sign in sign up
<<
Home , Hypertension, Hypertensive crisis, Moon face, Nicardipine, Phentolamine, Secondary hypertension

2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Pressure in Adults

GUIDELINES MADE SIMPLE A Selection of Tables and Figure

ACC.org/GMSHBP ©2018, American College of B18060 ©2018, American College of Cardiology CITATION: J Am CollCardiol. Sep2017, 23976; DOI:10.1016/j.jacc.2017.07.745 context. important Guideline andthefullpublication shouldbereviewed formorefigures andtablesas well as fromthe Management ofHighBlood PressureinAdults.Theresourceisonlyan excerpt AGS/APhA/ASH/ASPC/NMA/PCNA GuidelineforthePrevention, Detection, Evaluation, and andTablesThe followingresourcecontainsFigures fromthe2017ACC/AHA/AAPA/ABC/ACPM/ control ofhighBP. Thepresent guidelineupdatespriorJNCreports. published toassistthepracticecommunityand improve prevention, awareness, treatment, and NHLBI. Insubsequentyears, aseriesofJointNationalCommittee(JNC)BPguidelineswere evaluation, andmanagementofhigh BPwas publishedin1977, ofthe under the sponsorship comprehensive guideline fordetection, and managementofhighbloodpressureinadults. Thefirst The ACC andAHAconvened thiswritingcommittee toaddresstheprevention, detection, evaluation, Jackson T. Wright, Jr, MD, PhD, FAHA Jeff D. Williamson, MD, MHS Kim A.Williams, Sr, MD, MACC, FAHA Randal J.Thomas, MD, MS, FACC, FAHA Sandra J.Taler, MD, FAHA Randall S.Stafford, MD, PhD C.Spencer,Crystal JD Sidney C.Smith, Jr, MD, MACC, FAHA Ovbiagele,Bruce MD, MSc, MAS, MBAFAHA Paul Muntner, PhD, FAHA Eric J.MacLaughlin, PharmD Daniel W. Jones, MD, FAHA Kenneth A.Jamerson, MD Samuel Gidding, MD, FAHA Sondra M.DePalma, MHS, PA-C, CLS, AACC DennisonHimmelfarb, RN,Cheryl ANP, PhD, FAHA Karen J.Collins, MBA Donald E.Casey, Jr, MD, MPH, MBA, FAHA S.Aronow,Wilbert MD, FACC, FAHA M.Carey,Robert MD, FAHA, Chair Vice Paul K.Whelton, MB, MD, MSc, FAHA, Chair Writing Committee: Clinical PracticeGuidelines AssociationTask oftheAmericanCollegeCardiology/American ForceA report on and ManagementofHighBloodPressurein Adults 2017 GuidelineforthePrevention, Detection, Evaluation,

©2018, American College of Cardiology B18060 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High in Adults

GUIDELINES MADE SIMPLE

Selected Tables or Figure Page Categories of BP in Adults………………………………………………………………………………………… 4 Corresponding Values of Systolic BP/Diastolic BP for Clinic, Home (HBPM), Daytime, Nighttime, and 24-Hour Ambulatory (ABPM) Measurement……………………………………………………………………… 4 Detection of White Coat or Masked Hypertension in Patients Not on Drug Therapy………… 5 Detection of or Masked Hypertension in Patients on Drug Therapy……………… 6 for …………………………………………………………………………… 7 Causes of Secondary Hypertension with Clinical Indications and Diagnostic Screening Tests (1 of 3)……… 8 Causes of Secondary Hypertension with Clinical Indications and Diagnostic Screening Tests (2 of 3)……… 9 Causes of Secondary Hypertension with Clinical Indications and Diagnostic Screening Tests (2 of 3)…… 10 Frequently Used and Other Substances That May Cause Elevated BP………………………… 11 Best Proven Nonpharmacologic Interventions for Prevention and Treatment of Hypertension…………… 12 Basic and Optional Laboratory Tests for Primary Hypertension……………………………………………… 13 Blood Pressure (BP) Thresholds and Recommendations for Treatment and Follow-Up…………………… 14 BP Thresholds for and Goals of Pharmacologic Therapy in Patients with Hypertension According to Clinical Conditions………………………………………………………………………………………………… 15 Oral Antihypertensive Drugs (1 of 3)…………………………………………………………………………… 16 Oral Antihypertensive Drugs (2 of 3)…………………………………………………………………………… 17 Oral Antihypertensive Drugs (3 of 3)…………………………………………………………………………… 18 with Reduced Ejection Fraction (HFrEF)………………………………………………………… 19 Heart Failure with Preserved Ejection Fraction (HFpEF)……………………………………………………… 19 Mellitus………………………………………………………………………………………………… 19

Management of Hypertension in Specific Patient Populations Stable Ischemic Heart (SIHD)……………………………………………………………………… 20 Chronic Disease ...……………………………………………………………………………………… 21 Acute Intercerebral Hemorrhage……………………………………………………………………………… 22 Acute ischemic ………………………………………………………………………………………… 23 Previous History of Stroke (Secondary Stroke Prevention)………………………………………………… 24 Resistant Hypertension: Diagnosis, Evaluation, and Treatment…………………………………………… 25 Diagnosis and Management of a ……………………………………………………… 26 Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies (1 of 2)……………… 27 ©2018, American College of Cardiology B18060 ©2018, American College of Cardiology Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies (2 of 2)……………… 28 Corresponding Corresponding Values ofSystolicBP/DiastolicBPforClinic, Home(HBPM), BP Table 11 Table 6 *Individuals withSBPandDBPin2categories shouldbedesignatedtothehigherBPcategory. E N 6/0 4/0 4/0 4/5 145/90 140/85 145/90 160/100 145/90 130/80 120/70 135/85 140/90 135/85 125/75 110/65 130/80 130/80 115/75 100/65 120/80 120/80 Stage 2 Stage 1 P Daytime, Nighttime, and24-Hour (ABPM)Measurements.Ambulatory 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES M M M APM N APM D APM PM Categories ofBPin Adults*

2–2 mH and 120–129 mmHg 130–139 mmHg <120 mmHg ≥140 mmHg SP 4 and o o

80–89 mmHg ≥90 mmHg <80 mmHg <80 mmHg Back to Table ofContents DP

©2018, American College of Cardiology B18060 Figure 1 Figure (C) todetectprogression • AnnualABPMorHBPM • Lifestyle modication White CoatHypertension BP after 3motrialoflifestyle modicationandsuspect 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES ≥130/80 mmHgbut<160/100 Detection of orMasked Hypertension White CoatHypertension white coathypertension BP <130/80mmHg Yes Daytime ABPM Of ce BP: or HBPM (C) therapy drug antihypertensive start modicationand • Continuelifestyle Hypertension No in Patients NotonDrug Therapy

5 (C) therapy drug antihypertensive start modicationand • Continuelifestyle Masked Hypertension after 3motrialoflifestyle modicationandsuspect 120–129/<80 mmHg BP ≥130/80mmHg masked hypertension Yes Daytime ABPM Of ce BP: or HBPM (C) detectMHorprogression • AnnualABPMorHBPMto • Lifestyle modication Elevated BP No Back to Table ofContents

©2018, American College of Cardiology B18060 Figure 2 Figure ncontrolled Hertension BP Intensify therapy 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES (C ) Mased Detection of orMasked Hypertension White CoatHypertension hypertension withHBPM hypertension masked uncontrolled es above goal above goal (C ) Screen for HBPM BP ABPM BP or targetorgandamage No Increased CVDrisk es current therapycurrent Continue in Patients onDrug Therapy

No Masked UncontrolledHypertension not necessary Detection of White CoatEffector (No Bene t) Screening in Patients onDrug Therapy es Con rm withABPM Con rm White CoatEffect: 6 (C ) Of ce BP at goal white coateffect es with HBPM (C ) Screen for HBPM BP at goal No No es titrating therapy ≥5–10 mmHg above goalon ≥3 agents Of ce BP Continue No Back to Table ofContents not necessary (No Bene t) Screening

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Figure 3 Figure Refer toclinician New Onset or Uncontrolled Hypertension in New OnsetorUncontrolledHypertension Adults with speci c (C ) expertise • Unprovoked orexcessivehypokalemia inolderadults(≥65y) • Onsetofdiastolichypertension • Accelerated/malignanthypertension TODfordegreeofhypertension • Disproportionate controlledhypertension • Exacerbationofpreviously at<30y • Onsetofhypertension onsetofhypertension • Abrupt hypertension • Drug-resistant/induced Conditions Screening for Secondary Hypertension Screening forSecondary secondary hypertension secondary es (see Table 13) screening test

Screen for (C ) Positive es No not necessary (No bene t) Referral 7 No not indicated (No bene t) Screening Back to Table ofContents

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES induced - or Drug- ‡ Obstructive aldosteronism Primary disease Renovascular disease parenchymal Renal Coo C with ClinicalIndicationsandDiagnosticScreening Tests II

Tests Prevalence 2%–4% 25%–50% 8%–20%† 5%-34%* 1%–2% agents (MaHuang, ) withdrawal; herbal poiesis stimulatingagents; psychiatric agents; erythro- neuro other illicitdrugs; , amphetaminesand (, ); ; sympathomimetics contraceptives; cyclosporineor alcohol; NSAIDs;oral ; (); -containing antacids; sleepiness during sleep;daytime tful sleep;breathingpauses Resistant hypertension; snoring onset hypertension orstroke ofearly and familyhistory sleep apnea;hypertension hypertension andobstructive discovered adrenalmass; hypertension andincidentally muscle crampsorweakness; induced); hypertension and (spontaneous ordiuretic- hypertension withhypokalemia Resistant hypertension; hyperplasia) women ( bromuscular hypertension, especially in onset (atherosclerotic); early edemam pulmonary dif cult tocontrol;ash or worsening orincreasingly hypertension onset ofabrupt Resistant hypertension; urinalysis abnormal elevated ; serum of polycystickidney disease; abuse;familyhistory frequencyandnocturia; urinary obstruction, hematuria; tractinfections; Urinary Causes of Secondary Hypertension Causes ofSecondary Indications

lncl Physical Screening Clinical (cocaine) abdominal pain inhibitors); acute , MAO sweating (cocaine, , tremor,Fine fall BP nocturnal normal class III–IV;lossof , Mallampati brillation especially atrial ); Arrhythmias (with dysplasia), femoral bromuscular atherosclerotic or (carotid – over otherarteries diastolic ; Abdominal systolic- disease); skinpallor (polycystic kidney Abdominal mass 8 oo C Exam (illicit drugs) screen drug Urinary overnight oximetry Sleepiness Score(9); (8); Epworth Questionnaire Berlin 4–6 wk) antagonists for withdrawal of hypokalemia and of (correction conditions standardized ratiounder Plasma aldosterone/ MRA; abdominalCT Doppler ultrasound; Renal Duplex Renal ultrasound ill belistedintenetto pages Tests

Con rmatory Additional/ suspected agent withdrawal of Response to Polysomnography blockers§ of sampling. Trial scan,CT Adrenal infusion.of Adrenal aldosterone at4h test withplasma or IVsalineinfusion urine aldosterone) test (priorto24h Oral sodiumloading angiography renal intraarterial Bilateral selective disease cause ofrenal Tests toevaluate (1 of3) Back to Table ofContents

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES thyroidism hyperpara- Primary or repaired) (undiagnosed coarctation Aortic ism Hyperthyroid- ism Hypothyroid- syndrome Cushing’s paraganglioma cytoma/ Pheochromo- oo C with ClinicalIndicationsandDiagnosticScreening Tests

Tests Prevalence Rare 0.1% <1% <1% <0.1% 0.1%–0.6% Hypercalcemia hypertension (<30yofage) Young patientwith muscle weakness weight proximal loss;diarrhea; tremulousness; ; intolerance; nervousness; Warm, moistskin;heat constipation; hoarseness; skin;coldintolerance; Dry ; hyperglycemia proximal muscleweakness; with centraldistribution; Rapid weight gain, especially incidentaloma paraganglioma; adrenal / of positive familyhistory sweating, , ; “spells”, BPlability, , sustained hypertension; crisis superimposedon paroxysmal hypertension or Resistant hypertension; Causes of Secondary Hypertension Causes ofSecondary Indications

lncl Physical Screening Clinical Usually none (postoperative) thoracotomy scar left bruit; chest, or abdominal over patient’s back, continuous murmur femoral ; extremities; absent compared tolower extremities BP higherinupper skin hands; warm, moist of theoutstretched Lid lag; netremor movement; goiter skin; slow coarse skin;cold periorbital puf ness; Delayed anklereex; striae, (1 cm)violaceous pads, wide and supraclavicular “moon” face, dorsal Central obesity, orthostatic neuro bromas); (café-au-lait spots; neuro bromatosis Skin stigmataof 9 Exam oo C Serum Serum Echocardiogram thyroxine , free Thyroid stimulating thyroxine free hormone; Thyroid stimulating suppression test Overnight 1mg cannula) with indwelling IV (30’ supineposition standard conditions metanephrines under plasma metanephrines or fractionated 24-h urinary Tests ill continue intenetpage

Con rmatory Additional/ hormone parathyroidSerum MRA abdominal CTor Thoracic and uptake andscan Radioactive iodine None midnight salivary (preferably multiple); excretion cortisol free 24-h urinary abdomen/pelvis CT orMRIscanof (2 of3) Back to Table ofContents

©2018, American College of Cardiology B18060 BP Table 13 § pressureonlowering BPinpatients withhypertension have producedmixedresults hypertension, obstructive sleepapneaislistedasacauseofsecondary RCTsontheeffectsofcontinuouspositive airway ‡Although ingeneral populationwithhypertension; upto20%inpatientswithresistant hypertension.†8% , 28%;hypertension withcongestive intheelderly failure, heart 34%). *Depending ontheclinicalsituation(hypertension alone, 5%;hypertension dialysis, starting 22%;hypertension andperipheral 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES aldosteronism primary other than syndromes excess corticoid Mineralo- hyperplasia adrenal Congenital oo C For a list of frequently used drugs causinghypertensionFor alistoffrequentlyuseddrugs andaccompanying evidence, see Table 14onthenextpage. with ClinicalIndicationsandDiagnosticScreening Tests Tests Prevalence Rare Rare Rare continued frompreious page mellitus visual disturbances;diabetes glove orhatsize;headache, Acral features, enlargingshoe, hypokalemia orhyperkalemia resistant hypertension; onsethypertension; Early [17-alpha-OH]) hydroxylase de ciency in females(17-alpha- amenorrhea males andprimary incomplete masculinizationin de ciency [11-beta-OH]) (11-beta-hydroxylase hypokalemia; virilization and Hypertension Causes of Secondary Hypertension Causes ofSecondary Indications

lncl Physical Screening Clinical 10 frontal bossing hands andfeet; Acral features;large hypokalemia) Arrhythmias (with (17-alpha-OH) masculinization incomplete (11-beta-OH) or Signs ofvirilization Exam load during oralglucose ≥1ng/mL hormone growthSerum renin Low aldosteroneand renin aldosterone and low ornormal hypokalemia with and Hypertension Tests

Con rmatory Additional/ the pituitary level; MRIscanof sex-matched IGF-1 Elevated age- and testing metabolites; genetic cortisol Urinary and deoxycorticosterone ; elevated androgens and OH: decreased androgens 17-alpha- and 11-deoxycortisol costerone(DOC), elevated deoxycorti- 11-beta-OH: (3 of3) Back to Table ofContents

©2018, American College of Cardiology B18060 Frequently UsedMedicationsandOtherSubstances That May CauseElevated BP* Table 14 isnotall-inclusive. *List BP kinaseinhibitors(eg. sunitinib, ) Angiogenesis inhibitor(eg. ) and ) udrocortisone, , , (e.g.,Systemic dexamethasone, cocaine, , etc.) (e.g.,Recreational drugs “bath ” [MDPV], NSAIDs Oral contraceptives Immunosuppressants (e.g., cyclosporine) St. John’s wort[withMAO inhibitors, ]) Herbal supplements(e.g., MaHuang[ephedra], ) Decongestants (e.g., , Caffeine Atypical antipsychotics(e.g., , ) (e.g., MAOIs, SNRIs, TCAs) , ) (e.g., , Alcohol Agent 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES

Initiateorintensifyantihypertensive therapy when feasible Consideralternativemodesofadministration(e.g., inhaled, topical) Avoid orlimitusewhen possible Discontinueand/oravoid use NSAIDs,)dependingonindicationandrisk Consideralternativeanalgesics (e.g., acetaminophen, tramadol, topical Avoid systemicNSAIDswhen possible Avoid useinwomen withuncontrolledhypertension controlwhere ofbirth appropriate(e.g., barrier, abstinence, IUD) progestin-only ofcontraceptionand/orconsideralternativeforms form Uselow-dose (e.g., 20–30mcgethinyl )agents ora effectsonBP Considerconverting totacrolimus, which may beassociatedwithless use Avoid corticosteroids, antihistamines)asappropriate Consideralternativetherapies(e.g., nasalsaline, intranasal hypertension durationpossibleandavoid Useforshortest insevere oruncontrolled usenotassociatedwithincreasedBPorCVD inBP;long-term Coffeeuseinpatientswithhypertension associatedwithacuteincreases Avoid useinpatientswithuncontrolledhypertension Generallylimitcaffeineintake to<300 mg/d diabetesmellitus, anddyslipidemia (e.g., , ). Consideralternativeagents associatedwithlower riskofweight gain, Lifestylemodication(Section6.2) Considerbehavior therapy where appropriate Discontinueorlimitusewhen possible Avoid tyraminecontainingfoodswithMAOIs Consideralternativeagents (e.g., SSRIs,)dependingonindication Considerbehavioral therapiesfor ADHD Discontinueordecreasedose Limitalcoholto≤1drinkdailyforwomen and≤2drinksformen 11 Possible Management Strategy Back to Table ofContents

©2018, American College of Cardiology B18060 Table 15 (usuallyabout5%alcohol), 5ouncesofwine(usuallyabout12%alcohol)and1.5distilledspirits (usuallyabout40%alcohol). theUnitedStates,†In one “standard” drinkcontainsroughly14grams ofpurealcohol, which istypicallyfoundin12ounces ofregularbeer *Type, dose, BPandwithhypertension. andexpectedimpactonBPinadultswithanormal BP intake Moderation inalcohol Physical activity of dietary Enhanced intake sodium of dietary Reduced intake 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Best Proven Nonpharmacologic Interventions forPrevention Interventions Best ProvenNonpharmacologic Intervention Intervention Nonpharmacologic Alcohol consumption Isometric Resistance Dynamic Resistance Aerobic potassium Dietary sodium Dietary pattern DASH dietary Weight/body fat and Treatment ofHypertension*

Women: ≤1drinkdaily Men:≤2drinksdaily alcohol In individualswho drinkalcohol, reduce 8–10wk 3sessions/wk contraction, maximumvoluntary between , 30%–40% 4x2min(handgrip), 1minrest 10repetitions/set 6exercises, 3sets/, 50%–80%1repmaximum 90–150min/wk ratereserve 65%–75%heart 90–150min/wk consumption ofadietrichinpotassium 3,500–5,000 mg/d, preferablyby adults least 1,000mg/dreductioninmost <1,500 mg/disoptimalgoal butat l fat reduced contentofsaturatedandtrans grains, productswith andlow-fat dairy Diet richinfruits, vegetables, whole in body weight. 1kgreduction about 1mmHgforevery most adultswho areoverweight. Expect least 1kgreductioninbody weight for Ideal body weight isbestgoal butat † to: 12 Dose

Hypertension Normotension Hypertension Approimate ImpactonSBP -5/8 mmHg -4/5 mmHg -5/6 mmHg -11 mmHg -4 mmHg -5 mmHg -4 mmHg -5 mmHg Back to Table ofContents

-2/4 mmHg -2/3 mmHg -2/3 mmHg -3 mmHg -4 mmHg -2 mmHg -2 mmHg -3 mmHg

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Basic and Optional Laboratory Basic andOptionalLaboratory Tests Hypertension forPrimary Table 17 beincludedinacomprehensive*May metabolicpanel Optional Testing Basic Testing

Urinary albumin tocreatinineratio Urinary Echocardiogram Electrocardiogram Urinalysis Thyroid-stimulating hormone sodium,Serum potassium, calcium* creatininewitheGFR* Serum Lipid pro le Complete bloodcount Fasting bloodglucose* 13 Back to Table ofContents

©2018, American College of Cardiology B18060 Figure 4 Figure treatmenttoachieve BPtarget. oftreatment, reinforcementoftheimportance andassistancewith responsetotherapy, ofadherence, reinforcement oftheimportance white coateffect, documentationofadherence, monitoringofthe withposturalsymptoms), identificationof white coat ora hypertension hypotension detectionoforthostatic inselectedpatients (e.g., olderor tocontrolBP. asnecessary ReassessmentincludesBPmeasurement, carefullymonitored, andsubjecttoupwardmedicationdoseadjustment 2hypertension andBP≥160/100mmHgshouldbepromptlytreated, with2antihypertensive agents ofdifferentclasses. Patients withstage therapy initiation ofpharmacological forstage 2hypertension †Consider renalfunction2to4weeks afterinitiatingtherapy. ofRASinhibitorordiuretictherapy, assessbloodtests for electrolytesand orCKDareautomaticallyplacedinthehigh-riskcategory. Forinitiation the ACC/AHA*Using Pooled Equations. Cohort NotethatpatientswithDM BP Promote optimal lifestyle habits (BP <120/80 Normal BP Normal Reassess in (C ) mm Hg) 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES 1 y and Recommendationsfor Treatment and Follow-Up BP Thresholds andRecommendationsfor Treatment andFollow-up (BP 120–129/<80 Nonpharmacologic Elevated BP Reassess in (C ) (C ) mm Hg) 3–6 mo therapy Blood Pressure(BP) Thresholds

Nonpharmacologic Reassess in (C ) (C ) 3–6 mo therapy

or estimated10-yCVDrisk 14 Stage Hypertension

(BP 130–139/80-89

No

Clinical ASCVD mm Hg) ≥10%* intensication Assess and to therapy of therapy Consider optimize BP-lowering medication Nonpharmacologic es BP goal met therapy and No Reassess in (C ) (C ) 1 mo

es Reassess in (C ) 3–6 mo BP-lowering medication Stage 2Hypertension (BP ≥140/90mmHg) Back to Table ofContents Nonpharmacologic therapy and (C ) †

©2018, American College of Cardiology B18060 Table 23 BP Peripheral disease arterial stroke preventionSecondary disease Stable ischemicheart failure Heart Chronic kidney diseasepost-renaltransplantation Chronic Diabetes mellitus Speci c ambulatory, community-livingadults) Older persons(≥65years ofage; non-institutionalized, No clinicalCVDand10year ASCVD risk<10% Clinical CVDor10year ASCVD risk≥10% General Clinical Condition(s) 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES in Patients withHypertension According toClinicalConditions BP Thresholds forandGoalsofPharmacologic Therapy

15 PTrsodm g BPGoalmmHg BP Threshold mmHg ≥130/80 ≥140/90 ≥130/80 ≥130/80 ≥130/80 ≥130/80 ≥130/80 ≥130 (SBP) ≥140/90 ≥130/80 Back to Table ofContents <130/80 <130/80 <130/80 <130/80 <130/80 <130/80 <130/80 <130 (SBP) <130/80 <130/80

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Class Drug Range Drug Ag Prr Class nondihydropyridines CCB— dihydropyridines CCB— ARBs ACE Inhibitors -type Thiazide or onset ER -delayed Verapamil SR Verapamil IR Diltiaem ER LA SR Ailsartan Trandolapril uinapril Moeipril Benaepril Metolaone Hydrochlorothiaide Chlorthalidone Oral Antihypertensive Drugs Drugs Oral Antihypertensive m e a) (mgperday)* UsualDose,

12.5–150 150–300 600–800 100–300 120–360 120–360 1.25–2.5 120-360 12.5–25 60–120 80–320 50–100 2.5–10 2.5–10 2.5–20 7.5–30 40–80 10–40 17–34 30–90 20–80 20–40 10–80 10–40 10–40 25–50 2.5–5 8–32 5–10 4–16 5–40 1–4 16 Frequency 1 (inthe evening) 1 or2 1 or2 1 or2 1 or2 1 or2 1 or2 1 or2 2 or3 1 or2 Daily 3 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Table iscontinued intenettopages (CYP3A4majorsubstrateand moderate inhibitor) increasedriskofbradycardiablock andheart ismorecommoninwomen thanmen felodipinemay beusedif required ACEI discontinued. ACEI canreceive an ARB beginning6weeks after ofangioedemawithan Patients withahistory severe bilateralrenalartery onK+supplementsorK+-sparingdrugs directrenininhibitor inhibitors. stenosis severe bilateralrenalartery orK+-sparingdrugs patientswithCKDorinthoseonK+supplements renininhibitor unlesspatientisonuricacid-lowering therapy. ofacute Usewithcautioninpatientshistory acidandcalciumlevels. Monitorforhyponatremia andhypokalemia, uric half-lifeandproven trialreductionofCVD basedon prolonged preferred Chlorthalidone Avoid routineusewithbetablockers dueto Associated withdose-relatedpedaledema, which Avoid useinpatientswithHFrEF;amlodipineor Avoid inpregnancy Avoid inpregnancy Drug interactionswith diltiazemandverapamilDrug Do notuseinpatientswithHFrEF ofangioedemawith ARBs. Do notuseifhistory May causeacuterenalfailureinpatientswith Increased riskofhyperkalemia inCKDorthose Do notuseincombinationwith ACE inhibitorsor ofangioedemawith ACEDo notuseifhistory May causeacuterenalfailureinpatientswith Increased riskofhyperkalemia, especiallyin Do notuseincombinationwith ARBs ordirect (1 of3) Comments Back to Table ofContents

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Class Drug Range Drug Ag Sor Class activity sympathomimetic intrinsic Beta blockers— noncardioselective Beta blockers— and vasodilatory cardioselective Beta blockers— cardioselective Beta blockers— antagonists aldosterone Diuretics— potassium sparing Diuretics— Diuretics—loop LA Propranolol IR succinate Metoprolol tartrate Betaolol Torsemide Oral Antihypertensive Drugs Drugs Oral Antihypertensive m e a) (mgperday)* UsualDose,

200–800 100–200 25–100 25–100 50–100 50–100 80–160 80–160 40–120 50–200 2.5–10 10–60 10–40 20–80 0.5–2 5–20 5–10 5–10 5–40 17 Frequency 1 or2 1 or2 1 or2 Daily 2 1 2 1 2 1 1 1 2 1 1 2 2 1 2 2

Table iscontinued intenetpage Generallyavoid, especially in patientswithIHDorHF patientswithHFrEF diseaserequiringabetablocker agents unlessthepatienthasIHDorHF adequateBPlowering diureticsorsigni cantrenaldysfunction eplerenone andimpotencecomparedto gynecomastia resistanthypertension GFR<45mL/min) monotherapy patientswithhypokalemia onthiazide diureticwithathiazidecanbeconsideredin antihypertensives moderate-to-severe CKD(e.g., GFR<30mL/min) HF. over Preferred thiazidesinpatientswith Avoid cessation abrupt Avoid cessation abrupt Avoid inpatientswithreactive airways disease Avoid cessation abrupt Avoid cessation abrupt Avoid usewithK+supplements, otherK+-sparing Avoid inpatientswithsigni cantCKD(e.g., Induces nitricoxide-inducedvasodilation in Bisoprolol andmetoprololsuccinatepreferred inpatientswithbronchospasticairwayPreferred Beta blockers arenotrecommendedas rst-line Eplerenone oftenrequirestwicedailydosingfor Common add-ontherapy inresistanthypertension Spironolactone associatedwithgreater riskof aldosteronism and agentsPreferred inprimary Combination therapy ofpotassiumsparing Monotherapy agents minimallyeffective diureticsinpatientswithsymptomatic Preferred (2 of3) Comments Back to Table ofContents

©2018, American College of Cardiology B18060 BP Table 18 Prevention, Detection, Evaluation, and Treatment ofHighBloodPressure:theJNC7report. JAMA. 2003;289:2560-72 fromChobanian Adapted withpermission AV, BakrisGL, BlackHR, etal. The Seventh oftheJoint Report NationalCommitteeon *Dosages may fromthoselistedintheFDA vary approved labeling(available athttp://dailymed.nlm.nih.gov/dailymed/index.cfm). 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Class Drug Range Drug Ag Sor Class Direct vasodilators drugs centrally acting agonists andother Central Alpha2- Alpha-1 blockers inhibitor Direct renin beta-receptor alpha- and combined Beta blockers— Minoidil Hydralaine Clonidine patch Clonidine oral Teraosin Praosin Doaosin Aliskiren phosphate Carvedilol (continued frompreviouspage) Oral Antihypertensive Drugs Drugs Oral Antihypertensive m e a) (mgperday)* UsualDose,

250–1000 150–300 200–800 100-200 12.5–50 0.1–0.3 0.1–0.8 5–100 20–80 0.5–2 1–20 1–16 2-20 18 Frequency 1 weekly 2 or3 1 or2 2 or3 Daily 1 -3 1 2 2 1 1 2 1 2

Comments aloopdiuretic. Caninducepericardialeffusion like syndrome athigherdoses ablocker reextachycardia; usewithadiureticandbet taperedtoavoid reboundhypertension may inducehypertensive crisis;clonidinemustbe CNSadverse effects, especiallyinolderadults withconcomitantBPH especiallyinolderadults stenosis severe bilateralrenalartery onK+supplementsorsparingdrugs or ARBs Associated withsodiumandwaterretention Avoid discontinuationofclonidine, abrupt which hypotension,Associated withorthostatic Avoid inpregnancy longacting Aliskiren isvery Avoid cessation abrupt associatedwithhirsutismandrequires lupus- associatedwithdrug-induced aslast-lineduetosigni cant Generally reserved May considerassecond-lineagent inpatients May causeacuterenalfailureinpatientswith Increased riskofhyperkalemia inCKDorthose Do notuseincombinationwith ACE inhibitors inpatientswithHFrEF preferred Carvedilol (3 of3) Back to Table ofContents

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES No Bene t COR LOE COR LOE COR LOE III: IIb I I I I I Heart Failure with Preserved EjectionFraction FailureHeart (HF withPreserved Heart FailureHeart withReducedEjectionFraction (HF in Patients EjectionFraction Failure withHeart withPreserved in Patients Failure withHeart withReducedEjectionFraction Recommendations for Treatment inPatients ofHypertension DM With Referenced studies that support recommendationsaresummarizedin Referenced studiesthatsupport Referenced studies that support recommendationsaresummarizedin Referenced studiesthatsupport B-R B-NR DBP: C-EO C-EO C-EO SBP: C-LD B-R A SR SR Recommendations for Treatment ofHypertension Recommendations for Treatment ofHypertension

andbetablockers titratedtoattainsystolicBPlessthan 130 mmHg. ofvolume overload shouldbeprescribed ACE inhibitorsor ARB 2. Adults withHF overload, diureticsshouldbeprescribedtocontrolhepertension. withatreatmentgoal oflessthan130/80mmHg. treatmentshouldbeinitiatedataBPof130/80mmHg orhigher 1. InadultswithDMandhypertension, 1. In adultswithHF ofhypertension inadultswithHF 2. Nondihydropyridine CCBsarenotrecommendedinthetreatment titratedtoattainaBPlessthan130/80mmHg. 1. Adults withHF beconsideredinthepresence ofalbuminuria. 3. InadultswithDMandhypertension, ACE inhibitors or ARBs may CCBs)areusefulandeffective. antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and 2. InadultswithDMandhypertension, all rst-lineclassesof online DataSupplement35, 36 online DataSupplement34 Diabetes Mellitus 19 EF andhypertension shouldbeprescribedGDMT* EF andpersistenthypertension aftermanagement EF who presentwithsymptomsofvolume Recommendations Recommendations Recommendations EF . (HFr (HFp EF) r EF) p EF) EF) Back to Table ofContents

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Figure 5 Figure neededforBPcontrol. †If blocker atenololshouldnotbeusedbecauseitislesseffective thanplaceboinreducingcardiovascular events. nadolol, bisoprolol, propranolol, andtimolol. Avoid beta blockers withintrinsicsympathomimeticactivity. The beta betablockers forBPcontrolorreliefofanginaincludecarvedilol, metoprololtartrate, metoprololsuccinate, *GDMT Management inPatients ofHypertension with Stable Ischemic Heart Disease(SIHD) Stable IschemicHeart dihydropyridine CCBs * GDMT betablockers if needed (C )

Reduce BPto<130/80mmHgwith Add Hypertension WithSIHD Hypertension BP goal notmet es (C ) pectoris , ACE inhibitor, orARB 20 thiazide-type diuretics, dihydropyridine CCBs, No and/or MRAs as needed (C ) Add †

Back to Table ofContents

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Management inPatients ofHypertension with ≥300mg/dormg/gcreatinine. *CKD stage 3orhigherstage 1or2withalbuminuria Figure 6 Figure (C ) ARB* Treatment inPatients withCKD ofHypertension

es ACE inhibitor ACE inhibitor Chronic KidneyDisease (C ) intolerant (≥ 300mg/dor≥300mg/g BP goal<130/80mmHg ACE inhibitor* No (C ) es Albuminuria creatinine) (C ) 21 medication choices Usual “rst line” Usual “rst No

Back to Table ofContents

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Management inPatients ofHypertension with Figure 7 Figure Acute Intercerebral Hemorrhage 150–220 mmHg SBP loweringto <140 mmHg

(C ) Harm Harm SBP Acute (<6hfromsymptomonset) Spontaneous ICH 22 & closeBPmonitoring continuous IVinfusion SBP loweringwith >220 mmHg (C ) SBP

Back to Table ofContents

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Lower SBPto<185mmHgandDBP<110 Figure 8 Figure before initiationofIVthrombolysis for rst 24hafterIVthrombosis for rst Maintain BP<180/105mmHg Management inPatients ofHypertension with (C ) (C ) And Acute (<72hfromsymptomonset) Ischemic Stroke and Elevated BP Ischemic StrokeandElevated

Acute ischemicStroke Patient quali esforIV thrombolysis therapy es antihypertensive drugs afterneurologicalstability drugs antihypertensive hypertension within the rst 48-72hours withinthe rst hypertension effective deathordependency toprevent For pre-existinghypertension,reinitiate after anacuteischemicstrokeisnot Initiating orreinitiatingtreatmentof 23 No (C ff) ≤220/110 mmHg (C ) BP >220/110 mmHg during rst 24h during rst Lower BP15% (C ) Back to Table ofContents BP

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Figure 9 Figure SBP <130/80mmHg a Previous History of Stroke (Secondary Stroke Prevention) ofStroke (Secondary a PreviousHistory antihypertensive (C ) treatment (C ) Restart Aim for Management inPatients ofHypertension with and stableneurologicalstatusorTIA Stroke ≥72hfromsymptomonset Initiate antihypertensive treatment Initiate antihypertensive es or treatedhypertension Aim forSBP<130/80mmHg

Previous diagnosed Previous or DBP≥90mmHg SBP ≥140mmHg Established (C ) (C ) 24 No Usefulness of starting antihypertensive Usefulness ofstarting treatment isnotwellestablished and DBP mm Hg <90 SBP <140 mm Hg Established (C ) Back to Table ofContents

©2018, American College of Cardiology B18060 BP 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Resistant Hypertension: Diagnosis,Resistant Hypertension: Evaluation, and Treatment Figure 10 Figure Education Committee oftheCouncilforHighBlood PressureResearch. Hypertension. 2008;51:1403-19 evaluation, andtreatment. A scientificstatementfromthe AmericanHeart AssociationProfessional fromCalhounDA,Adapted withpermission Jones D, Textor S, etal. Resistanthypertension: diagnosis, Patient prescribed≥3antihypertensive medicationsatoptimaldoses, includingadiuretic, ifpossible Renal stenosis(young female, known atheroscleroticdisease, worsening kidney function) Refer to appropriate specialist for known or suspected secondary cause(s)ofhypertension Refer toappropriatespecialist for known orsuspectedsecondary Of ce SBP/DBP<130/80mmHgbutpatientrequires≥4antihypertensive medications Refer tohypertension specialistifBPremainsuncontrolledafter6mooftreatment Obstructive sleepapnea(snoring, witnessedapnea, excessive daytime sleepiness) Pheochromocytoma (episodichypertension, palpitations, diaphoresis, headache) Obtain home, work, BPreadingstoexcludewhite coateffect orambulatory and/or patientsreceivingpotentvasodilators (e.g., minoxidil) (elevatedPrimary aldosterone/reninratio) Sympathomimetic (e.g., amphetamines, decongestants) Add otheragents withdifferentmechanisms ofactions Identify andReverseContributingLifestyleFactors Discontinue orMinimizeInterferingSubstances Assess fornonadherencewithprescribedregimen Screen for Secondary CausesofHypertension Screen forSecondary

Add a mineralocorticoid receptorantagonistAdd amineralocorticoid Ensure accurateof ceBPmeasurements Use loopdiureticsinpatientswithCKD Of ce SBP/DBP≥130/80mmHg CKD (eGFR<60mL/min/1.73m Con rm Treatment Resistance TreatmentCon rm Exclude Pseudo-Resistance Excessive alcoholingestion Pharmacologic TreatmentPharmacologic Maximize diuretictherapy High , low- ber diet Refer toSpecialist Oral contraceptives Physical Inactivity Ephedra Licorice NSAIDs Obesity 25 or 2 ) Back to Table ofContents

©2018, American College of Cardiology B18060 BP Figure 11 Figure †If othercomorbiditiesarepresent, specified in selectadrug Table 20. specifiedin*Use drug(s) Table 19. 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES during 1 Reduce SBPto<140mmHg in aortic dissection in aortic st h *and to<120mmHg Diagnosis andManagement Crisis ofaHypertensive (C ) • Pheochromocytomacrisis pre-eclampsiaoreclampsia; • Severe ; • Aortic Conditions Hypertensive Admit toICU emergency (C ) † es

SBP >180mmHgand/orDBP>120 then to160/100–110mmHgover next2–6h, Target organdamagenew/ Reduce BPbymax25%over 1 No es then to normal overthen tonormal next24–48h progressive/worsening 26 (C ) No antihypertensive drug therapy drug antihypertensive Reinstitute/intensify oral and arrange follow-up and arrange st h † , elevated BP elevated Markedly Back to Table ofContents

©2018, American College of Cardiology B18060 BP Agent antagonist selective beta1 receptor blockers direct Vasodilators- dependent Vasodilators- dihydropyridines CCB- 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Esmolol Hydralaine nitroprusside Sodium Nicardipine for Treatment Emergencies ofHypertensive Drugs Drugs Intravenous Antihypertensive Drugs Intravenous Antihypertensive a maximumof200mcg/kg/min. mcg/kg/min incrementsasneededto and theinfusionincreasedin50 dosing, thebolusdoseisrepeated mcg/kg/min infusion. Foradditional kg/min over 1min followed by a50 Loading dose500–1,000mcg/ 4–6hasneeded. every (maximum initialdose20mg);repeat Initial 10mgviaslow IVinfusion a maximumof20mcg/min. 3–5minto ments of5mcg/minevery Initial 5mcg/min;increaseinincre- to prevent cyanide toxicity. min, thiosulfatecanbecoadministered ≥4–10 mcg/kg/minorduration>30 aspossible.as short Forinfusionrates 10 mcg/kg/min;durationoftreatment achieve BPtarget; maximumdose in incrementsof0.5mcg/kg/minto Initial 0.3–0.5mcg/kg/min;increase maximum duration72h. min; maximumdose32mg/h; increasing by 5–10

Usual DoseRange 27 lung functioninreactive airway disease. Higher dosesmay blockbeta2receptorsandimpact May worsen HF. Monitor forbradycardia. therapy, and/ordecompensatedHF beta-blocker Contraindicated inptswithconcurrent most pts. a desirable rst-lineagent foracutetreatmentin prolonged durationofactiondonotmake hydralazine fall lasts2–4h. Unpredictabilityofresponseand BP beginstodecreasewithin10–30minandthe depleted pts. .or acutepulmonary Donotuseinvolume- syndromeand/ Use onlyinptswithacutecoronary irreversible neurologicchanges andcardiacarrest. Cyanide toxicitywithprolonged usecanresultin elderly. Tachyphylaxis commonwithextendeduse. “overshoot”. Lower dosingadjustmentrequiredfor BPmonitoringrecommendedtopreventIntra-arterial dose range pts. forelderly lipoid nephrosisoracutepancreatitis). Uselow-end lipid (e.g., pathologicalhyperlipidemia, egg, andinptswithdefective andeggproductallergy Contraindicated inptswithsoybean, soy product, adjustment neededforelderly. Contraindicated inadvanced stenosis;nodose aortic Table illbecontinued intenetpage

(1 of2) Comments Back to Table ofContents

©2018, American College of Cardiology B18060 BP Agent inhibitor enzyme converting Angiotensin agonist selective receptor Dopamine1- antagonist alpha receptor non-selective blockers- beta receptor nonselective alpha1 and combined blockers- Adrenergic Table 19 2017 Guideline Prevention, the for Detection, Evaluation, and Management of High in Adults Blood Pressure SIMPLE MADE GUIDELINES Enalaprilat Phentolamine Labetalol for Treatment Emergencies ofHypertensive Drugs Drugs Intravenous Antihypertensive Drugs Intravenous Antihypertensive target. 6hasneededtoachieveevery BP Doses canbeincreasedupto5mg Initial 1.25mgover a5minperiod. 1.6 mcg/kg/min. BP isreached. Maximuminfusionrate 15minuntiltargetmcg/kg/min every increased inincrementsof0.05–0.1 Initial 0.1–0.3mcg/kg/min;may be lower BPtotarget. 10minasneededto doses every IV bolusdose5mg. Additional bolus 4–6h. every 300 mg. This dosecanberepeated rate uptototalcumulative doseof infusion upto3mg/kg/h. Adjust 10minor0.4–1.0mg/kg/hIV every (maximum 20mg)slow IVinjection Initial 0.3–1.0mg/kgdose

Usual DoseRange 28 unpredictability ofBPresponse. Relatively slow onsetofaction(15min)and Dose noteasilyadjusted. associated withhighplasmareninactivity. Mainly usefulinhypertensive emergencies stenosis. used inacuteMIorbilateralrenalartery Contraindicated inpregnancyandshouldnotbe pressure andthosewithsul teallergy. intraocular pressure()orintracranial Contraindicated inptsatriskforincreased amphetamine overdose orclonidinewithdrawal). orfood,and otherdrugs cocainetoxicity, interactions between monamineoxidaseinhibitors excess(pheochromocytoma, Used inhypertensive emergencies inducedby blockorbradycardia. heart should notbegiven inptswith2ndor3rddegree hyperadrenergic syndromes. May worsen HFand disease.obstructive pulmonary Especiallyusefulin Contraindicated inreactive airways diseaseorchronic

(2 of2) Comments Back to Table ofContents

©2018, American College of Cardiology B18060