What are the latest American Heart Association (AHA) guidelines for antihypertensive treatment?

Latest AHA Guidelines for Antihypertensive Treatment

The 2022 American Heart Association (AHA) guidelines recommend antihypertensive drug therapy for all adults with SBP ≥140 mm Hg or DBP ≥90 mm Hg, as well as for adults with SBP 130-139 mm Hg or DBP 80-89 mm Hg who have cardiovascular disease or a 10-year atherosclerotic cardiovascular disease risk ≥10%. 1

Blood Pressure Classification

• Normal BP: <120/80 mm Hg
• Elevated BP: 120-129/<80 mm Hg
• Stage 1 Hypertension: 130-139/80-89 mm Hg
• Stage 2 Hypertension: ≥140/90 mm Hg

Treatment Approach

Lifestyle Modifications

Lifestyle modifications are the cornerstone for prevention and treatment of hypertension 1:

• DASH diet (Dietary Approaches to Stop Hypertension) - reduces SBP by 3-11 mmHg 2
• Weight loss in overweight/obese individuals - approximately 1 mmHg reduction per kg lost 2
• Sodium reduction - reduces SBP by 3-6 mmHg 2
• Enhanced potassium intake - reduces SBP by 3-5 mmHg 2
• Physical activity - reduces SBP by 3-8 mmHg 2, 3
• Alcohol moderation or abstinence - reduces SBP by 3-4 mmHg 2

Pharmacologic Treatment Thresholds

1. All adults with SBP ≥140 mm Hg or DBP ≥90 mm Hg should receive antihypertensive medication along with lifestyle modifications 1

2. Adults with SBP 130-139 mm Hg or DBP 80-89 mm Hg should receive antihypertensive medication if they have:

   • Established cardiovascular disease, OR
   • 10-year ASCVD risk ≥10% (calculated using ACC/AHA Pooled Cohort Equations) 1

3. Adults with SBP 130-139 mm Hg or DBP 80-89 mm Hg without the above conditions should receive lifestyle modifications only 1

Blood Pressure Targets

• General target for all adults: <130/80 mm Hg 1
• Adults ≥65 years: SBP <130 mm Hg (if ambulatory, community-living) 1
• For older adults with high comorbidity burden/limited life expectancy: Treatment intensity and drug choice should be based on clinical judgment, patient preference, and risk/benefit assessment 1

Pharmacologic Treatment Strategy

First-Line Medications

Four primary drug classes are recommended for initial treatment 1, 2, 4:

• Thiazide or thiazide-like diuretics (preferably chlorthalidone)
• ACE inhibitors
• Angiotensin receptor blockers (ARBs)
• Calcium channel blockers (CCBs)

Treatment Algorithm

1. Initial Approach:

   • For most patients with uncomplicated hypertension, start with a combination of two drugs:
     • ACE inhibitor or ARB + CCB or diuretic 1
   • Single-pill combinations are preferred to improve adherence 1

2. For Black patients:

   • Initial therapy should include a thiazide-type diuretic or CCB 1
   • Consider starting with a 2-drug combination (diuretic + CCB) 1

3. For patients with more severe hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg and >20/10 mm Hg above target):

   • Start with 2-drug combination therapy 1

4. If BP remains above target:

   • Advance to triple therapy: ACE inhibitor or ARB + CCB + diuretic 1

5. For resistant hypertension (BP remains uncontrolled on optimal doses of 3 drugs including a diuretic):

   • Add spironolactone or other diuretic, alpha-blocker, or beta-blocker 1, 2
   • Consider referral to a hypertension specialist 1, 2

Special Populations

• Chronic Kidney Disease: ACE inhibitor or ARB preferred as part of the regimen 2
• Diabetes with albuminuria: ACE inhibitor or ARB preferred 2
• Coronary Artery Disease: ACE inhibitor or ARB preferred 2
• Pregnancy: Avoid ACE inhibitors and ARBs due to teratogenicity 2

Monitoring and Follow-up

• After initiating therapy, evaluate monthly until BP control is achieved 2
• Check serum creatinine and potassium 7-14 days after initiating ACE inhibitors, ARBs, or diuretics 2
• Consider home BP monitoring to assess control between office visits 2
• Once BP is controlled, follow up at least yearly 2

Common Pitfalls to Avoid

• Therapeutic inertia: Failing to intensify treatment when BP remains uncontrolled 2
• Neglecting lifestyle modifications: Continue to emphasize these even after starting medications 2
• Inappropriate drug combinations: Avoid combining two renin-angiotensin system blockers 1
• Inadequate dosing: Ensure medications are titrated to effective doses before adding new agents 4

The 2022 AHA guidelines emphasize early intervention with combination therapy for most patients with hypertension, with the goal of achieving rapid BP control to reduce cardiovascular morbidity and mortality.