What are the newest guidelines for managing hypertension (high blood pressure) in adults?

2017 ACC/AHA Hypertension Guidelines: Key Updates

The most current comprehensive hypertension guidelines are the 2017 ACC/AHA guidelines, which lowered the diagnostic threshold for hypertension to ≥130/80 mm Hg and recommend a treatment target of <130/80 mm Hg for most adults with confirmed hypertension. 1

Diagnostic Criteria - Major Change from Prior Guidelines

• Hypertension is now defined as BP ≥130/80 mm Hg, representing a significant shift from the previous threshold of ≥140/90 mm Hg 1
• Out-of-office BP measurements (home or ambulatory monitoring) are emphasized to confirm the diagnosis and exclude white coat hypertension 1
• This new definition means approximately 46% of U.S. adults now meet criteria for hypertension 1

Blood Pressure Treatment Targets

For adults with confirmed hypertension AND known CVD or 10-year ASCVD risk ≥10%: Target BP <130/80 mm Hg (Class I recommendation) 1

For adults with confirmed hypertension WITHOUT additional CVD risk markers: Target BP <130/80 mm Hg may be reasonable (Class IIb recommendation) 1

Special Population - Older Adults

• For noninstitutionalized, ambulatory, community-dwelling adults ≥65 years with average SBP ≥130 mm Hg: Target SBP <130 mm Hg 1
• For older adults with high comorbidity burden and limited life expectancy: Use clinical judgment and team-based approach for intensity of BP control 1

When to Initiate Pharmacologic Therapy

Stage 1 Hypertension (BP 130-139/80-89 mm Hg):

• Start medication if 10-year ASCVD risk ≥10% OR if clinical CVD, diabetes, or chronic kidney disease is present 1
• Otherwise, begin with lifestyle modifications alone 1

Stage 2 Hypertension (BP ≥140/90 mm Hg):

• Initiate pharmacologic therapy immediately, preferably with two first-line agents from different classes if BP is >20/10 mm Hg above target 1, 2

First-Line Medication Classes

The following are recommended as first-line agents 3:

• Thiazide or thiazide-like diuretics (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1
• ACE inhibitors or ARBs 3
• Calcium channel blockers 3

Resistant Hypertension Management

Resistant hypertension is redefined as BP ≥130/80 mm Hg despite adherence to ≥3 antihypertensive agents at optimal doses (including a diuretic), or requiring ≥4 medications 1

Systematic Approach to Resistant Hypertension:

1. Confirm true resistance by verifying accurate office BP measurements and obtaining home/ambulatory readings to exclude white coat effect 1

2. Assess medication adherence - up to 25% of patients don't fill initial prescriptions 1

3. Identify and address interfering substances: NSAIDs, stimulants, oral contraceptives, decongestants 1

4. Screen for secondary causes: primary aldosteronism, renal artery stenosis, pheochromocytoma, obstructive sleep apnea 1

5. Optimize pharmacologic therapy 1:

   • Maximize diuretic therapy (switch to chlorthalidone or indapamide)
   • Add mineralocorticoid receptor antagonist (spironolactone or eplerenone)
   • Use loop diuretics in patients with CKD
   • Refer to hypertension specialist if uncontrolled after 6 months

Implementation Strategies to Improve Control

• Team-based care approach is recommended for all adults with hypertension 1
• Once-daily dosing and combination pills improve adherence 1
• Electronic health records and patient registries help identify uncontrolled hypertension 1
• Telehealth strategies are useful adjuncts 1

Critical Pitfalls to Avoid

Measurement technique matters: The SPRINT trial used automated office BP (AOSBP) after 5 minutes of rest, which reads approximately 10-15 mm Hg lower than usual office BP 4. Ensure consistent measurement technique when applying these targets.

Pregnancy contraindications: Women who become pregnant must be transitioned OFF ACE inhibitors, ARBs, and direct renin inhibitors immediately; switch to methyldopa, nifedipine, or labetalol 1

Excessive diastolic lowering: In high-risk patients (diabetes, CKD, CAD, elderly), targeting intensive systolic goals may excessively lower diastolic BP and potentially increase cardiovascular risk 5

Evidence Base

The 2017 guidelines were heavily influenced by the SPRINT trial, which demonstrated that intensive BP control (SBP <120 mm Hg) reduced cardiovascular events and all-cause mortality compared to standard control (SBP <140 mm Hg) 1. Meta-analyses support that each 10 mm Hg reduction in SBP decreases CVD events by approximately 20-30% 3.

Note: A 2025 ACC/AHA guideline update has been released that further encourages reducing SBP to <120 mm Hg in appropriate patients 6, though the 2017 guidelines remain the most recent comprehensive framework for hypertension management.