Hypertension Guidelines

Updated: Feb 22, 2019
  • Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Guidelines

Guidelines Summary

Screening

Guidelines on screening for hypertension have been issued by the following organizations:

  • United States Preventive Services Task Force (USPSTF)
  • Joint National Committee (JNC)
  • American College of Obstetricians and Gynecologists (ACOG)
  • Department of Veterans Affairs (VA)/Department of Defense (DoD)
  • European Society of Hypertension (ESH)/European Society of Cardiology (ESC)

The 2013 joint European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) guidelines recommend that ambulatory blood-pressure monitoring (ABPM) be incorporated into the assessment of cardiovascular risk factors and hypertension. [124, 125]

A comparison of the recommendations for blood pressure screening is provided in Table 4 below.

Table 4. Guidelines for Blood Pressure Screening in Adults (Open Table in a new window)

Issuing Organization

Year

Screening Populations

Screening Measurement

Screening Interval

European Society of Cardiology/ European Society of Hypertension 

(ESC/ESH) [7]

2018

All adults

Office measurement

At regular intervals on the basis of the blood pressure level:

  • Healthy people with optimal office blood pressure (< 120/80 mm Hg): Every 5 years; remeasure if seen sooner.
  • Patients with normal blood pressure (120-129/80-84 mm Hg): Minimum of every 3 years.
  • Patients with high-normal blood pressure (130–139/85–89 mm Hg): Annually.

US Preventive Services Task Force (USPSTF) [126]

2015

Adults ≥18 years without known hypertension

Measurements outside of the clinical setting should be obtained for diagnostic confirmation before starting treatment.

No evidence was found for a single gold standard protocol for HBPM or ABPM. However, both may be used in conjunction with proper office measurement to make a diagnosis and guide management and treatment options.

Annually for adults age ≥40 and those at increased risk for high blood pressure including those who have high-normal blood pressure (130–139/85–89 mm Hg), are overweight or obese, or are African American.

Adults ages ≥18 to < 40 years with normal blood pressure (≤130/85mm Hg) with no known risk factors should be screened every 3-5 years

Seventh Report of the Prevention,

Detection,

Evaluation, and

Treatment of the Joint National Committee on

High Blood Pressure (JNC 7) [3]

2003

Adults ages ≥18 years

Diagnosis based on average of 2 or more seated blood pressure readings on each of two or more office visits

At least once every 2 years in adults with blood pressure less than 120/80 mm Hg and every year in those with levels of 120–139/80–89 mm Hg.

American College of Obstetricians and Gynecologists (ACOG) [127]

2013

All females ages ≥13 years

Office measurement

Annually as part of routine well-woman care

Department of Veterans Affairs/Department of Defense (VA/DoD) [128]

2014

All adults

Office measurement;

Diagnosis based on 2 readings at 2 separate visits; For patients where diagnosis remains uncertain, home blood pressure monitoring (2-3 times a day for 7 days) or 24 hour ambulatory monitoring to confirm diagnosis

Periodic, preferably annually, at time of routine preventative care or health assessment;

European Society of Hypertension /European Society of Cardiology 

(ESH/ESC) [125]

2013

All adults

Office measurement; Diagnosis based on at least 2 readings at 2 separate visits; Consider home blood pressure monitoring or 24 hour ambulatory monitoring to confirm diagnosis

At time of routine preventative care or health assessment

Hypertension Classification

In the United States, the most widely used classification of blood pressure for adults aged 18 years or older is from the 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), as follows [3] :

  • Normal: Systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg
  • Prehypertension: Systolic 120-139 mm Hg, diastolic 80-89 mm Hg
  • Stage 1: Systolic 140-159 mm Hg, diastolic 90-99 mm Hg
  • Stage 2: Systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater

However, the 2017, the American College of Cardiology/American Heart Association (ACC/AHA) updated their guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults by eliminating the classification of prehypertension and dividing it into two levels [69, 70] :

  • Elevated blood pressure with a systolic pressure between 120 and 129 mm Hg and diastolic pressure less than 80 mm Hg
  • Stage 1 hypertension, with a systolic pressure of 130 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg

The 2013 and 2018 ESH/ESC guidelines utilize the following classification system, which was first introduced in its 2002 guidelines [7, 125] :

  • Optimal: Systolic lower than 120 mm Hg and diastolic lower than 80 mm Hg
  • Normal: Systolic 120-129 mm Hg and/or diastolic 80-84 mm Hg
  • High normal: Systolic 130-139 mm Hg and/or diastolic 85-89 mm Hg
  • Grade 1: Systolic 140-159 mm Hg and/or diastolic 90-99 mm Hg
  • Grade 2: Systolic 160-179 mm Hg or greater and/or diastolic 100-109 mm Hg
  • Grade 3: Systolic 180 mm Hg or greater and/or diastolic 110 mm Hg or greater
  • Isolated systolic hypertension: 140 mm Hg or greater and diastolic lower than 90 mm Hg

Both the classifications above are based on the average of two or more readings taken at each of two or more visits after initial screening. [3, 125]  

Target Blood Pressure

Target blood pressures have been provided in guidelines from the following organizations:

  • Joint National Committee (JNC)
  • European Society of Hypertension (ESH)/European Society of Cardiology (ESC)
  • American Heart Association/American College of Cardiology/American Society of Hypertension (AHA/ACC/ASH)
  • American Heart Association/American College of Cardiology (ACC)/Centers for Disease Control and Prevention (AHA/ACC/CDC)
  • American Society of Hypertension/International Society of Hypertension (ASH/ISH)
  • Department of Veterans Affairs (VA)/Department of Defense (DoD)
  • American Diabetes Association (ADA)
  • American College of Cardiology/American Heart Association (ACC/AHA)

A group was empaneled to write the Eighth Joint National Committee (JNC8) guideline, but this effort was discontinued by the National Heart, Lung, and Blood Institute (NHLBI). A paper was published in The Journal of the American Medical Association in 2014 that is generally referred to as 'JNC 8' but officially, there are no JNC 8 guidelines sanctioned by the NHLBI, nor has JNC 8 been endorsed by the AHA, ACC, or many other organizations that endorsed JNC7. 

A comparison of the target blood pressure recommendations for the guidelines issued by various organizations is provided in Table 5, below.

Table 5. Target Blood Pressure Recommendations (Open Table in a new window)

Issuing Organization

Year

Population

Target Blood Pressure

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) [3]

2003

All adults except those with diabetes or chronic kidney disease

Adults with diabetes or chronic kidney disease

< 140/90 mm Hg

 

< 130/80 mm Hg

Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) [87]

2014

Adults age < 60 years and those >18 with diabetes or chronic kidney disease

 

Adults age ≥60 years

< 140/90 mm Hg

 

 

 

< 150/90 mm Hg

European Society of Hypertension/European Society of Cardiology (ESH/ECS) [125]

2013

All adults  except those with diabetes

 

 

 

Adults with diabetes

140-150 mm Hg systolic; consider < 140 mm Hg if the patient is fit and healthy; for ages ≥80 years, the patient's mental capacity and physical heath should also be considered if targeting to < 140 mm Hg

 

< 85 mm Hg diastolic BP

American Heart Association/American College of Cardiology/American Society of Hypertension (AHA/ACC/ASH) [129]

2015

Adults ages >80 years

 

 

Adults with CAD, except as noted below

 

Adults with MI, stroke, TIA, carotid artery disease, peripheral artery disease or abdominal aortic aneurysm

 

 

< 150/90 mm Hg

 

 

< 140/90 mm Hg

 

 

 

< 130/80 mm Hg

 

 

 

 

American Heart Association/American College of Cardiology (ACC)/Centers for Disease Control and Prevention (AHA/ACC/CDC) [130]

2014

All adults

< 140/90 mm Hg

American College of Cardiology/American Heart Association (ACC/AHA) [69]

2017

All adults

< 130/80 mm Hg

American Society of Hypertension/International Society of Hypertension (ASH/ISH) [131]

2014

Adults ages 18-79 years

 

Adults ages ≥80 years

< 140/90 mm Hg; < 130/80 mm Hg BP target may be considered in younger adults

< 150/90 mm Hg

Department of Veterans Affairs/Department of Defense (VA/DoD) [128]

2014

All adults

Adults with diabetes

< 150/90 mm Hg

< 150/85 mm Hg

American Diabetes Association (ADA) [68]

2016

Adults with diabetes

< 140/90 mm Hg; < 130/80 mm Hg target may be appropriate in younger adults

American Diabetes Association (ADA) [82]

2017

Adults with diabetes

< 140/90 mm Hg; < 130/80 mm Hg target may be appropriate for those at high risk of cardiovascular disease (if achievable without undue treatment burden)

CAD = coronary artery disease; MI = myocardial infarction; TIA = transient ischemic attack.

SPRINT Trial

It should be noted that, aside from the ADA guidelines, existing guideline recommendations on target BP goals were developed prior to the Systolic Blood Pressure Intervention Trial (SPRINT) study, an NIH sponsored trial that demonstrated a 25% decrease in cardiovascular events or death with targeting a systolic BP less than 120 mm Hg versus 140 mm Hg in patients at increased cardiovascular risk. [132] These intriguing results suggest a benefit from more-intensive BP targets than are recommended in existing guidelines. However, the generalizability of the SPRINT results remain unclear. Importantly, the SPRINT trial excluded patients with diabetes mellitus or prior cerebrovascular accident. These populations have been studied previously in the ACCORD and SPS3 trials, respectively, which failed to demonstrate significant benefits to stringent BP targets of below 120-130 mm Hg. [89, 133]

It is also important to recognize that the SPRINT trial utilized an automatic oscillometric office BP method without human participation, which typically yields a systolic BP that is 7-10 mm Hg lower than the standard office-based BP used in most studies. [108] This suggests that the lower systolic BP target in the SPRINT trial may be closer to more moderate targets in other studies, and that stringent systolic BP targeting of 120 mm Hg in standard clinical practice may increase the rate of adverse events such as hypotension, electrolyte abnormalities, and acute kidney injury. [132, 134]

A large meta-analysis of hypertension studies that tested systolic BP targets (including the SPRINT trial) demonstrated a reduction in cardiovascular outcomes and overall mortality with a systolic BP target below 130 mm Hg, although the magnitude of the benefit decreased with BP goals progressively below 150 mm Hg. [135] Future guidelines will likely incorporate the results of the SPRINT trial into target BP recommendations, which may result in lower target BPs, at least for patients with high cardiovascular risk but without diabetes or prior cerebrovascular accidents. 

Management

Many guidelines exist for the management of hypertension. Two of the most widely used recommendations are the 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) [3] and annually updated guidelines from the American Diabetes Association (ADA). [68]  

In 2013, both the JNC 8 and the updated joint guidelines from the European Society of Hypertension/European Society of Cardiology (ESH/ESC) were released. In 2014 and 2015, guidelines were issued by the following organizations:

  • American Heart Association/American College of Cardiology/American Society of Hypertension (AHA/ACC/ASH) [129]
  • American Society of Hypertension/International Society of Hypertension (ASH/ISH) [131]
  • Department of Veterans Affairs/Department of Defense (VA/DoD) [128]

In 2017, the ACC/AHA as well as the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults [69]  and the elderly, [71] respectively.

​JNC 7

Key messages of the JNC 7 were as follows [3] :

  • The goals of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality, with the focus on controlling the systolic BP, as most patients will achieve diastolic BP control when the systolic BP is achieved

  • Prehypertension (systolic 120-139 mm Hg, diastolic 80-89 mm Hg) requires health-promoting lifestyle modifications to prevent the progressive rise in BP and cardiovascular disease

  • In uncomplicated hypertension, a thiazide diuretic, either alone or combined with drugs from other classes, should be used for the pharmacologic treatment of most cases

  • In specific high-risk conditions, there are compelling indications for the use of other antihypertensive drug classes (eg, angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], beta blockers, calcium channel blockers)

  • Two or more antihypertensive medications will be required to achieve goal BP (< 140/90 mm Hg or < 130/80 mm Hg) for patients with diabetes and chronic kidney disease

  • For patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using 2 agents, one of which usually will be a thiazide diuretic, should be considered

  • Regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan

ADA 2016 Standard of Medical Care

In its 2016 Standards of Medical Care in Diabetes, the ADA makes the following recommendations for the control of high blood pressure  [68] :

  • Initiation of pharmacotherapy is recommended for all diabetic patients with confirmed office-based blood pressure >140/90 mm Hg
  • Treat with a regimen that includes either an ACEI or an ARB; if one class is not tolerated, the other can be substituted
  • Multiple-drug therapy (including a thiazide diuretic and ACEI/ARB, at maximal doses) is generally required to achieve blood pressure targets
  • Serum creatinine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored in patients receiving ACEIs, ARBs, or diuretics

2017 ADA guidelines

The ADA released updated guidelines for patients with hypertension and diabetes in 2017, as follows [82] :

Blood pressure should be measured at every routine clinical care visit. Patients found to have an elevated blood pressure (≥140/90 mm Hg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension.

All hypertensive patients with diabetes should have home blood pressure monitored to identify white coat hypertension.

Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed.

Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of < 140 mm Hg and a diastolic blood pressure goal of < 90 mm Hg.

Lower systolic and diastolic blood pressure targets, such as < 130/80 mm Hg, may be appropriate for individuals at high risk of cardiovascular disease if they can be achieved without undue treatment burden.

For patients with systolic blood pressure >120 mm Hg or diastolic blood pressure >80 mm Hg, lifestyle intervention consists of weight loss if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern, including reduced sodium and increased potassium intake; increased fruit and vegetable consumption; moderation of alcohol intake; and increased physical activity.

Patients with confirmed office-based blood pressure ≥140/90 mm Hg should, in addition to lifestyle therapy, have timely titration of pharmacologic therapy to achieve blood pressure goals.

Patients with confirmed office-based blood pressure ≥160/100 mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes.

Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: ACEIs, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers. Multiple-drug therapy is generally required to achieve blood pressure targets (but not a combination of ACEIs and ARBs).

An ACEI or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urine albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g creatinine. If one class is not tolerated, the other should be substituted.

For patients treated with an ACEI, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored.

Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic blood pressure < 160 mm Hg, diastolic blood pressure < 105 mm Hg, and no evidence of end-organ damage do not need to be treated with pharmacologic antihypertensive therapy.

In pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy, systolic or diastolic blood pressure targets of 120–160/80–105 mm Hg are suggested in the interest of optimizing long-term maternal health and fetal growth.

2017 ACC/AHA guidelines

The 2017 ACC/AHA guidelines eliminate the classification of prehypertension and divides it into two levels [69, 70] : (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg.

In adults at increased risk of heart failure (HF), the optimal BP in those with hypertension should be less than 130/80 mm Hg.

Adults with HFrEF (HF with reduced ejection fraction) and hypertension should be prescribed GDMT (guideline-directed management and therapy) titrated to attain a BP of less than 130/80 mm Hg.

Nondihydropyridine calcium channel blockers (CCBs) are not recommended in the treatment of hypertension in adults with HFrEF.

Adults with hypertension and chronic kidney disease (CKD) should be treated to a BP goal of less than 130/80 mm Hg.

After kidney transplantation, it is reasonable to treat patients with hypertension to a BP goal of less than 130/80 mm Hg. After kidney transplantation, it is reasonable to treat patients with hypertension with a calcium antagonist on the basis of improved glomerular filtration rate (GFR) and kidney survival.

Immediate lowering of SBP to lower than 140 mm Hg in adults with spontaneous intracerebral hemorrhage (ICH) who present within 6 hours of the acute event and have an SBP between 150 mm Hg and 220 mm Hg is not of benefit to reduce death or severe disability and can be potentially harmful.

Adults with acute ischemic stroke and elevated BP who are eligible for treatment with intravenous (IV) tissue plasminogen activator (tPA) should have their BP slowly lowered to below 185/110 mm Hg before thrombolytic therapy is initiated.

In adults with an acute ischemic stroke, BP should be less than 185/110 mm Hg before administration of IV tPA and should be maintained below 180/105 mm Hg for at least the first 24 hours after initiating drug therapy.

For adults who experience a stroke or transient ischemic attack (TIA), treatment with a thiazide diuretic, ACEI, or angiotensin receptor blocker (ARB), or combination treatment consisting of a thiazide diuretic plus ACEI, is useful.

In adults with an untreated SBP greater than 130 mm Hg but less than 160 mm Hg or a DBP greater than 80 mm Hg but less than 100 mm Hg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ABPM (ambulatory BP monitoring) or HBPM (home BPM) before diagnosis of hypertension.

In adults with untreated office BPs that are consistently between 120 mm Hg and 129 mm Hg for SBP or between 75 mm Hg and 79 mm Hg for DBP, screening for masked hypertension with home BPM (or ABPM) is reasonable.

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).

Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than two and one standard drinks per day, respectively.

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.

Women with hypertension who become pregnant should not be treated with ACEIs, ARBs, or direct renin inhibitors.

Use of BP-lowering medications is recommended for secondary prevention of recurrent cardiovascular disease (CVD) events in patients with clinical CVD and an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher, and for primary prevention in adults with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher.

Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk below 10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher.

Adults with an elevated BP or stage 1 hypertension who have an estimated 10-year ASCVD risk below 10% should be managed with nonpharmacologic therapy and have a repeat BP evaluation within 3 to 6 months.

Adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of 10% or higher should be managed initially with a combination of nonpharmacologic and antihypertensive drug therapy and have a repeat BP evaluation in 1 month.

For adults with a very high average BP (eg, SBP ≥180 mm Hg or DBP ≥110 mm Hg), evaluation followed by prompt antihypertensive drug treatment is recommended.

Simultaneous use of an ACE, ARB, and/or renin inhibitor is potentially harmful and is not recommended to treat adults with hypertension.

2017 ACP/AAFP guidelines

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released their guidelines regarding hypertension in adults aged 60 years, including the following [71] :

  • Clinicians should initiate treatment in patients aged 60 years or older who have persistent SBP at or above 150 mm Hg to achieve a target of less than 150 mm Hg to reduce the risk for stroke, cardiac events, and death.
  • If patients 60 years or older have a history of stroke or transient ischemic attack or have high cardiovascular risk, physicians should consider starting or increasing drug therapy to achieve an SBP of less than 140 mm Hg to reduce the risk for stroke and cardiac events.
  • Consider initiating or intensifying pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk based on individualized assessment, to achieve a target SBP of less than 140 mm Hg to reduce the risk for stroke and cardiac events. Factors include comorbidity, medication burden, risk of adverse events, and cost. Generally, increased cardiovascular risk includes known cardiovascular disease, diabetes, or chronic kidney disease with a glomerular filtration rate of less than 45 mL/min/1.73 m 2.

Collaborative AHA/ACC/CDC advisory recommendations

A science advisory on the treatment of hypertension, issued in November 2013 via a collaborative effort by the American Heart Association (AHA), the American College of Cardiology (ACC), and the Centers for Disease Control and Prevention (CDC), describes criteria for successful hypertension management algorithms and advocates the creation of algorithms that can be incorporated into a system-level approach to high BP, as well as modified to accommodate different practice settings and patient populations. [130, 136]

A joint AHA/ACC/CDC algorithm in the report includes the following recommendations [130, 136] :

  • BP: Recommended goal of 139/89 mm Hg or less

  • Stage 1 hypertension (systolic BP 140-159 mm Hg or diastolic BP 90-99 mm Hg): Can be treated with lifestyle modifications and, if needed, a thiazide diuretic

  • Stage 2 hypertension (systolic BP >160 mm Hg or diastolic BP >100 mm Hg): Can be treated with a combination of a thiazide diuretic and an ACEI, an angiotensin receptor blocker, or a calcium channel blocker

  • Patients who fail to achieve BP goals: Medication doses can be increased and/or a drug from a different class can be added to treatment

Joint ESH and ESC guidelines

In June 2013, the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) released new guidelines for the management of hypertension, recommending that all patients, except special populations such as patients with diabetes and the elderly, be treated to below 140 mm Hg systolic BP. [124, 125]  The guidelines advise that physicians should make decisions on treatment strategies based on the patient's overall level of cardiovascular risk.

Recommendations of the new ESH and ESC guidelines include [124, 125] :

  • In patients younger than 80 years, the systolic BP target should be 140 to 150 mm Hg, but physicians can go lower than 140 mm Hg if the patient is fit and healthy; the same advice applies to octogenarians—however, the patient's mental capacity and physical heath should also be considered if targeting to less than 140 mm Hg

  • Patients with diabetes should be treated to below 85 mm Hg diastolic BP

  • Salt intake should be limited to approximately 5 to 6 g per day

  • Body-mass index (BMI) should be reduced to 25 kg/m2 and waist circumferences should be reduced to less than 102 cm in men and less than 88 cm in women

  • Ambulatory BP monitoring (ABPM) should be incorporated into the assessment of risk

  • Effective combination therapies include thiazide diuretics with ARBs, calcium-channel antagonists, or ACEIs; or, calcium-channel antagonists with ARBs or ACEIs

  • Dual renin-angiotensin system blockade (ie, ARBs, ACEIs, and direct renin inhibitors) is not recommended because of the risks of hyperkalemia, low BP, and kidney failure

American Society of Hypertension/International Society of Hypertension

Joint guidelines were issued in 2013 by the American Society of Hypertension and the International Society of Hypertension (ASH/ISH) with the intent of providing an international primer with general information, especially for communities and countries with low resources. On their website, the ASH cautions that “these guidelines should be considered more as ‘an expert opinion piece,’ given that they are not systematically evidence-based and were not developed using guideline development protocol stipulated by the Institute of Medicine (IOM).” [131]

Treatment recommendations are given for hypertensive patients with or without another major medical condition are provided in Table 6, below. [137]

Table 6. American Society of Hypertension/International Society of Hypertension Treatment Recommendations (Open Table in a new window)

Patients Without Other Major Medical Condition

First-line Drugs

Added 2nd Drug (if needed to reach BP target)

Added 3rd Drug (if needed to reach BP target)

African ancestry

CCB or thiazide diuretic

ARB or ACEI

Combination of CCB plus ACEI or ARB plus thiazide diuretic

White and other non-African ancestry ages < 60 years

ARB or ACEI

CCB or thiazide diuretic

Combination of CCB plus ACEI or ARB plus thiazide diuretic

White and other non-African ancestry ages ≥60 years

CCB or thiazide diuretic; ARB or ACEI also effective

ARB or ACEI; CCB or thiazide diuretic if ARB or ACEI used first

Combination of CCB plus ACEI or ARB plus thiazide diuretic

Major medical condition

     

Diabetes (white and other non-African ancestry)

ARB or ACEI

CCB or thiazide diuretic

Alternative 2nd drug (CCB or thiazide diuretic)

Diabetes (African ancestry)

CCB or thiazide diuretic

ARB or ACEI

Alternative 1st drug (CCB or thiazide diuretic)

Chronic kidney disease

ARB or ACEI

CCB or thiazide diuretic

Alternative 2nd drug (CCB or thiazide diuretic)

Coronary artery disease

Beta-blocker plus ARB or ACEI

CCB or thiazide diuretic

Alternative 2nd drug (CCB or thiazide diuretic)

Stroke

ACEI or ARB

CCB or thiazide diuretic

Alternative 2nd drug (CCB or thiazide diuretic)

Symptomatic heart failure

Beta-blocker plus ARB or ACEI plus diuretic plus spironolactone regardless of BP; CCB can be added if needed for BP control

ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BP = blood pressure; CCB = calcium channel blocker.

Department of Veterans Affairs/Department of Defense

In 2014, the Department of Veteran’s Affairs/Department of Defense (VA/DoD) released an update of their 2004 guidelines for diagnosis and management of hypertension in primary care settings. Initiation of pharmacotherapy is recommended for all adults with either systolic BP ≥160 mm Hg or diastolic BP ≥90 mm Hg and for adults with a history of stroke, transient ischemic attack, or asymptomatic carotid artery disease and systolic BP ≥140 mm Hg. [128]

Treatment may also be considered for adults ages ≥60 years with systolic BP < 160 mm Hg. Combination therapy should be initiated for adults with systolic BP >20 mm Hg or diastolic BP >10 mm Hg above the target goal. Additional recommendations include the following [128] :

  • Thiazide-type diuretic as first-line therapy either as monotherapy or in combination with other drugs
  • Chlorthalidone or indapamide is preferred over hydrochlorothiazide
  • For patients who cannot tolerate thiazide-type diuretics, or as supplementary therapies for patients who do not reach their hypertensive goals with thiazide-type diuretics, or for those starting on combination therapy: ACEIs or ARBs (but not both together); long-acting dihydropyridine calcium channel blockers
  • For patients with chronic kidney disease, ACEIs or ARBs for improving kidney outcomes
  • In African Americans, recommend against ACEIs or ARBs as monotherapy
  • In African Americans with stage 1-3 chronic kidney disease, the combination of a thiazide-type diuretic (for cardiovascular protection) with either an ACEI or an ARB (for renal protection)

Lifestyle modifications

JNC 7 and AHA-ASA lifestyle modification recommendations

The Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommendations to lower blood pressure (BP) and decrease cardiovascular disease risk include the following, with greater results achieved when 2 or more lifestyle modifications are combined [3] :

  • Weight loss helps to prevent hypertension (range of approximate systolic BP reduction [SBP], 5-20 mm Hg per 10 kg); recommendations include the DASH (Dietary Approaches to Stop Hypertension) diet (range of approximate SBP reduction, 8-14 mm Hg), which is rich in fruits and vegetables and encourages the use of fat-free or low-fat milk and milk products

  • Limit alcohol intake to no more than 1 oz (30 mL) of ethanol per day for men (ie, 24 oz [720 mL] of beer, 10 oz [300 mL] of wine, 2 oz [60 mL] of 100-proof whiskey) or 0.5 oz (15 mL) of ethanol per day for women and people of lighter weight (range of approximate SBP reduction, 2-4 mm Hg)

  • Reduce sodium intake to no more than 100 mmol/d (2.4 g sodium or 6 g sodium chloride; range of approximate SBP reduction, 2-8 mm Hg) [6]

  • Maintain adequate intake of dietary potassium (approximately 90 mmol/d)

  • Maintain adequate intake of dietary calcium and magnesium for general health

  • Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health

  • Engage in aerobic exercise at least 30 minutes daily for most days (range of approximate SBP reduction, 4-9 mm Hg)

The 2010 American Heart Association-American Stroke Association (AHA-ASA) guidelines for the primary prevention of stroke makes the following recommendations [171] :

  • Hypertension: the AHA-ASA guidelines recommend regular blood pressure screening, lifestyle modification, and drug therapy; lower risk of stroke and cardiovascular events are seen when systolic blood pressure levels are lower than 140 mm Hg and diastolic blood pressure levels are less than 90 mm Hg

  • In patients who have hypertension with diabetes or renal disease, the BP goal is lower than 130/80 mm Hg

  • Diet and nutrition: a diet that is low in sodium and high in potassium is recommended to reduce BP; diets that promote the consumption of fruits, vegetables, and low-fat dairy products, such as the DASH-style diet, help lower BP and may lower the risk of stroke

  • Physical inactivity: increasing physical activity is associated with a reduction in the risk of stroke; the goal is to engage in 30 minutes or more of moderate intensity activity on a daily basis

  • Obesity and body fat distribution: weight reduction in overweight and obese persons is recommended to reduce BP and the risk of stroke

Hypertensive Emergencies

In the 2013, the American College of Emergency Physicians (ACEP) released an update of its 2006 guidelines for hypertension in the emergency department (ED), which are focused on treating hypertensive urgency. The recommendations include the following [138] :

  • In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, electrocardiogram [ECG]) is not required.
  • In select patient populations (eg, those with poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission)
  • In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required
  • In select patient populations (eg, poor follow-up available), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control (Consensus recommendation)
  • Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up (Consensus recommendation)

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommendations for hypertensive crises and emergencies include the following [69] :

  • Admit adults with a hypertensive emergency to an ICU for continuous monitoring of BP and target organ damage, as well as for parenteral administration of an appropriate medication.
  • For adults with a compelling condition (ie, aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma crisis), lower SBP to below 140 mm Hg during the first hour and to below 120 mm Hg in aortic dissection.
  • For adults without a compelling condition, reduce the SBP to a maximum of 25% within the first hour; then, if the patient is clinically stable, lower the BP to 160/100 -110 mm Hg over the next 2-6 hours, and then cautiously to normal over the following 24-48 hours.

Hypertension in Pregnancy

Hypertensive disorders during pregnancy are classified into the four following categories, as recommended by the 2000 National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy [139] :

  • Chronic hypertension

  • Preeclampsia-eclampsia

  • Preeclampsia superimposed on chronic hypertension

  • Gestational hypertension (transient hypertension of pregnancy or chronic hypertension identified in the latter half of pregnancy); this terminology is preferred over the older but widely used term pregnancy-induced hypertension (PIH) because it is more precise.

However, the JNC 7 categorizes hypertensive disorders during pregnancy as follows (see Table 7, below) [3] :

  • Chronic hypertension
  •  Preeclampsia
  • Chronic hypertension with superimposed preeclampsia
  • Gestational hypertension
  • Transient hypertension

The 2013 American College of Obstetricians and Gynecologists (ACOG) uses a classification system similar to that of JNC 7. [140]

In 2014, the Society of Obstetricians and Gynecologists of Canada (SOGC) released revised guidelines that classify hypertension in pregnancy as follows [137] :

  • Preexisting hypertension
  • Gestational hypertension
  • Preeclampsia
  • Other hypertensive effects (transient hypertensive effect, white-coat hypertensive effect, masked hypertensive effect)

Table 7. JNC 7 Classification of Hypertensive Disorders in Pregnancy (Open Table in a new window)

Classification

Characteristics

Chronic hypertension

SBP ≥140 mm Hg or DBP ≥90 mm Hg, present pre-pregnancy or before 20 weeks’ gestation and persisting >12 weeks postpartum

Preeclampsia

SBP ≥140 mm Hg or DBP ≥90 mm Hg with proteinuria (>300 mg/24 h) that develops >20 weeks’ gestation;

Can progress to eclampsia

More common in nulliparous women, multiple gestation, women with hypertension ≥4 years, family history of preeclampsia, previous hypertension in pregnancy, and renal disease

Chronic hypertension with superimposed preeclampsia

New-onset proteinuria after 20 weeks’ gestation in a hypertensive woman or

In a woman with hypertension and proteinuria before 20 weeks’ gestation:

• Sudden 2- to 3-fold increase in proteinuria

• Sudden increase in BP

• Thrombocytopenia

• Elevated AST or ALT levels

Gestational hypertension

Temporary diagnosis

Hypertension without proteinuria after 20 weeks’ gestation

May be a preproteinuric phase of preeclampsia or a recurrence of chronic hypertension that abated in mid-pregnancy

May lead to preeclampsia

Severe cases may cause higher rates of premature delivery and growth retardation relative to mild preeclampsia

Transient hypertension

Diagnosis made retrospectively

BP returns to normal by 12 weeks postpartum

May recur in subsequent pregnancies

Predictive of future primary hypertension

ALT = alanine aminotransferase; AST = aspartate aminotransferase; BP = blood pressure; DBP = diastolic BP; SBP = systolic BP

Specific guidelines for the management of hypertension during pregnancy have been issued by the American College of Obstetricians and Gynecologists (ACOG), Society of Obstetricians and Gynecologists of Canada (SOGC). In addition, recommendations for managing hypertension in pregnancy are included in broader hypertension management guidelines from the following organizations:

  • Joint National Committee (JNC)
  • European Society of Hypertension (ESH)/European Society of Cardiology (ESC)
  • American Diabetes Association (ADA)

JNC 7 recommends treating women with chronic (preexisting) hypertension and no evidence of end-organ damage whose blood pressure is 150-160 mm Hg systolic or 100-110 mm Hg diastolic [3]

The ESH/ESC guidelines recommend considering treatment for pregnant women with chronic hypertension and BP ≥150/95 mm Hg; or in those women with BP ≥140/90 mm Hg who have gestational hypertension, subclinical organ damage, or symptoms. [125]

The 2013 ACOG guidelines recommend that in pregnant women with chronic hypertension treated with antihypertensive medication, BP levels should be maintained between 120/80 mm Hg and 160/105 mm Hg. [140]

Although reducing maternal risk is the goal of treating chronic hypertension in pregnancy, fetal safety largely directs the choice of antihypertensive agent. Methyldopa is generally the preferred first-line agent because of its safety profile. [3, 125, 140] Other drugs that may be considered include labetalol, beta-blockers, and diuretics. [4] ACOG does not recommend the use of any of the following [140] :

  • ACEIs
  • ARBs
  • Renin inhibitors
  • Mineralocorticoid receptor antagonists

 

Severe hypertension

There is consensus across guidelines (JNC 7, ESH/ESC, ACOG, SOGC) for the need to acutely manage severe hypertension, defined as systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg or both, with the goal of preventing maternal stroke and avoiding intrauterine growth restriction (IUGR). [3, 125, 137, 140]

In 2015, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice issued updated guidelines regarding the emergency treatment of acute-onset severe hypertension during pregnancy, including the following [141] :

  • Acute-onset, severe hypertension that is accurately measured using standard techniques and is persistent for 15 minutes or longer is considered a hypertensive emergency
  • Intravenous (IV) labetalol and hydralazine have long been considered first-line medications for the management of acute-onset, severe hypertension in pregnant and post-partum women; available evidence suggests that oral nifedipine also may be considered as a first-line therapy
  • Parenteral labetalol should be avoided in women with asthma, heart disease, or congestive heart failure
  • When urgent treatment is needed before the establishment of IV access, the oral nifedipine algorithm can be initiated as IV access is being obtained, or a 200-mg dose of labetalol can be administered orally; the latter can be repeated in 30 minutes if appropriate improvement is not observed
  • Magnesium sulfate is not recommended as an antihypertensive agent, but it remains the drug of choice for seizure prophylaxis in severe preeclampsia and for controlling seizures in eclampsia
  • Sodium nitroprusside should be reserved for extreme emergencies and used for the shortest amount of time possible because of concerns about cyanide and thiocyanate toxicity in the mother and fetus or newborn, and increased intracranial pressure with potential worsening of cerebral edema in the mother
  • Adoption of standardized, evidence-based clinical guidelines for managing patients with preeclampsia is needed; individuals and institutions should have mechanisms in place for prompt initiation of medication when a patient presents with a hypertensive emergency

Hypertension and diabetes in pregnancy

In pregnant patients with diabetes and chronic hypertension, the ADA 2016 Standards of Medical Care in Diabetes recommends blood pressure targets of 110–129/65–79 mm Hg in the interest of optimizing long-term maternal health and minimizing impairment of fetal growth. ACEIs and ARBs are contraindicated during pregnancy. [141]

The 2017 ADA position statement on diabetes and hypertension indicates no antihypertensive pharmacotherapy is necessary for pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with an SBP below 160 mm Hg and a DBP below 105 mm Hg, and no evidence of end organ damage. [82] For pregnant women with diabetes and preexisting hypertension on antihypertensive therapy, suggested BP targets are an SBP of 120-160 mm Hg and a DBP target of 80-105 mm Hg.