2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults GUIDELINES MADE SIMPLE A Selection of Tables and Figure ACC.org/GMSHBP ©2018, American College of Cardiology B18060 ©2018, American College of Cardiology 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Writing Committee: Paul K. Whelton, MB, MD, MSc, FAHA, Chair Robert M. Carey, MD, FAHA, Vice Chair Wilbert S. Aronow, MD, FACC, FAHA Donald E. Casey, Jr, MD, MPH, MBA, FAHA Karen J. Collins, MBA Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA Sondra M. DePalma, MHS, PA-C, CLS, AACC Samuel Gidding, MD, FAHA Kenneth A. Jamerson, MD Daniel W. Jones, MD, FAHA Eric J. MacLaughlin, PharmD Paul Muntner, PhD, FAHA Bruce Ovbiagele, MD, MSc, MAS, MBA FAHA Sidney C. Smith, Jr, MD, MACC, FAHA Crystal C. Spencer, JD Randall S. Stafford, MD, PhD Sandra J. Taler, MD, FAHA Randal J. Thomas, MD, MS, FACC, FAHA Kim A. Williams, Sr, MD, MACC, FAHA Jeff D. Williamson, MD, MHS Jackson T. Wright, Jr, MD, PhD, FAHA The ACC and AHA convened this writing committee to address the prevention, detection, evaluation, and management of high blood pressure in adults. The first comprehensive guideline for detection, evaluation, and management of high BP was published in 1977, under the sponsorship of the NHLBI. In subsequent years, a series of Joint National Committee (JNC) BP guidelines were published to assist the practice community and improve prevention, awareness, treatment, and control of high BP. The present guideline updates prior JNC reports. The following resource contains Figures and Tables from the 2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. The resource is only an excerpt from the Guideline and the full publication should be reviewed for more figures and tables as well as important context. ©2018, American College of Cardiology B18060 ©2018, American College of Cardiology CITATION: J Am Coll Cardiol. Sep 2017, 23976; DOI: 10.1016/j.jacc.2017.07.745 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure 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 Hypertension or Masked Hypertension in Patients Not on Drug Therapy ……… 5 Detection of White Coat Hypertension or Masked Hypertension in Patients on Drug Therapy …………… 6 Screening for Secondary Hypertension ………………………………………………………………………… 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 Medications 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 Heart Failure with Reduced Ejection Fraction (HFrEF) ……………………………………………………… 19 Heart Failure with Preserved Ejection Fraction (HFpEF) …………………………………………………… 19 DIabetes Mellitus ……………………………………………………………………………………………… 19 Management of Hypertension in Specific Patient Populations Stable Ischemic Heart Disease (SIHD) …………………………………………………………………… 20 Chronic Kidney Disease ... …………………………………………………………………………………… 21 Acute Intercerebral Hemorrhage …………………………………………………………………………… 22 Acute ischemic Stroke ……………………………………………………………………………………… 23 Previous History of Stroke (Secondary Stroke Prevention) ……………………………………………… 24 Resistant Hypertension: Diagnosis, Evaluation, and Treatment ………………………………………… 25 Diagnosis and Management of a Hypertensive Crisis …………………………………………………… 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 GUIDELINES MADE SIMPLE Back to Table of Contents BP 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Categories of BP in Adults* BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated 120–129 mm Hg and <80 mm Hg Hypertension Stage 1 130–139 mm Hg or 80–89 mm Hg Stage 2 ≥140 mm Hg or ≥90 mm Hg *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. Table 6 Corresponding Values of Systolic BP/Diastolic BP for Clinic, Home (HBPM), Daytime, Nighttime, and 24-Hour Ambulatory (ABPM) Measurements. Clinic HBPM Daytime ABPM Nighttime ABPM 24-Hour ABPM 120/80 120/80 120/80 100/65 115/75 130/80 130/80 130/80 110/65 125/75 140/90 135/85 135/85 120/70 130/80 160/100 145/90 145/90 140/85 145/90 Table 11 ©2018, American College of Cardiology B18060 ©2018, American College of Cardiology 4 GUIDELINES MADE SIMPLE Back to Table of Contents BP 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Detection of White Coat Hypertension or Masked Hypertension in Patients Not on Drug Therapy Ofce BP: Ofce BP: ≥130/80 mm Hg but <160/100 mm Hg 120–129/<80 mm Hg after 3 mo trial of lifestyle modication and suspect after 3 mo trial of lifestyle modication and suspect white coat hypertension masked hypertension Daytime ABPM Daytime ABPM or HBPM or HBPM BP <130/80 mm Hg BP ≥ 130/80 mm Hg Yes No Yes No Hypertension Masked Hypertension White Coat Hypertension • Continue lifestyle • Continue lifestyle Elevated BP • Lifestyle modication modication and modication and • Lifestyle modication • Annual ABPM or HBPM start antihypertensive start antihypertensive • Annual ABPM or HBPM to to detect progression drug therapy drug therapy detect MH or progression (Class IIa) (Class IIa) (Class IIa) (Class IIa) Figure 1 ©2018, American College of Cardiology B18060 ©2018, American College of Cardiology 5 GUIDELINES MADE SIMPLE Back to Table of Contents BP 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Detection of White Coat Hypertension or Masked Hypertension in Patients on Drug Therapy Detection of White Coat Effect or Masked Uncontrolled Hypertension in Patients on Drug Therapy Ofce BP at goal Yes No Ofce BP Increased CVD risk ≥5–10 mm Hg or target organ damage above goal on ≥3 agents Yes No Yes No Screen for Screening Screen for Screening masked uncontrolled not necessary white coat effect not necessary hypertension with HBPM (No Benet) with HBPM (No Benet) (Class IIb) (Class IIb) HBPM BP HBPM BP above goal at goal Yes No ABPM BP White Coat Effect: above goal Conrm with ABPM Continue titrating therapy (Class IIa) Yes No Masked Uncontrolled Hypertension: Continue Intensify therapy current therapy (Class IIb) Figure 2 ©2018, American College of Cardiology B18060 ©2018, American College of Cardiology 6 GUIDELINES MADE SIMPLE Back to Table of Contents BP 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Screening for Secondary Hypertension New Onset or Uncontrolled Hypertension in Adults Conditions • Drug-resistant/induced hypertension • Abrupt onset of hypertension • Onset of hypertension at <30 y • Exacerbation of previously controlled hypertension • Disproportionate TOD for degree of hypertension • Accelerated/malignant hypertension • Onset of diastolic hypertension in older adults (≥ 65 y) • Unprovoked or excessive hypokalemia Yes No Screen for secondary hypertension Screening not indicated (Class I) (No benet) (see Table 13) Positive screening test Yes No Refer to clinician Referral with specic not necessary expertise (No benet) (Class IIb) Figure 3 ©2018, American College of Cardiology B18060 ©2018, American College of Cardiology 7 GUIDELINES MADE SIMPLE Back to Table of Contents BP 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Causes of Secondary Hypertension with Clinical Indications and Diagnostic Screening Tests (1 of 3) Clinical Physical Screening Additional/ Prevalence Conrmatory Indications Exam Tests Tests Common Causes Renal 1%–2% Urinary tract infections; Abdominal mass Renal ultrasound Tests to evaluate parenchymal obstruction, hematuria; (polycystic kidney cause of renal disease urinary frequency and nocturia; disease); skin pallor disease analgesic abuse; family history of polycystic kidney disease; elevated serum creatinine; abnormal urinalysis Renovascular 5%-34%* Resistant hypertension; Abdominal systolic- Renal Duplex Bilateral selective disease hypertension