2017 ACC/AHA Blood Pressure Guidelines: Key Recommendations
According to the 2017 ACC/AHA guidelines, hypertension is now defined as blood pressure ≥130/80 mmHg, with a recommended target of <130/80 mmHg for most adults with hypertension. 1
Blood Pressure Classification
The 2017 ACC/AHA guidelines revised the classification of blood pressure as follows:
- Normal: <120/80 mmHg
- Elevated: 120-129/<80 mmHg
- Stage 1 Hypertension: 130-139/80-89 mmHg
- Stage 2 Hypertension: ≥140/90 mmHg 1
This represents a significant change from previous guidelines, as the threshold for hypertension diagnosis was lowered from 140/90 mmHg to 130/80 mmHg.
Treatment Targets
The guidelines recommend specific BP targets based on cardiovascular risk:
- For adults with confirmed hypertension and known cardiovascular disease (CVD) or 10-year ASCVD risk ≥10%: Target BP <130/80 mmHg (Class I recommendation) 1
- For adults with confirmed hypertension without additional markers of increased CVD risk: Target BP <130/80 mmHg may be reasonable (Class IIb recommendation) 1
Treatment Approach
Non-pharmacological Interventions
For all patients with elevated BP or hypertension, lifestyle modifications are recommended:
- Low-sodium diet
- Regular physical activity
- Weight loss if overweight/obese
- Limited alcohol consumption
- Adequate potassium intake 1
Pharmacological Treatment
When to Start Medication:
Stage 1 Hypertension (130-139/80-89 mmHg):
- With clinical CVD or 10-year ASCVD risk ≥10%: Start drug therapy plus lifestyle changes
- Without clinical CVD and 10-year ASCVD risk <10%: Start with lifestyle changes only 1
Stage 2 Hypertension (≥140/90 mmHg):
- Start drug therapy plus lifestyle changes for all patients 1
Initial Drug Therapy:
- For Stage 1 Hypertension requiring medication: Start with a single antihypertensive drug (Class IIa recommendation) 1
- For Stage 2 Hypertension or BP >20/10 mmHg above target: Start with two first-line agents of different classes, either as separate agents or in a fixed-dose combination (Class I recommendation) 1
First-line Medication Options:
- Thiazide diuretics
- ACE inhibitors
- ARBs
- Calcium channel blockers 1
Follow-up and Monitoring
- After initiating therapy: Follow-up evaluation of adherence and response to treatment at monthly intervals until control is achieved (Class I recommendation) 1
- For long-term management: Systematic strategies including home BP monitoring, team-based care, and telehealth approaches are recommended 1
Special Considerations
White Coat and Masked Hypertension
- Out-of-office BP measurements (home or ambulatory monitoring) are recommended to confirm diagnosis and guide treatment 1
Older Adults
- The same BP targets apply to all age groups, unlike previous guidelines or European guidelines that recommend less stringent targets for older adults 2, 3
Comparison with European Guidelines
The 2018 ESC/ESH guidelines differ from the ACC/AHA guidelines in several key aspects:
- They maintain the definition of hypertension as BP ≥140/90 mmHg
- They recommend a target of <140/90 mmHg for most patients, with consideration of <130/80 mmHg only for high-risk patients if tolerated 1, 2
Potential Pitfalls
Overtreatment risk: Aggressive BP lowering below 120/70 mmHg may increase adverse events in some patients 3
Diastolic concerns: Excessive lowering of diastolic BP can compromise coronary perfusion, especially in patients with coronary artery disease 2
White coat effect: Failure to confirm elevated office readings with out-of-office measurements may lead to unnecessary treatment 1
Medication burden: The lower threshold for hypertension diagnosis may increase medication use and potential side effects 4
Always ensure proper BP measurement technique with validated devices, patient seated comfortably for 5 minutes, proper cuff size, and averaging multiple readings for accurate diagnosis and treatment decisions 1.