People with hypertension should have their absolute cardiovascular risk used in discussions about prognosis and decisions about management options.
Whelton PK, Carey RM, Aronow WS, Casey Jr DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith Jr SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams Sr KA, Williamson JD, Wright Jr JT, 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, Journal of the American College of Cardiology (2017), doi: 10.1016/j.jacc.2017.11.006
1.Use of BP-lowering medications is recommended for secondary prevention
of recurrent CVD events in patients with clinical CVD and an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher, and for primary prevention in adults with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average SBP 130 mm Hg or higher or an average DBP 80 mm Hg or higher (1-9).
2.Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher (3, 10-13).
National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults – 2016. Melbourne: National Heart Foundation of Australia, 2016.
For patients at low absolute CVD risk (>10% 5-year risk) with persistent blood pressure ≥ 160/100 mmHg, antihypertensive therapy should be started.
For patients at moderate absolute CVD risk (10-15% 5-year risk) with persistent blood pressure ≥ 140mmHg systolic and/or ≥ 90 mmHg diastolic, antihypertensive therapy should be started.
National Institute for Health and Care Excellence (NICE). Hypertension in adults: Diagnosis and management 2011. Available from: nice.org.uk/guidance/cg127. Accessed: August 2017.
Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors.
Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.
Leung AA, Nerenberg K, Daskalopoulou SS, et al. Hypertension Canada’s 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension. Can J Cardiol. 2016; 32(5): 569-588. doi: 10.1016/j.cjca.2016.02.066.
Antihypertensive therapy should be prescribed for average DBP measurements of >= 100 mm Hg (Grade A) or average SBP measurements of >= 160 mm Hg (Grade A) in patients without macrovascular target organ damage or other cardiovascular risk factors.
Antihypertensive therapy should be strongly considered if DBP readings average >= 90 mm Hg in the presence of macrovascular target organ damage or other independent cardiovascular risk factors (Grade A).
Antihypertensive therapy should be strongly considered if SBP readings average >= 140 mm Hg in the presence of macrovascular target organ damage (Grade C for 140-160 mm Hg; Grade A for > 160 mm Hg).
Consider informing patients of their global risk to improve the effectiveness of risk factor modification (Grade B). Consider also using analogies that describe comparative risk such as “cardiovascular age,” “vascular age,” or “heart age” to inform patients of their risk status (Grade B).
The magnitude of changes in nocturnal BP should be taken into account in any decision to prescribe or withhold drug therapy on the basis of ambulatory BP monitoring (Grade C) because a decrease in nocturnal BP of < 10% is associated with increased risk of cardiovascular events.
Mancia G, Fagard R, Narkiewicz K, et al. 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. J Hypertens. 2013; 31(10): 1925–1938. DOI:10.1097/HJH.0b013e328364ca4c
Initiation of antihypertensive drug treatment should also be considered in grade 1 hypertensive patients at low to moderate risk, when BP is within this range at several repeated visits or elevated by ambulatory BP criteria, and remains within this range despite a reasonable period of time with lifestyle measures.
Antihypertensive drug treatment may also be considered in the elderly (at least when younger than 80 years) when SBP is in the 140–159 mmHg range, provided that antihypertensive treatment is well tolerated.
Lowering BP with drugs is also recommended when total CV risk is high because of OD, diabetes, CVD or CKD, even when hypertension is in the grade 1 range.
Prompt initiation of drug treatment is recommended in individuals with grade 2 and 3 hypertension with any level of CV risk, a few weeks after or simultaneously with initiation of lifestyle changes.
In elderly hypertensive patients drug treatment is recommended when SBP is ≥160 mmHg.