- ACRONYMS AND DEFINITIONS
- AAFP - American Academy of Family Physicians
- AAP - American Academy of Pediatrics
- ACC - American College of Cardiology
- ACP - American College of Physicians
- ADA - American Diabetes Association
- AHA - American Heart Association
- BP - Blood pressure
- CAD - Coronary artery disease
- CKD - Chronic kidney disease
- CVD - Cardiovascular disease
- DBP - Diastolic blood pressure
- DM - Diabetes mellitus
- HFpEF - Heart failure with preserved ejection fraction (diastolic heart failure)
- HFrEF - Heart failure with reduced ejection fraction
- HTN - Hypertension
- JNC 8 - Eighth Joint National Committee
- KDIGO - Kidney Disease: Improving Global Outcomes
- RCT - Randomized controlled trial
- SBP - Systolic blood pressure
- AHA/ACC 2017 HYPERTENSION GUIDELINES
AHA/ACC Blood Pressure Categories | ||
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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 |
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Patients with any of the following: CVD, HFrEF, CKD, DM, 10-year risk of CVD ≥ 10%
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Patients with HFpEF
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All other patients
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AHA/ACC Medication Recommendations |
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Nonblack patients without comorbidities
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Black patients without comorbidities
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Diabetes
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Chronic kidney disease (CKD)
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Heart failure preserved ejection fraction (HFpEF)
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Atrial fibrillation
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Patients with thoracic aortic disease (e.g. aneurysms)
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Women who are pregnant or planning to become pregnant
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- JNC 8 GUIDELINES
JNC 8 Blood Pressure Goals |
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Adults without diabetes or chronic kidney disease
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Adults with diabetes or chronic kidney disease
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JNC 8 Medication Recommendations |
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Adults without chronic kidney disease
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Adults with chronic kidney disease (diabetic or other)
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- ACP/AAFP 2017 RECOMMENDATIONS FOR ADULTS ≥ 60 YEARS OLD
ACP/AAFP Recommendations for adults ≥ 60 years old |
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Adults ≥ 60 years with a history of stroke or TIA, or who are at high risk for CVD disease
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All other adults ≥ 60 years old
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Other
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2021 KDIGO blood pressure recommendations for CKD patients not on dialysis |
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Blood pressure measurement
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Lifestyle interventions for lowering BP
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BP goals
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Medication choice
Medication management
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Kidney transplant recipients
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Children with CKD
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- AAP PEDIATRIC RECOMMENDATIONS
- Screening
- Screen all children and adolescents ≥ 3 years old annually
- Screen children and adolescents ≥ 3 years at every health encounter if they have obesity, renal disease, history of aortic arch obstruction or coarctation, diabetes, or are taking medications known to increase blood pressure
- Diagnosis
- AAP definitions for blood pressure categories are defined in the table below. The second table is a quick reference guide for upper limits of normal values by age.
- In order to make a diagnosis of hypertension, auscultatory-confirmed blood pressure readings ≥ 95th percentile must be performed at 3 different visits
- Ambulatory blood pressure monitoring should be performed for confirmation of HTN in children and adolescents with office blood pressure measurements in the elevated blood pressure category for ≥ 1 year, stage 1 HTN over three clinic visits, and/or suspected white coat hypertension [6]
AAP BLOOD PRESSURE CATEGORIES | |
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Children aged 1 - 13 years | |
Normal BP |
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Elevated BP |
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Stage 1 HTN |
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Stage 2 HTN |
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Children aged ≥ 13 years | |
Normal BP |
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Elevated BP |
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Stage 1 HTN |
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Stage 2 HTN |
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Upper limits of blood pressure by age | ||
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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 |
- Workup
- All patients diagnosed with hypertension should have the following studies:
- Urinalysis
- Basic metabolic profile (BMP)
- Lipid panel
- Renal ultrasonography in those < 6 years of age or those with abnormal urinalysis or renal function
- Secondary hypertension
- Providers should look for signs and symptoms of secondary hypertension (see table below)
- Patients ≥ 6 years of age do not require an extensive evaluation for secondary causes of hypertension if they have a positive family history of hypertension, are overweight or obese, and/or do not have history or physical examination findings suggestive of secondary hypertension
SELECT CAUSES OF SECONDARY HYPERTENSION | |
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Condition | Comments |
Renal disease |
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Coarctation of the aorta |
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Obstructive sleep apnea |
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Medications / Supplements |
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Congenital adrenal hyperplasia |
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Hyperaldosteronism |
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Cushing syndrome |
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Hyperthyroidism |
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Environmental exposures |
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Neurofibromatosis |
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- Treatment
- Treatment goals
- SBP and DBP < 90th percentile or < 130/80 mmHg, whichever is lower (see pediatric BP values above)
- Medications
- Initiate therapy with one of the following:
- Other
- Children and adolescents with hypertension may participate in competitive sports once hypertensive target organ effects and cardiovascular risk have been assessed
- STUDIES | BP GOALS
- Overview
- Two very large trials have now been published that compared outcomes between lower and higher blood pressure targets. The SPRINT trial, which took place in the U.S. and was published in 2015, treated patients to a target SBP of <120 or <140 over a median of 3.26 years. The STEP trial, which took place in China and was published in 2021, treated patients to a target SBP of <130 or <150 over a median of 3.34 years. Because a previous trial had found no advantage of lower BP targets in diabetics (ACCORD), the SPRINT trial excluded diabetics, but the STEP trial did not. Both trials are detailed below.
- 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 |
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Average SBP during follow-up | 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 |
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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.
- 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 |
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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 |
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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.
- The STEP study enrolled 8511 Chinese patients 60 - 80 years old with hypertension
Main inclusion criteria
- 60 - 80 years of age
- SBP 140 - 190 mmHg or taking BP meds
- Han ethnicity
Main exclusion criteria
- History of ischemic or hemorrhagic stroke
- MI within 6 months
- PCI or CABG within 12 months
- NYHA class III - IV heart failure
- HgA1C > 8%
Baseline characteristics
- Average age 66 years
- Average BMI - 26
- Average BP - 146/82
- Diabetes - 19%
- History of CVD - 6.3%
- Current smoker - 16%
Randomized treatment groups
- Group 1 (4243 patients): SBP target of 110 to <130 mmHg (Intensive group)
- Group 2 (4268 patients): SBP target of 130 to <150 mmHg (Standard group)
- Treatment was standardized with an algorithm that included olmesartan, amlodipine, and HCTZ
- Patients were seen every 3 months, and all were given home BP machines that uploaded readings to a data center. Patients were required to measure their home BP at least once a week.
Primary outcome: Composite of stroke (ischemic or hemorrhagic), acute coronary syndrome (acute myocardial infarction and hospitalization for unstable angina), acute decompensated heart failure, coronary revascularization, atrial fibrillation, or death
from cardiovascular causes
Results
Duration: Median of 3.34 years | |||
Outcome | Intensive | Standard | Comparisons |
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Average BP during follow-up | 127/76 | 136/79 | N/A |
Average number of BP meds | 1.9 | 1.5 | N/A |
Primary outcome | 3.5% | 4.6% | HR 0.74 95%CI [0.60 - 0.92], p=0.007 |
Stroke | 1.1% | 1.7% | HR 0.67 95%CI [0.47 - 0.97] |
Acute coronary syndrome | 1.3% | 1.9% | HR 0.67 95%CI [0.47 - 0.94] |
Acute heart failure | 0.1% | 0.3% | HR 0.27 95%CI [0.08 - 0.98] |
Coronary revascularization | 0.5% | 0.7% | HR 0.69 95%CI [0.40 - 1.18] |
Atrial fib | 0.6% | 0.6% | HR 0.96 95%CI [0.55 - 1.68] |
Death from CV cause | 0.4% | 0.6% | HR 0.72 95%CI [0.39 - 1.32] |
Overall mortality | 1.6% | 1.5% | HR 1.11 95%CI [0.78 - 1.56] |
Hypotension | 3.4% | 2.6% | HR 1.31 95%CI [1.02 - 1.68], p=0.03 |
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Findings: In older patients with hypertension, intensive treatment with a systolic blood pressure target of 110 to less than 130 mmHg resulted in a lower incidence of cardiovascular events than standard treatment with a target of 130 to less than
150 mmHg
- Summary
- The SPRINT trial showed that a SBP target of <120 mmHg (compared to <140 mmHg) reduced the absolute risk of a composite CV outcome by 1.6%. Overall mortality was also significantly better with the lower target by 1.2%. The subgroup analysis that looked at patients ≥ 75 years also confirmed a benefit. Adverse events related to antihypertensives were more common in the lower target group. One weakness of the study is that treatment was not standardized, and patients in the intensive therapy group were more likely to be taking medications that have proven beneficial in heart failure, a significant component of the primary outcome (ACEIs/ARBs - 77% vs 55% | beta blockers 41% vs 31% | diuretics 67% vs 43%). While the study excluded patients with overt heart failure (EF < 35%), it's conceivable that a fair number of patients had subclinical or undiagnosed heart failure at randomization or developed it during the trial, and drug classes in the intensive regimen were more effective for this comorbidity.
- The STEP study showed that a SBP target of <130 mmHg (compared to <150 mmHg) reduced the absolute risk of a composite CV outcome by 1.1%; overall mortality was not significantly better with the lower target. Adverse events were similar between groups except for a slightly higher incidence of hypotension in the intensive group. Unlike the SPRINT trial, treatment regimens were standardized so that the distribution of drug classes between groups remained similar. The study only enrolled Chinese patients, so it is unknown how its results would translate to other populations.
- In conclusion, targeting a SBP in the range of 120 - 130 mmHg improves CV outcomes when compared to a target of 130 - 140 mmHg. In practice, many patients are intolerant of lower blood pressure targets, but for those without issues, a benefit may be seen.
- STUDIES | MORNING VS EVENING DOSING
- Overview
- In most people, blood pressure tends to run higher in the morning when cortisol levels rise. Cardiovascular events are also more common during this time. Most blood pressure medications are taken once daily, meaning trough levels occur about 24 hours after dosing. Morning dosing of blood pressure medications causes the highest window of CV risk to coincide with the lowest levels of drugs. Taking medications at bedtime so that levels are higher in the morning could theoretically reduce the risk of CV events.
- The two large trials detailed below compared CV events between people assigned to take their blood pressure medications in the morning versus the evening
- STUDY
- Design: Randomized controlled trial (N=19,084 | length = median 6.3 years) in patients with hypertension being treated with ≥ 1 antihypertensive medication(s)
- Treatment: Take all BP medications at bedtime vs Take all BP meds upon awakening
- Primary outcome: Composite of myocardial infarction, coronary revascularization, heart failure, ischaemic stroke, haemorrhagic stroke, and CVD death
- Results:
- Primary outcome: Bedtime to awakening hazard ratio 0.55 (95%CI [0.50–0.61]), p <0.001
- Findings: Routine ingestion by hypertensive patients of ≥ 1 prescribed BP-lowering medications at bedtime, as opposed to upon waking, results in improved ambulatory BP control (significantly enhanced decrease in asleep BP and increased sleeptime relative BP decline, i.e. BP dipping) and, most importantly, markedly diminished occurrence of major CVD events.
- STUDY
- Design: Randomized controlled trial (N=21,104 | length = median 5.2 years) in adults with hypertension taking at least one antihypertensive
- Treatment: Take all BP meds in the morning (0600 - 1000 h) vs Take all BP meds in the evening (2000 - 0000 h)
- Primary outcome: Composite of vascular death or hospitalization for non-fatal myocardial infarction or non-fatal stroke
- Results:
- Primary outcome: Morning - 3.7%, Evening - 3.4% (p=0.53)
- Findings: Evening dosing of usual antihypertensive medication was not different from morning dosing in terms of major cardiovascular outcomes. Patients can be advised that they can take their regular antihypertensive medications at a convenient time that minimizes any undesirable effects.
- Summary
- The two trials above had conflicting results, with one finding a benefit with evening dosing and the other finding no effect. Both studies were very large and similar in design, so it's difficult to favor one over the other. Additional trials evaluating the morning versus evening effect are currently underway. Given the current evidence, patients should be advised to take their medications at whatever time optimizes their compliance.
- STUDIES | BLACKS
- STUDY
- Design: Randomized controlled trial (N=621 | length = 6 months) in black patients with uncontrolled hypertension
- Treatment: Amlodipine 10 mg/HCTZ 25 mg vs Amlodipine 10 mg/Perindopril 8 mg vs Perindopril 8 mg/HCTZ 25 mg
- Primary outcome: Change in the 24-hour ambulatory systolic blood pressure between baseline and 6 months
- Results:
- Primary outcome: Amlodipine/HCTZ was 3.14 mmHg lower than Perindopril/HCTZ (p=0.03). Amlodipine/Perindopril was 3.00 mmHg lower than Perindopril/HCTZ (p=0.04). There was no significant difference between Amlodipine/HCTZ and Amlodipine/Perindopril (p=0.92)
- Findings: These findings suggest that in black patients in sub-Saharan Africa, amlodipine plus either hydrochlorothiazide or perindopril was more effective than perindopril plus hydrochlorothiazide at lowering blood pressure at 6 months.
- BIBLIOGRAPHY
- 1 - PMID 24352797
- 2 - PMID 25829340
- 3 - PMID 28135725 - Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians, Annals of Internal Medicine (2017)
- 4 - ADA Standards of Medical Care in Diabetes 2016
- 5 - PMID 27979887 - ADA Standards of Medical Care in Diabetes - 2017: Summary of Revisions
- 6 - PMID 28827377 - Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, Pediatrics (2017)
- 6 - PMID 29133356 - 2017 ACC/AHA 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. Hypertension (2017)
- 7 - ADA 2019 Standards of Medical Care in Diabetes
- 8 - PMID 34152826 - Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice Guideline, Ann Intern Med (2021)