Blood pressure and the new ACC/AHA hypertension guidelines

The ACC/AHA hypertension guidelines cover virtually all aspects of the diagnosis, evaluation, monitoring, secondary causes as well as drug and non-drug treatment of hypertension. Substantial and appropriate emphasis has been given to the strategies necessary for accurate measurement of blood pressure in any setting where valid blood pressure measurements are desired. Most "errors" made during blood pressure measurement bias readings upwards resulting in over-diagnosis of hypertension and, amongst those already on drug therapy, underestimating the true magnitude of blood pressure lowering resulting in over-treatment. Hypertension is diagnosed when blood pressure is consistently ≥130 and/or ≥80 mm Hg. However, the majority of patients with hypertension between 130–139/80–89 mm Hg (stage 1 hypertension) do not qualify for immediate drug therapy. The guideline breaks new ground with some of its recommendations. Absolute cardiovascular risk is utilized, for the first time, to determine high-risk status when BP 130–139/80–89 mm Hg (Stage 1 hypertension) and high-risk patient characteristics/co-morbidities are absent including age 65 and older, diabetes, chronic kidney disease, known cardiovascular disease; high-risk individuals initiate drug therapy when BP ≥ 130/80 mm Hg. The exception amongst high-risk individuals is for secondary stroke prevention in drug naïve individuals as drug therapy is initiated when blood pressure ≥140/90 mm Hg. Non-high risk individuals will initiate drug therapy when BP is ≥140/90 mm Hg. Irrespective of blood pressure threshold for initiation of drug therapy, the target BP is minimally <130/80 mm Hg in most. However, target BP is <130 systolic amongst those 65 and older as the committee made no recommendation for a DBP target. Treatment should be initiated with two drugs having complementary mechanisms of action when blood pressure is >20/10 mm Hg above goal.