The new update on hypertension guidelines in 2017

1. 2017 ACC/AHA
Guidelines

3. Scope of the Guideline
• Update of the JNC 7
• Information from studies of office-based
BP-related risk of CVD, ambulatory
blood pressure monitoring (ABPM),
home blood pressure monitoring
(HBPM), telemedicine, and various
other areas

4. BP AND CVD RISK

5. • Associations between higher systolic
blood pressure (SBP) and diastolic blood
pressure (DBP) and increased CVD risk
• Increased in the risk of CVD from SBP
<115 mmHg to >180 mmHg; DBP <75
mmHg and >105 mmHg

6. • Higher SBP and DBP were also
associated with increased risk:
– CVD incidence and angina
– Myocardial infarction (MI)
– HF
– Stroke
– Peripheral artery disease
– Abdominal aortic aneurysm

7. CVD Risk Factors in Patients
with Hypertension
Modifiable Relatively Fixed
Current cigarette smoking,
second hand smoking
CKD
Diabetes mellitus Family history
Dyslipidemia Increased age
Overweight/Obesity Low socioeconomic/educational
status
Physical inactivity/low fitness Male sex
Unhealthy diet Obstructive sleep apnea
Psychosocial stress

8. CLASSIFICATION OF BP

9. BP Category SBP DBP
Normal < 120 mmHg And < 80 mmHg
Elevated 120-129 mmHg And < 80 mmHg
Hypertension
Stage 1 130-139 mmHg Or 80-89 mmHg
Stage 2 ≥ 140 mmHg Or ≥ 90 mmHg
2017 ACC/AHA Hypertension Guidelines
BP Classification SBP DBP
Normal < 120 mmHg And < 80 mmHg
Prehypertension 120-139 mmHg Or 80-89 mmHg
Stage 1 hypertension 140-159 mmHg Or 90-99 mmHg
Stage 2 hypertension ≥ 160 mmHg Or ≥ 100 mmHg
7th Joint National Committee (JNC) on
Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure (2003)

10. JNC 7 2017 ACC/AHA
Normal
Elevated
Stage 1
Stage 2
Normal
Elevated
Stage 1
Stage 2

11. Prevalence of Hypertension
2017 ACC/AHA
Guidelines
JNC 7
Overall, crude 46% 32%
Men
(n=4717)
Women
(n=4906)
Men
(n=4717)
Women
(n=4906)
Overall, age-sex
adjusted
48% 43% 31% 32%
Age group (years)
20-44 30% 19% 11% 10%
45-54 50% 44% 33% 27%
55-64 70% 63% 53% 52%
65-74 77% 75% 64% 63%
75+ 79% 85% 71% 78%

12. MEASUREMENT OF BP

13. The misleading of BP
measurement
• Measurement of BP in office settings is
relatively easy, but errors are common
and can result in misleading estimation
of individual’s true level of BP

14. Common Errors
• Failure to allow for a rest period and/or
talking with the patient during or
immediately before the recording
• Improper patient positioning (e.g.,
sitting or lying on an examination table)
• Rapid cuff deflation
• Reliance on BPs measured at a single
occasion

15. Accurate Measurement of BP
• Have the patient relax, sitting in a chair (feet on floor,
back supported) for >5 min
• The patient should avoid caffeine, exercise, and
smoking for at least 30 min before measurement
• Ensure patient has emptied his/her bladder
• Neither the patient nor the observer should talk
during the rest period or during the measurement
• Remove all clothing covering the location of cuff
placement
• Measurements made while the patient is sitting or
lying on an examining table do not fulfill these
criteria
1. Properly prepare the patient

16. • Use a BP measurement device that has been validated, and
ensure that the device is calibrated periodically
• Support the patient’s arm (e.g., resting on a desk)
• Position the middle of the cuff on the patient’s upper arm at
the llevel of the right atrium (the midpoint of the sternum)
• Use the correct cuff size, such that the bladder encircles 80%
of the arm
• Either the stethoscope diaphragm or bell may be used for
auscultatory readings
2. Use proper technique for BP measurements

17. • At the first visit, record BP in both arms. Use the arm
that gives the higher reading for subsequent readings
• Separate repeated measurements by 1-2 min
• For auscultatory determinations, use a palpated
estimate of radial pulse obliteration pressure to
estimate SBP. Inflate the cuff 20-30 mmHg above this
level for an auscultatory determination of the BP level
• For auscultatory readings, deflate the cuff pressure 2
mmHg per second, and listen for Korotkoff sounds
3. Take the proper measurements
needed for diagnosis and treatment of
elevated BP/hypertension

18. • Record SBP and DBP. If using the auscultatory
technique, record SBP and DBP as onset of the first
Korotkoff sound and disappearance of all Korotkoff
sounds, respectively using the nearest even number
• Note the time of most recent BP medication taken
before measurements
4. Properly document accurate BP readings
• Use an average of ≥ 2 readings obtained on ≥ 2
occasions to estimate the individual’s level of BP
5. Average the readings

19. Class of Recommendation Level of Evidence
I ASR
Out-of-office BP measurements are recommended to
confirm the diagnosis of hypertension and for titration of
BP-lowering medication, in conjunction with telehealth
counseling or clinical interventions

20. SECONDARY HYPERTENSION

21. Secondary Hypertension
• A specific, remediable cause of
hypertension can be identified in
approximately 10% of adult patients
with hypertension

22. • Secondary hypertension can underlie:
– Severe elevation of BP
– Pharmacologically resistant hypertension
– Sudden onset of hypertension
– Increased BP in patients with hypertension
previously controlled on drug therapy
– Onset of diastolic hypertension in older
adults
– Target organ damage disproportionate to
the duration or severity of the hypertension

24. MASKED AND WHITE COAT
HYPERTENSION

28. NON PHARMACOLOGICAL
INTERVENTION

29. Approximate Impact on SBP
Dose Hypertension Normotension
Weight loss Best goal is ideal body
weight, but aim for at least a
1-kg reduction in body
weight for most adults who
are overweight. Expect about
1 mmHg for every 1 kg
reduction in body weight
- 5 mmHg - 2/3 mmHg

30. Approximate Impact on SBP
Dose Hypertension Normotension
Healthy diet Consume a diet rich in
fruits, vegetables, whole
grains, and low-fat dairy
products, with reduced
content of saturated and
total fat
- 11 mmHg - 3 mmHg

31. Approximate Impact on SBP
Dose Hypertension Normotension
Reduced
intake of
dietary
sodium
Optimal goal is < 1500 mg/d,
but aim for at least a 1000
mg/day reduction in most
adults
- 5/6 mmHg - 2/3 mmHg
Approximate Impact on SBP
Dose Hypertension Normotension
Enhanced
intake of
dietary
potassium
Aim for 3500-5000 mg/d,
preferably by consumption of
a diet rich in potassium
- 4/5 mmHg - 2 mmHg

32. Approximate Impact on SBP
Dose Hypertension Normotension
Physical
activity
(aerobic)
90-150 min/week
65-75% heart rate reserve
- 5/8 mmHg - 2/4 mmHg
Physical
activity
(dynamic
resistance)
90-150 min/week
50-80% 1 rep maximum
6 exercises, 3 sets/exercises,
10 repetitions/set
- 4 mmHg - 2 mmHg
Physical
activity
(isometric
resistance)
4x2 min (hand grip), 1 min
rest between exercises, 30-
40% maximum voluntary
contraction, 3 sessions/week,
8-10 week
- 5 mmHg - 4 mmHg

33. Approximate Impact on SBP
Dose Hypertension Normotension
Moderation
in alcohol
intake
In individuals who drink
alcohol, reduce alcohol to:
• Men: ≤ 2 drinks daily
• Women: ≤ 1 drink daily
- 4 mmHg - 3 mmHg

34. BP TARGET

35. Clinical Condition(s) BP treshold (mmHg) BP Goal (mmHg)
General
Clinical CVD or 10 year ASCVD risk ≥
10%
≥ 130/80 < 130/80
No clinical CVD and 10 year ASCVD
risk < 10%
≥ 140/90 < 130/80
Older persons (≥ 65 years of age;
noninstitutionalized, ambulatory,
community-living adults)
≥ 130 (SBP) < 130 (SBP)
Specific comorbidities
Diabetes mellitus ≥ 130/80 < 130/80
Chronic kidney disease ≥ 130/80 < 130/80
Chronic kidney disease after renal
trasnplantation
≥ 130/80 < 130/80
Heart failure ≥ 130/80 < 130/80
Stable ischemic heart disease ≥ 130/80 < 130/80
Secondary stroke prevention ≥ 140/90 < 130/80
Secondary stroke prevention (lacunar) ≥ 130/80 < 130/80
Peripheral arterial disease ≥ 130/80 < 130/80

36. HYPERTENSION AND STROKE

37. Intracranial Hemorrhage

38. Acute Ischemic Stroke

39. Secondary Stroke Prevention