New Guidelines Redefine Hypertension

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Updated recommendations lower the blood pressure threshold for a hypertension diagnosis from 140/90 to 130/80 mm Hg.
Updated recommendations lower the blood pressure threshold for a hypertension diagnosis from 140/90 to 130/80 mm Hg.

Newly released guidelines from the American Heart Association and the American College of Cardiology lower the blood pressure (BP) cutoff for hypertension diagnosis from 140/90 mm Hg to 130/80 mm Hg.

The term prehypertension is no longer recommended. Instead, stage 1 hypertension will refer to levels of 130 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic pressure; 120 to 129 mm Hg systolic and diastolic less than 80 is considered “elevated.” By lowering the cutoff, nearly half of American adults, particularly the younger individuals, will now be considered hypertensive.

"You've already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure," Paul K. Whelton, MB, MD, MSc, lead author of the guidelines, stated in a news release. "We want to be straight with people – if you already have a doubling of risk, you need to know about it. It doesn't mean you need medication, but it's a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches."

For otherwise healthy stage 1 hypertension patients, lifestyle modifications –  such as a reduced-sodium diet in line with the Dietary Approaches to Stop Hypertension (DASH) study eating plan as well as exercise and stress reduction – could be the initial approach rather than immediate medical therapy. Patients with stage 1 hypertension, however, who are at higher risk for a cardiovascular event, such as individuals with chronic kidney disease (CKD) or diabetes, should be treated with medication.

Patients with CKD or diabetes need to target blood pressure below 130/80 mm Hg. To slow kidney disease progression, patients with advanced CKD or stage 1-2 CKD with macroalbuminuria could be started on an angiotensin converting enzyme (ACE) inhibitor or, if intolerant, an alpha receptor blocker.

When resistant hypertension is suspected, clinicians should screen for contributing conditions beyond CKD and albuminuria, such as sleep apnea.

"The lower threshold for hypertension diagnosis should raise awareness and lead to earlier management of hypertension," George Thomas, MD, director of the Center for Blood Pressure Disorders at Cleveland Clinic, told Renal & Urology News. "Lifestyle modifications are still a cornerstone of management. It is also important that blood pressure be measured correctly, with an emphasis on out-of-office measurements, such as home or ambulatory blood pressure monitoring."

"Most nephrologists are already targeting lower blood pressure in patients with proteinuria based on post hoc analyses of SPRINT and KDIGO recommendations," added Dr Thomas, who was not involved in creating the new guidelines. "The new lower target is reasonable, with the caveat that patients should be very close monitored – particularly because of hemodynamically induced reductions in GFR when blood pressure is lowered, which was seen in the SPRINT study. It remains unclear whether hemodynamically induced reductions in GFR would translate into longer term adverse renal events. Treatment should be individualized, as some patients may not tolerate attempts to lower blood pressures (this also applies to diabetes patients). Medication side effects, intolerances, patient preferences, renal function, electrolyte imbalances, etc. also need to be taken into account."

Csaba P Kovesdy, MD, nephrology section chief of the Memphis VA Medical Center, offers this view: "The blood pressure treatment target for CKD is based solely on the SPRINT results. SPRINT suggested a benefit in patients with eGFR below 60 mL/min/1.73m2, but did not assess whether the benefit was uniform for those with more advanced stages of CKD. Our recent re-analysis of SPRINT (Obi Y et al, J Int Med 2017) suggests that there is in fact no benefit for those with eGFR below 45, who also experience a higher risk of AKI, indicating that a blanket recommendation for stricter blood pressure treatment targets in all CKD patients is not supported by available data."

Read the executive summary of the guidelines



References

Whelton PK, Carey RM, Aronow WS, 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 Amer Coll Cardiol. November 2017. doi: 10.1016/j.jacc.2017.11.006

New ACC/AHA High Blood Pressure Guidelines Lower Definition of Hypertension [news release]. American College of Cardiology, November 13, 2017.

Rubenfire M. 2017 Guideline for High Blood Pressure in Adults. American College of Cardiology. November 13, 2017.

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