What are the current American Heart Association (AHA) recommendations for blood pressure management in adults?

Current AHA Recommendations on Blood Pressure Management

According to the 2017 ACC/AHA guidelines, hypertension is defined as blood pressure ≥130/80 mmHg, with a recommended target of <130/80 mmHg for most adults with hypertension. 1, 2

Blood Pressure Classification

The ACC/AHA classifies 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

Blood Pressure Targets

The guidelines recommend different BP targets based on cardiovascular risk:

1. For adults with confirmed hypertension and known CVD or 10-year ASCVD risk ≥10%: Target BP <130/80 mmHg (Class I recommendation) 1
2. 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

All patients with elevated BP or hypertension should implement lifestyle modifications:

• Low-sodium diet
• Regular physical activity
• Weight loss if overweight/obese
• Limited alcohol consumption
• Adequate potassium intake 2

Pharmacological Treatment

Treatment decisions are based on BP category and cardiovascular risk:

1. Elevated BP (120-129/<80 mmHg):

   • Recommend lifestyle modifications
   • Reassess in 3-6 months

2. Stage 1 Hypertension (130-139/80-89 mmHg):

   • Without clinical CVD and 10-year ASCVD risk <10%: Start with lifestyle changes only
   • With clinical CVD or 10-year ASCVD risk ≥10%: Start drug therapy plus lifestyle changes 1

3. Stage 2 Hypertension (≥140/90 mmHg):

   • Start drug therapy plus lifestyle changes for all patients
   • Consider initiation with two first-line agents of different classes when BP is ≥20/10 mmHg above target (Class I recommendation) 1

First-Line Antihypertensive Medications

• Thiazide diuretics
• ACE inhibitors
• ARBs
• Calcium channel blockers 2

Monitoring and Follow-up

• Monthly follow-up until BP control is achieved (Class I recommendation) 1
• Use home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) to confirm diagnosis and monitor treatment response 1
• For HBPM, target BP is <135/85 mmHg (equivalent to clinic BP <140/90 mmHg) 1

Special Considerations

Secondary Hypertension

Screen for secondary causes of hypertension in patients with:

• Resistant hypertension
• Abrupt onset or worsening hypertension
• Age <30 years at onset
• Target organ damage disproportionate to BP levels
• Unprovoked hypokalemia 1

Hypertensive Crisis

For hypertensive emergencies:

• Admit to ICU for continuous monitoring
• For compelling conditions (aortic dissection, severe preeclampsia, pheochromocytoma crisis), reduce SBP to <140 mmHg in first hour
• For non-compelling conditions, reduce SBP by no more than 25% in first hour, then to 160/100 mmHg within 2-6 hours 1

Important Caveats

1. Measurement technique matters: Proper BP measurement is essential, including patient seated comfortably for 5 minutes, proper cuff size, and averaging multiple readings 2

2. White coat and masked hypertension: Consider ABPM or HBPM to detect these conditions before diagnosis or treatment intensification 1

3. International guideline differences: While ACC/AHA defines hypertension as ≥130/80 mmHg, other international guidelines (European, Canadian, Japanese) maintain the traditional definition of ≥140/90 mmHg 3, 4

4. Lifestyle modification effectiveness: The PREMIER trial demonstrated that comprehensive lifestyle modifications can reduce systolic BP by 3.7-4.3 mmHg and significantly reduce hypertension prevalence 5

5. Elderly considerations: For adults aged 60-79 years, target BP <140/90 mmHg; for those ≥80 years, target systolic BP 140-145 mmHg if tolerated 6

The 2017 ACC/AHA guidelines represent a significant shift in hypertension management, with lower thresholds for diagnosis and treatment compared to previous guidelines, emphasizing early intervention to reduce cardiovascular risk.