Hypertension - Article122

Annals of Internal Medicine䊛
In the Clinic®
Hypertension Screening and Prevention
R
ecent guidelines on diagnosis and manage-
ment of high blood pressure (BP) include Diagnosis
substantial changes and several new con-
cepts compared with previous guidelines. These
are reviewed and their clinical implications are Treatment
discussed in this article. The goal is to provide a
practical reference to assist clinicians with up-to-
date management of patients with high BP. Im-
portant issues include new diagnostic thresholds,
out-of-office BP monitoring, intensified treatment
goals, and a different approach to resistant hyper-
tension. Finally, differences among guidelines, the
persistent controversies that have led to them, and
their implications for clinical practice are discussed.
CME/MOC activity available at Annals.org.
Physician Writers doi:10.7326/AITC201905070

James Brian Byrd, MD, MS
Robert D. Brook, MD CME Objective: To review current evidence for screening and prevention, diagnosis, and
From University of Michigan, treatment of hypertension.
Ann Arbor, Michigan. Acknowledgment: The authors thank Matthew R. Weir, MD, author of the previous version
of this In the Clinic.
Funding Source: American College of Physicians.
Disclosures: Dr. Byrd, ACP Contributing Author, reports a grant from the National Heart,
Lung, and Blood Institute during the conduct of the study and a pending patent related to
diagnosis of primary aldosteronism. He is also a co-investigator on research funded by Apple
to understand health trajectories. Dr. Brook, ACP Contributing Author, has nothing to
disclose. Disclosures can also be viewed at www.acponline.org/authors/icmje
/ConflictOfInterestForms.do?msNum=M19-0150.
With the assistance of additional physician writers, the editors of Annals of Internal Medicine
develop In the Clinic using MKSAP and other resources of the American College of
Physicians.
In the Clinic does not necessarily represent official ACP clinical policy. For ACP clinical
guidelines, please go to https://www.acponline.org/clinical_information/guidelines/.
© 2019 American College of Physicians
Downloaded from https://annals.org by University of Virginia on 08/15/2022.

Since the previous version of this Among persons aged 40 to 70
In the Clinic (1), several new hy- years with usual BP of 115/75 to
1. Weir MR. In the Clinic:
pertension guidelines have been 185/115 mm Hg, every 20 –mm
hypertension. Ann Intern published (2– 4). The new guide- Hg higher systolic BP or 10 –mm
Med. 2014;161:ITC1-15.
[PMID: 25437425] lines include considerable Hg higher diastolic BP doubles
2. Whelton PK, Carey RM, changes that were based on re- the risk for death from both isch-
Aronow WS, Casey DE Jr,
Collins KJ, Dennison Him- cent clinical trials and updated emic heart disease and stroke
melfarb C, et al. 2017
ACC/AHA/AAPA/ABC/ medical evidence (2– 4). How- (13). Given this continuous asso-
ACPM/AGS/APhA/ASH/ ever, differences among guide- ciation between high BP and
ASPC/NMA/PCNA guide-
line for the prevention, lines with regard to several issues morbidity and mortality, “hyper-
detection, evaluation, and tension” is impossible to define
management of high
have provoked substantial con-
blood pressure in adults: troversy (5–9). Different experts exactly. Previous guidelines (17,
executive summary: a
report of the American can impartially review the avail- 18) used a goal of 140/90 mm
College of Cardiology/ able scientific evidence but have Hg, which was maintained in the
American Heart Associa-
tion Task Force on Clinical different ideas on how the data 2018 guidelines from the Euro-
Practice Guidelines. Hy- pean Society of Cardiology and
pertension. 2018;71: should be translated into medical
1269-324. [PMID: practice. We have chosen to prin- the European Society of Hyper-
29133354]
3. Williams B, Mancia G, cipally follow a single set of tension (ESC/ESH) (3) for certain
Spiering W, Agabiti Rosei
guidelines issued by the Ameri- patients, but a goal of less than
E, Azizi M, Burnier M,
et al. 2018 ESC/ESH can College of Cardiology and 130/80 mm Hg is endorsed by
guidelines for the man-
agement of arterial hyper- the American Heart Association the ESC/ESH for most patients
tension: The Task Force for (ACC/AHA) in 2017 to provide a and by the ACC/AHA for all pa-
the Management of Arte-
rial Hypertension of the coherent and clinically relevant tients (2). However, mounting
European Society of Cardi-
ology and the European update for health care providers evidence suggests that the most
Society of Hypertension: (2). We outline key updates in the effective management should
The Task Force for the
Management of Arterial Box and address controversies account for each patient's global
Hypertension of the Euro-
and differences among guide- cardiovascular risk in addition to
pean Society of Cardiology
and the European Society lines in the Appendix (available BP (19 –21). Many clinical trials
of Hypertension. J Hyper- and meta-analyses have shown
tens. 2018;36:1953- at Annals.org).
2041. [PMID: 30234752] that the relative reduction in risk
4. Qaseem A, Wilt TJ, Rich R, High blood pressure (BP) is the
Humphrey LL, Frost J, for cardiovascular events with
Forciea MA; Clinical leading risk factor for morbidity antihypertensive drug treatment
Guidelines Committee of
the American College of and mortality around the globe is similar across patient groups
Physicians and the Com- (10). Approximately 1 billion per- defined by age, sex, and race;
mission on Health of the
Public and Science of the sons worldwide have a systolic most drug regimens; and comor-
American Academy of
Family Physicians. Phar-
BP above 140 mm Hg, and 3.5 bidities, such as diabetes and
macologic treatment of billion have a BP above the ideal renal disease, and thus the rela-
hypertension in adults
aged 60 years or older to level of 115/75 mm Hg (10 –12). tive risk reduction is driven pri-
higher versus lower blood Of note, 30% to 50% of the pub-
pressure targets: a clinical marily by the magnitude of the
practice guideline from lic health burden is attributable decrease in systolic BP (2, 3, 20,
the American College of
Physicians and the Ameri- to systolic BPs of 115 to 139 mm 22–24). As a result, patients at
can Academy of Family Hg (11–16). The mean number higher overall cardiovascular risk
Physicians. Ann Intern
Med. 2017;166:430-7. of lost cardiovascular disease derive a greater absolute risk re-
[PMID: 28135725]
5. Wilt TJ, Kansagara D,
(CVD)–free life-years associated duction from the same degree of
Qaseem A; Clinical Guide- with hypertension is 5.0 from age BP lowering. Recent analyses
lines Committee of the
American College of Physi- 30 years, 3.4 from age 60 years, have shown that treating systolic
cians. Hypertension lim- and 1.6 from age 80 years (14).
bo: balancing benefits,
BP to a target of 130 mm Hg
harms, and patient prefer- High BP is linked to renal and yields the maximum balance of
ences before we lower the
bar on blood pressure. peripheral vascular diseases, an- health benefits and risks from
Ann Intern Med. 2018; eurysms, retinopathy, neurocog- treatment (22, 23). In accordance
168:369-70. [PMID:
29357397] nitive decline, and atrial fibrilla- with the overall scientific evi-
6. Miyazaki K. Overdiagnosis
or not? 2017 ACC/AHA
tion. It also causes damage to dence and the concept that hy-
high blood pressure clini- many organs, leading to left ven- pertension is “a BP level above
cal practice guideline:
consequences of intellec- tricular hypertrophy, proteinuria, which investigation and treat-
tual conflict of interest. J atherosclerosis, and white matter ment do more good than harm”
Gen Fam Med. 2018;19:
123-6. [PMID: 29998041] disease. (21), the ACC/AHA guidelines
姝 2019 American College of Physicians ITC66 In the Clinic Annals of Internal Medicine 7 May 2019

Key Updates to the 2017 American College of Cardiology/American Heart 7. Bell KJL, Doust J, Glasziou
Association Hypertension Guidelines* P. Incremental benefits
and harms of the 2017
• New categorization of blood pressure, including lower threshold for American College of Cardi-
hypertension (Table 1) ology/American Heart
Association high blood
• Emphasis on accurate technique for blood pressure measurement in the clinic pressure guideline. JAMA
• Incorporation of out-of-office (home or ambulatory) blood pressure monitoring Intern Med. 2018;178:
755-7. [PMID: 29710197]
to confirm diagnosis of hypertension, rule out white coat hypertension or 8. Whelton PK, Williams B.
masked hypertension in selected patients, and guide treatment decisions The 2018 European Soci-
ety of Cardiology/Euro-
• Outline of criteria for when to consider an evaluation for secondary causes of pean Society of Hyperten-
hypertension (Appendix Table 1, available at Annals.org) sion and 2017 American
College of Cardiology/
• Enhanced emphasis on lifestyle/nonpharmacologic therapy for high blood American Heart Associa-
pressure tion blood pressure guide-
lines: more similar than
• Calculation of 10-y atherosclerotic cardiovascular disease risk score to guide different. JAMA. 2018;
initiation and intensity of medication treatment 320:1749-50. [PMID:
• Nonpharmacologic therapy for all patients in the new “elevated blood pressure” 30398611]
9. Wright JT Jr, Williamson
category or with higher blood pressure (i.e., all people with blood pressure JD, Whelton PK, Snyder
≥120/80 mm Hg) JK, Sink KM, Rocco MV,
et al; SPRINT Research
• Earlier initiation of pharmacologic therapy for the new stage 1 hypertension Group. A randomized trial
(blood pressure of 130 –139/80 – 89 mm Hg) in high-risk persons (those with of intensive versus stan-
established atherosclerotic cardiovascular disease, 10-y risk for atherosclerotic dard blood-pressure con-
trol. N Engl J Med. 2015;
cardiovascular disease >10%, diabetes mellitus, and chronic kidney disease) 373:2103-16. [PMID:
• Immediate pharmacologic therapy for all patients with a confirmed diagnosis of 26551272]
10. GBD 2016 Risk Factors
the new stage 2 hypertension (blood pressure ≥140/90 mm Hg) Collaborators. Global,
• Lower blood pressure target of <130/80 mm Hg for almost all patients regional, and national
comparative risk assess-
• Greater emphasis on earlier use of combination pharmacologic therapy ment of 84 behavioural,
• Guidelines for many different patients with comorbid conditions environmental and occu-
pational, and metabolic
• Endorsement of novel strategies to combat hypertension risks or clusters of risks,
1990 –2016: a system-
* Reference 2. atic analysis for the
Global Burden of Disease
Study 2016. Lancet.
2017;390:1345-422.
[PMID: 28919119]
decreased the threshold to 130/80 ing its definition to recognize the 11. Forouzanfar MH, Liu P,
Roth GA, Ng M, Biryukov
mm Hg or higher (Table 1). new understanding of the BP at S, Marczak L, et al.
which treatment benefit outweighs Global burden of hyper-
The changes in the definition of tension and systolic
harm means more people have blood pressure of at least
hypertension in the ACC/AHA 110 to 115 mm Hg,
the problem. All guidelines recog- 1990 –2015. JAMA.
guidelines led to substantial in- 2017;317:165-82.
creases in the prevalence of hy- nize that earlier and more intensive [PMID: 28097354]
pertension (31.9% to 46.5%) and treatment will be increasingly nec- 12. Rahimi K, Emdin CA,
MacMahon S. The epide-
higher rates of uncontrolled BP essary to successfully combat miology of blood pres-
sure and its worldwide
among treated patients (39.0% to this problem. In addition, the management. Circ Res.
53.4%) in the United States (25). ACC/AHA endorsed several ap- 2015;116:925-36.
[PMID: 25767281]
Hypertension was already an ur- proaches to help control BP in the 13. Lewington S, Clarke R,
Qizilbash N, Peto R,
gent health problem, and chang- population (Box) (26 –28). Collins R; Prospective
Studies Collaboration.
Age-specific relevance of
usual blood pressure to
Table 1. Blood Pressure Categories for Adults* vascular mortality: a
meta-analysis of individ-
Category† Systolic BP, mm Hg Diastolic BP, mm Hg ual data for one million
adults in 61 prospective
Normal†† <120 and <80 studies. Lancet. 2002;
Elevated 120–129 and <80 360:1903-13. [PMID:
12493255]
Hypertension 14. Rapsomaniki E, Timmis
Stage 1 130–139 or 80–89 A, George J, Pujades-
Rodriguez M, Shah AD,
Stage 2 ≥140 or ≥90 Denaxas S, et al. Blood
pressure and incidence
of twelve cardiovascular
*Adapted from the 2017 American College of Cardiology/American Heart Associa- diseases: lifetime risks,
tion hypertension guidelines (2). healthy life-years lost,
†Patients should be designated to whichever systolic or diastolic BP category is and age-specific associa-
higher. Diagnostic categorization should be based on ≥2 BP measurements at ≥2 tions in 1.25 million
clinic visits. people. Lancet. 2014;
††Not receiving antihypertension medication. 383:1899-911. [PMID:
24881994]
7 May 2019 Annals of Internal Medicine In the Clinic ITC67 姝 2019 American College of Physicians

Approaches to Improving Blood Pressure Control in the Population*
• Improve patient-level adherence
• Reduce pill burden and use once-daily medications
15. Tajeu GS, Booth JN 3rd, • Prescribe combination tablet medications
Colantonio LD, Gottes-
man RF, Howard G,
• Use effective behavioral and motivational strategies for lifestyle treatments
Lackland DT, et al. Inci- • Home blood pressure monitoring
dent cardiovascular dis- • Consider self-directed blood pressure care and algorithms
ease among adults with
blood pressure <140/90
• Enhance clinical practice patterns
mm Hg. Circulation. • Team-based approach (integration of nonphysician providers)
2017;136:798-812. • Quality improvement strategies
[PMID: 28634217]
16. Karmali KN, Ning H, Goff
• Electronic medical records
DC, Lloyd-Jones DM. • Financial incentives for patients and clinicians to achieve blood pressure control
Identifying individuals at • Out-of-clinic strategies
risk for cardiovascular
events across the spec-
• Pharmacy-based clinics
trum of blood pressure • Community outreach efforts (e.g., barbershop blood pressure screening)
levels. J Am Heart Assoc. • Telemedicine
2015;4:e002126.
[PMID: 26391134]
• Plan-of-care strategies
17. James PA, Oparil S, • Individual patient care plans (health literacy, insurance coverage, social/community
Carter BL, Cushman WC, services)
Dennison-Himmelfarb C,
Handler J, et al. 2014 *Adapted from the 2017 American College of Cardiology/American Heart
evidence-based guide- Association hypertension guidelines (2).
line for the management
of high blood pressure in
adults: report from the
panel members ap-
pointed to the Eighth
Joint National Commit-
tee (JNC 8). JAMA. Screening and Prevention
2014;311:507-20.
[PMID: 24352797] Should clinicians screen for tion, Evaluation, and Treatment
18. Chobanian AV, Bakris GL, of High Blood Pressure, where it
Black HR, Cushman WC,
hypertension?
Green LA, Izzo JL Jr, et al; The U.S. Preventive Services Task was defined as a BP of 120/80 to
Joint National Commit-
tee on Prevention, Detec- Force (USPSTF) recommends an- 139/89 mm Hg (18). This term
tion, Evaluation, and
nual screening for hypertension was not included in recent guide-
Treatment of High Blood
Pressure. National Heart, in adults aged 40 years or older lines for management of high BP
Lung, and Blood Insti-
tute. Seventh report of who are at high risk for hyperten- in adults because of the lowering
the Joint National Com- sion, which includes those with a of the threshold for overt hyper-
mittee on Prevention,
Detection, Evaluation, BP of 130 to 139/85 to 89 mm tension (2, 3). Instead, the term
and Treatment of High
Hg, those with overweight or “elevated BP” was designated for
Blood Pressure. Hyper-
tension. 2003;42:1206- obesity, and African Americans persons with a systolic BP of 120
52. [PMID: 14656957]
19. Grundy SM, Stone NJ, (29). In contrast, screening is rec- to 129 mm Hg (Table 1). The ra-
Bailey AL, Beam C, ommended every 3 to 5 years in tionale is that these persons are
Birtcher KK, Blumenthal
RS, et al. 2018 AHA/ACC/ adults aged 18 to 39 years with not yet at the threshold for overt
AACVPR/AAPA/ABC/ hypertension; nevertheless, they
ACPM/ADA/AGS/APhA/ BP less than 130/85 mm Hg who
ASPC/NLA/PCNA do not have other risk factors. If are important to recognize be-
guideline on the man-
agement of blood cho- BP is elevated on subsequent cause they have higher cardio-
lesterol: executive sum-
measurements, the USPSTF rec- vascular risk than those with truly
mary: a report of the
American College of ommends ambulatory BP moni- normal BP (<120/80 mm Hg).
Cardiology/American
Heart Association Task toring (ABPM) to confirm the They also are at increased risk for
Force on Clinical Practice diagnosis of hypertension, al- progression to hypertension. There-
Guidelines. J Am Coll
Cardiol. 2018. [PMID: though confirmation with home fore, enhanced monitoring and
30423391] follow-up are recommended.
20. Muntner P, Whelton PK.
BP monitoring may be accept-
Using predicted cardio- able. The 2017 ACC/AHA guide-
vascular disease risk in A clinically relevant question
conjunction with blood lines state that it is reasonable to
pressure to guide antihy- is whether patients with age-
measure BP annually in adults
pertensive medication related increases in BP would
treatment. J Am Coll with normal BP.
Cardiol. 2017;69:2446- benefit from early interventions
56. [PMID: 28494981] Does “prehypertension” exist?
21. Chalmers J. “Treating
to decrease the slope of their
hypertension” or “lower- Prehypertension first appeared change in BP over time. A cohort
ing blood pressure”?
Extending the concept as a BP category in the Seventh of 4681 young adults in the
[Editorial]. Blood Press. Report of the Joint National CARDIA (Coronary Artery Risk De-
2002;11:68-70. [PMID:
12035873] Committee on Prevention, Detec- velopment in Young Adults) study

was prospectively studied for 25 events or prevents long-term on-
years. Those with steeper BP slopes set of overt hypertension. 22. Reboussin DM, Allen NB,
Griswold ME, Guallar E,
had higher risk for coronary artery Hong Y, Lackland DT,
Other studies have examined the
calcification than those with flatter et al. Systematic review
utility of lifestyle modification to for the 2017 ACC/AHA/
slopes (30). AAPA/ABC/ACPM/AGS/
prevent an increase in BP to APhA/ASH/ASPC/NMA/
TROPHY (Trial of Preventing Hypertension) ran- 140/90 mm Hg (32, 33). PCNA guideline for the
prevention, detection,
domly assigned participants with prehyperten- evaluation, and manage-
TOHP (Trials of Hypertension Prevention) ment of high blood
sion to active treatment with candesartan (an pressure in adults: a
phases I and II examined the benefits of re-
angiotensin-receptor blocker [ARB]) or placebo report of the American
duced weight, sodium intake, and stress and College of Cardiology/
for 2 years and followed them for 4 years. Ac-
supplementation with potassium, magne- American Heart Associa-
tive treatment delayed but did not prevent on- sium, fish oil, and calcium in persons with di-
tion Task Force on Clini-
cal Practice Guidelines.
set of hypertension (31). astolic BP of 80 to 90 mm Hg. TOHP I sug- Circulation. 2018;138:
e595-e616. [PMID:
gested that weight loss (3/2–mm Hg
Drug therapy is not recom- 30354656]
reduction) and sodium restriction (2/1–mm Hg 23. Bangalore S, Toklu B,
mended for persons in the new reduction) were effective in decreasing systolic Gianos E, Schwartzbard
A, Weintraub H, Oge-
“elevated BP” category because and diastolic BP, respectively (32). TOHP II con- degbe G, et al. Optimal
of a lack of evidence that it de- firmed that weight loss and sodium restriction systolic blood pressure
target after SPRINT: in-
creases risk for cardiovascular delay hypertension (33). sights from a network
meta-analysis of random-
ized trials. Am J Med.
2017;130:707-719.e8.
[PMID: 28109971]
Screening and Prevention... Cardiovascular risk increases as one's 24. Bundy JD, Li C, Stuchlik
usual BP increases above 115/75 mm Hg. The 2017 ACC/AHA guide- P, Bu X, Kelly TN, Mills
lines provide specific recommendations on screening intervals for adult KT, et al. Systolic blood
pressure reduction and
patients. Those with a steeper BP trajectory will probably reach a BP of risk of cardiovascular
140/90 mm Hg sooner, which may increase CVD risk. Lifestyle modifica- disease and mortality: a
systematic review and
tion can delay onset of hypertension and CVD. There is no evidence network meta-analysis.
that medications can prevent onset of hypertension, but the potential of JAMA Cardiol. 2017;2:
ARBs to delay onset is nonetheless an important finding. 775-81. [PMID:
28564682]
25. Muntner P, Carey RM,
Gidding S, Jones DW,
CLINICAL BOTTOM LINE Taler SJ, Wright JT Jr,
et al. Potential U.S. pop-
ulation impact of the
2017 ACC/AHA high
blood pressure guide-
line. J Am Coll Cardiol.
Diagnosis 2018;71:109-18. [PMID:

29146532]
26. Victor RG, Lynch K, Li N,
How should clinicians diagnose cuff that is too small. These mis- Blyler C, Muhammad E,
Handler J, et al. A
and stage hypertension? takes often occur because of cluster-randomized trial
The steps to diagnose hyperten- busy practices and lack of time of blood-pressure reduc-
tion in black barber-
sion are simple but are often not but are serious problems because shops. N Engl J Med.
2018;378:1291-301.
followed. The most common er- they can lead to falsely increased BP [PMID: 29527973]
rors relate to improper BP mea- readings and misdiagnoses. It is 27. Jaffe MG, Lee GA, Young
JD, Sidney S, Go AS.
surement, including failure to best for BP to be measured with the Improved blood pressure
have the patient sit quietly for 5 patient seated because this was control associated with a
large-scale hypertension
minutes before a reading is done in the outcome trials that es- program. JAMA. 2013;
310:699-705. [PMID:
taken, failure to support the limb tablished the value of treating hy- 23989679]
used to measure BP, and use of a pertension (34). Table 2 and the 28. Shahaj O, Denneny D,
Schwappach A, Pearce G,
Epiphaniou E, Parke HL,
et al. Supporting self-
management for people
with hypertension: a
Table 2. Blood Pressure Cuff Size Criteria meta-review of quantita-
tive and qualitative sys-
Arm Circumference, cm Weight, lb Cuff Size tematic reviews. J Hyper-
tens. 2019;37:264-79.
[PMID: 30020240]
Women Men 29. U.S. Preventive Services
24–32 <150 <200 Regular Task Force. Final Recom-
mendation Statement.
33–42* >150 >200 Large High Blood Pressure in
Adults: Screening. Rock-
38–50* — — Thigh ville, MD: U.S. Preventive
Services Task Force;
*Either cuff is acceptable for the overlapping circumferences. 2017.

30. Allen NB, Siddique J, Instructions for Measuring Blood Pressure
Wilkins JT, Shay C, Lewis
CE, Goff DC, et al. Blood
• Have the patient relax, sitting with feet on the floor and back supported, for ≥5
pressure trajectories in min. Sitting or lying on an examination table does not meet these criteria.
early adulthood and • The patient should avoid caffeine, exercise, and smoking for ≥30 min before the
subclinical atherosclero-
sis in middle age. JAMA. measurement.
2014;311:490-7. [PMID: • Ensure that the patient has emptied her or his bladder.
24496536]
31. Julius S, Nesbitt SD, • Support the patient's arm at the level of the heart (for example, resting on a desk).
Egan BM, Weber MA,
Michelson EL, Kaciroti N,
• Check blood pressure in both arms. Note which arm gives the higher reading
et al; Trial of Preventing and use it for all other (standing, lying down) and future readings.
Hypertension (TROPHY)
Study Investigators.
• Neither the patient nor the clinician should talk during the rest period or the
Feasibility of treating measurement.
prehypertension with an • Use the correct cuff size and note if a larger or smaller than normal cuff size is
angiotensin-receptor
blocker. N Engl J Med. needed (Table 2).
2006;354:1685-97. • Do not apply a cuff over a thick sleeve.
[PMID: 16537662]
32. Batey DM, Kaufmann
PG, Raczynski JM, Hollis
*Adapted from the 2017 American College of Cardiology/American Heart
JF, Murphy JK, Rosner B, Association hypertension guidelines (2).
et al. Stress manage-
ment intervention for
primary prevention of
hypertension: detailed
results from Phase I of
Box provide instructions on BP ple readings with health care
Trials of Hypertension measurement. providers out of the examination
Prevention (TOHP-I). Ann
Epidemiol. 2000;10:45- room. For example, this method
58. [PMID: 10658688] A person's BP can vary widely, figured prominently in SPRINT
33. Cook NR, Cutler JA,
Obarzanek E, Buring JE,
and it usually decreases over sev- (Systolic Blood Pressure Interven-
Rexrode KM, Kumanyika eral measurements taken a min- tion Trial), although the measure-
SK, et al. Long term
effects of dietary sodium ute apart. Most clinical trials of ment methods varied among
reduction on cardiovas- the effectiveness of medication
cular disease outcomes: sites (36). Only validated BP mea-
observational follow-up have used multiple measurements surement devices should be
of the Trials of Hyperten-
sion Prevention (TOHP). during a single visit rather than a used (37).
BMJ. 2007;334:885-8. single measurement. For these
[PMID: 17449506]
34. Pickering TG, Hall JE, reasons, a single measurement is The 2017 ACC/AHA guidelines
Appel LJ, Falkner BE,
Graves J, Hill MN, et al. inadequate to characterize BP or emphasize the importance of
Recommendations for diagnose hypertension—BP should out-of-office BP monitoring,
blood pressure measure-
ment in humans and be measured at least twice and which includes 24-hour ABPM
experimental animals:
part 1: blood pressure
averaged during each visit. In ad- and self-monitoring at home (37).
measurement in hu- dition, the average from multiple Out-of-office monitoring can help
mans: a statement for
professionals from the visits is more useful than the aver- confirm the diagnosis of hyper-
Subcommittee of Profes- age from a single visit. Therefore, tension or can suggest white coat
sional and Public Educa-
tion of the American the diagnosis of hypertension and hypertension or masked hyper-
Heart Association Council
on High Blood Pressure its severity should be based on at tension. It can also be useful
Research. Circulation.
2005;111:697-716.
least 2 BP readings taken on at in titrating antihypertensive
[PMID: 15699287] least 2 clinic visits (Table 1). medications (29, 38).
35. Myers MG. A short his-
tory of automated office What is white coat
blood pressure - 15 years Automated devices that measure
to SPRINT. J Clin Hyper- oscillations produced by pulsatile hypertension?
tens (Greenwich). 2016;
18:721-4. [PMID: blood flow in the arm have be- White coat hypertension is de-
27038200]
36. Johnson KC, Whelton come standard for measuring BP fined as an elevated BP at the
PK, Cushman WC, Cutler in the office because they elimi- office with BP in the normal
JA, Evans GW, Snyder
JK, et al; SPRINT Re- nate several types of measure- range measured at home or with
search Group. Blood
pressure measurement
ment error typical of manual a 24-hour ambulatory monitor
in SPRINT (Systolic Blood auscultation. Some newer oscillo- (39). The prevalence of white
Pressure Intervention
Trial). Hypertension. metric devices take multiple coat hypertension is 15% to 30%
2018;71:848-57. [PMID:
29531173]
measurements automatically. among patients with an elevated
37. Melville S, Byrd JB. Out- Moreover, recent studies have office BP (40, 41). Patients with
of-office blood pressure
monitoring in 2018. shown the value of “unattended” white coat hypertension are at
JAMA. 2018;320: BP measurement (35), whereby increased risk for overt hyperten-
1805-6. [PMID:
30398589] automated devices obtain multi- sion. Although they might have

modestly higher cardiovascular readings and ABPM are valuable 38. McManus RJ, Mant J,
Franssen M, Nickless A,
risk, this is likely primarily be- in screening patients with sus- Schwartz C, Hodgkinson
cause their out-of-office BP read- J, et al; TASMINH4 inves-
pected masked hypertension. tigators. Efficacy of self-
ings tend to be slightly higher The 2017 ACC/AHA guidelines monitored blood pres-
sure, with or without
(although still <130/80 mm Hg) state that it is reasonable to telemonitoring, for titra-
than among truly normotensive screen for masked hypertension tion of antihypertensive
medication (TASMINH4):
persons (42– 44). The 2017 ACC/ in untreated patients with systolic an unmasked ran-
AHA guidelines state that it is BP of 120 to 129 mm Hg or dia-
domised controlled trial.
Lancet. 2018;391:949-
reasonable to use ABPM or home stolic BP of 75 to 79 mm Hg in 59. [PMID: 29499873]
39. Angeli F, Verdecchia P,
BP monitoring to screen for white the office (class IIa recommenda- Gattobigio R, Sardone M,
coat hypertension in patients tion). In patients with BP less than Reboldi G. White-coat
hypertension in adults.
with untreated systolic BP above 130/80 mm Hg in the office, the Blood Press Monit.
130 mm Hg and below 160 mm incidence of masked hypertension
2005;10:301-5. [PMID:
16496443]
Hg or diastolic BP above 80 mm 40. O’Brien E, Parati G, Ster-
was recently found to be 30% with giou G, Asmar R, Beilin L,
Hg and below 100 mm Hg (class
daytime 24-hour ABPM (47). The Bilo G, et al; European
IIa recommendation). They also Society of Hypertension
ACC/AHA guidelines recommend Working Group on Blood
state that it is reasonable to an- Pressure Monitoring.
continued lifestyle modification;
nually monitor for progression to European Society of
sustained hypertension using however, for the first time they also Hypertension position
paper on ambulatory
either ABPM or home BP moni- recommend initiation of pharmaco- blood pressure monitor-
logic therapy specifically for masked ing. J Hypertens. 2013;
toring in patients diagnosed with 31:1731-68. [PMID:
white coat hypertension (class IIa hypertension. 24029863]
41. Franklin SS, Thijs L, Han-
recommendation). Current When is ABPM indicated? sen TW, O’Brien E, Staes-
sen JA. White-coat hyper-
guidelines do not recommend An ambulatory BP monitor is a tension: new insights
pharmacologic treatment for pa- portable device worn by a pa-
from recent studies.
Hypertension. 2013;62:
tients with white coat hyperten- tient during 24 hours of regular 982-7. [PMID:
24041952]
sion given the lack of evidence activity. It typically measures BP 42. Stergiou GS, Asayama K,
showing clinical benefit, but they every 15 to 30 minutes during Thijs L, Kollias A, Nii-
ranen TJ, Hozawa A,
do recommend lifestyle modifi- the day and every 30 to 60 min- et al; International Data-
cation and regular follow-up. utes at night. ABPM provides the base on HOme blood
pressure in relation to
“gold standard” assessment of Cardiovascular Outcome
What is masked hypertension? (IDHOCO) Investigators.
BP that most strongly predicts
As many as 10% to 40% of pa- future cardiovascular risk (37).
Prognosis of white-coat
and masked hyperten-
tients with BP less than 140/90 The Centers for Medicare & Med- sion: International Data-
base of HOme blood
mm Hg in the office have high BP icaid Services pays for ABPM only pressure in relation to
during home or ambulatory mon- when it is used to diagnose white Cardiovascular Outcome.
Hypertension. 2014;63:
itoring, which is known as coat hypertension, although it 675-82. [PMID:
“masked hypertension” (44, 45). recently sought public comment 24420553]
43. Eguchi K, Hoshide S,
Masked hypertension has been on this policy. The Box (Potential Ishikawa J, Ishikawa S,
Pickering TG, Gerin W,
associated with increased risk for Indications for Ambulatory Blood et al. Cardiovascular
sustained hypertension and car- Pressure Monitoring) lists other prognosis of sustained
and white-coat hyperten-
diovascular morbidity and mor- situations in which ABPM may be sion in patients with type
tality (44, 46). Therefore, home helpful. 2 diabetes mellitus.
Blood Press Monit.
2008;13:15-20. [PMID:
18199919]
44. Banegas JR, Ruilope LM,
de la Sierra A, Vinyoles E,
Potential Indications for Ambulatory Blood Pressure Monitoring Gorostidi M, de la Cruz
JJ, et al. Relationship
• Unusual variability in blood pressure between clinic and am-
• Possible white coat hypertension bulatory blood-pressure
measurements and mor-
• Evaluation of nocturnal hypertension tality. N Engl J Med.
2018;378:1509-20.
• Evaluation of drug-resistant hypertension [PMID: 29669232]
• Determining efficacy of drug treatment over 24 h 45. Mallion JM, Clerson P,
Bobrie G, Genes N,
• Diagnosis and treatment of hypertension in pregnancy Vaisse B, Chatellier G.
• Evaluation of symptomatic hypotension with use of various medications, Predictive factors for
masked hypertension
suggesting that the patient may be normotensive within a population of
• Evaluation of episodic hypertension or autonomic dysfunction controlled hypertensives.
J Hypertens. 2006;24:
• Possible masked hypertension 2365-70. [PMID:
17082717]

ABPM may also be useful in iden- stress, and physical activity level. The
tifying high-risk BP patterns that family history should identify any
are associated with increased hypertension, renal disease, cardio-
cardiovascular events in patients vascular problems, stroke, and dia-
46. Bobrie G, Chatellier G,
Genes N, Clerson P, Vaur with hypertension. One pattern is betes mellitus.
L, Vaisse B, et al. Cardio- loss of “nocturnal dipping,” which
vascular prognosis of Sudden onset of severe hyper-
“masked hypertension” is a normal decrease in BP of at
detected by blood pres-
least 10% during sleep relative to tension with previously normal
sure self-measurement
in elderly treated hyper- daytime (48). Loss of nocturnal BP suggests that the patient is
tensive patients. JAMA.
dipping is associated with worse among the approximately 10% of
2004;291:1342-9.
[PMID: 15026401]
cardiovascular outcomes (48). hypertensive patients with an
47. de la Sierra A, Banegas
JR, Vinyoles E, Segura J, The other high-risk pattern is identifiable cause (“secondary
Gorostidi M, de la Cruz
early-morning BP surges (49), hypertension”). In these patients,
JJ, et al. Prevalence of
masked hypertension in which are associated with in- clinicians should ask about symp-
untreated and treated toms that might reveal the cause.
patients with office blood creased cerebrovascular disease
pressure below 130/80
risk. A surge is generally defined For example, palpitations, tachy-
mm Hg [Letter]. Circula-
tion. 2018;137:2651-3. as an average systolic BP during cardia, paroxysmal headache,
[PMID: 29712713]
the 2 hours after waking that is and sweating suggest pheochro-
48. Cuspidi C, Macca G,
Sampieri L, Fusi V, Sev-
more than 55 mm Hg above the mocytoma. Muscle weakness and
ergnini B, Michev I, et al.
Target organ damage lowest value during sleep (49). In polyuria suggest hypokalemia
and non-dipping pattern
these patients, physicians may from severe primary aldosteron-
defined by two sessions
of ambulatory blood wish to target treatment at the ism. Snoring and daytime sleepi-
pressure monitoring in ness can indicate sleep apnea,
recently diagnosed es- high systolic values in the morn-
sential hypertensive
ing. However, although some and heat intolerance and weight
patients. J Hypertens.
2001;19:1539-45. studies have shown a benefit of loss suggest hyperthyroidism.
[PMID: 11564972]
49. Kario K, Pickering TG, chronotherapy (50), others have The clinician should ask about
Umeda Y, Hoshide S,
Hoshide Y, Morinari M,
not (51, 52). Tailoring treatment current medications that may af-
et al. Morning surge in of high BP during specific times is fect BP, such as oral contracep-
blood pressure as a
predictor of silent and still being studied and is not for- tives; corticosteroids; sympatho-
clinical cerebrovascular mally recommended by guide- mimetics; antimigraine drugs;
disease in elderly hyper-
tensives: a prospective lines. It should be done only on a and over-the-counter drugs, such
study. Circulation. 2003;
107:1401-6. [PMID: case-by-case basis. as nonsteroidal anti-inflammatory
12642361]
50. Basile JN, Bloch MJ. What are the key elements of drugs other than aspirin. The cli-
Analysis of recent papers
the history? nician also should ask about lico-
in hypertension: night-
time administration of at
The history should define the risk rice and supplements, such as
least one antihyperten-
sive medication is associ- factors for “primary hyperten- ma huang, ephedra, guarana,
ated with better blood
sion” that can be addressed (for bitter orange, and black cohosh.
pressure control and
cardiovascular outcomes example, obesity or high-sodium
in patients with type 2 What are the essential elements
diabetes or chronic kid- diet), identify the cardiometa- of the physical examination?
ney disease. J Clin Hy-
pertens (Greenwich). bolic risk factors that are used to The physical examination should
2013;15:2-4. [PMID: calculate 10-year global cardio- look for signs of secondary
23282118]
51. Rahman M, Greene T, vascular risk, and identify any BP- causes of hypertension and
Phillips RA, Agodoa LY,
Bakris GL, Charleston J,
related target organ damage (for end-organ damage related to
et al. A trial of 2 strate- example, albuminuria or chronic hypertension (Table 3).
gies to reduce nocturnal
blood pressure in blacks kidney disease) that might play a
with chronic kidney dis- role in causing hypertension or Which laboratory tests should
ease. Hypertension.
2013;61:82-8. [PMID: might modify medication selec- be done in newly diagnosed
23172931]
52. Poulter NR, Savopoulos tion or target BP. It should also patients?
C, Anjum A, Apostolo- include the duration, rapidity of In patients with newly diagnosed
poulou M, Chapman N,
Cross M, et al. Random- onset, and severity of the hyperten- hypertension, clinicians should
ized crossover trial of the
impact of morning or
sion; presence of other medical order a hemoglobin or hemato-
evening dosing of anti- conditions; past treatment of hyper- crit test; measurement of serum
hypertensive agents on
24-hour ambulatory tension and its effects; and lifestyle electrolytes, glucose, and creati-
blood pressure. Hyper- factors, such as diet (including salt nine (to calculate glomerular fil-
tension. 2018;72:870-3.
[PMID: 30354703] intake), alcohol and tobacco use, tration rate); and a fasting lipid

Table 3. Physical Examination and Key Findings in Patients With Hypertension
Item Routine Evaluation
General appearance, height, weight, body mass Look for signs of metabolic syndrome (overweight, abdominal obesity)
index, waist circumference, skin lesions Skin changes can indicate rare causes of secondary hypertension
(striae in Cushing syndrome; mucosal fibromas can indicate MEN II)
Funduscopy* Retinal changes reflect severity of hypertension: arteriolar narrowing
(grade 1), arteriovenous compression (grade 2), hemorrhages or
exudates (grade 3), and papilledema (grade 4)
Examination of neck Assess for thyroid enlargement and carotid bruits
Cardiopulmonary examination Rales and gallops may indicate heart failure
Interscapular murmur during auscultation of the back can indicate
coarctation of the aorta
Abdominal examination Palpable kidneys suggest polycystic kidney disease
Midepigastric bruits can indicate renal arterial disease
Neurologic examination Look for evidence of previous stroke
Evaluate cognition (hypertension is a risk factor for cognitive decline)
Peripheral pulses Reduced leg pulses can indicate coarctation of the aorta or systemic
atherosclerosis
MEN = multiple endocrine neoplasia.

*Should be done by a trained eye specialist.
level test (to calculate global car- increase serum uric acid levels.
diovascular risk). They should Estimated glomerular filtration
also order urinalysis with micro- rate and urine albumin–creatinine
scopic examination and 12-lead ratio can help in risk stratification for
electrocardiogram. Echocardiog- CVD; the latter can also help in se-
raphy is more sensitive than elec- lection of therapy in patients with 53. Cordain L, Eaton SB,
trocardiography for identifying diabetes. Sebastian A, Mann N,
Lindeberg S, Watkins BA,
left ventricular hypertrophy, et al. Origins and evolu-
which could help diagnose hy- Additional testing may be indi- tion of the Western diet:
health implications for
pertension, estimate its severity, cated depending on clinical fac- the 21st century. Am J
Clin Nutr. 2005;81:341-
distinguish white coat hyperten- tors, suspicion of secondary 54. [PMID: 15699220]
sion from true hypertension, and causes, and anticipated treatment. 54. Mattes RD, Donnelly D.
Relative contributions of
guide therapy selection (for ex- dietary sodium sources. J
ample, drug treatment vs. life- Am Coll Nutr. 1991;10:
Which patients should be 383-93. [PMID:
style changes). However, the cost evaluated for secondary 1910064]
55. Institute of Medicine.
of echocardiography precludes Sodium Intake in Popu-
hypertension, and how?
its use as a screening tool in all lations: Assessment of
patients with hypertension. If a The Box lists symptoms and Evidence. Washington,
DC: National Academies
patient has gout, serum uric signs that suggest secondary hy- Pr; 2013.
56. Newberry SJ, Chung M,
acid levels should be checked pertension. Appendix Table 1 Anderson CAM, Chen C,
before diuretics are prescribed. (available at Annals.org) summa- Fu Z, Tang A, et al. So-
dium and Potassium
Angiotensin-converting enzyme rizes laboratory tests that may Intake: Effects on Chronic
Disease Outcomes and
(ACE) inhibitors, ARBs (except be useful in evaluating possible Risks. Comparative Effec-
losartan), and ␤-blockers can also secondary hypertension. tiveness Review no. 206.
(Prepared by the RAND
Southern California
Evidence-based Practice
Center under contract
no. 290-2015-00010-I.)
Symptoms and Signs That Suggest Secondary Hypertension AHRQ publication no.
18-EHC009-EF. Rockville,
• New-onset hypertension at age <25 or >55 y MD: Agency for Health-
• Drug-resistant hypertension (requires ≥3 drugs of different classes at maximum doses) care Research and Qual-
ity; June 2018.
• Spontaneous hypokalemia 57. O’Donnell M, Mente A,
Rangarajan S, McQueen
• Palpitations, headaches, and sweating MJ, Wang X, Liu L, et al;
• Severe vascular disease, including coronary artery disease, carotid disease, and PURE Investigators. Uri-
nary sodium and potas-
peripheral vascular disease sium excretion, mortality,
• Epigastric bruit and cardiovascular
events. N Engl J Med.
• Radial-femoral pulse delay, especially with an interscapular murmur 2014;371:612-23.
[PMID: 25119607]

58. Mente A, O’Donnell M,
Rangarajan S, McQueen
Diagnosis... Diagnosis of hypertension requires careful measurement
M, Dagenais G, Wielgosz of BP, with a finding of an average systolic BP of 130 mm Hg or higher
A, et al. Urinary sodium or an average diastolic BP of 80 mm Hg or higher based on 2 or more
excretion, blood pres-
sure, cardiovascular
readings obtained on 2 or more occasions. The diagnosis should be
disease, and mortality: a confirmed with out-of-office BP monitoring if possible. The goals of the
community-level pro- initial evaluation are to search for a secondary cause, detect other CVD
spective epidemiological
cohort study. Lancet. risk factors, and detect damage to target organs. The history should
2018;392:496-506. focus on past treatment, current medications, and modifiable lifestyle
[PMID: 30129465]
59. Appel LJ, Moore TJ,
factors. The physical examination should focus on the eyegrounds, the
Obarzanek E, Vollmer cardiovascular system, and the nervous system. The clinician should
WM, Svetkey LP, Sacks measure hemoglobin, serum creatinine, glucose, lipid, and electrolyte
FM, et al. A clinical trial
of the effects of dietary levels and arrange for urinalysis and an electrocardiogram.
patterns on blood pres-
sure. DASH Collaborative
Research Group. N Engl
J Med. 1997;336:1117- CLINICAL BOTTOM LINE
24. [PMID: 9099655]
60. Bray GA, Vollmer WM,
Sacks FM, Obarzanek E,
Svetkey LP, Appel LJ;
DASH Collaborative Re-
search Group. A further
subgroup analysis of the
Treatment
effects of the DASH diet
and three dietary sodium
What are the new thresholds cal CVD but with a 10-year risk
levels on blood pressure: for treatment in patients with for ASCVD less than 10% if the
results of the DASH-
Sodium Trial. Am J Car- hypertension? BP is 140/90 mm Hg or higher
diol. 2004;94:222-7.
The 2017 ACC/AHA guidelines (class I recommendation). Finally,
[PMID: 15246908]
61. Whelton PK, Appel LJ, recommend treatment with life- they recommend BP-lowering med-
Espeland MA, Applegate
style modification for patients ications in patients treated for sec-
WB, Ettinger WH Jr,
Kostis JB, et al. Sodium with BP of 120/80 mm Hg or ondary prevention of stroke if the
reduction and weight
higher. Previous guidelines have BP is 140/90 mm Hg or higher.
loss in the treatment of
hypertension in older recommended other treatments What are the new treatment
persons: a randomized
controlled trial of non- based on the presence of cate-
goals?
pharmacologic interven- gorical comorbidities, such as
tions in the elderly
diabetes or chronic kidney dis- The 2017 ACC/AHA guidelines
(TONE). TONE Collabora-
tive Research Group. ease. In contrast, the new guide- promote a single BP goal to sim-
JAMA. 1998;279:839-
lines recommend treatment plify management. The new goal
46. [PMID: 9515998]
62. Piercy KL, Troiano RP, decisions based on a global as- is less than 130/80 mm Hg and is
Ballard RM, Carlson SA, the same for office, home, and
Fulton JE, Galuska DA, sessment of cardiovascular risk.
et al. The physical activity For example, the new guidelines daytime ambulatory measure-
guidelines for Americans.
JAMA. 2018;320: recommend BP-lowering medi- ments. Although the goal is the
2020-8. [PMID: cations for patients with clinical same for these methods, it
30418471]
63. Fagrell B, De Faire U, CVD. However, they also recom- should be noted that these mea-
Bondy S, Criqui M, Ga- mend these medications for pa- surements are likely to differ. The
ziano M, Gronbaek M,
et al. The effects of light tients without clinical CVD but clinician should intensify treat-
to moderate drinking on with an estimated 10-year risk for ment in most patients to reach
cardiovascular diseases. J
Intern Med. 1999;246: atherosclerotic CVD (ASCVD) of the goal as long as it is prudent
331-40. [PMID: 10% or higher as long as the av- and possible.
10583704]
64. Roerecke M, Kaczorowski erage systolic BP is 130 mm Hg
J, Tobe SW, Gmel G, or higher or the average diastolic An exception is a goal of a sys-
Hasan OSM, Rehm J.
The effect of a reduction BP is 80 mm Hg or higher. The tolic BP less than 130 mm Hg
in alcohol consumption ASCVD risk calculation can be without a diastolic BP goal for
on blood pressure: a
systematic review and performed using the ACC/AHA persons aged 65 years or older
meta-analysis. Lancet pooled cohort equations (http: who are ambulatory and living in
Public Health. 2017;2:
e108-e120. [PMID: //tools.acc.org/ASCVD-Risk the community. One reason is
29253389] -Estimator). The new guidelines that most of them already have
65. McGuire HL, Svetkey LP,
Harsha DW, Elmer PJ, also recommend medications for low diastolic BP due to arterial
Elmer PJ, Appel LJ, et al.
patients with diabetes or chronic stiffening. Another reason is that
Comprehensive lifestyle
modification and blood kidney disease (stage 3 or excessively low diastolic values
pressure control: a re- could lead to increased cardio-
view of the PREMIER
higher) and a BP of 130/80 mm
trial. J Clin Hypertens Hg or higher. In addition, they vascular risk, particularly among
(Greenwich). 2004;6:
383-90. [PMID:
recommend BP-lowering medi- those with established coronary
15249794] cations in patients without clini- artery disease. It is prudent to

monitor for symptoms, such as ever, the association between
increased angina and syncope, cardiovascular outcomes and
in persons with diastolic BP less sodium intake remains controver- 66. Brook RD, Appel LJ,
Rubenfire M, Ogedegbe
than 65 to 70 mm Hg and to sial. For example, a 2013 Institute G, Bisognano JD, Elliott
decrease treatment intensity if of Medicine report suggested WJ, et al; American
Heart Association Profes-
needed. In addition, clinical judg- that studies that examined health sional Education Com-
ment and patient preference are outcomes had inconsistent qual- mittee of the Council for
High Blood Pressure
more important in older adults ity and insufficient quantity to Research, Council on
because they have a high fre- determine whether sodium in- Cardiovascular and
Stroke Nursing, Council
quency of comorbidities, which take less than 2300 mg/d in- on Epidemiology and
makes them less homogeneous creases or decreases risk for Prevention, and Council
on Nutrition, Physical
than when they were younger. heart disease, stroke, or all-cause Activity. Beyond medica-
They also have limited life expec- death (55). In addition, a recent tions and diet: alterna-
tive approaches to lower-
tancy, which highlights the con- report by the Agency for Health- ing blood pressure: a
sequences of overaggressive care Research and Quality found scientific statement from
the American Heart Asso-
treatment. In these circum- “limited evidence” that sodium ciation. Hypertension.
2013;61:1360-83.
stances, some clinicians and their intake is associated with all-cause [PMID: 23608661]
patients decide on a goal of a mortality (56). Moreover, a 2014 67. Pareek AK, Messerli FH,
Chandurkar NB, Dharma-
systolic BP less than 140 mm Hg. study that used fasting urine sam- dhikari SK, Godbole AV,
ples to estimate sodium intake in Kshirsagar PP, et al.
What are recommended Efficacy of low-dose
more than 100 000 persons from chlorthalidone and hy-
lifestyle modifications for 17 countries found that intake of drochlorothiazide as
treating hypertension? 3 to 6 g/d was associated with assessed by 24-h ambu-
latory blood pressure
The 2017 ACC/AHA guidelines lower risk for CVD compared monitoring. J Am Coll
Cardiol. 2016;67:379-
recommend lifestyle modification with higher or lower intake (57). 89. [PMID: 26821625]
for all patients with elevated BP A more recent report suggests 68. ALLHAT Officers and
Coordinators for the
or hypertension (2). Although an association between sodium ALLHAT Collaborative
lifestyle changes can substantially intake and CVD or stroke only Research Group. The
Antihypertensive and
decrease BP, these changes and with intake above 5 g/d (58). Lipid-Lowering Treatment
their benefits are difficult to sus- to Prevent Heart Attack
tain, so clinicians should encour- In TOHP I, adults with diastolic BP of 80 to 89 Trial. Major outcomes in
high-risk hypertensive
age patients to maintain lifestyle mm Hg and systolic BP less than 160 mm Hg patients randomized to
were randomly assigned to 18-month inter- angiotensin-converting
changes, especially when drug enzyme inhibitor or
ventions to lose weight or reduce sodium in-
therapy becomes necessary. take or to 1 of 2 control groups. After 7 years,
calcium channel blocker
vs diuretic: the Antihy-
Appendix Table 2 (available at the incidence of hypertension was 18.9% in pertensive and Lipid-
Annals.org) shows the expected the weight loss group and 40.5% in the control Lowering Treatment to
Prevent Heart Attack Trial
effects of lifestyle modification. group, and the incidence of hypertension was (ALLHAT). JAMA. 2002;
22.4% in the sodium reduction group and 288:2981-97. [PMID:
Salt restriction and increased 32.9% in the control group (32). 12479763]
69. Beckett NS, Peters R,
potassium intake Fletcher AE, Staessen JA,
Some experts believe that dietary The DASH (Dietary Approaches to Stop Hyper- Liu L, Dumitrascu D,
et al; HYVET Study
sodium restriction reduces sys- tension) trial randomly assigned 459 adults Group. Treatment of
tolic BP by about 3 mm Hg. As a with systolic BP less than 160 mm Hg and di- hypertension in patients
result, the 2017 ACC/AHA guide- astolic BP of 80 to 95 mm Hg to 8 weeks of a 80 years of age or older.
N Engl J Med. 2008;
control diet; a diet rich in fruits and vegeta-
lines recommend sodium intake 358:1887-98. [PMID:
bles; or a “combination” diet rich in fruits, veg- 18378519]
of no more than 1500 mg/d in etables, and low-fat dairy products (59). The 70. Pitt B, Zannad F, Remme
most hypertensive patients or, if combination diet reduced systolic BP by 5.5
WJ, Cody R, Castaigne A,
Perez A, et al. The effect
that is not possible, reducing so- mm Hg more and diastolic BP by 3.0 mm Hg of spironolactone on
dium intake by 1000 mg/d. The more than the control diet (P < 0.001); the morbidity and mortality
in patients with severe
average Western diet contains fruits-and-vegetables diet reduced systolic BP heart failure. Random-
3400 mg of sodium per day, and by 2.8 mm Hg more (P < 0.001) and diastolic ized Aldactone Evalua-
tion Study Investigators.
patients are often unaware of the BP by 1.1 mm Hg more (P = 0.07) than the N Engl J Med. 1999;
high sodium content of many control diet. Reductions were larger in 133 pa- 341:709-17. [PMID:
tients with hypertension than in normotensive 10471456]
foods (53, 54). To comply with 71. Zannad F, McMurray JJ,
patients. This study concluded that a combina- Krum H, van Veldhuisen
these recommendations, patients
tion diet rich in fruits, vegetables, and low-fat DJ, Swedberg K, Shi H,
should avoid processed foods, dairy products decreases BP (60). et al; EMPHASIS-HF
Study Group. Eplerenone
lunchmeats, soups, bread, in patients with systolic
cheese, Chinese food, and Other lifestyle interventions heart failure and mild
symptoms. N Engl J
canned food and should eat Clinicians should encourage Med. 2011;364:11-21.
fresh fruit and vegetables. How- weight loss to less than 20% [PMID: 21073363]

above the ideal weight for the spite lifestyle modification. The 2017
patient's height. Systolic BP de- ACC/AHA guidelines provide a
creases by approximately 1 mm class I recommendation for use of a
Hg for every kilogram of weight thiazide-type diuretic, an ACE inhibi-
72. Yusuf S, Sleight P, Pogue lost (61). In addition, clinicians tor, an ARB, or a calcium-channel
J, Bosch J, Davies R,
Dagenais G; Heart Out- should recommend at least 30 blocker (CCB) for the initial medica-
comes Prevention Evalu- minutes of aerobic exercise on tion in patients with stage 1 hyper-
ation Study Investigators.
Effects of an angiotensin- most days of the week. Physical tension. On the basis of clinical trial
converting-enzyme in-
hibitor, ramipril, on
activity guidelines published in evidence of reduction in clinical out-
cardiovascular events in 2018 might help clinicians tailor comes beyond mere BP lowering
high-risk patients. N Engl their advice to patients (62).
J Med. 2000;342:145-
and greater potency and duration of
53. [PMID: 10639539] These guidelines acknowledge action (67), chlorthalidone or indap-
73. Dahlöf B, Sever PS, for the first time that both moder-
Poulter NR, Wedel H,
amide is recommended by most
Beevers DG, Caulfield M, ate weightlifting and isometric experts over hydrochlorothiazide
et al; ASCOT Investiga-
tors. Prevention of car-
exercises may also help decrease when using a diuretic. ␤-Blockers
diovascular events with BP. Moreover, clinicians should are not a first-line choice for most
an antihypertensive
regimen of amlodipine
strongly encourage smoking cessa- patients (unless specifically indi-
adding perindopril as tion as an essential part of reducing cated due to a comorbidity) be-
required versus atenolol
adding bendroflumethia-
cardiovascular risk. Finally, clinicians cause they are inferior for stroke
zide as required, in the should recommend that their hyper- prevention. Appendix Table 3
Anglo-Scandinavian
Cardiac Outcomes Trial-
tensive patients reduce alcohol in- (available at Annals.org) shows the
Blood Pressure Lowering take to no more than 2 mixed drinks, doses, mechanisms, advantages,
Arm (ASCOT-BPLA): a
multicentre randomised two 12-oz cans of beer, or two 4-oz and disadvantages of commonly
controlled trial. Lancet. glasses of wine daily for men and to used antihypertensive drugs. The
2005;366:895-906.
[PMID: 16154016] one half these quantities for women Figure provides an algorithm for
74. Carey RM, Calhoun DA, (63, 64). hypertension treatment, and Ap-
Bakris GL, Brook RD,
Daugherty SL, Dennison- pendix Table 4 (available at Annals
Himmelfarb CR, et al; The PREMIER trial randomly assigned 810 par-
American Heart Associa- ticipants to weight loss, exercise, and limited .org) elaborates on compelling
tion Professional/Public sodium and alcohol intake; these same inter- drug indications. Finally, the guide-
Education and Publica-
tions Committee of the ventions plus the DASH diet; or a control lines endorse use of medications
Council on Hyperten- group that received only 1-time advice. Com- that combine more than 1 drug
sion; Council on Cardio-
vascular and Stroke Nurs-
pared with the control group at 6 months, sys- in the same pill because they can
ing; Council on Clinical tolic BP decreased by 3.7 mm Hg in the group improve adherence (class IIa
Cardiology; Council on randomly assigned to weight loss, exercise,
Genomic and Precision
recommendation).
Medicine; Council on and limited sodium and alcohol intake versus
Peripheral Vascular Dis- 4.3 mm Hg in the group randomly assigned to ALLHAT (Antihypertensive and Lipid-Lowering Treat-
ease; Council on Quality
of Care and Outcomes
these plus the DASH diet (65). ment to Prevent Heart Attack Trial) randomly as-
Research; and Stroke signed 44 000 patients older than 55 years with hy-
Council. Resistant hyper- Fish oil, magnesium, and calcium pertension and 1 additional cardiovascular risk factor
tension: detection, evalu-
ation, and management:
supplementation have not been to initial treatment with a diuretic (chlorthalidone),
a scientific statement shown to reduce BP. Several an ␣-blocker (doxazosin), an ACE inhibitor (lisino-
from the American Heart pril), or a CCB (amlodipine). Addition of a second
Association. Hyperten-
other lifestyle changes have un-
sion. 2018;72:e53-e90. certain value. It is difficult to de- drug was permitted as needed. The doxazosin group
[PMID: 30354828]
sign adequate controls to allow was discontinued when interim results showed that
75. Funder JW. Mineralocor-
ticoid receptor antago- studies to show the effect of heart failure occurred more frequently in this group.
nists: emerging roles in
some lifestyle changes. Thera- The results for the remaining groups supported use
cardiovascular medicine. of diuretics as first-line therapy because they were
Integr Blood Press Con- pies or potential therapies, such more effective in reducing cardiovascular death,
trol. 2013;6:129-38.
[PMID: 24133375] as yoga, acupuncture, device- nonfatal myocardial infarction, heart failure, and
76. Calhoun DA, White WB. guided breathing, and medita- stroke and had lower cost (68). The cost of all of these
Effectiveness of the selec-
tive aldosterone blocker, tion, have been reviewed in drugs has since decreased, and the ACC/AHA guide-
eplerenone, in patients detail (66). Caffeine transiently lines do not prioritize diuretics over ACE inhibitors,
with resistant hyperten-
sion. J Am Soc Hyper- increases BP but has little sus- ARBs, or CCBs.
tens. 2008;2:462-8. tained effect.
[PMID: 20409927] Clinicians should strongly con-
77. Noubiap JJ, Nansseu JR,
Nyaga UF, Sime PS,
When is antihypertensive sider treating hypertension in
Francis I, Bigna JJ. therapy indicated, and which very elderly patients.
Global prevalence of
resistant hypertension: a drugs should clinicians
meta-analysis of data HYVET (Hypertension in the Very Elderly Trial)
from 3.2 million pa- prescribe initially? randomly assigned 3845 patients older than
tients. Heart. 2019;105:
98-105. [PMID:
Many patients with hypertension 80 years with systolic BP of 160 to 199 mm Hg
30087099] require drug therapy for control de- to either placebo or a diuretic (indapamide,

Figure. General approach to treatment of hypertension per the 2017
American College of Cardiology/American Heart Association guidelines.
Diagnosis of hypertension (BP >130/80 mm Hg)

78. Daugherty SL, Powers
JD, Magid DJ, Tavel HM,
Lifestyle modification Masoudi FA, Margolis KL,
et al. Incidence and
prognosis of resistant
hypertension in hyper-
Stage 1 hypertension (>130/80 mm Hg): Stage 2 hypertension (≥140/90 mm Hg): tensive patients. Circula-
Treat with antihypertensive medication* Treat with antihypertensive medication* tion. 2012;125:1635-42.
if 10-y ASCVD risk ≥10% per pooled regardless of baseline risk [PMID: 22379110]
79. Williams B, MacDonald
cohort equations†
TM, Morant S, Webb DJ,
Sever P, McInnes G,
ASCVD = atherosclerotic cardiovascular disease; BP = blood pressure. et al; British Hyperten-
* First-line therapy can be an angiotensin-converting enzyme inhibitor, angiotensin-receptor sion Society's PATHWAY
blocker, thiazide-type diuretic, or calcium-channel blocker. In black persons, a thiazide-type Studies Group. Spirono-
diuretic or calcium-channel blocker is recommended. Combination antihypertensives are lactone versus placebo,
bisoprolol, and doxazo-
strongly recommended for most patients, particularly those with stage 2 hypertension.
sin to determine the
† Patients with diabetes and/or chronic kidney disease are automatically in this category. optimal treatment for
drug-resistant hyperten-
sion (PATHWAY-2): a
randomised, double-
1.5 mg/d), with addition of an ACE inhibitor blind, crossover trial.
combination of an ACE inhibitor Lancet. 2015;386:2059-
(perindopril, 4 to 8 mg/d) as needed. The trial plus an ARB or direct renin inhibitor 68. [PMID: 26414968]
was stopped early because of a large treatment should be avoided because excess 80. Krieger EM, Drager LF,
Giorgi DMA, Pereira AC,
benefit, which included an expected 30% re- adverse effect risks have been re- Barreto-Filho JAS,
duction in fatal and nonfatal stroke and an un- ported in clinical trials. Because Afri- Nogueira AR, et al; Re-
expected 21% reduction in all-cause mortality. HOT Investigators. Spi-
This study confirmed the value of drug treat-

can Americans with hypertension ronolactone versus cloni-
dine as a fourth-drug
ment for patients aged 80 years or older tend to be salt-sensitive, their initial therapy for resistant
who have systolic BP of at least 150 mm Hg medications should include a hypertension: the ReHOT
randomized study (Resis-
(69). thiazide-type diuretic or CCB (class I tant Hypertension Opti-
recommendation). mal Treatment). Hyper-
SPRINT investigated whether a systolic BP goal tension. 2018;71:681-
90. [PMID: 29463627]
of 120 mm Hg would lead to better cardiovas- An ACE inhibitor or ARB is a 81. Byrd JB, Turcu AF, Au-
cular outcomes than a goal of 140 mm Hg in good initial choice for younger chus RJ. Primary aldoste-
ronism. Circulation.
9361 patients aged 50 years or older with in- patients with hypertension be- 2018;138:823-35.
creased cardiovascular risk but without diabe- cause they often respond well to [PMID: 30359120]
tes or prior stroke. Patients randomly assigned 82. Calhoun DA, Nishizaka
suppression of the renin– MK, Zaman MA, Thakkar
to the lower goal had better scores on a com- RB, Weissmann P. Hy-
posite cardiovascular outcome than those ran-
angiotensin system. Patients with peraldosteronism among
domly assigned to the higher goal, although heart failure can benefit from black and white subjects
with resistant hyperten-
syncope, acute kidney injury, and acute renal ACE inhibitors; diuretics; carve- sion. Hypertension.
failure occurred more frequently. These effects dilol and metoprolol succinate; 2002;40:892-6. [PMID:
12468575]
also occurred in the subset of patients who ARBs; and, in many instances, 83. Williams B, MacDonald
were aged 75 years or older. mineralocorticoid-receptor an- TM, Morant SV, Webb
DJ, Sever P, McInnes GT,
tagonists as guided by RALES et al; British Hyperten-
How should clinicians modify
(Randomized Aldactone Evalua- sion Society Programme
the choice of antihypertensive tion Study) and EMPHASIS-HF
of Prevention And Treat-
ment of Hypertension
treatment on the basis of (Eplerenone in Mild Patients Hos- With Algorithm Based
Therapy (PATHWAY)
patient characteristics and pitalization and Survival Study in Study Group. Endocrine
comorbidities? Heart Failure) (70, 71). ␤-Blockers and haemodynamic
changes in resistant
In patients with diabetes, all 4 and ACE inhibitors are good for hypertension, and blood
pressure responses to
classes of first-line medications patients who have had a myocar- spironolactone or
(thiazide-type diuretic, ACE in- dial infarction. Appendix Table amiloride: the
PATHWAY-2 mechanisms
hibitor, ARB, and CCB) are rec- 4 summarizes medication indica- substudies. Lancet Diabe-
ommended (class I recommen- tions for specific comorbidities. tes Endocrinol. 2018;6:
464-75. [PMID:
dation). In hypertensive patients 29655877]
The HOPE (Heart Outcomes Prevention Evaluation) 84. Hwang AY, Dave C,
with stage 3 or higher chronic trial randomly assigned more than 9000 patients Smith SM. Trends in
kidney disease (with or without older than 55 years with CVD to ramipril, 10 mg at antihypertensive medica-
diabetes and especially in the tion use among US pa-
night, or placebo and found that those receiving tients with resistant hy-
presence of significant protein- ramipril had lower morbidity and mortality than pla- pertension, 2008 to
2014. Hypertension.
uria), an ACE inhibitor or ARB cebo recipients. Because half the patients also had 2016;68:1349-54.
should be considered, although the hypertension, the authors concluded that an ACE in- [PMID: 27777360]

hibitor is reasonable for initial hypertension therapy
in patients with vascular disease (72). Situations in Which Severe Hypertension Constitutes a Crisis
In ASCOT (Anglo-Scandinavian Cardiac Outcomes Cardiovascular
Trial) (73), investigators randomly assigned more • Left ventricular failure
than 19 000 adults with hypertension and 3 or • Myocardial infarction
more CVD risk factors to either a combination of a • Unstable angina
␤-blocker plus an as-needed thiazide-type diuretic • Aortic dissection
or a combination of a CCB (amlodipine) plus an as- • After vascular surgery or coronary artery bypass grafting
needed ACE inhibitor (perindopril). After a median
of 5.5 years, the trial was stopped early because car- Neurologic
diovascular events and total mortality were signifi- • Hypertensive encephalopathy
cantly lower in the amlodipine group (25% for • Subarachnoid or intracranial hemorrhage
stroke, 15% for coronary events and procedures, • Thrombotic stroke
and 25% for cardiovascular deaths). BP was well Other
controlled in both groups but was lower in the am- • Severe catecholamine excess, such as clonidine withdrawal, pheochromocytoma,
lodipine group by an average of 2.7/1.9 mm Hg interaction between tyramine and monoamine oxidase inhibitor, or intoxication
(73). (cocaine, phencyclidine, phenylpropanolamine)
What is resistant hypertension, • Eclampsia in pregnancy
and how is it treated?
Patients have resistant hypertension
when their BP is above the goal and based therapy) (79) and ReHOT hyperkalemia. For example,
they are taking 3 or more antihyper- (Resistant Hypertension Optimal among the 285 patients in the
tensive drugs (including a diuretic) Treatment) (80) have established PATHWAY-2 trial who received
from different classes at maximally spironolactone, an antagonist of spironolactone, 2% had a serum
tolerated doses (74). Resistant hy- the mineralocorticoid receptor, potassium level above 6.0
pertension is diagnosed more of- as the preferred fourth drug to mmol/L. New guidelines on resis-
ten than it actually occurs. One rea- add when patients have resistant tant hypertension have been
son is that common measurement hypertension. One reason is that published (74). A clinician will
mistakes often lead to overesti- many patients with resistant hy- occasionally encounter a patient
mates of BP. Therefore, measuring pertension have primary aldoste-
BP according to a rigorous protocol who requires more urgent atten-
ronism (81, 82). Another possible tion to the BP than usual. Some
is especially important when diag-
reason is that other patients with such situations are listed in the
nosing and monitoring resistant
hypertension. In addition, mount- resistant hypertension may have Box.
ing evidence suggests that 30% to a more subtle excess of aldoste-
50% of patients who apparently rone secretion (83). Although PATHWAY-2 was a double-blind crossover
have resistant hypertension instead spironolactone is roughly twice trial comparing the addition of placebo, an
as efficacious as ␤-blockers or ␣-blocker (doxazosin), a ␤-blocker (bisoprolol), or a
have white coat hypertension or are
mineralocorticoid-receptor antagonist (spironolac-
nonadherent to treatment. ␣-blockers and is inexpensive, it
tone) as the fourth drug in adults with uncontrolled
is underutilized in treatment of BP despite use of 3 drugs at maximally tolerated
Secondary causes of hypertension resistant hypertension (84). This
(Appendix Table 1) must be con- doses. PATHWAY-2 was innovative in that it used
may be because it requires peri- home BP measurements. In the final analysis, spi-
sidered when a patient has resistant
hypertension. The most common is odic monitoring of serum elec- ronolactone was the most effective add-on therapy
trolytes given the possibility of for resistant hypertension.
primary aldosteronism, which is
underdiagnosed and undertreated
(75); it occurs in approximately 20%
of patients with resistant hyperten- Treatment... Recent hypertension guidelines largely concur on major
points in the treatment of hypertension, and their recommendations will
sion (76). Resistant hypertension is lead to treatment of more persons than in the past. Clinicians should
also common in patients with counsel all patients about the role of lifestyle modifications (such as
chronic kidney disease (77). weight loss, dietary sodium restriction, and aerobic exercise) in the
management of hypertension. In addition, clinicians should use the
Patients with resistant hyperten- 2017 ACC/AHA guidelines as 1 of several guides during discussions
sion have approximately a 50% with patients about medical management of hypertension, especially
higher risk for cardiovascular when pursuing lower treatment goals.
events than those without it (78).
The clinical trials PATHWAY-2 CLINICAL BOTTOM LINE
(Prevention And Treatment of
Hypertension With Algorithm-

In the Clinic Patient Information
www.cdc.gov/bloodpressure/materials_for_patients
Tool Kit .htm

High blood pressure educational materials for patients
from the Centers for Disease Control and Prevention.
www.heart.org/en/health-topics/high-blood-pressure
/find-high-blood-pressure-tools–resources/blood-
pressure-fact-sheets
Hypertension
Blood pressure fact sheets in English and Spanish from
the American Heart Association.
https://medlineplus.gov/highbloodpressure.html
Resources related to high blood pressure from Medline-
Plus of the National Institutes of Health, including pa-
tient handouts in English and Spanish.
www.nhlbi.nih.gov/health-topics/high-blood-pressure
Resources related to high blood pressure in English and
Spanish from the National Heart, Lung, and Blood
Institute of the National Institutes of Health.
Clinical Guidelines and Other Information for

Health Professionals
IntheClinic
www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel
-MS-Word-etc/Guidelines/2017/Guidelines_Made
_Simple_2017_HBP.pdf
2017 Guideline for the Prevention, Detection, Evaluation,
and Management of High Blood Pressure in Adults from
the American College of Cardiology and the American
Heart Association.
https://annals.org/aim/fullarticle/2670318/prevention
-detection-evaluation-management-high-blood
-pressure-adults-synopsis-2017
Prevention, Detection, Evaluation, and Management of
High Blood Pressure in Adults: Synopsis of the 2017
American College of Cardiology/American Heart
Association Hypertension Guideline.
www.aafp.org/patient-care/clinical-recommendations
/all/highbloodpressure.html
Hypertension clinical practice guideline from the Ameri-
can Academy of Family Physicians.
https://professional.heart.org/idc/groups/ahamah-public
/@wcm/@sop/@smd/documents/downloadable
/ucm_497371.pdf
Top Ten Things to Know: 2017 Hypertension Clinical
Guidelines from the American Heart Association.

WHAT YOU SHOULD KNOW In the Clinic
Annals of Internal Medicine
ABOUT HYPERTENSION
What Is Hypertension?
Hypertension, or high blood pressure, is a com-
mon and urgent health problem. Blood pressure
is the force of blood pushing against the walls of
your arteries as your heart pumps blood through
your body. High blood pressure makes your heart
work harder with every beat. Untreated hypertension
puts you at higher risk for heart attack, heart failure,
stroke, kidney failure, and death.
What Are the Warning Signs?
People with hypertension often have no symp-
toms. The only way to know for sure if your
blood pressure is high is to have it checked.
How Often Should I Have My
Blood Pressure Checked?
It is a good idea to have your blood pressure checked systolic pressure (the pressure when your heart
at least once a year if you are older than 40 years. If pushes blood into your vessels with each beat),
you are 18 to 39 years old, your blood pressure and the second number is the diastolic pressure
should be checked every 3 to 5 years. (the pressure while the heart is relaxed between
beats).
Am I at Risk? If your provider suspects you have hypertension,
There is no single identifiable cause of hyperten- you will have a physical examination and addi-
sion. Many factors can contribute, including: tional laboratory tests. Your provider also will
• Being overweight or obese ask you questions about your lifestyle, medical
• Eating a diet high in sodium (salt) history, and current medications.
• Not getting enough physical activity
• Being older or African American How Is It Treated?
• Smoking Lifestyle changes are helpful for everyone with
• Drinking too much alcohol high blood pressure. Follow these healthy hab-
• Having a personal or family history of its, even if you take blood pressure medicine:
hypertension • Exercise vigorously enough to raise your heart
rate (30 minutes a day)
Patient Information
• Having other chronic diseases, especially
diabetes or kidney disease • Lose weight
• Taking specific medications that are known to • Eat more fruits, vegetables, and dairy products
cause hypertension • Eat less salt
• Drink less alcohol
How Is It Diagnosed? • Quit smoking
Your health care provider will ask you to sit quietly Many medicines can treat high blood pressure.
for several minutes before taking a reading of Your doctor may prescribe 1 medicine or a com-
your blood pressure. bination of several. Almost everyone with high
Blood pressure is measured by inflating a cuff around blood pressure can bring down their blood
the arm—this is connected to a device that measures pressure with lifestyle changes with or without
the pressure. The test is easy and painless. Your pro- medicines.
vider should make sure that your arm is supported
and the cuff fits you correctly. Questions for My Doctor
Your provider may take several readings at differ- • How often should I have my blood pressure
ent times before diagnosing you with hyperten- checked?
sion. This is because blood pressure usually • Should I check my blood pressure at home?
changes during the day. • What is my blood pressure goal?
Some people's blood pressure readings differ be- • Do I need to take medicine to treat my high
tween the doctor's office and at home. If your blood pressure?
provider suspects this, you may be given the • What are the possible side effects of blood
option to monitor your blood pressure away pressure medicines?
from the office with a special device. • If I lose weight and exercise, is it possible that
The blood pressure reading is given as 2 numbers my blood pressure will return to normal?
(for example, 120/80). The first number is the • How much salt should I eat each day?
For More Information

American Heart Association
www.heart.org/en/health-topics/high-blood-pressure
MedlinePlus
https://medlineplus.gov/highbloodpressure.html

Appendix: Guideline Differences and Controversies
Current hypertension guidelines achieving BP less than 130/80
have many similarities. For example, mm Hg yields better outcomes
most include greater acceptance of than BP less than 140/90 mm Hg.
out-of-office BP measurements, con- However, the more aggressive
sideration of global cardiovascular treatment required to achieve
risk to guide treatment, earlier com- lower BP comes with risks, such
bination therapy, removal of as hypotension and falls (particu-
␤-blockers from first-line regimens, larly in elderly persons) and renal
and lower BP goals (2, 3). However, or electrolyte abnormalities, that 85. Bress AP, Kramer H,
several differences and controver- offset some of the benefits and Khatib R, Beddhu S,
Cheung AK, Hess R, et al.
sies merit consideration. need to be considered when Potential deaths averted
making recommendations (85). and serious adverse
Threshold definition of events incurred from
adoption of the SPRINT
hypertension We believe clinicians should aim (Systolic Blood Pressure
to achieve a BP less than 130/80 Intervention Trial) inten-
Unlike the 2017 ACC/AHA guide- sive blood pressure regi-
lines, the 2018 ESC/ESH guide- mm Hg in most patients when men in the United
States: projections from
lines retain the long-standing possible, but we also recognize NHANES (National
definition of hypertension as BP that treatment decisions can be Health and Nutrition
Examination Survey).
of 140/90 mm Hg or higher (3). individualized (23–28, 85– 88). Circulation. 2017;135:
However, both recognize that Recent studies suggest that the 1617-28. [PMID:
28193605]
BPs of 120 to 139/80 to 89 mm greatest (or only) benefit from 86. Basu S, Sussman JB,
Hg pose significant public health aggressive BP lowering occurs in Rigdon J, Steimle L,
Denton BT, Hayward RA.
risks. To emphasize this, the high-risk patients (85– 88). Thus, Benefit and harm of
intensive blood pressure
ACC/AHA changed the designa- some may choose the less ag- treatment: derivation
tion for this subset of patients gressive goal of less than 140/90 and validation of risk
models using data from
from “prehypertension” (17, 18) mm Hg, such as young or low- the SPRINT and ACCORD
to “stage 1 hypertension,” which risk patients; frail persons; and trials. PLoS Med. 2017;
14:e1002410. [PMID:
assigns more persons to a dis- those with limited life expec- 29040268]
ease state that should be treated tancy, refractory hypertension, or 87. Phillips RA, Xu J, Peter-
son LE, Arnold RM, Dia-
with nonpharmacologic therapy many adverse effects from medi- mond JA, Schussheim
AE. Impact of cardiovas-
(25). However, only a modest cation. We believe that enhanced cular risk on the relative
proportion will develop higher strategies to individualize BP benefit and harm of
intensive treatment of
BP and require drug treatment. goals, such as using risk models hypertension. J Am Coll
We believe it will be important to (86, 87) or coronary artery cal- Cardiol. 2018;71:1601-
10. [PMID: 29525494]
determine the consequences of cium scores (88), should be de- 88. McEvoy JW, Martin SS,
this change over the next de- veloped and tested. Dardari ZA, Miedema
MD, Sandfort V, Yeboah J,
cade. In contrast, the 2018 ESC/ et al. Coronary artery cal-
Elderly patients cium to guide a personal-
ESH guidelines recognized that ized risk-based approach
BP below 130/80 mm Hg should Guidelines differ in their defini- to initiation and intensifi-
be targeted if well tolerated, but tions of “elderly” and their rec- cation of antihypertensive
therapy. Circulation. 2017;
only for persons younger than 65 ommendations for this popula- 135:153-65. [PMID:
years (3). tion (2, 4 – 8). The 2017 ACC/AHA 27881560]
89. Williamson JD, Supiano
guidelines use the same thresh- MA, Applegate WB,
BP goals old for treatment and the same Berlowitz DR, Campbell
RC, Chertow GM, et al;
The 2017 ACC/AHA guidelines systolic BP goal (<130 mm Hg) SPRINT Research Group.
decreased the BP goal to less for persons older than 65 years Intensive vs standard
blood pressure control
than 130/80 mm Hg on the basis and for younger patients (2). This and cardiovascular dis-
ease outcomes in adults
of consensus, meta-analyses, and recommendation is based largely aged ≥75 years: a ran-
the SPRINT trial (2). This goal is on results from SPRINT (89). domized clinical trial.
JAMA. 2016;315:2673-
uniform for all patients, even However, they recognize that 82. [PMID: 27195814]
though few trials have evaluated some elderly adults may not tol- 90. Garrison SR, Kolber MR,
Korownyk CS, McCracken
the possible benefits of lower erate this lower target. There are RK, Heran BS, Allan GM.
goals. The 2018 ESC/ESH guide- no specific recommendations for Blood pressure targets
for hypertension in older
lines retained the primary goal of those older than 80 to 85 years. adults. Cochrane Data-
base Syst Rev. 2017;8:
less than 140/90 mm Hg, but all The ESC/ESH guidelines recom- CD011575. [PMID:
guidelines acknowledge that mend a systolic BP goal of 130 to 28787537]
姝 2019 American College of Physicians Annals of Internal Medicine 7 May 2019

140 mm Hg for persons older cebo in intermediate-risk patients
than 65 years (3). They also rec- without established CVD who
ommend drug therapy for pa- started with borderline BP eleva-
tients older than 80 years only if tions (mean systolic BP, 138.1
their systolic BP is above 160 mm mm Hg). There were no signifi-
Hg. The 2017 guidelines from the cant benefits of antihypertensive
American College of Physicians therapy despite BP being 6/3
and the American Academy of mm Hg lower in the active treat-
Family Physicians recommend ment group. These important
starting treatment in persons findings indirectly support that it
older than 60 years only if their is probably safe and reasonable
systolic BP is above 150 mm Hg to defer antihypertensive therapy
(4). The goal for these patients is to low-risk patients (10-year risk
systolic BP less than 150 mm Hg, <10%) with mild hypertension
but some can choose a more ag- (systolic BP <160 mm Hg) to al-
gressive goal of less than 140 low for a trial period of 3 to 12
mm Hg (90). months of lifestyle interventions
alone on a case-by-case basis
We believe most elderly patients
using shared decision making.
should have a systolic BP goal of
However, the 2017 ACC/AHA
less than 130 mm Hg with an al-
ternative goal of less than 140 guidelines recommend identical
91. Chow CK, Teo KK, Ranga- mm Hg if the treatment required treatment of all patients with BP
rajan S, Islam S, Gupta R,
to reach the lower goal cannot of 140/90 mm Hg or higher, re-
Avezum A, et al; PURE
(Prospective Urban Rural
be tolerated. Because far fewer gardless of age and absolute
Epidemiology) Study
Investigators. Prevalence, people older than 80 to 85 years cardiovascular risk, by starting
awareness, treatment,
have been included in clinical lifestyle changes plus medica-
and control of hyperten-
sion in rural and urban trials, we believe that their BP tions immediately after confirma-
communities in high-,
goals should be individualized, tion of the diagnosis (2). In
middle-, and low-income
countries. JAMA. 2013; ranging from ideal (<130 mm contrast, the ESC/ESH guidelines
310:959-68. [PMID:
24002282] Hg) to minimally acceptable recommend a more nuanced ap-
92. Viera AJ, Hawes EM.
(<150 mm Hg), based on health proach. Patients with a BP less
Management of mild
hypertension in adults. status and patient preferences. than 160/100 mm Hg can safely
BMJ. 2016;355:i5719. undergo a 3- to 6-month trial of
[PMID: 27872051]
93. Musini VM, Gueyffier F,
Mild hypertension in lifestyle therapy before starting
Puil L, Salzwedel DM, lower-risk patients medications (3). This approach is
Wright JM. Pharmaco-
therapy for hypertension Clinicians frequently encounter compatible with all other current
in adults aged 18 to 59
years. Cochrane Data-
the question of when to initiate guidelines except the ACC/AHA
base Syst Rev. 2017;8: drug treatment in younger (aged guidelines (17, 18, 92).
CD008276. [PMID:
28813123] 18 to 55 years) and lower-risk
94. Lonn EM, Bosch J, patients with BP of 140 to 159/90 We agree with the ESC/ESH ap-
López-Jaramillo P, Zhu
J, Liu L, Pais P, et al; to 99 mm Hg. Roughly half of pa- proach to this issue. We believe the
HOPE-3 Investigators. tients with high BP have mild hy- ACC/AHA approach to the issue
Blood-pressure lowering in
intermediate-risk persons pertension and are at lower risk prematurely promotes unproven
without cardiovascular
(no diabetes, CVD, or renal dis- medical therapy that is unnecessary
disease. N Engl J Med.
2016;374:2009-20. ease and 10-year ASCVD risk because nonpharmacologic therapy
[PMID: 27041480]
95. Jamerson K, Weber MA, <10%) (91). However, no trials is safe and effective and has the po-
Bakris GL, Dahlöf B, Pitt have specifically enrolled this tential to control high BP in a sub-
B, Shi V, et al; ACCOM-
PLISH Trial Investigators. group of patients, so the risk– stantial proportion of persons with
Benazepril plus amlodip- benefit ratio for medical therapy mild hypertension. We also suggest
ine or hydrochlorothia-
zide for hypertension in is unknown (20, 92, 93). The that further testing can be beneficial.
high-risk patients. N Engl For example, a coronary artery cal-
J Med. 2008;359:2417-
HOPE-3 trial (94) did not report a
28. [PMID: 19052124] reduction in the primary compos- cium score of zero or absence of left
96. Brook RD, Weder AB.
Initial hypertension treat- ite outcome over 5.6 years of ventricular hypertrophy on echocar-
ment: one combination follow-up when low-dose combi- diography would support a 3- to
fits most? [Editorial]. J
Am Soc Hypertens. nation treatment (candesartan, 6-month trial of lifestyle changes
2011;5:66-75. [PMID: 16 mg, plus hydrochlorothiazide, before moving on to drug
21414561] doi:10.1016/
j.jash.2011.01.002 12.5 mg) was compared with pla- therapy.
7 May 2019 Annals of Internal Medicine 姝 2019 American College of Physicians

Combination treatment (73, 95, 96). This has been
More than 75% of persons with proved to be superior to both a
hypertension require 2 or more combination of a ␤-blocker and a
medications to achieve their BP diuretic and a combination of an
goal, and this will increase now RAAS blocker and hydrochlo-
that the goal is below 130/80 mm rothiazide in preventing cardio-
Hg. Therefore, we agree with the vascular events (73, 95). The
ACC/AHA that most patients benefits have been observed
should start initial therapy with a across most outcomes (for exam-
combination antihypertensive ple, cardiovascular and renal)
tablet (2). Preferred combina- and patient subgroups (for exam-
tions include a ␤-blocker or reni- ple, those with diabetes, kidney
n–angiotensin–aldosterone sys- disease, and coronary artery dis-
tem (RAAS) blocker combined ease) (96). Therefore, we recom-
with a thiazide diuretic or CCB. mend that health care providers
start by prescribing an RAAS
We disagree with the guidelines blocker plus a CCB when toler-
about selection of the specific ated or possible. Should BP re-
combination regimen. Clinical main uncontrolled, a thiazide-like
trial evidence supports a combi- diuretic (typically chlorthalidone)
nation of an RAAS blocker and a should be added as the third
CCB for optimal first-line therapy agent in most circumstances.
Appendix Table 1. Work-up to Pursue Possible Secondary Hypertension

Secondary Cause Evaluation (Findings)
Coarctation of aorta Chest film (rib notching; reverse “3” sign), 2-dimensional echocardiogram, aortogram
(coarctation directly seen), MRI
Cushing syndrome Dexamethasone suppression test (failure to suppress cortisol), 24-h urinary free cortisol
(elevated), CT (adrenomegaly)
Primary aldosteronism Plasma aldosterone–renin ratio (increased), aldosterone excretion rate during salt loading
(increased), adrenal CT (adenoma with low Hounsfield units)
Pheochromocytoma Plasma catecholamines or metanephrines (increased); most would recommend 24-h fractionated
catecholamines and metanephrines by HPLC with electrochemical detection or tandem mass
spectroscopy, clonidine suppression test (failure to suppress plasma norepinephrine after
clonidine administration), adrenal CT, MRI (adrenal tumor; T2-weighted MRI has characteristic
appearance), iodine131-metaiodobenzylguanidine scan (significant adrenal or extra-adrenal
tumor uptake)
Renal vascular disease Renal duplex sonography (requires good operators; increased renal artery compared with aorta
velocities suggests stenosis), MRA (renal vessel narrowing), CTA (renal vessel narrowing),
angiography (gold standard; renal vessel narrowing), renal vein–renin ratio (limited value)
Renal parenchymal disease Spot urine protein–creatinine ratio or 24-h urine protein and creatinine levels, renal
ultrasonography (small kidneys, unusual architecture), glomerular filtration rate (low), renal
biopsy (usually done to determine type of glomerular disease)
Parathyroid disorders Calcium and phosphorus levels (increased and decreased, respectively), serum parathyroid
hormone level (increased), serum calcitonin level (when MEN is suspected)
Thyroid disease Serum thyroid hormone level (increased in hyperthyroidism), thyrotropin level (suppressed in
hyperthyroidism)
CT = computed tomography; CTA = computed tomographic angiography; HPLC = high-performance liquid chromatography;
MEN = multiple endocrine neoplasia; MRA = magnetic resonance angiography; MRI = magnetic resonance imaging.

Appendix Table 2. Lifestyle Modifications to Decrease BP
Lifestyle Modification Recommendation Potential Decrease in Systolic BP
Dietary sodium restriction Restrict dietary sodium intake to no more than 2–8 mm Hg
2400 mg/d or 100 mEq/d
Weight loss Maintain normal body weight (BMI of 18.5–24.9 kg/m2) 5–20 mm Hg per 10 kg of weight lost
Aerobic exercise Engage in regular aerobic exercise, aiming for 30 min 4–9 mm Hg
on most days of the week
It is suggested that patients walk about 1 mile above
current activity level per day
DASH diet Consume a diet rich in fruits, vegetables, and low-fat 4–14 mm Hg
dairy products, with reduced saturated and total fat
Limited alcohol intake Consume no more than 2 mixed drinks, two 12-oz cans 2–4 mm Hg
of beer, or two 4-oz glasses of wine daily (men) or
half this quantity (women)
BMI = body mass index; BP = blood pressure; DASH = Dietary Approaches to Stop Hypertension.

Appendix Table 3. Drug Treatments for Hypertension*
Drug Class (Daily Dose, mg) Advantages Disadvantages
Diuretics Most effective in elderly persons, Electrolyte abnormalities, including
Hydrochlorothiazide (12.5–50) those with isolated systolic hypokalemia and hyponatremia; may
Chlorothiazide (250–500) hypertension, those with increase glucose, cholesterol, and uric
Chlorthalidone (12.5–50) diabetes, and African Americans, acid levels; photosensitivity
Indapamide (1.25–5) who are likely to be salt-sensitive
ACE inhibitors Preferred for chronic kidney disease, Hyperkalemia and increased uric acid level;
Enalapril (5–40) heart failure, and diabetes; work cough in 15% (switch to an ARB); can
Fosinopril (10–40) well with diuretics accept up to 30% increase in serum
Lisinopril (5–40) creatinine with ACE inhibitors;
Perindopril (4–16) angioedema in 0.1%–0.7%;
Quinapril (5–80) contraindicated in pregnancy
Ramipril (1.25–20)
ARBs Usually well tolerated; angioedema Hyperkalemia and increased uric acid level
Losartan (25–100) uncommon; work well with (except losartan); dizziness; relatively
Candesartan (16–32) diuretics; do not cause cough expensive; contraindicated in pregnancy
Irbesartan (150–300)
Potassium-sparing diuretics Most useful when a thiazide causes Hyperkalemia (rare with triamterene);
Spironolactone (25–100) hypokalemia gynecomastia (spironolactone); weak
Triamterene (25–100) antihypertensives
ß-Blockers Carvedilol is an ␣- and ß-blocker; Bronchospasm, bradycardia, heart failure;
Atenolol (25–100) nebivolol is also a vasodilator masks insulin-induced hypoglycemia;
Metoprolol (50–300) Note: Do not use ß-blockers as impairs peripheral circulation; insomnia;
Propranolol (40–480) initial therapy except in patients fatigue; decreased exercise tolerance;
Nebivolol (2.5–10) with heart failure hypertriglyceridemia (unless ISA is
Carvedilol (12.5–50) present); several trials showed worse
outcomes with atenolol than ACE
inhibitors, ARBs, and CCBs
CCBs Well tolerated and effective; Diuretic-resistant edema (lesser problem if
Amlodipine (2.5–10) dihydropyridines, like ACE inhibitor or ARB added); headache;
Diltiazem (120–360) amlodipine, are very potent cardiac conduction defects; constipation;
Verapamil (120–480) gingival hypertrophy
Nifedipine (30–120)
Reserpine (0.05–0.25) — Nasal congestion; depression; peptic ulcer
Central ␣-agonists Can be effective when other options Sedation; dry mouth; bradycardia;
Methyldopa (500–3000) have failed withdrawal (rebound) hypertension with
Clonidine (0.2–1.2) abrupt discontinuation
Guanfacine (0.5-2)
␣-Blockers Very potent Postural hypotension; diarrhea; heart
Prazosin (2–30) failure increased with doxazosin in
Doxazosin (1–16) ALLHAT
Terazosin (1–20)
Hydralazine (50–300) — Lupus reaction; headache; edema;
frequent dosing
Direct renin inhibitor Reduced plasma renin could be Diarrhea
Aliskiren (150–300) therapeutic per se; effective in
combination
Found to cause harm among
patients with diabetes in the
ALTITUDE trial
ACE = angiotensin-converting enzyme; ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial;
ALTITUDE = Aliskiren Trial in Type 2 Diabetes Using Cardiorenal Endpoints; ARB = angiotensin-receptor blocker; CCB = calcium-
channel blocker; ISA = intrinsic sympathomimetic activity.

Appendix Table 4. Compelling Indications for Individual Drug Classes*
Compelling Indication† Recommended Drugs
Heart failure Diuretic, ß-blocker, ACE inhibitor, ARB, mineralocorticoid receptor antagonist
Postmyocardial infarction ß-blocker (carvedilol, metoprolol succinate), ACE inhibitor, mineralocorticoid receptor antagonist
High coronary disease risk Diuretic, ß-blocker, ACE inhibitor, ARB + CCB
Diabetes Diuretic, ß-blocker, ACE inhibitor, ARB, CCB
Chronic kidney disease ACE inhibitor, ARB
Recurrent stroke Diuretic, ACE inhibitor
prevention
ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; CCB = calcium-channel blocker.

*Adapted from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (www.nhlbi.nih.gov/guidelines/hypertension/express.pdf).
†Based on benefits from outcome studies or existing clinical guidelines. The compelling indication is managed in parallel with the
blood pressure.

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Annals of Internal Medicine䊛

Hypertension Screening and Prevention

CME/MOC activity available at Annals.org.

Physician Writers doi:10.7326/AITC201905070

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Diagnosis 2018;71:109-18. [PMID:

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MEN = multiple endocrine neoplasia.

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Diagnosis of hypertension (BP >130/80 mm Hg)

This study conﬁrmed the value of drug treat-

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Tool Kit .htm

Clinical Guidelines and Other Information for

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For More Information

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姝 2019 American College of Physicians Annals of Internal Medicine 7 May 2019

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7 May 2019 Annals of Internal Medicine 姝 2019 American College of Physicians

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Appendix Table 1. Work-up to Pursue Possible Secondary Hypertension

姝 2019 American College of Physicians Annals of Internal Medicine 7 May 2019

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7 May 2019 Annals of Internal Medicine 姝 2019 American College of Physicians

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姝 2019 American College of Physicians Annals of Internal Medicine 7 May 2019

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ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; CCB = calcium-channel blocker.

7 May 2019 Annals of Internal Medicine 姝 2019 American College of Physicians

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