The new guidelines also place an increased emphasis on the use of out-of-office and self-monitoring of blood pressure, i.e., home blood pressure monitoring (HBPM) and/or ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension and for titration of blood pressure medication, with a class I-A recommendation. These drug classes are useful and effective (with a class I-A recommendation) in addition, ACE inhibitors or ARBs may be considered in the presence of albuminuria (Class IIb).
Furthermore, the guidelines indicate that persons with DM should use first-line classes of antihypertensive medication, including diuretics, ACE inhibitors, ARBs, and CCBs. This suggests an individualized approach to treatment even if calculated risk does not reach 10%, because the recommendations do not give specific guidance for thresholds of treatment in such persons. It should be noted, however, that because several key risk factors-notably waist circumference, glucose levels, and triglycerides-are not included in the ASCVD risk score, such calculated risk may actually be underestimated. These guidelines also hold for adults with metabolic syndrome, who for many, but not all, the 10-year ASCVD risk will reach 10%, warranting drug treatment at a blood pressure threshold of 130/80 mmHg, based on the multiple risk factors often present in such individuals. 3 The current guideline committee, however, considered evidence from meta-analyses that included one study involving persons with diabetes mellitus (DM) and frequently combined with chronic kidney disease, where intensive blood pressure lowering to 133/76 mmHg versus 140/81 mmHg in the standard arm was shown to result in significant reductions in major ASCVD events of 14%, myocardial infarction 13%, and stroke 22%.
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1 This is of course a reversal of recent recommendations, including those from panel members appointed by the JNC-8 as well as the European Society of Cardiology and American Diabetes Association who had all increased the treatment threshold to 140/90 mmHg in light of the failure of the ACCORD BP (Action to Control Cardiovascular Risk in Diabetes-Blood Pressure) trial to show benefit in the primary cardiovascular disease endpoint (despite showing a benefit from stroke) from the stricter 120 mmHg versus 140 mmHg SBP target. These guidelines for drug treatment initiation and goal BP levels hold for most adults, including those with diabetes (who are given a class I B-R recommendation for a 130 mmHg SBP and class I C-EO for an 80 mmHg DBP initiation and target level). 2 In the presence of BP >140/90 mmHg, even if ASCVD risk is 150/90 mmHg as outlined in the new guidelines. The use of the risk calculator to identify those in the primary prevention population who should be treated at the new lower 130/80 mmHg threshold is an important advancement, consistent with European risk-based treatment guidelines for hypertension, and with the use of the pooled cohort risk calculator in the 2014 ACC/AHA guideline for blood cholesterol treatment. However, these new recommendations are based on 10-year atherosclerotic cardiovascular disease (ASCVD) risk derived from the ACC/AHA pooled cohort risk calculator of 10-year risk or higher. However, non-drug treatment management is recommended for the majority of adults who would be newly classified as having SBP 120-129 mmHg with DBP remaining 130/80 mmHg, both for persons with known cardiovascular disease as well as those without. The new classification is estimated to increase the total number of American adults with elevated blood pressure to 46%, using the proposed SBP and DBP cut-points for definition of "elevated" BP, as compared to 32% of elevated BP in the adult population recommended in the 2003 JNC guidelines. In the old 2003 JNC 7 guidelines SBP of 120-139 mm Hg and DBP of 80-89 mm Hg were called pre-hypertension-a term no longer used. The new 2017 ACC/AHA high blood pressure guidelines, 1 released November 13, 2017, has reclassified grades of hypertension for the first time as having "elevated" blood pressure with a systolic blood pressure (SBP) level of 120-129 mmHg (and with a diastolic blood pressure level remaining 140/>90 mmHg, respectively.
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