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Home Books CURRENT Diagnosis & Treatment: Family Medicine, 5e

Chapter 35: Hypertension

Maureen O’Hara Padden; Kevin M. Bernstein; Kerry Sadler; Courtney M. Saint; Joseph Sapoval

GENERAL CONSIDERATIONS

The definition of “hypertension” remains controversial between multiple organizations with the publications of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults by the Eighth Joint National Committee (JNC-8) followed by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Clinical Practice Guideline for High Blood Pressure in Adults (Table 35–1). The American Academy of Family Physicians continues to support the JNC-8 recommendations after a thorough review and has chosen not to endorse the ACC/AHA guidelines. The ACC/AHA guidelines substantially increase the number of people diagnosed with hypertension, resulting in a small increase in the percentage of US adults recommended to begin antihypertensive medication as well as recommending more intensive therapy and blood pressure lowering for those already taking antihypertensive medications.

Table 35–1.Classification and management of blood pressure in adults.a
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Table 35–1. Classification and management of blood pressure in adults.a
JNC-8 ACC/AHA
BP Classification SBPa (mmHg) DBPa (mmHg) Lifestyle Modification Initial Drug Therapy BP Classification SBPa (mmHg) DBPa (mmHg) Lifestyle Modification Initial Drug Therapy
Without Compelling Indication With Compelling Indication (see Table 35–6) Without Compelling Indication With Compelling Indication (see Table 35–6)
Normal <120 and <80 Encourage No antihypertensive drug indicated Drug(s) for compelling indicationsb Normal <120 and <80 Encourage No antihypertensive drug indicated; repeat BP evaluation annually Drug(s) for compelling indicationsb,c
Prehypertension 120–129 or <80 Yes     Elevated 120–129 and <80 Yes    
Stage 1 hypertension 130–139 or 80–89 Yes No specific medication is recommended as first line—most important is to control blood pressure; start with ACE inhibitors for most; also, thiazide-type diuretics, ARB, β-blocker, calcium channel blocker, or combination Drug(s) for compelling indications;d other antihypertensive drugs (diuretics, ACE inhibitors, β-blockers, calcium channel blockers) as needed Stage 1 hypertension 130–139 or 80–89 Yes

Without clinical ASCVD or 10-year CVD risk ≤10%: No antihypertensive drug indicated; repeat BP evaluation in 3–6 months

With clinical ASCVD or 10-year CVD risk ≥10%: BP-lowering medication. Single agent recommended; first-line agents include thiazide-type diuretics, calcium channel blockers, ACE inhibitors, or ARBs; Repeat BP evaluation in 1 month

 Drug(s) for compelling indications;c,d other antihypertensive drugs (diuretics, ACE inhibitors, β-blockers, calcium channel blockers) as needed
Stage 2 hypertension ≥140 or ≥90 Yes Two-drug combination for mostd (usually ACE inhibitor and calcium channel blocker; or thiazide-type diuretic or ARB or β-blocker)   Stage 2 hypertension ≥140 or ≥90 Yes Two first-line agents of different classes, either as separate agents or in a fixed-dose combination, are recommended; repeat BP evaluation in 1 month  

aTreatment determined by highest BP category.

bTreat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

cTreat patients with known CVD or 10-year ASCVD risk ≥10% to goal BP of ≤130/80 mmHg; consider treating patients without known CVD to goal BP ≤130/80 ...

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