What are the new American Heart Association (AHA) guidelines for managing hypertension?

New AHA Guidelines for Hypertension

Blood Pressure Definition and Classification

The 2017 ACC/AHA guidelines redefined hypertension as blood pressure ≥130/80 mmHg, a significant departure from the previous threshold of ≥140/90 mmHg. 1 This lower threshold means approximately 46% of U.S. adults now meet criteria for hypertension, emphasizing earlier identification and intervention to prevent cardiovascular morbidity and mortality. 1

The classification system includes:

• 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

When to Initiate Pharmacological Treatment

Initiate antihypertensive medications for all patients with BP ≥140/90 mmHg regardless of cardiovascular risk. 1, 2 This represents a Class I, Level A recommendation. 1

For patients with BP 130-139/80-89 mmHg, initiate pharmacological therapy if any of the following are present: 1, 2

• Clinical atherosclerotic CVD (coronary disease, stroke, peripheral artery disease) 1
• Heart failure 1
• Chronic kidney disease 1
• Diabetes mellitus 1
• 10-year ASCVD risk ≥10% using the Pooled Cohort Equation 1, 2

This approach differs substantially from European guidelines, which recommend drug therapy only at BP ≥140/90 mmHg for most patients. 1

Blood Pressure Treatment Targets

Target BP <130/80 mmHg for most adults with hypertension, regardless of age. 1, 2 This is a Class I, Level B recommendation for systolic targets. 1 The evidence supporting this lower target comes primarily from the SPRINT trial, which demonstrated significant reductions in cardiovascular events and mortality with intensive BP lowering. 1

Specific population targets include: 2

• Diabetes or CKD: <130/80 mmHg (ACE inhibitors or ARBs preferred) 2, 3
• Older adults (<65 years): <130/80 mmHg if well tolerated 2, 3
• Adults ≥65 years: SBP <130 mmHg 3
• Very elderly (≥85 years): Consider more lenient target of <140/90 mmHg 2

This represents a more aggressive approach than European guidelines, which recommend initial targets of <140/90 mmHg with subsequent lowering to 130/80 mmHg if tolerated. 1

First-Line Pharmacological Therapy

Recommended first-line antihypertensive agents include: 1, 2, 3

• Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide) 1, 3
• ACE inhibitors 1, 2, 3
• Angiotensin receptor blockers (ARBs) 1, 2, 3
• Dihydropyridine calcium channel blockers 1, 2, 3

Beta-blockers are NOT recommended as first-line therapy unless compelling indications exist (heart failure with reduced ejection fraction, coronary artery disease, post-myocardial infarction, or atrial fibrillation requiring rate control). 2 This differs from some European guidelines that still include beta-blockers as first-line options. 1

Initial Combination Therapy Strategy

For patients with BP ≥20/10 mmHg above target (typically Stage 2 hypertension with BP ≥150/90 mmHg), initiate treatment with two first-line agents from different classes. 2, 3 This approach achieves faster BP control and improves adherence compared to sequential monotherapy. 1

Preferred two-drug combinations include: 1, 3

• ACE inhibitor or ARB + thiazide diuretic 1
• ACE inhibitor or ARB + calcium channel blocker 1
• Calcium channel blocker + thiazide diuretic 1

Single-pill combination products are strongly preferred to enhance adherence and simplify regimens. 1

Lifestyle Modifications

All patients with elevated BP or hypertension should receive intensive lifestyle counseling as first-line therapy. 1, 4 For patients with BP 130-139/80-89 mmHg without high cardiovascular risk, attempt lifestyle modifications alone for 3-6 months before initiating medications. 4

Evidence-based lifestyle interventions include: 1, 4, 3

• Weight loss: Achieve and maintain healthy BMI (18.5-24.9 kg/m²); each 1 kg weight loss reduces BP by approximately 1 mmHg 1, 4
• DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy, lean protein; reduces BP by 8-14 mmHg 4, 3
• Sodium restriction: Limit to <1,500 mg/day (ideal) or at least <2,300 mg/day; reduces BP by 5-6 mmHg 1, 4, 3
• Potassium supplementation: Increase dietary potassium to 3,500-5,000 mg/day unless contraindicated by CKD 1, 4, 3
• Physical activity: 90-150 minutes/week of aerobic exercise plus resistance training 2-3 times weekly 1, 4, 5
• Alcohol limitation: ≤2 standard drinks/day for men, ≤1 drink/day for women 1, 4, 3

Among these interventions, the DASH diet combined with sodium restriction produces the most substantial BP reductions (up to 14 mmHg systolic). 4

Accurate Blood Pressure Measurement

Proper BP measurement technique is critical to avoid misdiagnosis and inappropriate treatment. 1 The guidelines emphasize:

• Use validated automated oscillometric devices 1
• Patient should be seated quietly for 5 minutes with back supported, feet flat on floor, arm at heart level 1
• Use appropriate cuff size (bladder encircling ≥80% of arm) 1
• Take average of 2-3 readings separated by 1-2 minutes 1

Out-of-office BP monitoring is strongly recommended to confirm the diagnosis and exclude white coat hypertension. 1 Home BP monitoring or 24-hour ambulatory BP monitoring should be used before initiating treatment in most patients with elevated office readings. 1

Follow-Up and Monitoring

After initiating antihypertensive therapy, reassess BP within 1 month. 1 Once BP goal is achieved, follow-up every 3-6 months. 1 For patients managed with lifestyle modifications alone, reassess every 3-6 months. 1

Home BP monitoring should be encouraged for all patients on treatment to assess response and improve adherence. 1 Target home BP is typically 5-10 mmHg lower than office targets. 1

Implementation and Team-Based Care

The guidelines emphasize multidisciplinary team-based approaches including physicians, nurses, pharmacists, and community health workers to improve BP control rates. 2 Use of electronic health records with clinical decision support systems and patient registries can facilitate systematic hypertension management. 2

Common pitfalls to avoid: 1, 3

• Inadequate BP measurement technique leading to misclassification
• Failure to use out-of-office BP monitoring to confirm diagnosis
• Therapeutic inertia (not intensifying therapy when BP remains above goal)
• Poor medication adherence (address with single-pill combinations and patient education)
• Ignoring lifestyle modifications in patients on medications