HYPERTENSION GUIDELINES









  • Hypertension is present if either SBP or DBP meet criteria
AHA/ACC Blood Pressure Categories
Category SBP (mmHg) DBP (mmHg)
Normal < 120 < 80
Elevated 120 - 129 < 80
Stage 1 hypertension 130 - 139 80 - 89
Stage 2 hypertension ≥ 140 ≥ 90

AHA/ACC BP Treatment Recommendations
Patients with any of the following: CVD, HFrEF, CKD, DM, 10-year risk of CVD ≥ 10%
  • Treat with medications if average SBP ≥ 130 mmHg
  • Treat with medications if average DBP ≥ 80 mmHg
  • Use ACC/AHA risk estimator to estimate 10-year risk
Patients with HFpEF
  • Treat with medication if average SBP ≥ 130 mmHg
All other patients
  • Treat with medication if average SBP ≥ 140 mmHg
  • Treat with medication if average DBP ≥ 90 mmHg

  • Reference [7]
AHA/ACC Medication Recommendations
Nonblack patients without comorbidities
  • Use one of the first-line therapies below
  • Two first-line agents are recommended in stage 2 hypertension for patients with an average BP ≥ 20/10 mmHg above their BP target
Black patients without comorbidities
  • Thiazide diuretic or calcium channel blocker is preferred
  • A randomized controlled trial published in 2019 found that amlodipine was superior to an ACE inhibitor and HCTZ for lowering blood pressure in black patients. See amlodipine study below.
Diabetes
  • Patients without albuminuria: Any first-line agent
  • Patients with albuminuria: ACE inhibitor or ARB
Chronic kidney disease (CKD)
  • Treatment with an ACE inhibitor is reasonable to slow kidney disease progression
  • ARB may be used if ACE inhibitor is not tolerated
Heart failure preserved ejection fraction (HFpEF)
  • Diuretics should be used first-line in patients with volume overload
  • ACE inhibitor / ARB and beta blockers can be used for further blood pressure lowering
Atrial fibrillation
  • ARBs may help prevent recurrence of A fib
Patients with thoracic aortic disease (e.g. aneurysms)
  • Beta blockers are preferred
Women who are pregnant or planning to become pregnant
  • Use methyldopa, nifedipine, and/or labetalol



JNC 8 Blood Pressure Goals
Adults without diabetes or chronic kidney disease
  • Adults < 60 years old
    • Systolic blood pressure goal < 140 mmHg
    • Diastolic blood pressure goal < 90 mmHg
  • Adults ≥ 60 years old
    • Systolic blood pressure goal < 150 mmHg
    • Diastolic blood pressure goal < 90 mmHg
Adults with diabetes or chronic kidney disease
  • Systolic blood pressure goal < 140 mmHg
  • Diastolic blood pressure goal < 90 mmHg

JNC 8 Medication Recommendations
Adults without chronic kidney disease
  • Nonblack patients
    • For patients with higher initial blood pressures (SBP > 160, DBP > 100), therapy may be initiated with 2 drugs
    • Therapy should be titrated to achieve goal
    • Dose of one drug may be maximized before adding another medication, or another medication may be added before previous drug is maximized
    • DO NOT combine ACE inhibitors and Angiotensin Receptor Blockers
    • If goal is not achieved with medications in the initial therapy group, then other medications may be added (ex. beta blockers, aldosterone antagonists, etc.)

  • Black patients
    • For patients with higher initial blood pressures (SBP > 160, DBP > 100), therapy may be initiated with 2 drugs
    • Therapy should be titrated to achieve goal
    • Dose of one drug may be maximized before adding another medication, or another medication may be added before previous drug is maximized
    • DO NOT combine ACE inhibitors and Angiotensin Receptor Blockers
    • If goal is not achieved with one medication in the initial therapy group, then other medications may be added (ex. beta blockers, aldosterone antagonists, ACE inhibitors, etc.)
Adults with chronic kidney disease (diabetic or other)
  • For patients with higher initial blood pressures (SBP > 160, DBP > 100), therapy may be initiated with 2 drugs
  • Therapy should be titrated to achieve goal
  • Dose of one drug may be maximized before adding another medication, or another medication may be added before previous drug is maximized
  • DO NOT combine ACE inhibitors and Angiotensin Receptor Blockers
  • If goal is not achieved with one of the medications in the initial therapy group, then other medications may be added (ex. thiazide diuretic, calcium channel blocker beta blockers, aldosterone antagonists, etc.)



  • Reference [3]
ACP/AAFP Recommendations for adults ≥ 60 years old
Adults ≥ 60 years with a history of stroke or TIA, or who are at high risk for CVD disease
  • Systolic blood pressure goal < 140 mmHg
  • High risk for cardiovascular disease was generally defined as any of the following:
    • Persons with known vascular disease
    • Most patients with diabetes
    • Older persons with chronic kidney disease (GFR < 45 ml/min)
    • Metabolic syndrome (abdominal obesity, hypertension, diabetes, and dyslipidemia)
    • Older persons
All other adults ≥ 60 years old
  • Systolic blood pressure goal < 150 mmHg
Other
  • Guidelines state there is insufficient evidence to make recommendations based on diastolic blood pressure
  • Accurate blood pressure measurement (home and clinic) is important before initiating treatment





  • *See table below for upper limits of normal blood pressure readings by age
  • Reference [6]
AAP BLOOD PRESSURE CATEGORIES
Children aged 1 - 13 years
Normal BP
  • < 90th percentile
Elevated BP
  • ≥90th percentile to < 95th percentile OR 120/80 mmHg to < 95th percentile (whichever is lower)
Stage 1 HTN
  • ≥ 95th percentile to < 95th percentile + 12 mmHg, OR 130/80 to 139/89 mmHg (whichever is lower)
Stage 2 HTN
  • ≥ 95th percentile + 12 mmHg, OR ≥ 140/90 mmHg (whichever is lower)
Children aged ≥ 13 years
Normal BP
  • <120/< 80 mmHg
Elevated BP
  • 120/<80 to 129/<80 mmHg
Stage 1 HTN
  • 130/80 to 139/89 mmHg
Stage 2 HTN
  • ≥140/90 mmHg

  • Blood pressure readings above these values are considered high
  • Reference [6]
Upper limits of blood pressure by age
AGE
(years)
Boys
(SBP/DBP)
Girls
(SBP/DBP)
1 98 / 52 98 / 54
2 100 / 55 101 / 58
3 101 / 58 102 / 60
4 102 / 60 103 / 62
5 103 / 63 104 / 64
6 105 / 66 105 / 67
7 106 / 68 106 / 68
8 107 / 69 107 / 69
9 107 / 70 108 / 71
10 108 / 72 109 / 72
11 110 / 74 111 / 74
12 113 / 75 114 / 75
≥ 13 120 / 80 120 / 80



  • Reference [6]
SELECT CAUSES OF SECONDARY HYPERTENSION
Condition Comments
Renal disease
  • Most common cause of secondary hypertension in children, particularly those < 6 years old
Coarctation of the aorta
  • Right arm SBP that is ≥ 20 mmHg more than the lower extremity SBP
  • Hypertension is common even after successful repair (up to 77% of patients)
  • Masked hypertension is common and ambulatory blood pressure monitoring should be performed
Obstructive sleep apnea
  • Snoring
  • Adenotonsillar hypertrophy
Medications / Supplements
  • Oral contraceptives
  • Corticosteroids and anabolic steroids
  • Herbal and nutritional supplements
  • Diet products
Congenital adrenal hyperplasia
  • Low potassium
  • Acne, hirsutism, and virilization in girls
  • Pseudoprecocious puberty in boys
Hyperaldosteronism
  • Low potassium
  • May be familial
Cushing syndrome
  • Central obesity and enlarged fat pad on upper back (buffalo hump)
  • Hirsutism and acne
  • Moon facies
  • Absent or irregular menses
Hyperthyroidism
  • Tachycardia, anxiety, sweating, heat intolerance
Environmental exposures
  • Lead, cadmium, mercury, phthalates
Neurofibromatosis
  • Cafe-au-lait macules
  • Neurofibromas
  • Lisch nodules of the iris
  • Axillary freckling




SPRINT Trial - Intensive (SBP < 120) vs Standard (SBP < 140) Blood Pressure Control for CVD Outcomes, NEJM (2015) [PubMed abstract]
  • The SPRINT trial enrolled 9361 patients with a SBP ≥ 130 mmHg who were at increased risk of cardiovascular disease
Main inclusion criteria
  • Age ≥ 50 years
  • SBP 130 - 180 mmHg
  • Increased cardiovascular risk defined as ≥ 1 of the following: clinical or subclinical cardiovascular disease (except stroke), chronic kidney disease (CrCl 20 - < 60 ml/min), 10-year heart attack risk of ≥ 15% (Framingham risk calculator), age ≥ 75 years
Main exclusion criteria
  • Diabetes
  • History of stroke
  • Symptomatic heart failure within the past 6 months or EF < 35%
Baseline characteristics
  • Average age 68 years
  • Chronic kidney disease - 28%
  • Average SBP - 140 mmHg
  • Average DBP - 78 mmHg
  • Average Framingham 10-year risk - 20%
Randomized treatment groups
  • Group 1 (4678 patients) - Target SBP < 120 mmHg (Intensive)
  • Group 2 (4683 patients) - Target SBP < 140 mmHg (Standard)
  • There was no set treatment algorithm; patients could receive any blood pressure medication(s). Certain medications were encouraged in the study protocol - thiazides as first-line agents, loop diuretics for chronic kidney disease, beta blockers for CAD. Chlorthalidone was recommended as the primary thiazide diuretic. Amlodipine was the recommended calcium channel blocker.
Primary outcome: Composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular causes
Results

Duration: After a median of 3.26 years, the study was stopped early because the intensive group was superior
Outcome Intensive Standard Comparisons
Average SBP throughout study 121.5 134.6 N/A
Average number of BP meds 2.8 1.8 N/A
Primary outcome 5.2% 6.8% HR 0.75, 95%CI [0.64 - 0.89], p<0.001
Myocardial infarction 2.1% 2.5% HR 0.83, 95%CI [0.64 - 1.09], p=0.19
Acute coronary syndrome 0.9% 0.9% HR 1.0, 95%CI [0.64 - 1.55], p=0.99
Stroke 1.3% 1.5% HR 0.89, 95%CI [0.63 - 1.25], p=0.50
Heart failure 1.3% 2.1% HR 0.62, 95%CI [0.45 - 0.84], p=0.002
Death from cardiovascular cause 0.8% 1.4% HR 0.57, 95%CI [0.38 - 0.85], p=0.005
Death from any cause 3.3% 4.5% HR 0.73, 95%CI [0.60 - 0.90], p=0.003
Hypotension 3.4% 2.0% p<0.001
Syncope 3.5% 2.4% p=0.003
Electrolyte abnormality 3.8% 2.8% p=0.006
Acute kidney injury/failure 4.4% 2.6% p<0.001
  • Medication types: ACE or ARB: Intensive - 77%, Standard - 55% | Beta blocker: Intensive - 41%, Standard - 31% | Diuretic: Intensive - 67%, Standard - 43%

Findings: Among patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group.
SPRINT Subgroup Analysis of Participants ≥ 75 Years Old at Randomization, JAMA (2016) [PubMed abstract]
  • A subgroup analysis of the SPRINT trial looked at the 2636 patients who were ≥ 75 years old at randomization

Duration: After a median follow-up of 3.14 years, the study was stopped early because the intensive group was better
Outcome Intensive Standard Comparisons
Average BP during follow-up 123/62 135/67 N/A
Average number of BP meds 2.6 1.8 N/A
Primary outcome 7.7% 11.2% HR 0.66, 95%CI [0.51 - 0.85], p=0.001
Myocardial infarction 2.8% 4.0% HR 0.69, 95%CI [0.45 - 1.05], p=0.09
Acute coronary syndrome 1.3% 1.3% HR 1.03, 95%CI [0.52 - 2.04], p=0.94
Stroke 2.1% 2.6% HR 0.72, 95%CI [0.43 - 1.21], p=0.22
Heart failure 2.7% 4.2% HR 0.62, 95%CI [0.40 - 0.95], p=0.03
Death from cardiovascular cause 1.4% 2.2% HR 0.60, 95%CI [0.33 - 1.09], p=0.09
Death from any cause 5.5% 8.1% HR 0.67, 95%CI [0.49 - 0.91], p=0.009
Hypotension event 3.3% 2.0% HR 1.66, 95%CI [1.03 - 2.73], p=0.039
Syncope 4.3% 3.3% HR 1.28, 95%CI [0.85 - 1.92], p=0.240
Electrolyte abnormality 4.6% 3.3% HR 1.44, 95%CI [0.97 - 2.16], p=0.067
Fall with injury 11.6% 14.1% HR 0.80, 95%CI [0.64 - 0.99], p=0.040
Kidney injury/failure 5.5% 4.2% HR 1.39, 95%CI [0.97 - 1.99], p=0.072
  • Medication types: ACE or ARB: Intensive - 71%, Standard - 52% | Beta blocker: Intensive - 43%, Standard - 34% | Diuretic: Intensive - 62%, Standard - 42%

Findings: Among ambulatory adults aged 75 years or older, treating to an SBP target of less than 120 mm Hg compared with an SBP target of less than 140 mm Hg resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause.