Elevated systolic and diastolic BPs are associated with an increased risk of cardiovascular disease (CVD), including myocardial infarction (MI), heart failure, stroke, and kidney failure, with their associated direct and indirect costs, disability, and premature death.1,2 The estimated direct and indirect cost of treating hypertension was $51.2 billion in 2012-2013 and total direct cost is estimated to be $200 billion by 2030.3 Lifestyle modifications and antihypertensive medications reduce elevated BP and the associated morbidity and mortality.1 Ideal BP targets and treatments optimize the balance between the complications of elevated BP and adverse reactions from excessive BP lowering. Hypertension guidelines are intended to reflect critical evaluation of the available evidence and provide recommendations for the prevention, detection, evaluation, and treatment of hypertension to provide the greatest patient benefit and least amount of harm.
HISTORY OF HYPERTENSION GUIDELINES
Since the first report of the Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High Blood Pressure was published in 1976, six updated reports were commissioned and published by the National Heart, Lung, and Blood Institute (NHLBI), with the last, JNC 7, published in 2003.4 The JNC 8 panel convened work in 2008 on a strictly evidence-based hypertension guideline that relied exclusively on evidence from randomized controlled trials and was limited in scope. In 2013, the NHLBI announced it would discontinue developing clinical guidelines, including those in progress.5 The JNC 8 writing group declined partnership with the American College of Cardiology (ACC) and the American Heart Association (AHA) and published its report in the Journal of the American Medical Association in 2014.6
To address the lack of a comprehensive hypertension guideline that might incorporate additional forms of evidence beyond that from randomized controlled trials, and because new data were available, the ACC and AHA sponsored development of a new guideline for the prevention, detection, evaluation, and management of high BP in adults.7 Compared with its JNC predecessors, this guideline used a new methodology and evidence review approach intended to provide clinicians with useful, comprehensive evidence-based recommendations. Evidence was drawn primarily from randomized controlled trials but also included consideration of meta-analyses of randomized controlled trials, systematic reviews, nonrandomized studies, cohort studies, and expert opinion.
For the first time, the ACC/AHA Task Force on Clinical Practice Guidelines excluded members with relevant relationships with industry, to avoid real or perceived bias. The task force included representative experts from diverse backgrounds, perspectives, scopes of practice, and interests: physicians, a pharmacist, a nurse, a physician assistant, epidemiologists, public health experts, and two lay persons; with representatives from the American Academy of PAs, American College of Preventative Medicine, American Geriatric Society, American Pharmacists Association, American Society of Hypertension, Association of Black Cardiologists, National Medical Association, and Preventive Cardiovascular Nurses Association.
The task force was assisted by an independent evidence review committee consisting of methodologists, epidemiologists, biostatisticians, and clinicians. The evidence review committee systematically surveyed and assessed evidence to address key clinical questions for review by the task force. Using this approach, the 2017 guideline is the most current, comprehensive, and collaborative guideline for the prevention, detection, evaluation, and management of hypertension.
NEW RECOMMENDATIONS FOR HYPERTENSION
BP classification A log-linear relationship exists between BP and increased CVD risk.8,9 BP classification is useful for clinical management and population health initiatives. The 2017 guideline classifies BP into four categories: normal, elevated, and stages 1 and 2 hypertension.7Table 1 compares the current classification to the JNC 7 taxonomy. Classification is based on two or more correctly measured BP readings obtained on two or more occasions.
The greatest departures from the JNC 7 are the elimination of prehypertension, the addition of a new definition for elevated BP, and the reclassification of the stages of hypertension. Reclassifying a systolic BP of 130 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg as stage 1 hypertension instead of prehypertension increases awareness of the CVD risk associated with these BP ranges. Earlier recognition of CVD risk can promote intensified lifestyle modification and earlier intensive pharmacologic treatment.
The foundation of BP treatment is nonpharmacologic intervention. Weight loss is indicated to reduce BP in adults who are overweight or obese.7 Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension.7 In addition, a diet such as the Dietary Approaches to Stop Hypertension eating plan, reduced intake of dietary sodium, enhanced intake of dietary potassium (unless contraindicated), and moderation in alcohol intake are recommended as nonpharmacologic therapies for the treatment of elevated BP and hypertension (Table 2).7
Nonpharmacologic therapy is the preferred therapy for adults classified with elevated BP.7 This also should be the first-line therapy in patients with stage 1 hypertension who are not at elevated CVD risk (that is, those without coronary heart disease, heart failure, stroke, or an estimated 10-year risk of CVD of 10% or greater calculated by the ACC/AHA Pooled Cohort Equations).7,10 Along with lifestyle modification, antihypertensive medication should be initiated in patients with stage 1 hypertension and elevated CVD risk and in patients with stage 2 hypertension.7Figure 1 provides an overview of BP classifications and recommendations for treatment and follow-up.
Select BP-lowering medications based on evidence and shared decision-making, considering patient preferences, comorbidities, overall health, drug interactions, and drug cost. When a patient has comorbidities (such as heart failure, ischemic heart disease, or chronic kidney disease), choose drugs based on data supporting specific antihypertensive drug classes (Table 3).7 A meta-analysis conducted by the evidence review committee found no evidence of differences in prevention of all-cause mortality for major drug classes: angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, calcium channel blockers, and thiazide diuretics.9 However, differences did exist in some forms of major morbidity, such as cardiovascular events and heart failure.11 Therefore, the primary agents that should be employed, in the absence of a specific compelling indication, include ACE inhibitors, ARBs, calcium channel blockers, and thiazide diuretics.7,11
Also consider the patient's ethnicity and race in initial antihypertensive drug selection. In black patients without heart failure or nephropathy, including those with diabetes, initial treatment should favor a thiazide diuretic or calcium channel blocker over an ACE inhibitor or ARB, based on the superior results from clinical trials in reducing BP and CV events.11
Combination therapy with two or more drugs often is necessary to reach BP goals.12 For patients with stage 2 hypertension, initiation of drug therapy with two agents, either as separate drugs or in fixed-dose combination, is recommended.7 Numerous two- and three-drug combinations are available as fixed-dose combinations. Avoid prescribing drugs with similar mechanisms of action or clinical effects (for example, two different nondihydropyridine calcium channel blockers or more than one renin-angiotensin system blocker).
Look for modifiable causes of resistance or secondary causes of hypertension in patients with resistant hypertension and those who need four or more antihypertensive medications to attain goal BP. Ask if the patient is adhering to his or her prescribed medications. Reviewing pharmacy fill rates may be helpful but it can be difficult to accurately verify or disprove adherence. If the patient's BP is resistant to treatment and the patient is thought to be adherent, obtain ambulatory or home BP measurements to exclude a white-coat effect, which is associated with minimal or no increase in CVD risk.13,14
Assess patients for contributing lifestyle factors, including obesity, physical inactivity, excessive alcohol use, and high sodium intake, and counsel them to make changes. Discontinue substances that may elevate BP, such as nonsteroidal anti-inflammatory drugs, stimulants, oral contraceptives, decongestants, and certain herbal supplements. Evaluate for secondary causes of hypertension and maximize pharmacologic treatment if indicated. Refer patients to a hypertension specialist or an endocrinologist when the treatment of secondary causes of hypertension exceeds the scope of practice of the managing clinician.7
BP treatment goals
Adequately powered randomized controlled trials and meta-analyses of randomized controlled trials provide the best evidence for optimal BP targets. However, variations in inclusion and exclusion criteria, pharmacologic therapies, and methods of BP measurement may limit extrapolation to the general population. Despite these limitations, the recent Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that more intensive BP control (systolic BP below 120 mm Hg) compared with standard control (systolic BP below 140 mm Hg) was associated with improved clinical outcomes—including lower risk for heart failure, death from CV events, and death from any cause—particularly among patients at the greatest risk for CV events (number needed to treat [NNT] for primary composite outcome = 61, median follow-up 3.26 years).15 In patients age 75 years and older in the SPRINT trial who had higher baseline CVD risk, improvement in outcomes was more pronounced (NNT = 27).16 Meta-analyses, including SPRINT, comparing less-intense versus more-intense BP control demonstrate that more intensive BP reduction (to a systolic BP less than 130 mm Hg, compared with higher targets) significantly reduced the risk of stroke, major CV events, and CV mortality but not heart failure or all-cause death in patients with elevated CVD risk.4 Based on these studies, the guideline writing committee concluded that adults with hypertension and at high risk of CVD should be treated to a target BP of less than 130/80 mm Hg.7,16,17
Treating adults without elevated risk of CVD to a goal of less than 130/80 mm Hg also may be reasonable.7 Although limited data indicate that BP treatment decreases CV morbidity and mortality in lower-risk patients, this group is systemically understudied and clinical trial evidence is lacking. Clinical trials demonstrating reduced morbidity and mortality for lower-risk patients would likely require significant numbers of patients with a prolonged follow-up, which would be unrealistic and cost-prohibitive. However, clinical evidence has shown that both drug and nondrug therapy can interrupt the progressive course of hypertension.18 In addition, observational studies suggest that more intense BP lowering can slow the progression of hypertension and reduce the lifetime risk of CV events.7 Based on the most recent and highly powered randomized controlled trials, the 2017 guideline does not recommend different BP goals for patients based on age. Results from SPRINT and the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial demonstrated that treatment goals for adults age 65 years and older need not differ from those for adults under age 65 years.15,19 Therefore, community-dwelling, ambulatory older adults with hypertension should be treated to a systolic BP of less than 130 mm Hg with careful monitoring for adverse reactions including orthostatic hypotension, falls, and reduced renal function.6 For older patients with multiple comorbidities and limited life expectancy, advanced cognitive impairment, or frequent falls, a less-aggressive BP target may be reasonable based on clinical judgment and patient preference.7
EVALUATION AND DIAGNOSIS
Before diagnosis and treatment, obtain a thorough history and perform a physical examination. A physical examination can identify features suggestive of secondary hypertension and assess for target-organ damage caused by hypertension.
Historical and physical features suggestive of primary hypertension include a gradual increase in BP over time, lifestyle factors associated with elevated BP (such as decreased physical activity, increased dietary sodium, and excessive alcohol consumption), and overweight or obesity.7 Evaluate the patient's clinical features for common secondary causes of hypertension (Table 4) and address them as appropriate.
To confirm the diagnosis of hypertension, obtain accurate patient BP measurements using the average of two to three measurements obtained on two to three occasions and measured while the patient is relaxed and has been sitting in a chair for at least 5 minutes.7 Use a validated device and appropriate size cuff, and support the patient's arm during measurement.4 Initially, obtain and record BP from both arms. Use the arm with the higher reading for subsequent measurements.7 Although office measurements are recommended for initial diagnosis and management, out-of-office measurement using home BP monitoring or ambulatory BP monitoring is useful to confirm the diagnosis, screen for white-coat effect and masked hypertension, and to monitor patient response to treatment.
Several basic and optional tests are recommended in patients newly diagnosed with hypertension to establish a baseline for medication use, screen for secondary causes, and identify other CVD risk factors. Basic testing should include a fasting blood glucose level, complete blood cell count, metabolic profile, lipid profile, thyroid-stimulating hormone, urinalysis, and ECG.7 Optional studies include a urinary albumin to creatinine ratio, serum uric acid, and an echocardiogram.7 Additional screening tests for secondary causes of hypertension are included in the guideline.
Appropriate follow-up is necessary to assess patient adherence and response to treatment. Patients with elevated BP or stage 1 hypertension who have initiated lifestyle modifications should have a repeat BP evaluation in 3 to 6 months.7 Patients started on antihypertensive therapy should have a repeat BP evaluation in 1 month.7 The follow-up evaluation should include BP measurement, assessment of adherence to medication and lifestyle modifications, review of medication adverse reactions, assessment of target organ damage, determination of the need for laboratory testing (including electrolyte and renal function status), and need for adjustment of medication regimen.7 Consider intensifying therapy if the BP goal is not met.7
The inconsistencies between office and out-of-office BP measurements increasingly are being recognized. These inconsistencies, together with more aggressive targets for hypertension control, have led to increased focus on out-of-office BP readings, especially home BP monitoring. Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for medication titration.7
Promote medication adherence and lifestyle modification
Educate patients about hypertension and its consequences: adhering to prescribed medications and/or a healthful lifestyle helps patients achieve optimal BP control and reduce CVD morbidity and mortality. Patient factors affecting poor adherence include low health literacy, health beliefs, lack of involvement in the treatment decision-making process, complexity or inconvenience of medication regimen, and resource constraints.7
Clinicians can improve patient health literacy by using the teach-back method, using visual education, and empowering patients to ask questions.7 Encourage patients to use adherence support tools such as reminders and pillboxes.7 Prescribing medications dosed once daily rather than multiple times daily and using combination antihypertensive drugs rather than multiple individual drugs are recommended to improve adherence.7 Consider the costs and potential adverse reactions when choosing antihypertensive therapy for patients.
Screen all adults for tobacco, alcohol, and substance abuse, and provide behavioral interventions if needed.7 Cognitive behavioral interventions and support groups may help patients lose weight and increase their physical activity.4 Address barriers to healthful behavior, such as lack of access to affordable, healthful foods; unsafe environments; transportation and language barriers; and lack of knowledge of healthful foods and activities. Dietitians, social workers, nurses, and community healthcare providers may be helpful in addressing barriers to lifestyle modification.
Effective BP reductions can be improved through team-based care.7 Team members may include physicians, physician assistants, nurses, pharmacists, and other healthcare professionals who can provide patient support and increase access to care. Team members, within the scope of their knowledge and training, can diagnose and manage hypertension, titrate and change medications, provide patient education, facilitate lifestyle changes, coordinate care, and implement process changes to improve care and outcomes.
Detection, accurate diagnosis, and evidence-based treatment of hypertension are important to reduce CV events. Once diagnosed with hypertension, patients should be treated to achieve a target BP of less than 130/80 mm Hg. Nonpharmacologic therapy with appropriate lifestyle modification is recommended for all patients with elevated BP or hypertension. In addition, antihypertensive medication is recommended for patients with stage 1 hypertension who are at high risk for CVD and patients with stage 2 hypertension, and should be considered in others who have not achieved goal BP despite nonpharmacologic therapy.
Choose antihypertensive medications based on the patient's comorbid conditions, contraindications, potential drug interactions and adverse reactions, ethnicity and race, and patient preference. Follow up appropriately to assess for possible adverse medication reactions and to ensure that patients reach their BP targets. Evaluate each patient's adherence to nonpharmacologic and pharmacologic therapies and use team-based approaches to improve BP control and reduce hypertension-associated morbidity and mortality.
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Keywords:Copyright © 2018 American Academy of Physician Assistants
BP; high BP; hypertension; guideline; diagnosis; treatment