Clinical Review & Education
JAMA Clinical Guidelines Synopsis
Prevention, Detection, Evaluation, and Management
of High Blood Pressure in Adults
Adam S. Cifu, MD; Andrew M. Davis, MD, MPH
GUIDELINE TITLE 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
DEVELOPER American College of Cardiology (ACC) and
American Heart Association (AHA)
RELEASE DATE November 13, 2017
PRIOR VERSION 2003 (Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure [JNC 7])
FUNDING SOURCE ACC/AHA
TARGET POPULATION Patients with or at risk of developing
cardiovascular disease (CVD)
MAJOR RECOMMENDATIONS
1. Diagnosis
a. Blood pressure (BP) should be categorized as normal
(<120/80 mm Hg), elevated (120-129/<80 mm Hg), stage 1
hypertension (130-139/80-89 mm Hg), or stage 2
hypertension (ⱖ140/90 mm Hg) (strong recommendation;
moderate-quality evidence).
b. Out-of-office BP measurements are recommended to
confirm the diagnosis of hypertension and for titration
of BP-lowering medication in conjunction with
telehealth counseling or clinical interventions
(strong recommendation; high-quality evidence).
Summary of the Clinical Problem
Hypertension is a leading risk factor for mortality and disability. Re-
cent estimates are that 874 million adults worldwide have an SBP
of 140 mm Hg or higher.1,2 With its association with CVD, stroke (cere-
brovascular accident [CVA]),
heart failure, and chronic kid-
Viewpoint and Editorial ney disease (CKD), hyperten-
sion is second only to cigarette
smoking as a preventable cause of death in the United States.3 Given
demographic trends and the increasing prevalence of hyperten-
sion with increasing age (79% of men and 85% of women >75 years
old have hypertension), the consequences of hypertension are ex-
pected to increase.1,2
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2. Initiating therapy
a. Many nonpharmacologic interventions that are effective
in lowering BP are recommended for people with
elevated BP or hypertension (strong recommendation;
high-quality evidence).
b. Blood pressure–lowering medication is recommended
for patients with clinical CVD or an estimated 10-year
atherosclerotic CVD (ASCVD) risk of 10% or higher who
have a systolic BP (SBP) of 130 mm Hg or higher or a
diastolic BP (DBP) of 80 mm Hg or higher (strong
recommendation; high-quality evidence [for SBP] and
expert opinion [for DBP]).
c. For patients with no history of CVD and an ASCVD risk of
less than 10%, BP-lowering medication is recommended
for patients who have an SBP of 140 mm Hg or higher or
a DBP of 90 mm Hg or higher (strong recommendation;
low-quality evidence).
3. Management
a. In patients with CVD or ASCVD event risk of 10% or
higher, a BP target of less than 130/80 mm Hg is
recommended (strong recommendation;
moderate-quality evidence [for SBP] and expert
opinion [for DBP]). A BP target of less than 130/80 mm Hg
may also be reasonable in low-risk patients (weak
recommendation; moderate-quality evidence [for SBP]
and expert opinion [for DBP]).
b. In patients warranting pharmacotherapy, thiazide
diuretics, calcium channel blockers (CCBs), and
angiotensin-converting enzyme (ACE) inhibitors
or angiotensin II receptor blockers (ARBs) are
recommended as first-line agents (strong recommendation;
high-quality evidence).
c. Patients with stage 2 hypertension and an average BP of
more than 20/10 mm Hg above their BP target should
begin therapy with 2 first-line agents of different classes
(strong recommendation; expert opinion).
Characteristics of the Guideline Source
This guideline was developed by the ACC and the AHA in partner-
ship with other professional societies. The ACC/AHA Task Force on
Clinical Practice Guidelines selected a writing committee that was
notable for its inclusion of people with a breadth of backgrounds,
wide scope of practice, and freedom from conflicts of interest. This
writing committee reviewed the relevant evidence and commis-
sioned an independent evidence review committee to conduct for-
mal systematic reviews regarding 4 questions of critical impor-
tance. The guideline document was reviewed by individuals
representing the partner specialty societies and other content re-
viewers. The writing committee was aware of any conflicts of inter-
est among reviewers (Table).
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Evidence Base
The guideline provides a comprehensive overview of the diagnosis
and therapy of hypertension with 106 graded recommendations di-
vided into 47 “modular knowledge chunks.” The 8 recommenda-
tions covered in this JAMA Clinical Guidelines Synopsis were cho-
sen for their clinical relevance.
This guideline recommends classifying BP into 4 categories: nor-
mal (<120/80 mm Hg); elevated (120-129/<80 mm Hg); stage 1 hy-
pertension (130-139/80-89 mm Hg); and stage 2 hypertension
(ⱖ140/ⱖ90 mm Hg). This categorization is designed to facilitate
clinical and public health decision making and to reflect observa-
tional data suggesting a gradient in CVD risk as BP increases from
normal to elevated to hypertension stages 1 and 2.1,2
In a change from current practice, the guideline recommends rou-
tine use of out-of-office BP measurements (home or ambulatory BP
monitoring) in the diagnosis and treatment of hypertension. This rec-
ommendation reflects the known frequent inconsistencies be-
tween office and home BP values (there is extensive discussion of
masked hypertension and white-coat hypertension in the guide-
line) and acknowledges that the tighter BP goals recommended in
this guideline may require closer BP monitoring. The evidence for this
recommendation was reviewed in one of the commissioned system-
atic reviews.4 Compared with usual care, patients using home BP
monitoring had a greater reduction in office SBP at 6 months vs office-
measured BP (4.9 [95% CI, 1.3-8.6] mm Hg). This result did not per-
sist at 12 months. There was also no evidence of clinical benefit.
Nonpharmacologic interventions are strongly supported in the
guideline for their primary and complementary effect in lowering BP.
These interventions include weight loss in patients who are over-
weight or obese; a heart-healthy diet, such as the DASH (Dietary Ap-
proaches to Stop Hypertension) diet; sodium reduction; potassium
supplementation; increased physical activity; and moderation of al-
cohol consumption. Most of these interventions have been shown in
randomized trials to reduce SBP by 5 to 10 mm Hg. Weight loss has
been shown to decrease BP by about 1 mm Hg per 1 kg of weight loss.1,2
Adoption of the DASH diet yielded an 11-mm Hg decrease in SBP.5
Initiation of pharmacologic therapy for hypertension is recom-
mended for patients with or at high risk of CVD at BP levels of 130/80
mm Hg or higher. Therapy is recommended for patients without and at
low risk of CVD at 140/90 mm Hg or higher. To stratify risk, the guide-
linerecommendsusinganASCVDriskscore(theestimated10-yearrisk
of myocardial infarction, CVA, or coronary heart disease death) of 10%.
Thisriskstratificationhasbeenusedinotherrecenthypertensionguide-
lines (referenced in this guideline) and could help translate group-level
evidence from trials to individual patients.6 The lower systolic thresh-
old for individuals with or at high risk of CVD is well supported by data
from a patient-level meta-analysis.7
Therecommendationtoinitiatepharmacologictherapyinpatients
without and at low risk of CVD at BPs ⱖ140/90 is unchanged from the
JNC 7 and JNC 8 recommendations. The evidence for this recommen-
dationisstrongbutmostlyindirect.Themostdirectevidencemaycome
fromameta-analysisofpatientswithoutCVDandwithBPlevelsof140/
90 to 159/99 mm Hg who were randomly assigned to an antihyperten-
sive vs a control (placebo in 95%; less intensive regimen in 5%) BP-
lowering regimen.8 The odds ratios for events over the 5 years in this
studywere0.72(95%CI,0.55-0.94)forstroke,0.75(95%CI,0.57-0.98)
for cardiovascular death, and 0.78 (95% CI, 0.67-0.92) for overall mor-
tality.Benefitsfortotalcardiovascularevents,coronaryevents,andheart
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JAMA Clinical Guidelines Synopsis Clinical Review & Education
Table. Guideline Rating
Standard Rating
Establishing transparency Good
Management of conflict of interest in the guideline development group Good
Guideline development group composition Good
Clinical practice guideline–systematic review intersection Fair
Establishing evidence foundations and rating strength Good
for each of the guideline recommendations
Articulation of recommendations Good
External review Good
Updating Good
Implementation issues Good
failure did not reach statistical significance. Notably, the BP difference
in this study between treatment and control groups was only 3.6/2.4
mm Hg and 96% of the patients had diabetes mellitus.
The appropriate target BP for high-risk patients with hyperten-
sion has been the subject of many large trials over the last decade.
This was the focus of another systematic review commissioned for
this guideline.4 In an analysis limited to trials that compared an SBP
target of less than 130 mm Hg with any higher target, patients ben-
efited in terms of major cardiovascular events (relative risk [RR],
0.84; 95% CI, 0.73-0.99) and stroke (RR, 0.82; 95% CI, 0.70-
0.96) but not myocardial infarction (RR, 0.85; 95% CI, 0.73-1.00)
or all-cause mortality (RR, 0.92; 95% CI, 0.79-1.06). Similar to the
data on initiating therapy, very little information from clinical trials
is available to guide recommendations about treating DBP. The rec-
ommendation for low-risk patients was graded as weak and was
based on moderate-quality evidence and expert opinion (for SBP and
DBP, respectively). There are few data on low-risk patients be-
cause trials that evaluate intensive BP control generally enroll high-
risk patients who have comorbid conditions such as diabetes or CKD.
Recommendations regarding the choice of initial pharmacologic
therapy for hypertension were based on another commissioned sys-
tematic review.4 The network meta-analysis examined trials that com-
pared any 2 of the antihypertensive classes: thiazides, ACEIs, ARBs,
CCBs, and β-blockers. A total of 152 379 patients were included in this
meta-analysis, with an average of 3.5 years of follow-up. The meta-
analysis found that in terms of all-cause mortality, all classes were simi-
lar. Analysis of secondary end points (such as CVA, cardiovascular
events, and heart failure) demonstrated that thiazides had added ben-
efit. The authors of the guideline recommended thiazide diuretics,
CCBs, ACE inhibitors, or ARBs as first-line agents. Detailed recommen-
dations are included for initial antihypertensive therapy for patients
with numerous comorbidities including CAD, heart failure, CKD, acute
stroke, and hypertensive emergency, among others.
The recommendation for the use of 2 first-line agents of different
classesforpatientswithstage2hypertensionremainsunchangedsince
JNC 7. The recommendation rests on expert opinion based on studies
using fixed-dose combinations that show greater BP lowering and bet-
ter adherence to therapy with fixed-dose combinations.1,2
Benefits and Harms
From a public health perspective, considering the high population-
attributableriskofCVDassociatedwithhypertension,thepotentialben-
efits of tighter control of hypertension are substantial. The potential
harms associated with the adoption of this guideline are the adverse
(Reprinted) JAMA Published online November 20, 2017 E2
 Clinical Review & Education JAMA Clinical Guidelines Synopsis

effects of medications and tight BP and the costs of overuse (medica-
tionandhomeBPmonitors)ifthetreatmentthresholdsandtargetsare
shown to be overly aggressive. In the ACCORD trial, there was an in-
crease in serious adverse events attributable to BP medications (3.3%
vs 1.27%; P < .001).9 Although there was no overall increase in adverse
events in the SPRINT trial, there were increases in hypotension (2.4%
vs 1.4%; P < .001) and syncope (2.3% vs 1.7%; P = .05).10
Discussion
Hypertension guidelines have substantially evolved since the publi-
cation of JNC 7 in 2003. The JNC 7 categorized stage 1 hypertension
as a BP of 140-159/90-99 mm Hg and recommended 140/90 mm Hg
as the threshold for initiation of antihypertensive drug therapy in the
generaladultpopulationand130/80mmHgorhigherforpatientswith
diabetes or CKD. The JNC 8, published in 2014, recommended that
for people aged 60 years or older, pharmacologic therapy should be
initiated at a BP of 150/90 mm Hg or higher and treated to a goal of
less than that number. Recent randomized trials as well as observa-
tional and modeling studies support the idea that lower treatment
thresholds and targets are beneficial in higher-risk patients, since pro-
gressively greater absolute risk reductions occur as baseline risk
increases.4 A recent commentary reflected these findings.11
Although studies do suggest that lower BP is better for most pa-
tients, including those older than 75 years, the balance of the poten-
Within-Guideline Resources
tial benefits of hypertension management and medication costs, ad-
verse effects, and polypharmacy must be considered for each
individual patient. Shared decision making between patients and their
clinicians is required to arrive at an optimal treatment plan for each
patient.Thereislittlehigh-qualityevidenceintheliteratureaboutsome
patient populations, most notably the frail elderly. Chobanian has re-
cently commented on treatment in elderly persons.11 In addition, the
guideline strongly supports team-based, electronic medical record,
and population health approaches to BP control.
Areas in Need of Future Study or Ongoing Research
Future antihypertensive trials should be designed and adequately
powered for clinical end points. Because lower BP is associated with
better outcomes, future trials should refine knowledge regarding the
balance between harms and benefits of BP treatment. This is espe-
cially true for stage 1 hypertension, for which there is little informa-
tion regarding the balance between harms and benefits of treat-
ment. Trials of multifaceted interventions that include out-of-office
BP measurements are critical to understanding whether incorporat-
ing these measurements in management decisions will prove truly
beneficial. Tailoring BP treatment thresholds to individual cardiovas-
cular risk is attractive in that it could concentrate efforts on patients
whowillobtainthemostbenefit;however,itispossiblethatthegreater
complexity of applying guidelines based on ASCVD risk could under-
mine the expected benefit. Electronic health record support that cal-
culates and trends individual ASCVD risk may reduce this burden in
clinical practice and is a promising area for exploration.

This extensive guideline includes multiple resources that are useful

to the practicing physician. Some include
Table 18. Oral Antihypertensive Drugs (pp 94-96)
Figure 10. Resistant Hypertension: Diagnosis, Evaluation, and
Treatment (p 162)
Figure 3. Screening for Secondary Hypertension (p 51)
Table 10. Procedures for the Use of Home BP Monitoring (p 33)
Section 9. Hypertension in Patients With Comorbidities (pp 108-147)
Related Guidelines and Other Resources
Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure
Eighth Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure
2017 ACC/AHA Guideline—20-Page Summary
ASCVD Risk Estimator

ARTICLE INFORMATION
Author Affiliations: University of Chicago,
Chicago, Illinois.
Corresponding Author: Adam S. Cifu, MD,
University of Chicago, 5841 S Maryland Ave, MC
3051, Chicago, IL 60637 (adamcifu@uchicago.edu).
Published Online: November 20, 2017.
doi:10.1001/jama.2017.18706
Conflict of Interest Disclosures: The authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
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