Latest ACC/AHA Hypertension Guidelines
According to the 2017 ACC/AHA Hypertension Guidelines, hypertension is now defined as blood pressure ≥130/80 mm Hg, with treatment recommendations based on both BP levels and cardiovascular risk assessment. 1
Blood Pressure Classification
The 2017 ACC/AHA guidelines introduced significant changes to BP classification:
| BP Category | Systolic BP | Diastolic BP |
|---|---|---|
| Normal | <120 mm Hg | and <80 mm Hg |
| Elevated | 120-129 mm Hg | and <80 mm Hg |
| Stage 1 Hypertension | 130-139 mm Hg | or 80-89 mm Hg |
| Stage 2 Hypertension | ≥140 mm Hg | or ≥90 mm Hg |
This represents a major departure from previous guidelines, as the threshold for hypertension diagnosis was lowered from 140/90 mm Hg to 130/80 mm Hg 1.
BP Measurement Recommendations
The guidelines emphasize proper BP measurement technique:
- Use validated devices with appropriate cuff size
- Patient should be seated comfortably with back supported
- Feet flat on floor, legs uncrossed
- Arm supported at heart level
- No talking during measurement
- Average ≥2 readings on ≥2 occasions
Out-of-office BP measurements (home BP monitoring or ambulatory BP monitoring) are strongly recommended to confirm diagnosis and monitor treatment effectiveness 1.
Treatment Thresholds and Targets
Treatment recommendations vary based on BP level and cardiovascular risk:
- BP ≥140/90 mm Hg: Initiate pharmacologic therapy regardless of risk (Class I recommendation)
- BP 130-139/80-89 mm Hg: Initiate pharmacologic therapy if:
- Clinical atherosclerotic CVD exists
- Diabetes mellitus is present
- Chronic kidney disease is present
- 10-year ASCVD risk ≥10% (using Pooled Cohort Equations)
The BP treatment target is <130/80 mm Hg for most adults, including those with clinical CVD, diabetes, or high cardiovascular risk 1.
Nonpharmacologic Interventions
All patients with elevated BP or hypertension should implement lifestyle modifications:
- Weight loss for overweight/obese patients (Class I)
- DASH dietary pattern rich in fruits, vegetables, whole grains, and low-fat dairy (Class I)
- Sodium restriction to <1500 mg/day (Class I)
- Potassium supplementation (Class I)
- Physical activity with structured exercise program (Class I)
- Alcohol limitation (≤2 drinks/day for men, ≤1 drink/day for women) (Class I)
These interventions can reduce SBP by 4-11 mm Hg depending on the intervention and patient adherence 1.
Pharmacologic Treatment
First-line antihypertensive medications include:
- Thiazide or thiazide-like diuretics
- ACE inhibitors
- Angiotensin receptor blockers (ARBs)
- Calcium channel blockers (dihydropyridine type)
For most patients with Stage 1 hypertension, monotherapy is recommended initially. For Stage 2 hypertension (≥140/90 mm Hg), or for those with BP >20/10 mm Hg above their target, combination therapy with two first-line agents of different classes is recommended 1.
Special Populations
Older Adults
- For adults ≥65 years with hypertension and high burden of comorbidity, clinical judgment and patient preference should be considered for BP target
- For noninstitutionalized ambulatory community-dwelling adults ≥65 years, BP target is <130 mm Hg SBP 1
Diabetes
- BP target <130/80 mm Hg
- ACE inhibitors or ARBs are preferred first-line agents 1
Chronic Kidney Disease
- BP target <130/80 mm Hg
- ACE inhibitors or ARBs are preferred first-line agents 1
Resistant Hypertension
Resistant hypertension is defined as BP that remains above goal despite concurrent use of 3 antihypertensive agents of different classes (including a diuretic) at optimal doses, or requiring ≥4 medications to achieve control.
Management includes:
- Maximizing diuretic therapy (chlorthalidone or indapamide preferred over hydrochlorothiazide)
- Adding mineralocorticoid receptor antagonist (spironolactone or eplerenone)
- Using loop diuretics in patients with CKD
- Referral to a hypertension specialist if BP remains uncontrolled 1
Strategies to Improve Hypertension Control
The guidelines recommend:
- Team-based care approach
- Electronic health record and patient registry use
- Telehealth strategies as adjuncts to interventions
- Once-daily dosing and combination pills to improve adherence
- Evidence-based care plans for self-management 1
Comparison with European Guidelines
The 2017 ACC/AHA guidelines differ from European guidelines in several key aspects:
- Lower threshold for hypertension diagnosis (130/80 mm Hg vs. 140/90 mm Hg in European guidelines)
- More aggressive BP targets
- Different approach to initial combination therapy 1
The ACC/AHA guidelines represent a more aggressive approach to hypertension diagnosis and management, with the goal of earlier intervention to reduce cardiovascular morbidity and mortality.