2017 guideline for hypetension by acc and aha

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
© American College of Cardiology Foundation and American Heart Association, Inc.

Publication Information
This slide set is adapted from the 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
Published on November 13, 2017, available at: Hypertension
and Journal of the American College of Cardiology.
The full-text guidelines are also available on the following
websites: AHA (professional.heart.org) and ACC (www.acc.org)

2017 High Blood Pressure Guideline Writing Committee
Paul K. Whelton, MB, MD, MSc, FAHA, Chair
Robert M. Carey, MD, FAHA, Vice Chair
Wilbert S. Aronow, MD, FACC, FAHA*
Donald E. Casey, Jr, MD, MPH, MBA, FAHA†
Karen J. Collins, MBA‡
Bruce Ovbiagele, MD, MSc, MAS,
MBA,FAHA†
Sidney C. Smith, Jr, MD, MACC, FAHA††
Crystal C. Spencer, JD‡
Cheryl Dennison Himmelfarb, RN, ANP, PhD,
FAHA§
Sondra M. DePalma, MHS, PA-C, CLS, AACC║
Samuel Gidding, MD, FACC, FAHA¶
Kenneth A. Jamerson, MD#
Daniel W. Jones, MD, FAHA†
Eric J. MacLaughlin, PharmD**
Paul Muntner, PhD, FAHA†
Randall S. Stafford, MD, PhD‡‡
Sandra J. Taler, MD, FAHA§§
Randal J. Thomas, MD, MS, FACC, FAHA║║
Kim A. Williams, Sr, MD, MACC, FAHA†
Jeff D. Williamson, MD, MHS¶¶
Jackson T. Wright, Jr, MD, PhD, FAHA##
*American Society for Preventive Cardiology Representative. †ACC/AHA
Representative. ‡Lay Volunteer/Patient Representative. §Preventive
Cardiovascular Nurses Association Representative. ║American Academy
of Physician Assistants Representative. ¶Task Force Liaison. #Association
of Black Cardiologists Representative. **American Pharmacists
Association Representative. ††ACC/AHA Prevention Subcommittee
Liaison. ‡‡American College of Preventive Medicine Representative.
§§American Society of Hypertension Representative. ║║Task Force on
Performance Measures Liaison. ¶¶American Geriatrics Society
Representative. ##National Medical Association Representative.

Applying Class of
Recommendation and
Level of Evidence to
Clinical Strategies,
Interventions,
Treatments, or
Diagnostic Testing
in Patient Care*
(Updated August 2015)

Systematic Review Questions on High BP in Adults
Question
Number
Question
1 Is there evidence that self-directed monitoring of BP and/or
ambulatory BP monitoring are superior to office-based
measurement of BP by a healthcare worker for 1) preventing
adverse outcomes for which high BP is a risk factor and 2)
achieving better BP control?
2 What is the optimal target for BP lowering during
antihypertensive therapy in adults?
3 In adults with hypertension, do various antihypertensive drug
classes differ in their comparative benefits and harms?
4 In adults with hypertension, does initiating treatment with
antihypertensive pharmacological monotherapy versus initiating
treatment with 2 drugs (including fixed-dose combination
therapy), either of which may be followed by the addition of
sequential drugs, differ in comparative benefits and/or harms on
specific health outcomes?
BP indicates blood pressure.

BP Measurement Definitions
BP Measurement Definition
SBP First Korotkoff sound*
DBP Fifth Korotkoff sound*
Pulse pressure SBP minus DBP
Mean arterial pressure DBP plus one third pulse pressure†
Mid-BP Sum of SBP and DBP, divided by 2
*See Section 4 for a description of Korotkoff sounds.
†Calculation assumes normal heart rate .
BP indicates blood pressure; DBP, diastolic blood pressure; and
SBP, systolic blood pressure.

2017 Hypertension Clinical Practice Guidelines

Coexistence of Hypertension and Related Chronic
Conditions
COR LOE
Recommendation for Coexistence of
Hypertension and Related Chronic Conditions
I B-NR
Screening for and management of other modifiable
CVD risk factors are recommended in adults with
hypertension.

*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.
Modifiable Risk Factors* Relatively Fixed Risk Factors†
• Current cigarette smoking,
secondhand smoking
• Diabetes mellitus
• Dyslipidemia/hypercholesterolemia
• Overweight/obesity
• Physical inactivity/low fitness
• Unhealthy diet
• CKD
• Family history
• Increased age
• Low socioeconomic/educational
status
• Male sex
• Obstructive sleep apnea
• Psychosocial stress

Definition of High BP
COR LOE Recommendation for Definition of High BP
I B-NR
BP should be categorized as normal, elevated, or
stage 1 or 2 hypertension to prevent and treat high
BP.

*Individuals with SBP and DBP in 2 categories should be
designated to the higher BP category.
BP indicates blood pressure (based on an average of ≥2
careful readings obtained on ≥2 occasions, as detailed in
DBP, diastolic blood pressure; and SBP systolic blood
pressure.
BP Category SBP DBP
Normal <120 mm Hg and <80 mm Hg
Elevated 120–129 mm
Hg
and <80 mm Hg
Hypertension
Stage 1 130–139 mm
Hg
or 80–89 mm
Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg

SBP/DBP ≥130/80 mm Hg or
Self-Reported
Antihypertensive Medication†
SBP/DBP ≥140/90 mm Hg or Self-
Reported Antihypertensive
Medication‡
Overall, crude 46% 32%
Men
(n=4717)
Women
(n=4906)
Men
(n=4717)
Women
(n=4906)
Overall, age-sex
adjusted
48% 43% 31% 32%
Age group, y
20–44 30% 19% 11% 10%
45–54 50% 44% 33% 27%
55–64 70% 63% 53% 52%
65–74 77% 75% 64% 63%
75+ 79% 85% 71% 78%
Race-ethnicity§
Non-Hispanic White 47% 41% 31% 30%
Non-Hispanic Black 59% 56% 42% 46%
Non-Hispanic Asian 45% 36% 29% 27%
Hispanic 44% 42% 27% 32%
The prevalence estimates have been rounded to the nearest full percentage.
*130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014.
†BP cutpoints for definition of hypertension in the present guideline.
‡BP cutpoints for definition of hypertension in JNC 7.
§Adjusted to the 2010 age-sex distribution of the U.S. adult population.
BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health
and Nutrition Examination Survey; and SBP, systolic blood pressure.

Accurate Measurement of BP in the Office
COR LOE
Recommendation for Accurate Measurement of
BP in the Office
I C-EO
For diagnosis and management of high BP, proper
methods are recommended for accurate
measurement and documentation of BP.

Key Steps for Proper BP Measurements
Step 1: Properly prepare the patient.
Step 2: Use proper technique for BP measurements.
Step 3: Take the proper measurements needed for diagnosis and
treatment of elevated BP/hypertension.
Step 4: Properly document accurate BP readings.
Step 5: Average the readings.
Step 6: Provide BP readings to patient.

Arm
Circumference
Usual Cuff Size
22–26 cm Small adult
27–34 cm Adult
35–44 cm Large adult
45–52 cm Adult thigh

Out-of-Office and Self-Monitoring of BP
COR LOE
Recommendation for Out-of-Office and Self-
Monitoring of BP
I ASR
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.
SR indicates systematic review.

ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure;
DBP diastolic blood pressure; HBPM, home blood pressure monitoring; and
SBP, systolic blood pressure.
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
COR LOE
Recommendations for Masked and White Coat
Hypertension
IIa B-NR
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 coat hypertension by using either daytime
ABPM or HBPM before diagnosis of hypertension.
IIa C-LD
In adults with white coat hypertension, periodic monitoring
with either ABPM or HBPM is reasonable to detect transition
to sustained hypertension.
IIa C-LD
In adults being treated for hypertension with office BP
readings not at goal and HBPM readings suggestive of a
significant white coat effect, confirmation by ABPM can be
useful.

Masked and White Coat Hypertension (cont.)
COR LOE
Recommendations for Masked and White Coat
Hypertension
IIa B-NR
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 mm Hg for DBP, screening for masked
hypertension with HBPM (or ABPM) is reasonable.
IIb C-LD
In adults on multiple-drug therapies for hypertension and
office BPs within 10 mm Hg above goal, it may be reasonable
to screen for white coat effect with HBPM (or ABPM).
IIb C-EO
It may be reasonable to screen for masked uncontrolled
hypertension with HBPM in adults being treated for
hypertension and office readings at goal, in the presence of
target organ damage or increased overall CVD risk.
IIb C-EO
In adults being treated for hypertension with elevated HBPM
readings suggestive of masked uncontrolled hypertension,
confirmation of the diagnosis by ABPM might be reasonable
before intensification of antihypertensive drug treatment.

ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.
Office/Clinic/Healthcare
Setting
Home/Nonhealthcare/
ABPM Setting
Normotensive No hypertension No hypertension
Sustained
hypertension
Hypertension Hypertension
Masked
hypertension
No hypertension Hypertension
White coat
hypertension
Hypertension No hypertension

Colors correspond to Class of Recommendation in Table 1.
ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM,
home blood pressure monitoring.

ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure;
and HBPM, home blood pressure monitoring.
Office BP
≥5–10 mm Hg
above goal on
≥3 agents
Continue titrating
therapy
Yes
Screening
not necessary
(No Benefit)
Screen for
white coat effect with
HBPM
(Class IIb)
White coat effect:
Confirm with ABPM
(Class IIa)
No
Yes
HBPM BP
at goal
No
Increased
CVD risk or
target organ
damage
Continue current
therapy
(Class IIa)
Yes
Screening
not necessary
(No Benefit)
Screen for
masked uncontrolled
hypertension with HBPM
(Class IIb)
Masked uncontrolled
hypertension:
Intensify therapy
(Class IIb)
No
Yes
HBPM BP
above goal
No
Yes No
Detection of white coat effect or masked uncontrolled
hypertension in patients on drug therapy
Office BP
at goal
ABPM BP
above goal

Secondary Forms of Hypertension
COR LOE
Recommendations for Secondary Forms of
Hypertension
I C-EO
Screening for specific form(s) of secondary
hypertension is recommended when the clinical
indications and physical examination findings are
present or in adults with resistant hypertension.
IIb C-EO
If an adult with sustained hypertension screens
positive for a form of secondary hypertension,
referral to a physician with expertise in that form of
hypertension may be reasonable for diagnostic
confirmation and treatment.

Colors correspond to Class of Recommendation in Table 1 .
TOD indicates target organ damage (e.g., cerebrovascular disease,
hypertensive retinopathy, left ventricular hypertrophy, left ventricular
dysfunction, heart failure, coronary artery disease, chronic kidney disease,
albuminuria, peripheral artery disease).
New-onset or uncontrolled hypertension in adults
Referral not
necessary
(No Benefit)
Refer to clinician with
specific expertise
(Class IIb)
NoYes
Screening not
indicated
(No Benefit)
Screen for
secondary hypertension
(Class I)
(see Table 13)
Yes No
Positive
screening test
Conditions
• Drug-resistant/induced hypertension
• Abrupt onset of hypertension
• Onset of hypertension at <30 y
• Exacerbation of previously controlled hypertension
• Disproportionate TOD for degree of hypertension
• Accelerated/malignant hypertension
• Onset of diastolic hypertension in older adults (age ≥65 y)
• Unprovoked or excessive hypokalemia

Common causes
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Uncommon causes
Pheochromocytoma/paraganglioma
Cushing’s syndrome
Hypothyroidism
Hyperthyroidism
Aortic coarctation (undiagnosed or repaired)
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary aldosteronism
Acromegaly

Primary Aldosteronism
COR LOE Recommendations for Primary Aldosteronism
I C-EO
In adults with hypertension, screening for primary
aldosteronism is recommended in the presence of any of
the following concurrent conditions: resistant hypertension,
hypokalemia (spontaneous or substantial, if diuretic
induced), incidentally discovered adrenal mass, family
history of early-onset hypertension, or stroke at a young
age (<40 years).
I C-LD
Use of the plasma aldosterone: renin activity ratio is
recommended when adults are screened for primary
aldosteronism.
I C-EO
In adults with hypertension and a positive screening test for
primary aldosteronism, referral to a hypertension specialist
or endocrinologist is recommended for further evaluation
and treatment.

Renal Artery Stenosis
COR LOE Recommendations for Renal Artery Stenosis
I A
Medical therapy is recommended for adults with
atherosclerotic renal artery stenosis.
IIb C-EO
In adults with renal artery stenosis for whom medical
management has failed (refractory hypertension,
worsening renal function, and/or intractable HF) and
those with nonatherosclerotic disease, including
fibromuscular dysplasia, it may be reasonable to refer
the patient for consideration of revascularization
(percutaneous renal artery angioplasty and/or stent
placement).

Obstructive Sleep Apnea
COR LOE Recommendation for Obstructive Sleep Apnea
IIb B-R
In adults with hypertension and obstructive sleep
apnea, the effectiveness of continuous positive airway
pressure (CPAP) to reduce BP is not well established.

Nonpharmacological Interventions
COR LOE
Recommendations for Nonpharmacological
Interventions
I A
Weight loss is recommended to reduce BP in adults
with elevated BP or hypertension who are overweight
or obese.
I A
A heart-healthy diet, such as the DASH (Dietary
Approaches to Stop Hypertension) diet, that
facilitates achieving a desirable weight is
recommended for adults with elevated BP or
hypertension.
I A
Sodium reduction is recommended for adults with
elevated BP or hypertension.
I A
Potassium supplementation, preferably in dietary
modification, is recommended for adults with elevated
BP or hypertension, unless contraindicated by the
presence of CKD or use of drugs that reduce
potassium excretion.

Nonpharmacological Interventions (cont.)
COR LOE
Recommendations for Nonpharmacological
Interventions
I A
Increased physical activity with a structured
exercise program is recommended for adults with
elevated BP or hypertension.
I A
Adult men and women with elevated BP or
hypertension who currently consume alcohol should
be advised to drink no more than 2 and 1 standard
drinks* per day, respectively.
*In the United States, 1 “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).

Nonpharmacologi
-cal Intervention
Dose Approximate Impact on SBP
Hypertension Normotension
Weight loss Weight/body
fat
Best goal is ideal body weight, but aim
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.
-5 mm Hg -2/3 mm Hg
Healthy diet DASH dietary
pattern
Consume a diet rich in fruits,
vegetables, whole grains, and low-fat
dairy products, with reduced content
of saturated and total fat.
-11 mm Hg -3 mm Hg
Reduced intake
of dietary
sodium
Dietary sodium Optimal goal is <1500 mg/d, but aim
for at least a 1000-mg/d reduction in
most adults.
-5/6 mm Hg -2/3 mm Hg
Enhanced
intake of
dietary
potassium
Dietary
potassium
Aim for 3500–5000 mg/d, preferably
by consumption of a diet rich in
potassium.
-4/5 mm Hg -2 mm Hg
*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

Nonpharmacologica
l Intervention
Dose Approximate Impact on SBP
Hypertension Normotension
Physical
activity

Aerobic ● 90–150 min/wk
● 65%–75% heart rate reserve
-5/8 mm Hg -2/4 mm Hg
Dynamic resistance ● 90–150 min/wk
● 50%–80% 1 rep maximum
● 6 exercises, 3 sets/exercise, 10
repetitions/set
-4 mm Hg -2 mm Hg
Isometric resistance ● 4 × 2 min (hand grip), 1 min rest
between exercises, 30%–40%
maximum voluntary contraction, 3
sessions/wk
● 8–10 wk
-5 mm Hg -4 mm Hg
Moderation
in alcohol
intake
Alcohol
consumption
In individuals who drink alcohol,
reduce alcohol† to:
● Men: ≤2 drinks daily
● Women: ≤1 drink daily
-4 mm Hg -3 mm
*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).

Patient Evaluation
2017 Hypertension Guideline

Basic testing Fasting blood glucose*
Complete blood count
Lipid profile
Serum creatinine with eGFR*
Serum sodium, potassium, calcium*
Thyroid-stimulating hormone
Urinalysis
Electrocardiogram
Optional testing Echocardiogram
Uric acid
Urinary albumin to creatinine ratio
*May be included in a comprehensive metabolic panel.
eGFR indicates estimated glomerular filtration rate.

BP Treatment Threshold and the Use of CVD Risk Estimation to
Guide Drug Treatment of Hypertension
COR LOE
Recommendations for BP Treatment Threshold and Use of
Risk Estimation* to Guide Drug Treatment of Hypertension
I
SBP:
A
Use of BP-lowering medications is recommended for secondary
prevention of recurrent CVD events in patients with clinical CVD
and an average SBP of 130 mm Hg or higher or an average
DBP of 80 mm Hg or higher, and for primary prevention in adults
with an estimated 10-year atherosclerotic cardiovascular disease
(ASCVD) risk of 10% or higher and an average SBP 130 mm Hg
or higher or an average DBP 80 mm Hg or higher.
DBP:
C-EO
I C-LD
Use of BP-lowering medication is recommended for primary
prevention of CVD in adults with no history of CVD and with an
estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg
or higher or a DBP of 90 mm Hg or higher.
*ACC/AHA Pooled Cohort Equations (
http://tools.acc.org/ASCVD-Risk-Estimator/) to estimate 10-year
risk of atherosclerotic CVD.

Normal BP
(BP <120/80
mm Hg)
Promote optimal
lifestyle habits
Elevated BP
(BP 120–129/<80
mm Hg)
Stage 1 hypertension
(BP 130–139/80-89
mm Hg)
Nonpharmacologic
therapy
(Class I)
Reassess in
3–6 mo
(Class I)
Reassess in
1 mo
(Class I)
Nonpharmacologic
therapy and
BP-lowering medication
(Class I)
Reassess in
1 y
(Class IIa)
Clinical ASCVD
or estimated 10-y CVD risk
≥10%*
YesNo
Nonpharmacologic
therapy
(Class I)
BP thresholds and recommendations for treatment and follow-up
Nonpharmacologic therapy
and
BP-lowering medication†
(Class I)
Reassess in
3–6 mo
(Class I)
Stage 2 hypertension
(BP ≥ 140/90 mm Hg)

*Using the ACC/AHA Pooled Cohort Equations. Note that patients with DM or CKD are automatically placed in the high-
risk category. For initiation of RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and renal function 2 to
4 weeks after initiating therapy.
†Consider initiation of pharmacological therapy for stage 2 hypertension with 2 antihypertensive agents of different
classes. Patients with stage 2 hypertension and BP ≥160/100 mm Hg should be promptly treated, carefully monitored,
and subject to upward medication dose adjustment as necessary to control BP. Reassessment includes BP
measurement, detection of orthostatic hypotension in selected patients (e.g., older or with postural symptoms),
identification of white coat hypertension or a white coat effect, documentation of adherence, monitoring of the response to
therapy, reinforcement of the importance of adherence, reinforcement of the importance of treatment, and assistance with
treatment to achieve BP target.
3–6 mo
(Class I)
BP goal met
No Yes
Reassess in
3–6 mo
(Class I)
Assess and
optimize
adherence to
therapy
Consider
intensification of
therapy
Reassess in
1 mo
(Class I)
BP-lowering medication
(Class I)
1 y
(Class IIa)
therapy
(Class I)
BP-lowering medication†
(Class I)
Reassess in
3–6 mo
(Class I)

Follow-Up After Initial BP Evaluation
COR LOE
Recommendations for Follow-Up After Initial BP
Elevation
I B-R
Adults with an elevated BP or stage 1 hypertension who
have an estimated 10-year ASCVD risk less than 10%
should be managed with nonpharmacological therapy and
have a repeat BP evaluation within 3 to 6 months.
I B-R
Adults with stage 1 hypertension who have an estimated
10-year ASCVD risk of 10% or higher should be managed
initially with a combination of nonpharmacological and
antihypertensive drug therapy and have a repeat BP
evaluation in 1 month.
I B-R
Adults with stage 2 hypertension should be evaluated by
or referred to a primary care provider within 1 month of
the initial diagnosis, have a combination of
nonpharmacological and antihypertensive drug therapy
(with 2 agents of different classes) initiated, and have a
repeat BP evaluation in 1 month.

Follow-Up After Initial BP Evaluation (cont.)
COR LOE
Recommendations for Follow-Up After Initial BP
Elevation
I B-R
For adults with a very high average BP (e.g., SBP ≥180
mm Hg or DBP ≥110 mm Hg), evaluation followed by
prompt antihypertensive drug treatment is recommended.
IIa C-EO
For adults with a normal BP, repeat evaluation every year
is reasonable.

General Principles of Drug Therapy
COR LOE
Recommendation for General Principle of Drug
Therapy
III:
Harm
A
Simultaneous use of an ACE inhibitor, ARB, and/or renin
inhibitor is potentially harmful and is not recommended to
treat adults with hypertension.

BP Goal for Patients With Hypertension
COR LOE
Recommendations for BP Goal for Patients
With Hypertension
I
SBP:
B-RSR
For adults with confirmed hypertension and known
CVD or 10-year ASCVD event risk of 10% or higher
a BP target of less than 130/80 mm Hg is
recommended.
DBP:
C-EO
IIb
SBP:
B-NR
For adults with confirmed hypertension, without
additional markers of increased CVD risk, a BP
target of less than 130/80 mm Hg may be
reasonable.DBP:
C-EO

Choice of Initial Medication
COR LOE Recommendation for Choice of Initial Medication
I ASR
For initiation of antihypertensive drug therapy, first-
line agents include thiazide diuretics, CCBs, and
ACE inhibitors or ARBs.

Choice of Initial Monotherapy Versus Initial Combination
Drug Therapy
COR LOE
Recommendations for Choice of Initial Monotherapy
Versus Initial Combination Drug Therapy*
I C-EO
Initiation of antihypertensive drug therapy with 2 first-line
agents of different classes, either as separate agents or in
a fixed-dose combination, is recommended in adults with
stage 2 hypertension and an average BP more than 20/10
mm Hg above their BP target.
IIa C-EO
Initiation of antihypertensive drug therapy with a single
antihypertensive drug is reasonable in adults with stage 1
hypertension and BP goal <130/80 mm Hg with dosage
titration and sequential addition of other agents to achieve
the BP target.

Follow-Up After Initiating Antihypertensive Drug
Therapy
COR LOE
Recommendation for Follow-Up After Initiating
Antihypertensive Drug Therapy
I B-R
Adults initiating a new or adjusted drug regimen for
hypertension should have a follow-up evaluation of
adherence and response to treatment at monthly intervals
until control is achieved.

Monitoring Strategies to Improve Control of BP in
Patients on Drug Therapy for High BP
COR LOE
Recommendation for Monitoring Strategies to
Improve Control of BP in Patients on Drug Therapy
for High BP
I A
Follow-up and monitoring after initiation of drug therapy
for hypertension control should include systematic
strategies to help improve BP, including use of HBPM,
team-based care, and telehealth strategies.

Stable Ischemic Heart Disease
COR LOE
Recommendations for Treatment of Hypertension in
Patients With Stable Ischemic Heart Disease (SIHD)
I
SBP:
B-R
In adults with SIHD and hypertension, a BP target of less than
130/80 mm Hg is recommended.
DBP:
C-EO
I
SBP:
B-R
Adults with SIHD and hypertension (BP ≥130/80 mm Hg) should
be treated with medications (e.g., GDMT beta blockers, ACE
inhibitors, or ARBs) for compelling indications (e.g., previous MI,
stable angina) as first-line therapy, with the addition of other
drugs (e.g., dihydropyridine CCBs, thiazide diuretics, and/or
mineralocorticoid receptor antagonists) as needed to further
control hypertension.
DBP:
C-EO

Stable Ischemic Heart Disease (cont.)
COR LOE
Patients With Stable Ischemic Heart Disease (SIHD)
I B-NR
In adults with SIHD with angina and persistent uncontrolled
hypertension, the addition of dihydropyridine CCBs to GDMT
beta blockers is recommended.
IIa B-NR
In adults who have had a MI or acute coronary syndrome, it is
reasonable to continue GDMT beta blockers beyond 3 years as
long-term therapy for hypertension.
IIb C-EO
Beta blockers and/or CCBs might be considered to control
hypertension in patients with CAD (without HFrEF) who had an
MI more than 3 years ago and have angina.

•ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker;
BP, blood pressure; CCB, calcium channel blocker; GDMT, guideline-directed
management and therapy; and SIHD, stable ischemic heart disease.
Hypertension With SIHD
Reduce BP to <130/80 mm Hg with
GDMT beta blockers*, ACE inhibitor, or ARBs†
(Class I)
Add
dihydropyridine CCBs
if needed
(Class I)
Add
dihydropyridine CCBs,
thiazide-type diuretics,
and/or MRAs as needed
(Class I)
Angina
pectoris
No
BP goal not met
Yes
*GDMT beta blockers for BP control or relief of angina include carvedilol, metoprolol tartrate, metoprolol succinate,
nadolol, bisoprolol, propranolol, and timolol. Avoid beta blockers with intrinsic sympathomimetic activity. The beta
blocker atenolol should not be used because it is less effective than placebo in reducing cardiovascular events.
†If needed for BP control.

Heart Failure
COR LOE
Recommendation for Prevention of HF in Adults
With Hypertension
I
SBP:
B-R
In adults at increased risk of HF, the optimal BP in those
with hypertension should be less than 130/80 mm Hg.
DBP:
C-EO

Heart Failure With Reduced Ejection Fraction
COR LOE
Recommendations for Treatment of Hypertension
in Patients With HFrEF
I C-EO
Adults with HFrEF and hypertension should be prescribed
GDMT titrated to attain a BP of less than 130/80 mm Hg.
III: No
Benefit
B-R
Nondihydropyridine CCBs are not recommended in the
treatment of hypertension in adults with HFrEF.

Heart Failure With Preserved Ejection Fraction
COR LOE
Recommendations for Treatment of
Hypertension in Patients With HFpEF
I C-EO
In adults with HFpEF who present with symptoms of
volume overload, diuretics should be prescribed to control
hypertension.
I C-LD
Adults with HFpEF and persistent hypertension after
management of volume overload should be prescribed
ACE inhibitors or ARBs and beta blockers titrated to attain
SBP of less than 130 mm Hg.

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

•Colors correspond to Class of Recommendation in Table 1.
•*CKD stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d or ≥300 mg/g
creatinine.
•ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP
blood pressure; and CKD, chronic kidney disease.
Treatment of hypertension in patients with CKD
Albuminuria
(≥300 mg/d or ≥300 mg/g
creatinine)
ACE inhibitor*
(Class IIa)
Yes
Usual “first-line”
medication choices
ACE inhibitor
(Class IIa)
ARB*
(Class IIb)
No
Yes
ACE inhibitor
intolerant
No
BP goal <130/80 mm Hg
(Class I)

Hypertension After Renal Transplantation
COR LOE
After Renal Transplantation
IIa
SBP:
B-NR
After kidney transplantation, it is reasonable to treat patients
with hypertension to a BP goal of less than 130/80 mm Hg.
DBP:
C-EO
IIa B-R
After kidney transplantation, it is reasonable to treat patients
with hypertension with a calcium antagonist on the basis of
improved GFR and kidney survival.

Acute Intracerebral Hemorrhage
COR LOE
Recommendations for Management of Hypertension
in Patients With Acute Intracerebral Hemorrhage (ICH)
IIa C-EO
In adults with ICH who present with SBP greater than 220 mm
Hg, it is reasonable to use continuous intravenous drug infusion
and close BP monitoring to lower SBP.
III:
Harm
A
Immediate lowering of SBP to less than 140 mm Hg in adults
with spontaneous ICH who present within 6 hours of the acute
event and have an SBP between 150 mm Hg and 220 mm Hg is
not of benefit to reduce death or severe disability and can be
potentially harmful.

BP indicates blood pressure; ICH, intracerebral hemorrhage; IV,
intravenous; and SBP, systolic blood pressure.
Acute (<6 h from symptom onset)
spontaneous ICH
SBP lowering to
<140 mm Hg
(Class III:Harm)
SBP lowering with
continuous IV infusion and
close BP monitoring
(Class IIa)
SBP 150–220 mm Hg SBP >220 mm Hg

Acute Ischemic Stroke
COR LOE
in Patients With Acute Ischemic Stroke
I B-NR
Adults with acute ischemic stroke and elevated BP who are
eligible for treatment with intravenous tissue plasminogen
activator should have their BP slowly lowered to less than
185/110 mm Hg before thrombolytic therapy is initiated.
I B-NR
In adults with an acute ischemic stroke, BP should be less than
185/110 mm Hg before administration of intravenous tissue
plasminogen activator and should be maintained below
180/105 mm Hg for at least the first 24 hours after initiating
drug therapy.
IIa B-NR
Starting or restarting antihypertensive therapy during
hospitalization in patients with BP greater than 140/90 mm Hg
who are neurologically stable is safe and reasonable to
improve long-term BP control, unless contraindicated.

Acute Ischemic Stroke (cont.)
COR LOE
in Patients With Acute Ischemic Stroke
IIb C-EO
In patients with BP of 220/120 mm Hg or higher who did not
receive intravenous alteplase or endovascular treatment and
have no comorbid conditions requiring acute antihypertensive
treatment, the benefit of initiating or reinitiating treatment of
hypertension within the first 48 to 72 hours is uncertain. It
might be reasonable to lower BP by 15% during the first 24
hours after onset of stroke.
III:
No
Benefit
A
In patients with BP less than 220/120 mm Hg who did not
receive intravenous thrombolysis or endovascular treatment
and do not have a comorbid condition requiring acute
antihypertensive treatment, initiating or reinitiating treatment of
hypertension within the first 48 to 72 hours after an acute
ischemic stroke is not effective to prevent death or
dependency.

BP indicates blood pressure; DBP, diastolic blood pressure; IV, intravenous; and SBP,
systolic blood pressure.
Acute (<72 h from symptom onset) ischemic
stroke and elevated BP
Yes
Initiating or reinitiating treatment of
hypertension within the first 48-72
hours after an acute ischemic stroke is
ineffective to prevent death or
dependency
(Class III: No Benefit)
Lower SBP to <185 mm Hg and
DBP <110 mm Hg before
initiation of IV thrombolysis
(Class I)
Lower BP 15%
during first 24 h
(Class IIb)
Patient
qualifies for IV
thrombolysis
therapy
BP ≤220/110 mm Hg BP >220/110 mm Hg
For preexisting hypertension,
reinitiate antihypertensive drugs
after neurological stability
(Class IIa)
Maintain BP <180/105 mm Hg for
first 24 h after IV thrombosis
(Class I)
No
And

Secondary Stroke Prevention
COR LOE
Recommendations for Treatment of Hypertension for
I A
Adults with previously treated hypertension who experience a
stroke or transient ischemic attack (TIA) should be restarted on
antihypertensive treatment after the first few days of the index
event to reduce the risk of recurrent stroke and other vascular
events.
I A
For adults who experience a stroke or TIA, treatment with a
thiazide diuretic, ACE inhibitor, or ARB, or combination
treatment consisting of a thiazide diuretic plus ACE inhibitor, is
useful.
I B-R
Adults not previously treated for hypertension who experience a
stroke or TIA and have an established BP of 140/90 mm Hg or
higher should be prescribed antihypertensive treatment a few
days after the index event to reduce the risk of recurrent stroke
and other vascular events.

Secondary Stroke Prevention (cont.)
COR LOE
Recommendations for Treatment of Hypertension for
I B-NR
For adults who experience a stroke or TIA, selection of specific
drugs should be individualized on the basis of patient
comorbidities and agent pharmacological class.
IIb B-R
For adults who experience a stroke or TIA, a BP goal of less
than 130/80 mm Hg may be reasonable.
IIb B-R
For adults with a lacunar stroke, a target SBP goal of less than
130 mm Hg may be reasonable.
IIb C-LD
In adults previously untreated for hypertension who experience
an ischemic stroke or TIA and have a SBP less than 140 mm
Hg and a DBP less than 90 mm Hg, the usefulness of initiating
antihypertensive treatment is not well established.

DBP indicates diastolic blood pressure; SBP, systolic blood pressure; and TIA, transient
ischemic attack.
Stroke ≥72 h from symptom onset and stable
neurological status or TIA
Initiate
antihypertensive
treatment
(Class I)
Restart
antihypertensive
treatment
(Class I)
Usefulness of starting
antihypertensive
treatment is not
well established
(Class IIb)
Previous
diagnosed or treated
hypertension
Established
SBP ≥140 mm Hg or
DBP ≥90 mm Hg
No
Aim for
BP <140/90 mm Hg
(Class IIb)
Established
SBP <140 mm Hg and
DBP <90 mm Hg
Aim for
BP <130/80 mm Hg
(Class IIb)
Yes

Peripheral Arterial Disease
COR LOE
Recommendation for Treatment of Hypertension in
Patients With PAD
I B-NR
Adults with hypertension and PAD should be treated similarly
to patients with hypertension without PAD.

Diabetes Mellitus
COR LOE
Patients With DM
I
SBP:
B-RSR
In adults with DM and hypertension, antihypertensive drug
treatment should be initiated at a BP of 130/80 mm Hg or
higher with a treatment goal of less than 130/80 mm Hg.
DBP:
C-EO
I ASR
In adults with DM and hypertension, all first-line classes of
antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs,
and CCBs) are useful and effective.
IIb B-NR
In adults with DM and hypertension, ACE inhibitors or ARBs
may be considered in the presence of albuminuria.

Atrial Fibrillation
COR LOE
Recommendation for Treatment of Hypertension in
Patients With AF
IIa B-R
Treatment of hypertension with an ARB can be useful for
prevention of recurrence of AF.

Valvular Heart Disease
COR LOE
Patients With Valvular Heart Disease
I B-NR
In adults with asymptomatic aortic stenosis, hypertension
should be treated with pharmacotherapy, starting at a low dose
and gradually titrating upward as needed.
IIa C-LD
In patients with chronic aortic insufficiency, treatment of systolic
hypertension with agents that do not slow the heart rate (i.e.,
avoid beta blockers) is reasonable.

Aortic Disease
COR LOE
Recommendation for Management of Hypertension
in Patients With Aortic Disease
I C-EO
Beta blockers are recommended as the preferred
antihypertensive agents in patients with hypertension and
thoracic aortic disease.

Racial and Ethnic Differences in Treatment
COR LOE Recommendations for Race and Ethnicity
I B-R
In black adults with hypertension but without HF or CKD,
including those with DM, initial antihypertensive treatment
should include a thiazide-type diuretic or CCB.
I C-LD
Two or more antihypertensive medications are recommended to
achieve a BP target of less than 130/80 mm Hg in most adults
with hypertension, especially in black adults with hypertension.

Pregnancy
COR LOE
Pregnancy
I C-LD
Women with hypertension who become pregnant, or are
planning to become pregnant, should be transitioned to
methyldopa, nifedipine, and/or labetalol during pregnancy.
III:
Harm
C-LD
Women with hypertension who become pregnant should not be
treated with ACE inhibitors, ARBs, or direct renin inhibitors.

Age-Related Issues
COR LOE
Older Persons
I A
Treatment of hypertension with a SBP treatment goal of less
than 130 mm Hg is recommended for noninstitutionalized
ambulatory community-dwelling adults (≥65 years of age) with
an average SBP of 130 mm Hg or higher.
IIa C-EO
For older adults (≥65 years of age) with hypertension and a
high burden of comorbidity and limited life expectancy, clinical
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.

Resistant Hypertension: Diagnosis, Evaluation, and Treatment
.
BP indicates blood pressure; CKD, chronic kidney disease; DBP, diastolic blood
pressure; eGFR, estimated glomerular filtration rate; NSAIDs, nonsteroidal anti-
inflammatory drugs; and SBP, systolic blood pressure.
Adapted with permission from Calhoun et al.

Hypertensive Crises: Emergencies and Urgencies
COR LOE
Recommendations for Hypertensive Crises and
Emergencies
I B-NR
In adults with a hypertensive emergency, admission to an
intensive care unit is recommended for continuous monitoring
of BP and target organ damage and for parenteral
administration of an appropriate agent.
I C-EO
For adults with a compelling condition (i.e., aortic dissection,
severe preeclampsia or eclampsia, or pheochromocytoma
crisis), SBP should be reduced to less than 140 mm Hg during
the first hour and to less than 120 mm Hg in aortic dissection.
I C-EO
For adults without a compelling condition, SBP should be
reduced by no more than 25% within the first hour; then, if
stable, to 160/100 mm Hg within the next 2 to 6 hours; and then
cautiously to normal during the following 24 to 48 hours.

*Use drug(s) specified in Table 19.
†If other comorbidities are present, select a drug specified in Table 20.
BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care
unit; and SBP, systolic blood pressure.
Diagnosis and Management of a Hypertensive Crisis
SBP >180 mm Hg and/or
DBP >120 mm Hg
Target organ damage new/
progressive/worsening
Reduce SBP to <140 mm Hg
during first h* and to <120 mm Hg
in aortic dissection†
(Class I)
Yes
Yes
Reduce BP by max 25% over first h†, then
to 160/100–110 mm Hg over next 2–6 h,
then to normal over next 24–48 h
(Class I)
No
Markedly elevated BP
Reinstitute/intensify oral
antihypertensive drug therapy
and arrange follow-up
Hypertensive
emergency
Admit to ICU
(Class I)
No
Conditions:
• Aortic dissection
• Severe preeclampsia or eclampsia
• Pheochromocytoma crisis

Cognitive Decline and Dementia
COR LOE
Recommendation for Prevention of Cognitive
Decline and Dementia
IIa B-R
In adults with hypertension, BP lowering is reasonable to
prevent cognitive decline and dementia.

Patients Undergoing Surgical Procedures
COR LOE
Patients Undergoing Surgical Procedures
Preoperative
I B-NR
In patients with hypertension undergoing major surgery who
have been on beta blockers chronically, beta blockers should
be continued.
IIa C-EO
In patients with hypertension undergoing planned elective
major surgery, it is reasonable to continue medical therapy for
hypertension until surgery.
IIb B-NR
In patients with hypertension undergoing major surgery,
discontinuation of ACE inhibitors or ARBs perioperatively may
be considered.

Patients Undergoing Surgical Procedures (cont.)
COR LOE
in Patients Undergoing Surgical Procedures
Preoperative
IIb C-LD
In patients with planned elective major surgery and SBP of
180 mm Hg or higher or DBP of 110 mm Hg or higher,
deferring surgery may be considered.
III:
Harm
B-NR
For patients undergoing surgery, abrupt preoperative
discontinuation of beta blockers or clonidine is potentially
harmful.
III:
Harm
B-NR
Beta blockers should not be started on the day of surgery in
beta blocker–naïve patients.
Intraoperative
I C-EO
Patients with intraoperative hypertension should be managed
with intravenous medications until such time as oral
medications can be resumed.

Antihypertensive Medication Adherence Strategies
COR LOE
Recommendations for Antihypertensive Medication
Adherence Strategies
I B-R
In adults with hypertension, dosing of antihypertensive
medication once daily rather than multiple times daily is
beneficial to improve adherence.
IIa B-NR
Use of combination pills rather than free individual
components can be useful to improve adherence to
antihypertensive therapy.

Strategies to Promote Lifestyle Modification
COR LOE
Recommendation for Strategies to Promote
Lifestyle Modification
I C-EO
Effective behavioral and motivational strategies to achieve a
healthy lifestyle (i.e., tobacco cessation, weight loss,
moderation in alcohol intake, increased physical activity,
reduced sodium intake, and consumption of a healthy diet) are
recommended for adults with hypertension.

Structured, Team-Based Care Interventions for
Hypertension Control
COR LOE
Recommendation for Structured, Team-Based Care
Interventions for Hypertension Control
I A
A team-based care approach is recommended for adults with
hypertension.

EHR and Patient Registries
COR LOE Recommendations for EHR and Patient Registries
I B-NR
Use of the EHR and patient registries is beneficial for
identification of patients with undiagnosed or undertreated
hypertension.
I B-NR
Use of the EHR and patient registries is beneficial for guiding
quality improvement efforts designed to improve hypertension
control.

Telehealth Interventions to Improve Hypertension
Control
COR LOE
Recommendation for Telehealth Interventions to
Improve Hypertension Control
IIa A
Telehealth strategies can be useful adjuncts to interventions
shown to reduce BP for adults with hypertension.

Performance Measures
COR LOE Recommendation for Performance Measures
IIa B-NR
Use of performance measures in combination with other
quality improvement strategies at patient-, provider-, and
system-based levels is reasonable to facilitate optimal
hypertension control.

Quality Improvement Strategies
COR LOE
Recommendation for Quality Improvement
Strategies
IIa B-NR
Use of quality improvement strategies at the health system,
provider, and patient levels to improve identification and
control of hypertension can be effective.

Financial Incentives
COR LOE Recommendations for Financial Incentives
IIa B-R
Financial incentives paid to providers can be useful in
achieving improvements in treatment and management of
patient populations with hypertension.
IIa B-NR
Health system financing strategies (e.g., insurance coverage
and copayment benefit design) can be useful in facilitating
improved medication adherence and BP control in patients
with hypertension.

The Plan of Care for Hypertension
COR LOE Recommendations for Financial Incentives
I C-EO
Every adult with hypertension should have a clear, detailed,
and current evidence-based plan of care that ensures the
achievement of treatment and self-management goals,
encourages effective management of comorbid conditions,
prompts timely follow-up with the healthcare team, and
adheres to CVD GDMT.

Clinician’s Sequential Flow Chart for the Management of Hypertension
Clinician’s Sequential Flow Chart for the Management of Hypertension
Measure office BP accurately
Detect white coat hypertension or masked hypertension by using ABPM and HBPM
Evaluate for secondary hypertension
Identify target organ damage
Introduce lifestyle interventions
Identify and discuss treatment goals
Use ASCVD risk estimation to guide BP threshold for drug therapy
Align treatment options with comorbidities
Account for age, race, ethnicity, sex, and special circumstances in antihypertensive treatment
Initiate antihypertensive pharmacological therapy
Insure appropriate follow-up
Use team-based care
Connect patient to clinician via telehealth
Detect and reverse nonadherence
Detect white coat effect or masked uncontrolled hypertension
Use health information technology for remote monitoring and self-monitoring of BP
ASCVD indicates atherosclerotic cardiovascular
disease; BP, blood pressure; CVD, cardiovascular
disease; and SBP, systolic blood pressure.

BP Thresholds for and Goals of Pharmacological Therapy in Patients
With Hypertension According to Clinical Conditions
Clinical Condition(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% ≥140/90 <130/80
Older persons (≥65 years of age; noninstitutionalized,
ambulatory, community-living adults)
≥130 (SBP) <130 (SBP)
Specific comorbidities
Diabetes mellitus ≥130/80 <130/80
Chronic kidney disease ≥130/80 <130/80
Chronic kidney disease after renal transplantation ≥130/80 <130/80
Heart failure ≥130/80 <130/80
Stable ischemic heart disease ≥130/80 <130/80
Secondary stroke prevention ≥140/90 <130/80
Secondary stroke prevention (lacunar) ≥130/80 <130/80
Peripheral arterial disease ≥130/80 <130/80
ASCVD indicates atherosclerotic cardiovascular
disease; BP, blood pressure; CVD, cardiovascular
disease; and SBP, systolic blood pressure.

2017 guideline for hypetension by acc and aha

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