Written By: IJCP Editorial Team

Published On: 04 Mar, 2025 1:36 PM | Updated On: 04 Mar, 2025 1:44 PM

Driven Management of Hypertension according to American College of Cardiology (ACC)/American Heart Association (AHA)

High blood pressure (BP) is the foremost global risk factor for cardiovascular disease (CVD) morbidity and mortality, especially in the developed countries, where it significantly contributes to coronary heart disease, heart failure, and strokes. Effective management of hypertension through antihypertensive medications can lower the risk of CVD and overall mortality, making hypertension a critical health issue that is largely preventable.

It is essential to prevent high BP and manage hypertension through accurate diagnosis, lifestyle changes, and appropriate medication to reduce the incidence of CVD events and mortality. While awareness and treatment of hypertension have improved in recent years, BP control remains suboptimal, with a noticeable decline in control rates from 2013-2018. New guidelines have emerged, including recommendations to lower treatment goals and redefine hypertension thresholds.

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines redefined hypertension as an average BP of 130/80 mm Hg or higher and recommended a treatment goal of less than 130/80 mm Hg for most adults. This was based on evidence indicating that lower BP levels significantly reduce the risk of CVD events and mortality. However, adherence to these guidelines varies, and many patients remain untreated.

Management strategies for hypertension include accurate BP measurement, evaluating for secondary causes, lifestyle modifications, and pharmacological treatments, such as diuretics and ACE inhibitors. It's vital to address treatment-resistant hypertension and promote adherence to prescribed therapies. Optimizing care through team-based approaches and utilizing telehealth technologies can enhance patient management and improve BP control.

Summary of Major Findings (January, 2018-March, 2021) and Relevance to the Management of Hypertension:

• Trends in BP Control: Blood pressure control rates improved consistently until 2013-14, after which a decline was observed. Adhering to the 2017 ACC/AHA BP guidelines could help reverse this concerning trend.
• Out-of-Office BP Monitoring: Out-of-office BP measurements, such as Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM), are recommended to identify White Coat Hypertension (WCH) and Masked Hypertension (MH), with ABPM being more effective for detecting MH.
• Practical BP Documentation: HBPM is the most feasible method for documenting blood pressure during medication titration to achieve and sustain target BP levels.
• Aldosterone and Hypertension: Increased autonomous aldosterone production may contribute to stages 1 and 2 hypertension as well as resistant hypertension. All adults with difficult-to-control or resistant hypertension should be screened for primary aldosteronism. If the aldosterone-to-renin ratio is low and plasma renin is also low, a 24-hour urine aldosterone test during a high-sodium diet should be considered.
• Hypertension in Young Adults: Young adults with hypertension experience cardiovascular events earlier than those with normal BP. Therefore, delaying treatment may not be appropriate, even in the absence of randomized controlled trial (RCT) evidence. Initial management should include lifestyle changes for 6-12 months, followed by antihypertensive medication if BP remains elevated.
• Importance of Lifestyle Modifications: Lifestyle changes remain fundamental to managing hypertension. Each nonpharmacological intervention effectively lowers BP, and using multiple interventions together can enhance their effects. These modifications also boost the efficacy of pharmacological treatments.
• Intensive BP Control: Intensive blood pressure management does not lead to increased hospitalization rates or a higher risk of orthostatic hypotension. Asymptomatic orthostatic hypotension in hypertensive patients is not linked to elevated rates of cardiovascular events, syncope, harmful falls, or acute renal failure, and should not prompt treatment withdrawal or dosage reduction.
• Impact on Older Adults: For older adults with hypertension, aggressive BP management may help prevent or slow cognitive decline.
• Definition of Resistant Hypertension: Resistant hypertension is defined as having a BP of 130/80 mm Hg or higher in adults taking three or more antihypertensive medications from different classes at maximum or maximally tolerated doses, or having BP below this threshold but requiring four or more antihypertensive drugs after excluding pseudo-resistance factors (such as inaccurate BP measurements and poor medication adherence).
• Effective Implementation Strategies: Multilevel and multicomponent strategies, including team-based care, are the most effective approaches to controlling BP in patients with hypertension.
• Self-Monitoring and Telemonitoring: Home BP self-monitoring and telemonitoring have proven effective in facilitating the adjustment of antihypertensive medications, leading to the achievement and maintenance of target BP levels.

In summary, hypertension is a significant public health challenge that requires comprehensive management strategies, including prevention, early diagnosis, lifestyle interventions, and effective pharmacological treatment, to reduce the burden of cardiovascular diseases.

Source: Carey RM, Wright JT Jr, Taler SJ, Whelton PK. Guideline-Driven Management of Hypertension: An Evidence-Based Update. Circ Res. 2021 Apr 2;128(7):827-846. doi: 10.1161/CIRCRESAHA.121.318083. Epub 2021 Apr 1. PMID: 33793326; PMCID: PMC8034801.