What are the latest blood pressure (BP) guidelines?

Latest Blood Pressure Guidelines

According to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, hypertension is now defined as blood pressure ≥130/80 mmHg, with a general target BP of <130/80 mmHg for most hypertensive patients. 1

Blood Pressure Classification

The 2017 ACC/AHA guidelines redefined blood pressure categories as follows:

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

This represents a significant change from previous guidelines, which defined hypertension as BP ≥140/90 mmHg. The reclassification was based on evidence showing that adults with BP in the 130-139/80-89 mmHg range have approximately twice the cardiovascular disease risk compared to those with normal BP 1.

BP Measurement Recommendations

Proper BP measurement is crucial for accurate diagnosis:

• Average of ≥2 readings obtained on ≥2 separate occasions
• Greater use of out-of-office BP measurements (ambulatory or home monitoring) to confirm diagnosis and titrate medications
• Out-of-office monitoring helps detect white coat hypertension and masked hypertension 1

Target BP Goals for Special Populations

Elderly Patients

• For patients ≥80 years: Target BP <150/90 mmHg 1, 2
• For healthy elderly <80 years: Target BP <140/90 mmHg 1
• The definition of "elderly" varies between guidelines:
  • JNC 8 defined elderly as ≥60 years
  • European guidelines defined elderly as ≥80 years 1

Patients with Comorbidities

• Diabetes or Chronic Kidney Disease: Target BP <140/90 mmHg 1
• The European Society of Cardiology recommends a target BP of 120-129 mmHg systolic for patients with hypertension 2

Treatment Approach

Initial Treatment

1. Lifestyle modifications for all patients:

   • Weight management (BMI 18.5-24.9 kg/m²)
   • DASH diet
   • Sodium restriction (<2,300 mg/day)
   • Increased potassium intake
   • Physical activity (≥150 minutes/week)
   • Alcohol moderation 2

2. Pharmacological therapy:

   • First-line medications include:

     • ACE inhibitors
     • ARBs
     • Thiazide or thiazide-like diuretics
     • Dihydropyridine calcium channel blockers 2

   • For non-Black patients: Start with ACE inhibitor or ARB

   • For Black patients: Start with calcium channel blocker or thiazide/thiazide-like diuretic 2

Follow-up and Monitoring

• Check BP within 1-2 weeks of starting or adjusting medication
• Regular follow-up every 3 months until BP is controlled, then every 6 months
• Monitor serum creatinine, potassium, and lipid panel 4-12 weeks after initiating therapy 2

Controversies in BP Guidelines

While the ACC/AHA guidelines recommend a target BP <130/80 mmHg, other international guidelines have maintained the <140/90 mmHg target for the general population:

• The 2018 European, Canadian, Korean, Japanese, and Latin American guidelines recommend <140/90 mmHg as the primary target with reduction to <130/80 mmHg for higher-risk patients 3
• Some experts caution that targeting an intensive systolic BP goal may increase adverse effects, especially in high-risk patients 3, 4

The controversy centers on balancing cardiovascular risk reduction with potential harms from excessive BP lowering, particularly in elderly patients or those with comorbidities 5.