What are the American Heart Association (AHA) guidelines for initiating antihypertensive medication and managing hypertension?

AHA Guidelines for Hypertension Management

According to the 2017 ACC/AHA guidelines, hypertension is defined as blood pressure ≥130/80 mmHg, and antihypertensive medication should be initiated when BP is ≥130/80 mmHg in patients with cardiovascular disease or 10-year ASCVD risk ≥10%, or when BP is ≥140/90 mmHg in all other adults. 1

Blood Pressure Classification

Category	Systolic BP	Diastolic BP
Normal BP	<120 mmHg	<80 mmHg
Elevated BP	120-129 mmHg	<80 mmHg
Stage 1 Hypertension	130-139 mmHg	80-89 mmHg
Stage 2 Hypertension	≥140 mmHg	≥90 mmHg

Treatment Thresholds and BP Targets

When to Initiate Medication:

1. BP ≥130/80 mmHg:

   • Patients with known cardiovascular disease (CVD)
   • Patients with 10-year ASCVD risk ≥10%
   • Patients with diabetes mellitus
   • Patients with chronic kidney disease

2. BP ≥140/90 mmHg:

   • All other adults without the above conditions

BP Targets:

• <130/80 mmHg for most adults with hypertension, including:

  • Those with known CVD or 10-year ASCVD risk ≥10% (Strong recommendation, Level B-R) 1
  • Patients with diabetes mellitus
  • Patients with chronic kidney disease
  • Older adults (≥65 years) who are ambulatory and community-dwelling 1

• For older adults (≥65 years) with high comorbidity burden and limited life expectancy, a less stringent BP target may be reasonable based on clinical judgment and patient preference 1

Initial Treatment Approach

Lifestyle Modifications:

All patients should receive counseling on:

• Sodium restriction
• DASH diet
• Physical activity
• Weight management
• Limited alcohol consumption
• Smoking cessation

Pharmacological Therapy:

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

   • Start with a single antihypertensive drug if BP goal is <130/80 mmHg
   • Titrate dosage and add sequential agents to achieve target 1

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

   • Initiate with 2 first-line agents of different classes when BP is >20/10 mmHg above target
   • Can use separate agents or fixed-dose combinations 1

First-Line Medication Options

The guidelines recommend four primary classes of antihypertensive medications:

1. Thiazide diuretics (chlorthalidone preferred over hydrochlorothiazide)
2. ACE inhibitors (e.g., lisinopril)
3. Angiotensin II receptor blockers (ARBs)
4. Calcium channel blockers (CCBs) (dihydropyridines like amlodipine)

Special Population Considerations:

• Black adults: Initial therapy should include a thiazide-type diuretic or CCB 1
• Diabetes: All first-line classes are effective; ACE inhibitors or ARBs may be considered with albuminuria 1
• Chronic kidney disease: ACE inhibitors or ARBs are recommended 1
• Stable ischemic heart disease: Beta-blockers, ACE inhibitors, or ARBs as first-line 1

Follow-Up and Monitoring

• Patients initiating or adjusting antihypertensive medications should have follow-up evaluation at monthly intervals until BP control is achieved 1
• Systematic strategies to improve BP control should include:
  • Home BP monitoring
  • Team-based care
  • Telehealth strategies 1

Resistant Hypertension Management

For patients with resistant hypertension (BP ≥140/90 mmHg despite 3 antihypertensive agents including a diuretic):

• Add a mineralocorticoid receptor antagonist (spironolactone) 2
• Evaluate for secondary causes of hypertension
• Ensure medication adherence
• Optimize dosing of existing medications

Common Pitfalls to Avoid

1. Inadequate initial assessment: Failure to accurately measure BP using proper technique and multiple readings
2. Therapeutic inertia: Not intensifying treatment when BP remains above target
3. Ignoring white coat or masked hypertension: Not using out-of-office BP measurements to confirm diagnosis
4. Overlooking medication adherence: Not addressing barriers to medication compliance
5. Suboptimal drug combinations: Using inappropriate combinations or inadequate dosing
6. Neglecting lifestyle modifications: Focusing solely on medications without emphasizing non-pharmacological approaches

The 2017 ACC/AHA guidelines represent a significant shift from previous recommendations, with lower BP thresholds for diagnosis and treatment targets. This approach aims to reduce cardiovascular morbidity and mortality by earlier intervention and more intensive BP control based on evidence from clinical trials showing benefits of lower BP targets.