Aha Hypertension Guidelines 2022 Pdf Download

Hypertension is one of the leading causes of death globally each year, accounting for up to 30% of myocardial infarctions. Although the prevalence of hypertension is increasing, many patients are underdiagnosed and undertreated. The International Society of Hypertension (ISH) has published summary guidelines based on major international guidelines published between 2017 and 2020 on the control of hypertension. These summary guidelines include essential recommendations and suggestions for optimal care.

Because blood pressure (BP) readings vary by measurement technique, diagnostic criteria are specific to the technique (Table 1). In health care settings that include the physician's office, hypertension is diagnosed when BP is 140/90 mm Hg or greater, ideally using an electronic device and following standard protocols for measurement, including repeat measurements.

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The ISH recommends categorizing grade 1 hypertension for BP levels less than 160/100 mm Hg and grade 2 hypertension for any higher BP levels. Hypertension should only be diagnosed from a single BP reading if the measurement is 180/110 mm Hg or higher with evidence of cardiovascular disease requiring immediate treatment. Otherwise, the patient should be reassessed every one to four weeks to confirm BP elevations.

Although outpatient office measurements continue to be the most common means of diagnosing hypertension, home and ambulatory readings are more consistent and better reflect hypertension-mediated organ damage risk. Out-of-office readings can differentiate white coat hypertension, with elevated office measurements, and masked hypertension, where measurements are lower in the office.

When BP is measured at home, hypertension is diagnosed if readings are consistently 135/85 mm Hg or greater. With 24-hour ambulatory monitoring, hypertension is diagnosed based on one of three criteria: 24-hour average BP of 130/80 mm Hg or greater, daytime average BP of 135/85 mm Hg or greater, or nighttime average BP of 120/70 mm Hg or greater.

After diagnosing hypertension, further assessment is recommended to identify cardiovascular risk factors and signs of hypertension-mediated organ damage. The cardiovascular risk factors of diabetes mellitus, dyslipidemia, obesity, or nicotine use affect one-half of people with hypertension. In addition to history and physical examination, a cost-effective assessment includes serum chemistry levels, fasting glucose level, fasting lipid panel, urinalysis, and electrocardiography. Cardiovascular risk should be estimated using a calculator such as the Framingham Risk Score ( -risk-score-hard-coronary-heart-disease). Other studies, such as echocardiography, renal artery evaluation, or brain imaging, are not routinely recommended.

Lifestyle modifications are essential for managing hypertension, and optimal treatment starts with diet and activity. Dietary changes include salt reduction, moderation of alcohol consumption, and a diet high in vegetables and fruit that is low in added sugars and saturated fats (e.g., DASH diet). Activity recommendations include aerobic and resistance exercises for at least 30 minutes or more at least five days per week. Other important modifications include smoking cessation and stress reduction (Table 2).

Because medications require long-term adherence, initiating medication can be delayed in many cases. When patients have grade 1 hypertension without cardiovascular disease, chronic kidney disease, diabetes, or signs of organ damage, lifestyle therapy for three to six months is recommended. Pharmacotherapy should be started if BP remains uncontrolled, especially in patients 50 years or older. Treatment should be initiated immediately in patients with comorbidities or grade 2 hypertension, if possible.

A single antihypertensive is recommended in low-risk grade 1 hypertension or in patients 80 years or older. Otherwise, low-dose combination therapy should be initiated, most often an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker combined with a dihydropyridine calcium channel blocker. Increasing to full-dose treatment should be considered before adding a third anti-hypertensive, usually a thiazide-like diuretic if not already selected. Adding spironolactone is the next step, if full-dose treatment with three medications is ineffective. Beta blockers are not recommended unless indicated for other medical conditions.

Secondary hypertension affects up to 10% of people with hypertension. Secondary causes should be considered in patients 30 years or younger, especially without comorbidities, and any patient with resistant hypertension, sudden deterioration in control, severe BP elevations, or clinical signs of a cause for the secondary hypertension. Pseudo-secondary hypertension caused by nonadherence and drug-induced hypertension should be excluded before the evaluation. This evaluation should be guided by clinical presentation instead of a battery of tests.

Rather than 1 in 3 U.S. adults having high blood pressure (32 percent) with the previous definition, the new guidelines will result in nearly half of the U.S. adult population (46 percent) having high blood pressure, or hypertension. However, there will only be a small increase in the number of U.S. adults who will require antihypertensive medication, authors said. These guidelines, the first update to offer comprehensive guidance to doctors on managing adults with high blood pressure since 2003, are designed to help people address the potentially deadly condition much earlier.

The new guidelines stress the importance of using proper technique to measure blood pressure. Blood pressure levels should be based on an average of two to three readings on at least two different occasions, the authors said.

Paul K. Whelton, M.B., M.D., M.Sc., lead author of the guidelines published in the American Heart Association journal, Hypertension and the Journal of the American College of Cardiology, noted the dangers of blood pressure levels between 130-139/80-89 mm Hg.

The new guidelines eliminate the category of prehypertension, which was used for blood pressures with a top number (systolic) between 120-139 mm Hg or a bottom number (diastolic) between 80-89 mm Hg. People with those readings now will be categorized as having either Elevated (120-129 and less than 80) or Stage I hypertension (130-139 or 80-89).

The impact of the new guidelines is expected to be greatest among younger people. The prevalence of high blood pressure is expected to triple among men under age 45, and double among women under 45 according to the report.

Only prescribing medication for Stage I hypertension if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease or calculation of atherosclerotic risk (using the same risk calculator used in evaluating high cholesterol).

The new guidelines were developed by the American Heart Association, American College of Cardiology and nine other health professional organizations. They were written by a panel of 21 scientists and health experts who reviewed more than 900 published studies. The guidelines underwent a careful systematic review and approval process. Each recommendation is classified by the strength (class) of the recommendation followed by the level of evidence supporting the recommendation. Recommendations are classified I or II, with class III indicating no benefit or harm. The level of evidence signifies the quality of evidence. Levels A, B, and C-LD denote evidence gathered from scientific studies, while level C-EO contains evidence from expert opinion.

The new guidelines are the successor to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7), issued in 2003 and overseen by the National Heart, Lung, and Blood Institute (NHLBI). In 2013, the NHLBI asked the AHA and ACC to continue the management of guideline preparation for hypertension and other cardiovascular risk factors.

About the American College of Cardiology

The American College of Cardiology is the professional home for the entire cardiovascular care team. The mission of the College and its more than 52,000 members is to transform cardiovascular care and to improve heart health. The ACC leads in the formation of health policy, standards and guidelines. The College operates national registries to measure and improve care, offers cardiovascular accreditation to hospitals and institutions, provides professional medical education, disseminates cardiovascular research and bestows credentials upon cardiovascular specialists who meet stringent qualifications. For more, visit acc.org or follow @ACCinTouch on Twitter and Facebook.

In 2015, the US Preventive Services Task Force (USPSTF) reviewed the evidence for screening for hypertension in adults and issued an A recommendation.2 The USPSTF has decided to use a reaffirmation deliberation process to update this A recommendation. The USPSTF uses the reaffirmation process for well-established, evidence-based standards of practice in current primary care practice for which only a very high level of evidence would justify a change in the grade of the recommendation.3 In its deliberation of the evidence, the USPSTF considers whether any new evidence is of sufficient strength and quality to change its previous conclusions about the evidence.

Initial screening for hypertension should be performed with office blood pressure measurement (OBPM). Office blood pressure measurement is most commonly performed using a manual or automated sphygmomanometer.8,9 Various OBPM protocols are available; however, in the studies reviewed by the USPSTF, OBPM was measured at the brachial artery (upper arm) with the patient most commonly in a seated position after 5 minutes of rest and medical personnel present during measurement.8,9 Ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) with validated and accurate devices should be used outside of a clinical setting to confirm a diagnosis of hypertension before starting treatment. Ambulatory blood pressure monitoring involves wearing a programmed device that automatically takes frequent blood pressure measurements over the course of a day (or day and night); HBPM involves patients measuring their own blood pressure at home with an HBPM device. 17dc91bb1f