Almost half the US adult population (46%) will qualify for a diagnosis of hypertension under updated guidelines from the American Heart Association (AHA) and American College of Cardiology (ACC). The guidelines recommend:
A new threshold for diagnosing hypertension of 130 mmHg systolic or 80 mmHg diastolic blood pressure (adults with systolic of 130-139 mmHg or diastolic of 80-89 mmHg would previously have been classified as having pre-hypertension). The new blood pressure categories are: elevated (120-129/<80 mmHg); stage 1 hypertension (130-139/80-89 mmHg); and stage 2 hypertension (≥140/90 mmHg).
Overall cardiovascular risk should be used to guide decisions on whether to treat in patients with stage 1 hypertension. Antihypertensives are now recommended for primary prevention of cardiovascular disease in any patient with stage 1 hypertension whose 10-year atherosclerotic cardiovascular disease risk score is 10% or higher.
The blood pressure goal for most patients is now 130/80 mmHg (previously 140/90 mmHg).
Publication of the guidelines has prompted widespread debate, with some expert commentators highlighting the disparities between these new AHA/ACC recommendations and the less aggressive approach to diagnosis and treatment of hypertension set out in the 2014 JNC8 guidelines. Listen to our podcast for more on the controversy.
Typically diagnosed by screening of an asymptomatic individual.
Treatment of uncontrolled hypertension reduces the risks of mortality and of cardiac, vascular, renal, or cerebrovascular complications.
Lifestyle changes are recommended for all patients: weight loss, exercise, decreased sodium intake, and moderation of alcohol consumption.
Choice of drug therapy is often driven by considerations related to comorbid disease, but achievement of BP goal may be accomplished with a variety of therapeutic agent(s).
Essential hypertension is defined as BP ≥140/90 mmHg, with no secondary cause identified.     The main goal of treatment is to decrease the risk of mortality and of cardiovascular and renal morbidity. 
The Eighth Joint National Committee (JNC 8) guideline recommends starting pharmacological treatment in patients with chronic kidney disease and diabetes if BP ≥140/90 mmHg.  In the general population aged ≥60 years, treatment to lower blood pressure should begin when BP ≥150/90 mmHg. The latter recommendation was not agreed upon by all panel members because of the risk of cardiovascular events associated with BP ≥140/90 mmHg.
In the 2013 European Society of Hypertension (ESH) and European Society of Cardiology (ESC) guidelines, target BP is defined as <140/85 mmHg in patients with type 2 diabetes mellitus and <140/90 mmHg in all other patients.  This supersedes the earlier ESH/ESC target of <130/80 mmHg for patients with diabetes mellitus,  which was not supported by evidence from randomised controlled trials. In two trials and one meta-analysis, benefit was apparent when diastolic BP was reduced to between 80 and 85 mmHg.    None of these studies reduced systolic BP below 130 mmHg.
Blood pressure goals and recommendations continue to evolve in line with new evidence.
The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline defines hypertension as any systolic blood pressure measurement of 130 mmHg or higher or any diastolic BP measurement of 80 mmHg or higher.  This definition differs from the JNC 8, ESH, and ESC guidelines.
The SPRINT trial (Systolic Blood Pressure Intervention Trial) found that a lower systolic target of 120 mmHg (as measured by automated office blood pressure) reduced cardiovascular complications and deaths in people aged over 50 years with high blood pressure and at least one additional risk factor for heart disease.   Patients with diabetes or stroke were excluded from the trial.
Internal Medicine and Assistant Area Medical Director
JB declares that he has no competing interests.
Dr Jeffrey Brettler would like to gratefully acknowledge Dr Joel Handler, Dr Jonathan N. Bella, Dr Moustapha Atoui, Dr Liran Blum, and Dr Michael A. Spinelli, previous contributors to this topic. JH, JNB, MA, LB, and MAS declare that they have no competing interests.
Clinical Senior Lecturer in Clinical Pharmacology and Honorary Consultant Physician
University of Dundee
IM is an elected member of the British Hypertension Society Executive Committee.
Department of Cardiology
University of Texas MD Anderson Cancer Center
SWY declares that he has no competing interests.
Director Barts Blood Pressure Centre of Excellence
NHS Reader in Cardiovascular Medicine
Department of Clinical Pharmacology
William Harvey Heart Centre
ML is a consultant for ROX Medical. ML receives honorarium from Cardiosonic, St. Jude Medical, and institutional grant/research support from Medtronic.
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