate repeated measurements by 1–2 min.
• For auscultatory readings, estimate SBP by palpation and inflate cuff 20–30 mm

Hg above. Deflate 2 mm Hg per second and listen for Korotkoff sounds.

Step 4: Properly document accurate BP readings.

• Note time of most recent BP medication before measurements.
• Record SBP and DBP.

Step 5: Average the readings.

• Use average of ≥2 readings obtained on ≥2 occasions to estimate level of BP.

Step 6: Provide BP readings to patient.

• Provide patients SBP/DBP readings both verbally and in writing.

Office BP Readings: Checklist for Accurate Measurements

Greater use of out of office BP measurements (ABPM or HBPM) for confirmation

• f office hypertension and recognition of White Coat and Masked Hypertension

In adults not taking antihypertensive medication: Masked Hypertension (MH)

• Normal office BP but out of office BP hypertension
• Present in about 10-25% of adults with normal office BP
• CVD risk profile more like adults with sustained hypertension than adults without hypertension
• Should be considered for antihypertensive drug therapy

Out of Office BP Readings

Sustained hypertension

• Elevated office and out of office average BP
• Substantially higher risk of CVD compared to adults with normal office and out of office BPs
• Require therapy (nonpharmacological or combined nonpharmacological and antihypertensive drug therapy)

White Coat Hypertension (WCH)

• Office Hypertension not confirmed by out of office BP readings
• Present in about 10-25% of adults with office hypertension
• CVD risk profile more like adults with normal BP than adults with sustained hypertension
• May not need treatment for hypertension (should be monitored for development of sustained hypertension)

Detection of White Coat Hypertension or Masked Hypertension in Patients not on Drug Therapy

Whelton PK et al. Hypertension. 10.1161/HYP.0000000000000065. [Epub ahead of print]. Whelton PK et al. J Am Coll Cardiol. 2017; doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

BP Thresholds for Treatment

SBP DBP <120 and <80 120–129 and <80 130-139

• r

80-89 130–139

• r

80–89 ≥130

• r

≥80 ≥130 ≥140

• r

≥90

CVD Risk/other circumstances

N/A N/A No CVD/10-yr ASCVD risk <10% CVD/10-year ASCVD risk ≥ 10% Diabetes or CKD Age ≥65 years N/A Recommended Treatment

Healthy Lifestyle Nonpharmacological therapy Nonpharmacological therapy Antihypertensive drug therapy (plus nonpharmacological therapy)

Whelton PK et al. Hypertension. 10.1161/HYP.0000000000000065. [Epub ahead of print]. Whelton PK et al. J Am Coll Cardiol. 2017; doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

High BP Treatment Target

SBP DBP <120 and <80 120–129 and <80 130-139

• r

80-89 130–139

• r

80–89 ≥130

• r

≥80 ≥140

• r

≥90 ≥130 CVD Risk N/A N/A

No CVD and 10-year ASCVD risk <10% Clinical CVD or 10-year ASCVD risk ≥ 10%

Diabetes or CKD N/A Age ≥65 years Recommended Treatment

N/A N/A SBP <130 and DBP <80 mm Hg SBP <130 mm Hg

Whelton PK et al. Hypertension. 10.1161/HYP.0000000000000065. [Epub ahead of print]. Whelton PK et al. J Am Coll Cardiol. 2017; doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].

BP Targets in Guideline Recommendations

• 2016 Canadian Guidelines:
• Intensive BP treatment to target SBP ≤ 120 mm Hg in high risk patients (Grade B)
• Shared decision-making necessary for the safe implementation of intensive BP control
• 2016 Australian Guideline:
• In selected high CVD risk populations a target of <120 mm Hg SBP can improve CVD outcomes (Strong)
• Close follow-up is recommended to identify treatment-related adverse effects (Strong)
• 2017 ADA (Target BP <130/80 mm Hg in adult DM patients at high risk for CVD)
• 2017 ACC/AHA BP Guideline (Target BP < 130/80 mm Hg)

Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension

Intervention Dose

Approximate Impact on SBP

Hypertension Normotension Weight loss Calorie reduction & physical activity

Best goal is ideal body weight. Expect about 1 mm Hg for every 1-kg reduction in weight.

• 5 mm Hg
• 2/3 mm Hg

Healthy diet DASH diet

Diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced saturated and total fat.

• 11 mm Hg
• 3 mm Hg

Dietary sodium Reduced intake

Optimal goal <1500 mg/d, but at least a 1000-mg/d reduction in most adults.

• 5/6 mm Hg -2/3 mm Hg

Dietary potassium Enhanced intake through diet

3500–5000 mg/d, preferably by diet rich in potassium.

• 4/5 mm Hg -2 mm Hg

Physical activity Aerobic

• 90–150 min/wk (65%–75% heart rate reserve)
• 5/8 mm Hg -2/4 mm Hg

Dynamic resistance

• 90–150 min/wk (50%–80% 1 rep maximum)
• 6 exercises, 3 sets/exercise, 10 repetitions/set
• 4 mm Hg
• 2 mm Hg

Isometric resistance ● 4 × 2 min (hand grip), 1 min between exercises, 30%–

40% max. voluntary contraction, 3 sessions/wk (8–10 wk)

• 5 mm Hg
• 4 mm Hg

Moderation in alcohol intake Alcohol consumption

In individuals who drink alcohol, reduce alcohol to:

• Men: ≤2 drinks daily
• Women: ≤1 drink daily
• 4 mm Hg
• 3 mm

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

• First-step agents:
• Compelling indication for agent(s) that concurrently lower BP (e.g. post-MI, SIHD, HF)
• No compelling indication
• Achievement of BP goal more important than initial choice of drug therapy
• Agent from following classes acceptable but diuretic or CCB often good choice
• Diuretic (esp. long-acting thiazide-type agent such as chlorthalidone)
• Calcium channel blocker (CCB)
• Angiotensin converting enzyme inhibitor (ACEI)
• Angiotensin receptor blocker (ARB)
• Most patients should be treated initially with two drugs (esp. AA or stage 2 hypertension)
• Use agents that have complimentary modes of action (e.g. diuretic or CCB with ACEI or ARB)
• Simultaneous use of ACEI and ARB or renin inhibitor not recommended (potentially harmful)

Choice of Drug Therapy in Treatment of Hypertension

Global Awareness, Treatment and Control of Hypertension in Adults

Mills KT et al. Circulation. 2016;134:441-450 135 population-based surveys in 90 countries Aware [Hypertension = SBP ≥140, DBP ≥90 or antihypertensive meds] Treated = % adults with hypertension treated with antihypertensive medication Controlled = % adults with hypertension and SBP/DBP <140/90 mm Hg on BP meds

2000 2000 2000 2010 2010 2010

2000 and 2010

Global Awareness, Treatment and Control of Hypertension in Adults

Mills KT et al. Circulation. 2016;134:441-450 135 population-based surveys in 90 countries Hypertension = SBP ≥140, DBP ≥90 or antihypertensive meds Treated = treated with antihypertensive medication Controlled = % adults with hypertension and SBP/DBP <140/90 mm Hg on BP meds

Low and middle income Low and middle income Low and middle income High income High income High income

2010: L/MIC and HIC

1988 988-1994 1999 999-200 2002 2003 2003-2006 2009 2009-201 2012 Tempo poral T Trend nds in C n Cont ntrol o

• f Hype

pertens nsion Whelton PK. A Annu Rev P Public Health. 201 2015; 5; 36: 36:16. 6.1-16. 6.22. 22.

Expe perienc nce in n the he N Nationa nal Health a h and nd N Nutrition n Examina nation n Survey ( (NHANES)

Jaffe M MG et al. JAMA. 201 2013; 3;31 310: 0:699 99-705.

NCQA HED EDIS Hypertensio ion Control Rates

Kai aiser Perman manente No Northern C Cal alifornia, a, Cal alifornia a an and Nat National al

(Crude de rates based d on experience in hypertension registry ; 652,763 in 2009)

Crude R e Rates es

Multifaceted “system of care” q quality i improvement program

43. 43.6% 6% 80. 80.4% 4%

KPNC hypertension control rate reported d to be 90% in 2015.

Jaffe MG a and Y Young JD. J J C Clin H

• Hypertens. 2016. DOI:10.1111/jch.12803.

Control t to < <140 40 mm H Hg i in 90 90-95% of t those t treated, i if true, would suggest KPNC alrea eady a y ach chiev eving BP r P red educt ctions similar t to SPR PRINT inten ensive e trea eatmen ent arm

Strategies to Improve Hypertension Treatment and Control

• Adherence strategies
• Once daily dosing
• Combination pills
• Strategies to promote lifestyle modification
• Team-based care
• Health professionals: physicians, nurses, pharmacists
• Patient
• Staff: office staff and community health workers
• Others: spouse, relatives, friends
• Use of EHR and Patient Registries
• Telehealth strategies
• Performance measures and Quality Improvement initiatives
• Financial incentives

Shared Decision-making

Global Hearts

CDC/CMS initiative to improve US CVD health

• Improving access to effective care.
• Improving the quality of care for ABCS (Aspirin/BP/Lipids/Smoking)
• Focus clinical attention on the prevention of heart attack and stroke.
• Activate public to lead a heart-healthy lifestyle.
• Improve prescription/adherence to medications for the ABCS.

XPRIZE Foundation

and

Global Initiatives US Initiatives

and

Improve BP control

Concl clusio sions

• BP clinical practice guidelines
• Part of routine practice. NHLBI principal sponsor of BP guidelines for many years. In

2013, responsibility transferred to ACC and AHA

• 2017 ACC/AHA BP Guideline
• 21-member Writing Committee, with diverse backgrounds and no RWI
• Employed rigorous ACC/AHA Task Force methodology; extensive review and approval
• Written in 15 self-contained, easy to navigate, sections; 106 recommendations, and 448

evidence tables, covering classification, diagnosis, evaluation, treatment, patients with co-morbidities, special populations, strategies for improving BP control, and plan of care

• Selected highlights
• BP measurement, including accuracy and out-of-office readings
• Classification of BP
• CVD risk estimation in BP treatment decision-making
• BP treatment target
• Strategies for improved hypertension control

Summary of Recommendations from the 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

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA Professor of Medicine Tulane University School of Medicine Tulane Heart and Vascular Institute

• 7. Secondary Forms of Hypertension
• 8. Hypertension with Co-morbidities:

Focus on the Heart

• 9. Special populations:

Focus on African Americans

• 10. Resistant hypertension
• 11. Summary of Blood Pressure (BP) Thresholds

and BP Goals for Pharmacological Therapy Agenda

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

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

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

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

Secondary Forms of Hypertension

COR LOE Recommendations for Secondary Forms of Hypertension I C-EO Screening for specific form(s) of secondary hypertension is recommended when the clinical indications and physical examination findings are present or in adults with resistant hypertension. IIb C-EO If an adult with sustained hypertension screens positive for a form of secondary hypertension, referral to a physician with expertise in that form of hypertension may be reasonable for diagnostic confirmation and treatment.

Secondary Forms of Hypertension

COR LOE Recommendations for Secondary Forms of Hypertension I C-EO Screening for specific form(s) of secondary hypertension is recommended when the clinical indications and physical examination findings are present or in adults with resistant hypertension. IIb C-EO If an adult with sustained hypertension screens positive for a form of secondary hypertension, referral to a physician with expertise in that form of hypertension may be reasonable for diagnostic confirmation and treatment.

Screening for Secondary Hypertension

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).

New-onset or uncontrolled hypertension in adults Referral not necessary (No Benefit) Refer to clinician with specific expertise (Class IIb)

No Yes

Screening not indicated (No Benefit) Screen for secondary hypertension (Class I) (see Table 13)

Yes No

Positive screening test 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

Screening for Secondary Hypertension

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).

New-onset or uncontrolled hypertension in adults Referral not necessary (No Benefit) Refer to clinician with specific expertise (Class IIb)

No Yes

Screening not indicated (No Benefit) Screen for secondary hypertension (Class I) (see Table 13)

Yes No

Positive screening test 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

Screening for Secondary Hypertension

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).

New-onset or uncontrolled hypertension in adults Referral not necessary (No Benefit) Refer to clinician with specific expertise (Class IIb)

No Yes

Screening not indicated (No Benefit) Screen for secondary hypertension (Class I) (see Table 13)

Yes No

Positive screening test 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

Primary Aldosteronism

COR LOE Recommendations for Primary Aldosteronism I 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).

I C-LD

Use of the plasma aldosterone: renin activity ratio is recommended when adults are screened for primary aldosteronism.

I 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.

Primary Aldosteronism

COR LOE Recommendations for Primary Aldosteronism I 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).

I C-LD

Use of the plasma aldosterone: renin activity ratio is recommended when adults are screened for primary aldosteronism.

I 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.

Hypertension in Patients With Comorbidities

• Stable Ischemic Heart Disease (SIHD)
• Heart Failure with Reduced Ejection Fraction (HFrEF)
• Heart Failure with Preserved Ejection Fraction (HFpEF)
• Atrial Fibrillation
• Valvular Heart Disease
• Aortic Disease

2017 Hypertension Guideline

Stable Ischemic Heart Disease

COR LOE Recommendations for Treatment of Hypertension in Patients With Stable Ischemic Heart Disease (SIHD) I SBP: B-R

In adults with SIHD and hypertension, a BP target of less than 130/80 mm Hg is recommended.

DBP: C-EO I SBP: B-R

Adults with SIHD and hypertension (BP ≥130/80 mm Hg) should be treated with medications (e.g., GDMT beta blockers, ACE inhibitors, or ARBs) for compelling indications (e.g., previous MI, stable angina) as first-line therapy, with the addition of

• ther drugs (e.g., dihydropyridine CCBs, thiazide diuretics, and/or mineralocorticoid

receptor antagonists) as needed to further control hypertension.

DBP: C-EO

Stable Ischemic Heart Disease

COR LOE Recommendations for Treatment of Hypertension in Patients With Stable Ischemic Heart Disease (SIHD) I SBP: B-R

In adults with SIHD and hypertension, a BP target of less than 130/80 mm Hg is recommended.

DBP: C- EO I SBP: B-R

Adults with SIHD and hypertension (BP ≥130/80 mm Hg) should be treated with medications (e.g., GDMT beta blockers, ACE inhibitors, or ARBs) for compelling indications (e.g., previous MI, stable angina) as first-line therapy, with the addition of

• ther drugs (e.g., dihydropyridine CCBs, thiazide diuretics, and/or mineralocorticoid

receptor antagonists) as needed to further control hypertension.

DBP: C-EO

Stable Ischemic Heart Disease (cont.)

COR LOE Recommendations for Treatment of Hypertension in Patients With Stable Ischemic Heart Disease (SIHD) I B-NR In adults with SIHD with angina and persistent uncontrolled hypertension, the addition of dihydropyridine CCBs to GDMT beta blockers is recommended. IIa B-NR In adults who have had a MI or acute coronary syndrome, it is reasonable to continue GDMT beta blockers beyond 3 years as long-term therapy for hypertension. IIb C-EO Beta blockers and/or CCBs might be considered to control hypertension in patients with CAD (without HFrEF) who had an MI more than 3 years ago and have angina.

Stable Ischemic Heart Disease (cont.)

COR LOE Recommendations for Treatment of Hypertension in Patients With Stable Ischemic Heart Disease (SIHD) I B-NR In adults with SIHD with angina and persistent uncontrolled hypertension, the addition of dihydropyridine CCBs to GDMT beta blockers is recommended. IIa B-NR In adults who have had a MI or acute coronary syndrome, it is reasonable to continue GDMT beta blockers beyond 3 years as long-term therapy for hypertension. IIb C-EO Beta blockers and/or CCBs might be considered to control hypertension in patients with CAD (without HFrEF) who had an MI more than 3 years ago and have angina.

Hypertension With SIHD Reduce BP to <130/80 mm Hg with GDMT beta blockers*, ACE inhibitor, or ARBs† (Class I) Add dihydropyridine CCBs if needed (Class I) Add dihydropyridine CCBs, thiazide-type diuretics, and/or MRAs as needed (Class I) Angina pectoris No BP goal not met Yes

Heart Failure With Reduced Ejection Fraction

COR LOE Recommendations for Treatment of Hypertension in Patients With HFrEF

I C-EO Adults with HFrEF and hypertension should be prescribed GDMT titrated to attain a BP

• f less than 130/80 mm Hg.

Heart Failure With Reduced Ejection Fraction

COR LOE Recommendations for Treatment of Hypertension in Patients With HFrEF III: No Benefit B-R

Nondihydropyridine CCBs are not recommended in the treatment of hypertension in adults with HFrEF.

Heart Failure With Preserved Ejection Fraction

COR LOE Recommendations for Treatment of Hypertension in Patients With HFpEF I C-EO

In adults with HFpEF who present with symptoms of volume overload, diuretics should be prescribed to control hypertension.

I 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.

Atrial Fibrillation

COR LOE Recommendation for Treatment of Hypertension in Patients With AF

IIa B-R

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 B-NR

In adults with asymptomatic aortic stenosis, hypertension should be treated with pharmacotherapy, starting at a low dose and gradually titrating upward as needed.

IIa C-LD

In patients with chronic aortic insufficiency, treatment of systolic hypertension with agents that do not slow the heart rate (i.e., avoid beta blockers) is reasonable.

Valvular Heart Disease

COR LOE Recommendations for Treatment of Hypertension in Patients With Valvular Heart Disease

I B-NR In adults with asymptomatic aortic stenosis, hypertension should be treated with pharmacotherapy, starting at a low dose and gradually titrating upward as needed.

Valvular Heart Disease

COR LOE Recommendations for Treatment of Hypertension in Patients With Valvular Heart Disease

IIa C- LD In patients with chronic aortic insufficiency, treatment of systolic hypertension with agents that do not slow the heart rate (i.e., avoid beta blockers) is reasonable.

Aortic Disease

COR LOE Recommendation for Management of Hypertension in Patients With Aortic Disease

I C- EO Beta blockers are recommended as the preferred antihypertensive agents in patients with hypertension and thoracic aortic disease.

Special Patient Groups:

• African Americans

2017 Hypertension Guideline

Racial and Ethnic Differences in Treatment

COR LOE Recommendations for Race and Ethnicity

I B-R In black adults with hypertension but without HF

• r CKD, including those with DM, initial

antihypertensive treatment should include a thiazide-type diuretic or CCB.

Racial and Ethnic Differences in Treatment

COR LOE Recommendations for Race and Ethnicity

I B-R In black adults with hypertension but without HF

• r CKD, including those with DM, initial

antihypertensive treatment should include a thiazide-type diuretic or CCB.

Racial and Ethnic Differences in Treatment

COR LOE Recommendations for Race and Ethnicity

I C- LD Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension.

Racial and Ethnic Differences in Treatment

COR LOE Recommendations for Race and Ethnicity

I C- LD Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension.

Resistant Hypertension

2017 Hypertension Guideline

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 anti-inflammatory drugs; and SBP, systolic blood pressure. Adapted with permission from Calhoun et al.

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 anti-inflammatory drugs; and SBP, systolic blood pressure. Adapted with permission from Calhoun et al.

Summary of BP Thresholds and Goals of Pharmacological Therapy in Patients with Hypertension

2017 Hypertension Guideline

BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions

Clinical Condition(s) BP Threshold, mm Hg BP Goal, mm Hg General Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80 No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80 Older persons (≥65 years of age; noninstitutionalized, ambulatory, community-living adults) ≥130 (SBP) <130 (SBP) Specific comorbidities Diabetes mellitus ≥130/80 <130/80 Chronic kidney disease ≥130/80 <130/80 Chronic kidney disease after renal transplantation ≥130/80 <130/80 Heart failure ≥130/80 <130/80 Stable ischemic heart disease ≥130/80 <130/80 Secondary stroke prevention ≥140/90 <130/80 Secondary stroke prevention (lacunar) ≥130/80 <130/80 Peripheral arterial disease ≥130/80 <130/80 ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions Clinical Condition(s)

BP Threshold, mm Hg BP Goal, mm Hg

General Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80 No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80 Older persons (≥65 years of age; noninstitutionalized, ambulatory, community-living adults) ≥130 (SBP) <130 (SBP)

ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions Clinical Condition(s)

BP Threshold, mm Hg BP Goal, mm Hg

General Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80 No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80 Older persons (≥65 years of age; noninstitutionalized, ambulatory, community-living adults) ≥130 (SBP) <130 (SBP)

ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions Clinical Condition(s)

BP Threshold, mm Hg BP Goal, mm Hg

General Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80 No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80 Older persons (≥65 years of age; noninstitutionalized, ambulatory, community-living adults) ≥130 (SBP) <130 (SBP)

ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions

Clinical Condition(s) BP Threshold, mm Hg BP Goal, mm Hg

Specific comorbidities Diabetes mellitus ≥130/80 <130/80 Chronic kidney disease ≥130/80 <130/80 Chronic kidney disease after renal transplantation ≥130/80 <130/80 Heart failure ≥130/80 <130/80 Stable ischemic heart disease ≥130/80 <130/80 Secondary stroke prevention ≥140/90 <130/80 Secondary stroke prevention (lacunar) ≥130/80 <130/80 Peripheral arterial disease ≥130/80 <130/80

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