New hypertension guideline means nearly half of Americans have high BP

John Murphy, MDLinx | November 15, 2017

Hypertension is now defined as a systolic blood pressure (SBP) of 130 mm Hg and higher or a diastolic blood pressure (DBP) of 80 mm Hg and higher, according to a new blood pressure guideline developed by the American College of Cardiology (ACC), the American Heart Association (AHA), and nine other professional organizations.

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New cuff stuff

New BP guideline also recommends home monitoring, but using only validated devices along with appropriate training.

The new guideline — presented November 13 at the AHA’s 2017 Scientific Sessions conference in Anaheim, CA, and simultaneously published in both Hypertension and the Journal of the American College of Cardiology — is the first comprehensive revision of hypertension classifications since 2003.

The new guideline defines blood pressure categories as:

  • Normal: SBP less than 120 mm Hg and DBP less than 80 mm Hg
  • Elevated: SBP 120-129 mm Hg and DBP less than 80 mm Hg
  • Stage 1 Hypertension: SBP 130-139 mm Hg or DBP 80-89 mm Hg
  • Stage 2 Hypertension: SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg
  • Hypertensive crisis: SBP > 180 mm Hg and/or DBP > 120 mm Hg, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

An average of two or more readings should be obtained on two or more occasions to determine blood pressure measurements, the guideline recommends. The category of prehypertension, which was defined as a SBP between 120-139 mm Hg or a DBP between 80-89 mm Hg, has been eliminated.

A clear directive

Lowering the threshold of hypertension to 130/80 mm Hg from the previous definition of 140/90 mm Hg means that nearly half (46%) of the US adult population now has high blood pressure.

However, “The new definition results in only a small increase in the percentage of US adults for whom antihypertensive medication is recommended in conjunction with lifestyle modification,” wrote authors led by Paul K. Whelton, MB, MD, MSc, the Show Chwan professor of global public health at Tulane University School of Public Health and Tropical Medicine and School of Medicine in New Orleans, LA.

The new guideline reflects a stronger emphasis on the prevention, awareness, treatment, and control of high blood pressure, the authors noted.

“Details aside, the guideline sends a clear directive: We must more aggressively help people lower their blood pressure to healthier levels,” said AHA president John Warner, MD, MBA. “Early intervention can help prevent problems, slow damage that has already started, and lower the risk for a cardiac event or stroke.”

Nonpharmacologic interventions may be enough to prevent hypertension and meet blood pressure goals in many patients, the authors noted. The guideline recommends six such interventions:

  1. Weight loss
  2. A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet
  3. Reducing sodium intake
  4. Potassium supplementation, preferably in dietary modification (unless contraindicated by the presence of chronic kidney disease or use of drugs that reduce potassium excretion)
  5. Increased physical activity with a structured exercise program
  6. Limiting alcohol

Home BP monitoring

For confirmation and management of hypertension, the guideline also recommends out-of-office blood pressure monitoring using validated home blood pressure monitoring devices along with appropriate training.

Out-of-office measurement can reveal white-coat hypertension (higher blood pressure in the office versus out-of-office) as well as masked hypertension (normal blood pressure in the office but uncontrolled blood pressure in out-of-office settings).

“People with white-coat hypertension do not seem to have the same elevation in risk as someone with true sustained high blood pressure,” Dr. Whelton said. “Masked hypertension is more sinister and very important to recognize because these people seem to have a similar risk as those with sustained high blood pressure.”

Lastly, the authors acknowledged, “This document is, as its name implies, a guide. In managing patients, the responsible clinician’s judgment remains paramount.”

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