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2017 ACC Hypertension Guidelines
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- 3. Scope of theGuideline • 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 CVDRISK
- 5. • Associations betweenhigher 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 SBPand 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 Factorsin 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
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- 9. BP Category SBPDBP 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 2017ACC/AHA Normal Elevated Stage 1 Stage 2 Normal Elevated Stage 1 Stage 2
- 11. Prevalence of Hypertension 2017ACC/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%
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- 13. The misleading ofBP 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 • Failureto 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 ofBP • 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 aBP 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 thefirst 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 SBPand 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 RecommendationLevel 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
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- 21. Secondary Hypertension • Aspecific, remediable cause of hypertension can be identified in approximately 10% of adult patients with hypertension
- 22. • Secondary hypertensioncan 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 WHITECOAT HYPERTENSION
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- 29. Approximate Impact onSBP 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 onSBP 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 onSBP 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 onSBP 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 onSBP 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
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- 35. Clinical Condition(s) BPtreshold (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
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