According to the 2017 American College of Cardiology (ACC) and American Heart Association (AHA) hypertension guidelines, doctors should treat people with Stage 2 high blood pressure (BP ≥140/90 mm Hg) with two antihypertensives from two different classes of medication.1 Use of two BP-lowering medications is recommended for secondary prevention of recurrent cardiovascular disease (CVD) events in patients with clinical CVD and an average of 130 mm Hg or higher systolic or an average of 80 mm Hg or higher diastolic. Two medications are also recommended for primary prevention of CVD in adults with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average of 130 mm Hg or higher systolic or an average of 80 mm Hg or higher diastolic. People started on medication should be reassessed in one month.
The guidelines lowered the definition of high blood pressure (BP) and when to start pharmacologic treatment to account for complications that can occur at lower measurements and to allow for earlier intervention.1,2 The risk for heart attack, stroke, angina, heart failure, peripheral artery disease, and other high blood pressure complications begins to increase at any level above 120 mm Hg systolic and doubles at 130 mm Hg systolic.1,3,4
Experts reviewed recent randomized trials, observational studies, and modeling studies and determined that lower treatment thresholds and targets are beneficial to patients at higher risk of BP-associated complications.5-7 This systematic review of the literature found that lowering systolic BP to a target of <130 mm Hg may reduce the risk of several vital outcomes including risk of myocardial infarction (MI), stroke, heart failure, and major cardiovascular events.5,7-9
A systematic review5 and meta-analysis performed for the development of the 2017 ACC/AHA guideline looked at studies that compared a systolic blood pressure target of less than 130 mm Hg with trials with higher targets. An analysis of only random controlled trials that met this criteria found that patients had a significant risk reduction for stroke (relative risk [RR] 0.82, 95% confidence interval [CI] [0.70 – 0.96]) and major cardiovascular events (RR 0.84, 95% CI [0.73 – 0.99]), but had only marginally significant risk reduction for all-cause mortality (RR 0.92, 95% CI [0.79 – 1.06]) and MI (RR 0.85, 95% CI [0.73 – 1.00]).
ASCVD risk can be calculated by doctors or an online calculator.1,10
References
- Whelton PK, Carey RM, Aronow WS, et al. 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: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017.
- Whelton PK, Carey RM. The 2017 clinical practice guideline for high blood pressure. JAMA 2017; 318 (21): 2073-2074.
- Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360 (9349): 1903-1913.
- Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet 2014; 383 (9932): 1899-1911.
- Reboussin DM, Allen NB, Griswold ME, et al. Systematic review for 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: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017.
- Cifu AS, Davis AM. Prevention, detection, evaluation, and management of high blood pressure in adults. JAMA 2017; 318 (21): 2132-2134.
- Wright JT, Jr., Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373 (22): 2103-2116.
- Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged >/=75 Years: A Randomized Clinical Trial. JAMA 2016; 315 (24): 2673-2682.
- Yusuf S, Lonn E, Pais P, et al. Blood-pressure and cholesterol lowering in persons without cardiovascular disease. N Engl J Med 2016; 374 (21): 2032-2043.
- ASCVD Risk Estimator Plus. American College of Cardiology. 2017; http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/. Accessed 1/21/2018.
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