What are the current USA hypertension guidelines for blood pressure targets and treatment?

Current USA Hypertension Guidelines

The 2017 ACC/AHA guidelines define hypertension as BP ≥130/80 mmHg and recommend a treatment target of <130/80 mmHg for most adults with confirmed hypertension. 1

Blood Pressure Classification

The current U.S. classification system categorizes blood pressure as follows:

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

This represents a significant change from prior guidelines, increasing the prevalence of hypertension from 32% to 46% of U.S. adults, though most newly classified patients require only lifestyle modification rather than medication. 1

Treatment Initiation Thresholds

Medication should be initiated based on both BP level and cardiovascular risk:

• All adults with BP ≥140/90 mmHg should start antihypertensive medication regardless of cardiovascular risk 1, 2
• Adults with BP 130-139/80-89 mmHg AND either:
  • Known cardiovascular disease (CVD), OR
  • 10-year ASCVD risk ≥10% (calculated using ACC/AHA Pooled Cohort Equations) 1, 2
• Adults with BP 130-139/80-89 mmHg without elevated CVD risk should receive lifestyle modification with reassessment in 3-6 months 1

Blood Pressure Treatment Targets

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

For adults with confirmed hypertension without additional CVD risk markers, target BP <130/80 mmHg may be reasonable (Class IIb recommendation, Level B evidence). 1

The systolic target of <130 mmHg is supported by SPRINT trial data showing 25% reduction in primary CVD outcomes and 27% reduction in total mortality with intensive BP control (SBP <120 mmHg) versus standard control (SBP <140 mmHg). 1 However, the guideline recommends <130 mmHg rather than <120 mmHg for broader applicability across populations. 1

Initial Medication Strategy

For Stage 2 hypertension (BP >20/10 mmHg above target), initiate therapy with two first-line agents from different classes, either as separate agents or fixed-dose combination (Class I recommendation). 1, 2

For Stage 1 hypertension with BP goal <130/80 mmHg, initiation with a single antihypertensive drug is reasonable, with dosage titration and sequential addition of agents (Class IIa recommendation). 1

First-Line Medication Classes

First-line antihypertensive agents include:

• Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide) 1, 3
• ACE inhibitors (e.g., enalapril, lisinopril) 1, 3
• Angiotensin receptor blockers (ARBs) (e.g., candesartan, losartan) 1, 3
• Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 3

Combination therapy should include agents with complementary mechanisms of action, and simultaneous use of ACE inhibitor, ARB, and/or renin inhibitor is potentially harmful and not recommended. 1

Follow-Up and Monitoring

Adults initiating new or adjusted antihypertensive therapy should have monthly follow-up until BP control is achieved (Class I recommendation, Level B evidence). 1, 2

Once BP is controlled, reassess every 3-6 months. 1, 2

Systematic strategies including home BP monitoring (HBPM), team-based care, and telehealth should be used to improve BP control (Class I recommendation, Level A evidence). 1, 2

Special Population Considerations

Older Adults (≥65 years)

For noninstitutionalized, ambulatory, community-dwelling adults ≥65 years, target SBP <130 mmHg if tolerated, with careful monitoring for orthostatic hypotension and adverse effects. 1, 2

The SPRINT trial included adults aged 50 and older and demonstrated significant benefit with intensive BP control, supporting treatment of Stage 1 hypertension in older adults. 1

Patients with Diabetes

Adults with diabetes and hypertension should initiate treatment at BP ≥130/80 mmHg with target <130/80 mmHg, as most have ≥10% 10-year ASCVD risk. 2

Patients with Chronic Kidney Disease

Patients with CKD should initiate treatment at BP ≥130/80 mmHg with target <130/80 mmHg, as they are automatically assigned to high-risk category. 2

Important Caveats

The diastolic threshold of 80 mmHg for high-risk individuals is based primarily on expert opinion (Level C evidence), not high-quality trial data. 1 Strong evidence exists for treating confirmed DBP ≥90 mmHg, which should not be overlooked. 1

Avoid excessive diastolic BP lowering (<60 mmHg), which may increase cardiovascular risk in patients with treated SBP <130 mmHg. 1

Monitor for orthostatic hypotension, electrolyte abnormalities, and acute kidney injury, particularly in older adults and those on intensive therapy. 1

Avoid abrupt discontinuation of clonidine, which may induce hypertensive crisis; clonidine must be tapered. 1