by Ashley Jordan Ferira, PhD, RDN
Updated clinical practice guidelines from the 2017 American Heart Association (AHA) Scientific Sessions and co-published in Hypertension1 and the Journal of the American College of Cardiology2 by the American College of Cardiology (ACC) and AHA, revealed a new blood pressure (BP) classification system and updated hypertension (HTN) treatment recommendations, with a clear emphasis on lifestyle approaches.
How will these guidelines affect clinical decision-making? These updated, more conservative ACC/AHA criteria will translate into millions of newly diagnosed patients with HTN, shifting many from what was previously known as prehypertension (preHTN) into full-blown HTN. Currently, approximately 75 million US adults (1 in 3 US adults) have HTN,3 and only about half of them have their condition under control,4 underscoring the critical role of clinicians in helping patients achieve healthy blood pressure levels.
The etiology of HTN is multifaceted, but there are established, modifiable lifestyle contributors to high blood pressure pathology, including: overweight and obesity, lack of physical activity, poor nutrition, smoking tobacco, excessive alcohol intake, and being pre-hypertensive or diabetic. Age is also directly associated with high blood pressure. Poorly or unmanaged HTN can lead to numerous deleterious health conditions including myocardial infarct (MI), stroke, and heart failure, as well as associated chronic kidney disease which leads to disability and ultimately, increased mortality.
In 2003, the Seventh Joint National Committee (JNC 7) previously defined BP cutoffs:5
- Stage I HTN: systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg
- Stage II HTN: systolic ≥160 mmHg or diastolic ≥100
Normal blood pressure was considered <120/80 mmHg, while preHTN was considered systolic 120-139 mmHg or diastolic 80-89 mmHg.5
The more recent 2014 Eighth Joint National Committee (JNC 8) provided higher, more lenient age-specific BP goals:6
- <140/90 mmHg for ages 18-59 years old
- <130/80 mmHg for 60 years and older
While the latest 2017 ACC/AHA guideline maintains the previous definitions of normal BP, the guideline differs by eliminating the preHTN category and recommending more conservative cutoffs for elevated BP and stage I and II HTN:1
- Normal: systolic <120 mmHg and diastolic <80 mmHg
- Elevated: systolic 120-129 mmHg and diastolic <80 mmHg
- HTN Stage I: systolic 130-139 mmHg or diastolic 80-89 mmHg
- HTN Stage II: systolic ≥140 mmHg or diastolic ≥90 mmHg
- Hypertensive crisis: systolic >180 mmHg and/or diastolic >120 mmHg (guideline requires urgent medication changes or immediate hospitalization)
Along with the new classification system, the updated guideline provides updated treatment recommendations, with healthy lifestyle change as the primary focus for normal, elevated, stage I, and stage II HTN categories, along with pharmacologic interventions for stages I and II HTN (when indicated).1,7 To avoid medication, an evidence-based lifestyle medicine approach is paramount, providing patients the resources and empowerment to achieve:
- Healthy dietary pattern: emphasizing nutrient-dense fruits, vegetables, whole grains, and low-fat dairy products (i.e. DASH Diet approach), leading to increases in potassium and reductions in sodium intake
- Regular physical activity: 90-150 minutes/week of aerobic and/or resistance exercise and/or 3 sessions/week of isometric resistance exercises
- Moderate alcohol intake: ≤ 2 drinks/day for men and ≤ 1 drink/day for women
- Stress management
- Adequate sleep
- Tobacco cessation
Developed with 9 other health professional organizations, including a panel of 21 scientists and health experts, and reviewing 900+ publications, the ACC/AHA hypertension guidelines serve as a resource for practitioners, providing HTN diagnosis, prevention, evaluation, and treatment recommendations to inform patient care.
Why is this Clinically Relevant?
- The burden of HTN is significant; 1 in 3 US adults meet previous guidelines for HTN, and an additional 1 in 3 US adults have preHTN3
- The new ACC/AHA definition for stage I HTN is a systolic blood pressure 130-139 mmHg or diastolic blood pressure 80-89 mmHg
- Millions of additional patients will now meet the criteria for a hypertension diagnosis, requiring strategic clinical support to control their blood pressure
- Non-pharmacologic lifestyle interventions should be the primary treatment approach, starting with the implementation of a healthy dietary pattern and regular exercise
- Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 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: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(19):e127-e248.
- Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776-803.
- Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the US: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief, No. 133. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013.
- Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the U.S. by improvements in the use of clinical preventive services. Am J Prev Med. 2010;38(6):600–9.
- Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003 May 21;289(19):2560-72.
- See comment in PubMed Commons below James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. doi: 10.1001/jama.2013.284427.
- American Heart Association. Highlights from the 2017 guideline for the prevention, detection, evaluation and management of high blood pressure in adults. https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_497445.pdf. Accessed November 14, 2017.