Blood Pressure Target :

Insight from New ACC/AHA Hypertension

Guideline

RIA BANDIARA
PERHIMPUNAN NEFROLOGI INDONESIA (PERNEFRI)
KOORDINATOR WILAYAH JAWA BARAT
Background
• Hypertension is the leading cause of death and disability-adjusted life-
years worldwide

• In U.S hypertension accounts for more cardiovascular disease (CVD)

deaths than any other modifiable risk factor and is second only to
cigarette smoking as a preventable cause of death for any reason

• BP of 120/80 mm Hg or higher is linearly related to risk for fatal and

nonfatal stroke, ischemic heart disease, and non cardiac vascular disease,
and each increase of 20/10 mm Hg doubles the risk for a fatal CVD event

• The 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation,

and Management of High Blood Pressure in Adults provides an evidence
based approach to reduction of CVD risk through lowering of BP
Whelton PK, et al.
2017 High Blood Pressure Clinical Practice Guideline
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

A Report of the American College of Cardiology/American Heart Association Task Force on

Clinical Practice Guidelines
2017 Guideline for the Prevention, Detection,Evaluation
and Management of High Blood Pressure in Adults

A comprehensive guideline that represents an update

of JNC7, NOT the focused JNC 8 (2014 Guideline)
 Reclassification of high BP
 BP treatment tresholds and ASCVD risk
 BP treatment goals
 Management of hypertension in patients with
comorbidities
 Recommendations for BP management in older
adults
2017 Guideline for the Prevention, Detection, Evaluation and
Management of High Blood Pressure in Adults
BP Classification (JNC 7 and ACC/AHA Guidelines)

SBP DBP JNC 7 2017 ACC/AHA

<120 and <80 Normal BP Normal BP
120-129 and <80 Prehypertension Elevated BP
130-139 or 80-89 Prehypertension Stage 1 hypertension
140-159 or 90-99 Stage 1 hypertension Stage 2 hypertension
≥160 or ≥160 Stage 2 hypertension Stage 2 hypertension

• Blood Pressure should be based on average of ≥2 careful readings on ≥2 occasions

• Adults being treated with antihypertensive medication designated as having
hypertension
Comparison of blood pressure categories according to the ESH/ESC
2013 guidelines and the ACC/AHA 2017 recommendations

BP BP ACC/AHA
ESH/ESC
Category Category 2017
Systolic Diastolic Systolic Diastolic

Optimal <120 and <80

Normal 120-129 and/or 80-84 Normal <120 and <80

High normal 130-139 and/or 85-89 Elevated 120-129 and <80

Grade 1
140-159 and/or 90-99 Stage1 130-139 or 80-89
Hypertension

Grade 2
160-179 and/or 100-109 Stage2 ≥140 Or ≥90
Hypertension

Grade 3
≥180 and/or ≥110
Hypertension

Isolated
systolic ≥140 and <90
hypertension
U.S. Adults with Hypertension as Defined by the JNC7 and
ACC/AHA Guidelines and Effect on Use of Pharmacologic Therapy

Hypertension as Defined by JNC7 Goal

(>140/90 mmHg)
72.2

 31.1
Hypertension as Defined by ACC/AHA
Goal (>130/80 mmHg)
103.3

Additional Pharmacologic Therapy

4.2

0 20 40 60 80 100 120
No. of U.S. Adults (millions)

This change in BP classification is estimated to result in an increase of about 14%

(from 31.9% to 45.6%) in the prevalence of hypertension in the U S but only a 1.9%
increase in adults requiring antihypertensive drug therapy
Corresponding Values of Systolic BP / Diastolic BP for Clinic, Home (HBPM),
Daytime, Nighttime, and 24-Hour Ambulatory (ABPM) Measurements

Clinic HBPM Daytime ABPM Nighttime ABPM 24-Hour ABPM

120/80 120/80 120/80 100/65 115/75

130/80 130/80 130/80 110/65 125/75

140/90 135/85 135/85 120/70 130/80

160/100 145/90 145/90 140/85 145/90

 Masked and White Coat Hypertension

Recommendations for Masked and White Coat

COR LOE
Hypertension
In adults with an untreated SBP greater than 130 mm Hg but less
than 160 mm Hg or DBP greater than 80 mm Hg but less than
100 mm Hg, it is reasonable to screen for the presence of white
IIa B-NR coat hypertension by using either daytime ABPM or HBPM before
diagnosis of hypertension.

In adults with white coat hypertension, periodic monitoring with

either ABPM or HBPM is reasonable to detect transition to
IIa C-LD sustained hypertension.

In adults being treated for hypertension with office BP readings

not at goal and HBPM readings suggestive of a significant white
IIa C-LD coat effect, confirmation by ABPM can be useful.
 Masked and White Coat Hypertension (cont.)

Recommendations for Masked and White Coat

COR LOE
Hypertension
In adults with untreated office BPs that are consistently between
120 mm Hg and 129 mm Hg for SBP or between 75 mm Hg and 79
IIa B-NR
mm Hg for DBP, screening for masked hypertension with HBPM (or
ABPM) is reasonable.
In adults on multiple-drug therapies for hypertension and office
IIb C-LD BPs within 10 mm Hg above goal, it may be reasonable to screen
for white coat effect with HBPM (or ABPM).
It may be reasonable to screen for masked uncontrolled
hypertension with HBPM in adults being treated for hypertension
IIb C-EO and office readings at goal, in the presence of target organ damage
or increased overall CVD risk.
In adults being treated for hypertension with elevated HBPM
readings suggestive of masked uncontrolled hypertension,
IIb C-EO confirmation of the diagnosis by ABPM might be reasonable
before intensification of antihypertensive drug treatment.
 BP Patterns Based on Office and Out-of-Office Measurements

Office/Clinic/Healthcare Home/Nonhealthcare/AB
Setting PM Setting
Normotensive No hypertension No hypertension
Sustained
Hypertension Hypertension
hypertension
Masked
No hypertension Hypertension
hypertension
White coat
Hypertension No hypertension
hypertension
ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.
Detection of White Coat Hypertension
in Patients Not on Drug Therapy

Office BP :
≥130/80 mm Hg but <160/100 mm Hg
after 3 mo trial of lifestyle modification and suspect
white coat hypertension

Daytime ABPM
Or HBPM
BP <130/80 mm Hg

Yes No

White Coat Hypertension Hypertension

• Lifestyle modification
• Annual ABPM or HBPM
to detect progression
(Class IIa)
• Continue lifestyle
modification and
start antihypertensive
drug therapy
(Class IIa)
Detection of Masked Hypertension
in Patients Not on Drug Therapy

Office BP :
120-129/<80 mm Hg
after 3 mo trial of lifestyle modification and suspect
masked hypertension

Daytime ABPM
or HBPM
BP ≥130/80 mm Hg

Yes No

Masked Hypertension
Elevated BP
• Continue lifestyle
modification and • Lifestyle modification
start antihypertensive • Annual ABPM or HBPM
drug therapy to detect MH progression
(Class IIb) (Class IIb)
BP THRESHOLDS AND RECOMENDATIONS
FOR TREATMENT OF HYPERTENSION
 Blood Pressure (BP) Thresholds
and Recommendations for Treatment and Follow-up
BP Thresholds and Recommendations for Treatment and Follow-up

Normal BP Elevated BP Stage 1 Hypertension Stage 2 Hypertension

(BP <120/80 (BP <120-129/<80 (BP <130-139/80-89 (BP ≥ 140/90 mm Hg)
mm Hg) mm Hg) mm Hg)

Promote optimal Nonpharmacologic Clinical ASCVD

Lifestyle habits therapy Or estimated 10-y CVD risk
(Class I) ≥ 10%*
No Yes

Reasses in Reasses in Nonpharmacologic Nonpharmacologic Nonpharmacologic

1y 3-6 mo therapy therapy and therapy and
(Class IIa) (Class I) (Class I) BP-lowering medication BP-lowering medication
(Class I) (Class I)

Reassess in Reassess in
3-6 mo 3-6 mo
(Class I) (Class I)

BP goal met

No Yes

Assess and Reassess in

optimize 3-6 mo
adherence (Class I)
to therapy

Consider
intensification
to therapy
 CVD Risk Factors Common in Patients With Hypertension

Modifiable Risk Factors* Relatively Fixed Risk Factors†

 Current cigarette smoking,  CKD
secondhand smoking  Family history
 Diabetes mellitus  Increased age
 Dyslipidemia/hypercholesterolemia  Low socioeconomic/educational status
 Overweight/obesity  Male sex
 Physical inactivity/low fitness  Obstructive sleep apnea
 Unhealthy diet  Psychosocial stress

*Factors that can be changed and, if changed, may reduce CVD risk.
†Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive
sleep apnea, cannot be changed (family history, increased age, male sex), or, if changed through
the use of current intervention techniques, may not reduce CVD risk (psychosocial stress).
CKD indicates chronic kidney disease; and CVD, cardiovascular disease.
 BP goal for hypertension
• In adults WITH confirmed hypertension and known
CVD or 10-y ASCVD risk ≥10% (Class I)
 SBP target <130 mmHg
 DBP target <80 mmHg

• In adults with confirmed hypertension WITHOUT

additional CVD risk (Class II)
 SBP target <130 mmHg
 DBP target <80 mmHg
 Age-Related Issues

Recommendations for Treatment of Hypertension in

COR LOE
Older Persons
Treatment of hypertension with a SBP treatment goal of less
than 130 mm Hg is recommended for noninstitutionalized
I A ambulatory community-dwelling adults (≥65 years of age) with
an average SBP of 130 mm Hg or higher.

For older adults (≥65 years of age) with hypertension and a

high burden of comorbidity and limited life expectancy, clinical
IIa C-EO judgment, patient preference, and a team-based approach to
assess risk/benefit is reasonable for decisions regarding
intensity of BP lowering and choice of antihypertensive drugs.
 2017 Hypertension Guideline

Nonpharmacological Interventions
 Best Proven Nonpharmacological Interventions for Prevention and Treatment of
Hypertension*
Nonpharmacologi Dose Approximate Impact on SBP
-cal Intervention Hypertension Normotension
Weight loss Weight/body fat Best goal is ideal body weight, but aim -5 mm Hg -2/3 mm Hg
for at least a 1-kg reduction in body
weight for most adults who are
overweight. Expect about 1 mm Hg for
every 1-kg reduction in body weight.
Healthy diet DASH dietary Consume a diet rich in fruits, -11 mm Hg -3 mm Hg
pattern vegetables, whole grains, and low-fat
dairy products, with reduced content
of saturated and total fat.
Reduced intake Dietary sodium Optimal goal is <1500 mg/d, but aim -5/6 mm Hg -2/3 mm Hg
of dietary for at least a 1000-mg/d reduction in
sodium most adults.
Enhanced Dietary Aim for 3500–5000 mg/d, preferably -4/5 mm Hg -2 mm Hg
intake of potassium by consumption of a diet rich in
dietary potassium.
potassium
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure.
Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH?
Available at: https://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to.
Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp
 Best Proven Nonpharmacological Interventions for Prevention and Treatment of
Hypertension* (cont.)
Nonpharmacologica Dose Approximate Impact on SBP
l Intervention Hypertension Normotension
Physical Aerobic ● 90–150 min/wk -5/8 mm Hg -2/4 mm Hg
activity ● 65%–75% heart rate reserve
Dynamic resistance ● 90–150 min/wk -4 mm Hg -2 mm Hg
● 50%–80% 1 rep maximum
● 6 exercises, 3 sets/exercise, 10
repetitions/set
Isometric resistance ● 4 × 2 min (hand grip), 1 min rest -5 mm Hg -4 mm Hg
between exercises, 30%–40%
maximum voluntary contraction, 3
sessions/wk
● 8–10 wk
Moderation Alcohol In individuals who drink alcohol, -4 mm Hg -3 mm
in alcohol consumption reduce alcohol† to:
intake ● Men: ≤2 drinks daily
● Women: ≤1 drink daily
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular
beer (usually about 5% alcohol), 5 oz of wine (usually about 12%
alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).
 Initiating antihypertensive drug therapy

• First-line antihypertensive drugs include thiazide diuretics,

CCBs and ACEIs or ARBs

• Initiate antihypertensive drug therapy in stage 2 hypertension

with 2 first-line agents with different mechanisms of action

• Initiate antihypertensive drug therapy in stage 1 hypertension

and BP goal <130/80 mmHg with monotherapy
 2017 Hypertension Guideline

Summary of BP Thresholds and Goals for

Pharmacological Therapy Plan of Care for Hypertension
 BP Thresholds for and Goals of Pharmacologic Therapy
In Patients with Hypertension According to Clinical Conditions
Clinical Conditions (s) BP Threshold mm Hg BP Goal mm Hg

General
Clinical CVD or 10 year ASCVD risk  10% ≥130/80 <130/80

No clinical CVD and 10 year ASCVD risk < 10% ≥130/90 <130/80

Older persons (65 years of age; non-

institutionalized, ambulatory, community-living ≥130 (SBP) <130 (SBP)
adults)

Specific Comorbidities
Diabetes mellitus ≥130/80 <130/80

Chronic kidney disease ≥130/80 <130/80

Chronic kidney disease post-renal transplantation ≥130/80 <130/80

Heart failure ≥130/80 <130/80

Stable ischemic heart disease ≥130/90 <130/80

Secondary stroke prevention (lacunar) ≥130/80 <130/80

Pheripheral arterial disease ≥130/80 <130/80

 Chronic Kidney Disease
Recommendations for Treatment of Hypertension in
COR LOE
Patients With CKD
SBP: Adults with hypertension and CKD should be treated to a BP goal
B-RSR of less than 130/80 mm Hg.
I
DBP:
C-EO
In adults with hypertension and CKD (stage 3 or higher or
stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g
IIa B-R albumin-to-creatinine ratio or the equivalent in the first
morning void]), treatment with an ACE inhibitor is
reasonable to slow kidney disease progression.
In adults with hypertension and CKD (stage 3 or higher or
stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g
IIb C-EO albumin-to-creatinine ratio in the first morning void]),
treatment with an ARB may be reasonable if an ACE
inhibitor is not tolerated.
SR indicates systematic review.
 Management of Hypertension in Patients with
Chronic Kidney Disease
Treatment of Hypertension in Patients with CKD

BP goal <130/80 mm Hg
(Class I)

Albuminuria
( 300 mg/d or  300 mg/g
creatinin)
Yes No

ACE inhibitor Usual “first line”

(Class IIa) medication choices

ACE inhibitor
intolerant
Yes No

ARB* ACE inhibitor*

(Class IIb) (Class IIa)
A snapshot of the renal guidelines from different organisations :
(2017) (2012) (2013) (2016**) (2017) (2017)

CKD 140/90
140/90
No DM 130/80 140/90 140/90 SBP < 120 if
120 if tolerated
No proteinuria high CV risk*

CKD 140/90 140/90

No DM 130/80 140/90 140/90 120 if SBP < 120 if
Proteinuria tolerated high CV risk*

CKD 140/90
DM 130/80 140/90 140/90 120 if Stroke 130/80
No proteinuria priority

CKD 140/90
DM 130/80 140/90 140/90 120 if Stroke 130/80
Proteinuria priority

140/90
Renal No separate
130/80 140/90 140/90 SBP < 120 if
transplant recommendation
high CV risk*

Aim towards 140/90 < 150 (strong)

<140 if h/o
Elderly 130/80 Individualize 140/90 120 if SBP < 120 if stroke or high
tolerated high CV risk* CV risk (weak)#
Take home message
• The 2017 guideline :
 uses a different classification system for BP than previous
guidelines
 emphasizes out-of-office BP measurements to confirm the
diagnosis of and monitor success in control of
hypertension
 Recommends non pharmacologic interventions
 recommends addition of antihypertensive drug therapy
based on a combination of average BP, ASCVD risk, and
comorbid conditions
• An individualized approach to hypertension can help
determine the best choice for first-line therapy

• Absolute risk is an important determinant of the need for

treatment of hypertension

• While a blood-pressure treatment target of less than 130/80

mm Hg makes sense for high-risk patients, for everyone else it
seems more reasonable to continue defining hypertension as
a BP of 140/90 mm Hg or higher