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Elevated blood pressure is a major cause of morbidity and mortality worldwide. In the United States, it accounts for the most cardiovascular deaths of any modifiable cardiovascular risk factor and is the second leading cause of preventable all-cause mortality. Elevated blood pressure may also contribute to cognitive decline and dementia. The risk of cardiovascular disease increases with increasing blood pressure in a log-linear fashion, with some data suggesting a doubling of risk with a 20-mmHg increase in systolic blood pressure or a 10-mmHg increase in diastolic blood pressure. The 2017 consensus guidelines for diagnosis and management of blood pressure (Whelton et al, 2018) have shifted the recommendations for when to treat blood pressure, to a more aggressive approach, initiating treatment at 130/80 mmHg rather than 140/90 mmHg. As reviewed below, the consensus statement is a comprehensive document, covering specific recommendations based on comorbidities and different clinical settings.

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In the new guidelines, normal blood pressure is defined as a systolic blood pressure <120 mmHg and a diastolic blood pressure <80 mmHg. Elevated blood pressure is defined as a systolic blood pressure of 120–129 mmHg and a diastolic blood pressure <80 mmHg. State 1 hypertension is defined as a systolic blood pressure of 130–139 mmHg or a diastolic blood pressure of 80–89 mmHg, whereas stage 2 hypertension is a systolic or diastolic pressure exceeding the limits for stage 1 hypertension. The use of proper technique in blood pressure assessment is essential to ensure accurate measurements, including averaging the results of two or more readings on two or more occasions. Out-of-office blood pressure measurements (home-based and ambulatory blood pressure monitoring) can be leveraged for confirmation of a hypertension diagnosis, to assess for the presence of white coat hypertension, and in the titration of antihypertensive medication. Given evidence that other cardiovascular disease (CVD) risk factors are often present in patients with high blood pressure, with >15% of patients having three or more CVD risk factors, screening for (and management of) other modifiable CVD risk factors is recommended in all adults who have been diagnosed with hypertension. In patients with resistant hypertension or physical examination findings suggestive of secondary hypertension, screening for secondary hypertension should be pursued.

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In patients with elevated blood pressure or hypertension, increased physical activity, a heart-healthy diet, and sodium reduction should be recommended, and weight loss should be advised for those who are overweight or obese. Potassium supplementation is recommended unless contraindicated by pharmacotherapy or chronic kidney disease. Alcohol consumption should be limited to one drink a day in patients with hypertension, and two drinks a day in patients with elevated blood pressure. Behavioral and motivational strategies that will help patients achieve a healthy lifestyle should be pursued. A team-based approach is recommended. All patients with hypertension should have a clear care plan, including both treatment and self-management goals, that addresses comorbid conditions, includes appropriate follow-up, and adheres to appropriate goal-directed medical therapy guidelines.

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Antihypertensive medication is recommended in patients with known CVD (“secondary prevention”) whose average systolic blood pressure is ≥130 mmHg or whose average diastolic blood pressure is ≥80 mmHg, and in patients without CVD (“primary prevention”) whose estimated 10-year ASCVD risk is ≥10% and who have an average systolic blood pressure ≥130 mmHg or an average diastolic blood pressure ≥80 mmHg, or those with an estimated 10-year ASCVD risk of <10% who have an average systolic blood pressure ≥140 mmHg or an average diastolic blood pressure ≥90 mmHg. The recommended target blood pressure is 130/80 mmHg, although there are fewer supportive data for this target in patients without other CVD risk factors, chronic kidney disease, or risk factors for heart failure. The timing of blood pressure reassessment following initiation of pharmacologic or nonpharmacologic interventions depends on the severity of blood pressure elevation; in patients with normal blood pressure, annual evaluation is appropriate.

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Screening for primary aldosteronism with the plasma aldosterone:renin activity ratio is recommended in patients with resistant hypertension, an adrenal mass, hypokalemia, a family history of early-onset hypertension, or stroke before the age of 40; in patients who screen positive, referral to an endocrinologist or hypertension specialist is recommended. In patients found to have atherosclerotic renal artery stenosis, medical therapy is recommended; referral for revascularization can be considered if medical management fails in these patients.

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With respect to pharmacologic therapies, appropriate first-line therapies include calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or thiazide diuretics. In patients with stage 2 hypertension whose average blood pressure is >20/10 mmHg above their target, initiation of two first-line agents from different classes is recommended. For patients with stage 1 hypertension, it is reasonable to begin with a single antihypertensive agent with subsequent dose titration and consideration of additional agents if needed to reach the target blood pressure. The simultaneous use of an ACE inhibitor, ARB, and/or renin inhibitor is contraindicated and may be harmful. For any patient receiving a new or modified antihypertensive regimen, monthly follow-up should be pursued until blood pressure control has been achieved. Follow-up should include consideration of telehealth, team-based care, and home blood pressure monitoring as appropriate. In older adults with significant comorbidities and limited life expectancy, patient preference and clinical judgment should guide decisions regarding blood pressure control. Once-daily regimens are preferred in order to optimize adherence, and combination pills also can benefit compliance with pharmacotherapy.

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In patients with stable ischemic heart disease, the recommended blood pressure target is <130/80 mmHg. Patients with a blood pressure above this target should receive pharmacologic therapy, with preferential use of beta blockers, ACE inhibitors, or ARBs as first-line therapy as appropriate to their comorbidities, with addition of other classes of agents as needed to achieve blood pressure control. Beta blockers can be continued beyond 3 years, or restarted after 3 years, as long-term therapy for hypertension in patients with a history of myocardial infarction or acute coronary syndrome. Calcium channel blockers should be used in addition to beta blockers in patients with angina and persistent, uncontrolled hypertension.

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In patients with heart failure with reduced ejection fraction, goal-directed medical therapy should be titrated to achieve a goal blood pressure of <130/80 mmHg. Nondihydropyridine calcium channel blockers are not recommended for management of blood pressure in this population. In patients with heart failure with preserved ejection fraction who have evidence of volume overload, diuretics should be used as the first-line agent for blood pressure control. In those with persistent hypertension despite appropriate management of volume overload, ACE inhibitors, ARBs, or beta blockers are recommended.

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In patients with chronic kidney disease, prescription of an ACE inhibitor is a reasonable intervention given its potential to slow the progression of kidney disease. An ARB may be considered in patients who do not tolerate an ACE inhibitor. Following renal transplantation, calcium channel blockers are reasonable agents to use for the treatment of hypertension as they can improve both glomerular filtration rate and kidney survival.

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In patients with an acute intracerebral hemorrhage presenting with a systolic blood pressure exceeding 220 mmHg, a continuous infusion with an antihypertensive agent with close blood pressure monitoring is reasonable, but care should be taken to ensure that the systolic blood pressure is not lowered too aggressively, as rapid reduction of the blood pressure to under 140 mmHg may be harmful in patients with a spontaneous intracerebral hemorrhage.

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In patients with acute ischemic stroke who are eligible for IV tissue plasminogen activator, blood pressure should be lowered slowly to under 185/110 mmHg before administering thrombolytics, and it should be maintained under 180/105 for at least 24 h after thrombolytic administration. In patients hospitalized for ischemic stroke, initiation or resumption of antihypertensive therapy during the hospitalization is reasonable for patients with a blood pressure exceeding 140/90 mmHg, as long as the patient is neurologically stable. The role of acute antihypertensive therapy in acute ischemic stroke patients with a blood pressure exceeding 220/120 mmHg who are not undergoing endovascular treatment or thrombolytic therapy is unclear. In patients whose blood pressure is under 220/120 mmHg who are not receiving thrombolytics or endovascular treatment, early initiation of antihypertensives is not beneficial.

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In patients who have suffered a stroke or transient ischemic attack (TIA), antihypertensive therapy should be resumed, or (in patients with blood pressure ≥140/90 mmHg) initiated, a few days after the index event, with preference of treatment using a thiazide diuretic, ACE inhibitor, or ARB, although drug selection should be individualized based on a patient’s comorbidities. In patients who experience an ischemic stroke or TIA with systolic blood pressure <140/90 mmHg, the utility of antihypertensive therapy is unclear.

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In patients with hypertension and asymptomatic aortic stenosis, antihypertensives should be started at low doses with gradual uptitration as needed. In patients with chronic aortic insufficiency, agents without negative chronotropic effects are, in general, preferred. In patients with thoracic aortic disease, beta blockers are the preferred first-line agent. Treatment with an ARB may reduce the rate of recurrence of atrial fibrillation. The coexistence of peripheral arterial disease does not influence the treatment approach to hypertension. In patients with diabetes and hypertension, all first-line antihypertensive agents are reasonable and effective; however, in patients with albuminuria, ACE inhibitors or ARBs may be preferred.

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In black adults with hypertension, but without chronic kidney disease or heart failure, thiazide-type diuretics or calcium channel blockers should be prescribed, and two or more agents are recommended to achieve target blood pressure as needed.

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In women who are pregnant or are planning to become pregnant, nifedipine, methyldopa, and/or labetalol can be used for blood pressure control. ACE inhibitors, ARBs, and direct renin inhibitors should not be used in pregnant women.

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In patients presenting in a hypertensive emergency, continuous blood pressure monitoring in an intensive care setting is recommended; blood pressure should be treated with IV antihypertensive agents. If such patients are known to have severe preeclampsia or eclampsia, aortic dissection, or pheochromocytoma crisis, systolic blood pressure should be reduced to under 140 mmHg (120 mmHg for patients with aortic dissection) in the first hour. In patients without one of the aforementioned conditions, the systolic blood pressure should be reduced by ≤25% in the first hour; if the patient is stable, blood pressure should then be reduced to 160/100 mmHg in the next 2–6 h, and then cautiously to normal in the next 24–48 h.

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In patients with hypertension scheduled to undergo elective major surgery, medical therapy should be continued until surgery. In patients on chronic beta blockers, beta blockade should be continued perioperatively, as abrupt discontinuation of either beta blockers or clonidine can be harmful; discontinuation of ACE inhibitors or ARBs, however, may be considered. Deferral of elective major surgery may be considered in patients with systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg. Beta blockers should not be initiated in beta blocker–naïve patients on the day of surgery.

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Electronic health records can be beneficial both to assist with the identification of patients with undiagnosed or inadequately treated hypertension, and to facilitate quality improvement initiatives to optimize hypertension control in the patient population. Performance measures and quality improvement strategies targeted at the patient, provider, and system level can be effective, as can financial incentives and health system financing strategies. Telehealth strategies also may be beneficial in patients with hypertension.

Reference

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Whelton  PK et al: 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. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 71:e127, 2017.
[PubMed: 29146535]