ACC/AHA Hypertension Guidelines
Blood Pressure Classification and Diagnosis
The ACC/AHA defines hypertension as blood pressure ≥130/80 mmHg, which is lower than the traditional threshold of 140/90 mmHg. 1 This represents a significant departure from prior definitions and increases the number of adults classified as hypertensive. The guideline emphasizes accurate BP measurement using standardized techniques and encourages out-of-office BP monitoring (home or ambulatory) to confirm the diagnosis and avoid white coat hypertension. 2
Risk Stratification
The ACC/AHA guidelines mandate cardiovascular disease risk assessment using the 10-year ASCVD (atherosclerotic cardiovascular disease) risk calculator for all patients with elevated BP. 1, 2 This risk stratification directly determines treatment intensity, particularly for patients in the 130-139/80-89 mmHg range. 2
Treatment Thresholds
Pharmacological therapy is recommended immediately for all patients with BP ≥140/90 mmHg regardless of cardiovascular risk. 2, 1 For patients with BP 130-139/80-89 mmHg (Stage 1 hypertension), drug therapy is indicated if they have:
Patients with Stage 1 hypertension who do not meet these criteria should receive intensive lifestyle modification and be reassessed in 3-6 months. 3, 2
Blood Pressure Targets
The ACC/AHA recommends a BP target of <130/80 mmHg for most adults, including those with diabetes and chronic kidney disease. 1, 2 This is more aggressive than European guidelines. The target applies broadly across age groups, though patients ≥85 years may have a more lenient target of <140/90 mmHg if frailty or tolerability issues exist. 1
For older adults ≥65 years, the systolic target remains <130 mmHg if well tolerated, with careful monitoring for orthostatic hypotension. 1, 4
Lifestyle Modifications
Lifestyle interventions are the cornerstone of prevention and initial management for all patients with elevated BP. 2 The ACC/AHA specifically recommends:
- DASH diet (Dietary Approaches to Stop Hypertension) emphasizing fruits, vegetables, whole grains, and low-fat dairy 2, 5
- Sodium restriction to <2,300 mg/day, ideally <1,500 mg/day 2
- Potassium supplementation through dietary sources 2, 4
- Weight loss for overweight/obese patients (target BMI <25 kg/m²) 2, 4
- Physical activity: at least 150 minutes/week of moderate-intensity aerobic exercise 2
- Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2
- Smoking cessation for CVD risk reduction 2
These interventions have additive effects and can lower BP by 5-20 mmHg when combined. 4, 5
Pharmacological Treatment
First-Line Agents
The ACC/AHA identifies four classes as first-line therapy: 2, 1
- Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide based on trial data) 4, 2
- ACE inhibitors (e.g., enalapril, lisinopril) 4, 6
- Angiotensin receptor blockers (ARBs) (e.g., candesartan, losartan) 4, 6
- Dihydropyridine calcium channel blockers (e.g., amlodipine) 4, 6
Beta-blockers are NOT recommended as first-line therapy unless there are compelling indications such as heart failure with reduced ejection fraction, coronary artery disease, post-myocardial infarction, or atrial fibrillation requiring rate control. 1, 2
Combination Therapy
Initial combination therapy with two agents is recommended for patients with BP ≥20/10 mmHg above their target (i.e., ≥150/90 mmHg for most patients). 1, 2 Single-pill combinations are preferred to improve adherence. 2
The typical combination sequence is: 2
- Two-drug combination: ACE inhibitor or ARB + thiazide diuretic OR calcium channel blocker
- Three-drug combination: ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic
- Four-drug regimen: Add spironolactone (mineralocorticoid receptor antagonist) for resistant hypertension 7
A common pitfall is using hydrochlorothiazide at suboptimal doses (12.5-25 mg); chlorthalidone 12.5-25 mg is preferred based on outcomes data. 2
Special Populations
Diabetes and Chronic Kidney Disease
Target BP is <130/80 mmHg with ACE inhibitors or ARBs as preferred first-line agents due to renoprotective effects. 1, 2
Older Adults
Target remains <130/80 mmHg if tolerated, but requires gradual BP lowering and monitoring for orthostatic hypotension, falls, and cognitive effects. 1, 4 Measure standing BP to detect orthostatic changes.
Black Patients
Initial therapy should include a calcium channel blocker or thiazide diuretic, as ACE inhibitors/ARBs are less effective as monotherapy in this population. 3, 2
Follow-Up and Monitoring
The ACC/AHA specifies precise follow-up intervals: 2
- Normal BP (<120/80 mmHg): Reassess annually
- Elevated BP or Stage 1 hypertension on lifestyle therapy: Reassess in 3-6 months 3
- After initiating drug therapy: Follow-up in 1 month, then every 3-6 months once BP goal achieved 2
BP control should be achieved within 3 months of initiating pharmacological therapy. 2
Resistant Hypertension
Defined as BP remaining ≥130/80 mmHg despite adherence to three antihypertensive agents at optimal doses, including a diuretic. 7, 2 Management includes:
- Confirming true resistance (exclude white coat effect, medication non-adherence, interfering substances) 7
- Screening for secondary causes (renal artery stenosis, primary aldosteronism, obstructive sleep apnea, pheochromocytoma) 7, 2
- Adding spironolactone 25-50 mg daily as fourth agent 7
- Optimizing diuretic therapy (switch to chlorthalidone or add loop diuretic if eGFR <30 mL/min/1.73m²) 7
Implementation Strategies
The ACC/AHA emphasizes team-based care models involving physicians, nurses, pharmacists, and community health workers. 1 Electronic health records with clinical decision support systems and BP registries improve control rates. 1 Self-measured BP monitoring with clinical support improves outcomes compared to usual care. 2
A critical pitfall is therapeutic inertia—failure to intensify therapy when BP remains above goal. Address this by setting clear BP targets, using combination therapy early, and scheduling timely follow-up. 4