1. (Dueling) Hypertension Guidelines: Focus on ACC/AHA Guidelines
John M. Flack, M.D., M.P.H., F.A.H.A, F.A.S.H, M.A.C.P Professor and Chair, Department of Medicine, Southern Illinois University Specialist in Clinical Hypertension (ASH) President, American Hypertension Specialist Certification Program

2. Patient Cases
XO is a 48 year old man with nearly a one year history of elevated BP – 144 – 155/ mm Hg in the office and at home; BP in clinic today is 150/85 mm Hg. Physical examination reveals an S4 gallop, arteriolar narrowing and AV nicking, as well as a faint left carotid bruit. The only current medication prescribed is metformin 500 mg/d for pre-diabetes and rosuvastatin 10 mg/d. EGFR is 78 ml/min/1.73 m2.
Should antihypertensive drug therapy be prescribed? If so, which drug(s)?
What is his target BP?
TC is a 62 year old woman with a 15 year known duration of hypertension. She also had diabetes mellitus that has been well controlled with diet and metformin. Currently prescribed antihypertensive medications include HCTZ 25 mg/d, nifedipine ER 90 mg/d, and losartan 50 mg/d. The last change to her medications occurred 3 months ago. The last 4 clinic BP readings (over 6 months) have been between 140 – 156/78 – 90 mm Hg. EGFR is 34 ml/min/1.73 m2.
How would you change the current antihypertensive regimen for improved BP control?
Would non-pharmacological interventions be of benefit?

3. SPRINT Trial: Intensive Versus Standard BP Control (N=9361)
Primary outcome = MI, acute coronary syndromes, stroke, heart failure or CVD death
High-risk persons ≥ 50 years
SBP ≥ 130 – 180
BP Target
<120
Median f/u=
3.26 years
BP Target
<140
121.5 mm Hg1
D = 13.1
134.6 mm Hg2
 25% Primary Outcome3
 27% All-cause Mortality3
Adapted from SPRINT Research Group. NEJM 2015;373(22):
1 prescribed 2.8 meds; 2 prescribed 1.8 meds; 3 P <0.003.

4. Serious Adverse Events (SAE) Cluster
Amongst Study Participants Experiencing a
Primary Study Outcome: the SPRINT Study
Intensive Treatment (SBP ˂ 120)
SAE Event (0)
SAE Event (1)
P value
Primary outcome (0)
2881 (64.96)
1554 (35.04)
0.001
Primary outcome (1)
4 (1.65)
239 (98.45)
Total
2885 (61.65)
1793 (38.33)
Standard Treatment (SBP )
SAE Event (0)
SAE Event (1)
P value
Primary outcome (0)
2931 (67.16)
1433 (37.84)
0.001
Primary outcome (1)
16 (5.02)
303 (94.98)
Total
2947 (62.93)
1736 (37.07)
Composite primary outcome = MI, acute coronary syndrome, stroke, heart failure or CVD death
Botchway A, Buhnerkempe M, Prakash V, Nolasco-Morales C, Al-Akchar M, Flack JM. (manuscript in preparation)

5. Highlights of the ACC/AHA Hypertension Guidelines
New BP threshold ( ≥ 130/80 mmHg) for diagnosing hypertension
The majority of stage 1 hypertensives ( /80-89) do NOT qualify for immediate drug therapy
The BP thresholds for initiation of drug therapy is 130/80 in high-risk persons (DM, CKD, known CVD or 10-year ASCVD risk ≥ 10%) OR 140/90 in most other hypertensives
The target BP for MOST is ˂130/80 irrespective of the drug initiation BP threshold
– SBP ˂ 130 (65 and older¹)
¹Non-institutionalized, ambulatory, community-living adults

6. Highlights of the ACC/AHA Hypertension Guidelines, Cont.
The only patients with known CVD for which the drug initiation BP threshold is 140/90 is for secondary stroke prevention
Absolute 10-year CVD risk is utilized, for the first time, to determine “high-risk” states in those w/o DM, CKD, or known CVD
Thiazide diuretics, CCBs, and ACE inhibitors or ARBs are recommended for initial drug therapy

7. Highlights of the ACC/AHA Hypertension Guidelines, Cont.(2)
Monthly assessment of BP response to antihypertensive drugs with uptitration if NOT below goal
The initiation of drug therapy should occur with simultaneous use of non-pharmacological therapy
Consider initiating drug therapy with two first-time agents (different classes) in adults ≥ 20/10 mmHg above their target (stage 2 HTN)

8. Thoughts on the New ACC/AHA Guidelines
Why set the BP target higher than 120 mmHg given the clinical benefit observed at that BP Level in SPRINT?
a. SPRINT used a standard BP measurement protocol (like all prior studies); fewer than 50% had unattended measurement
b. Likely realization that most clinics will NOT have BP measurement protocols in place
c. Probably feared a “backlash” against such a low target (˂ 120 mmHg)

9. Thoughts on the New ACC/AHA Guidelines, Contd.
The BP treatment thresholds for “high risk” patients is 130/80 mmHg – even for such groups without clinical trial outcomes data to support the recommendation. Why?
This is a flashpoint area of contention for those who synthesize the data across the vast hypertension outcomes database versus those who are absolutists
The relative risk reduction for CVD events varies little across a broad range of BP’s and high-risk comorbid conditions
The absolute risk reduction for CVD events is directly related to the pre-treatment risk level

10. ACP/AAFP Recommend Systolic BP Targets Based on History and Risk Level in Adults ≥ 60 years old
SBP persistently ≥ 150 mmHg, initiate treatment to lower SBP to ˂ 150 mmHg (strong recommendation, high quality evidence)
In patients with prior stroke or TIA, initiate or intensify drug therapy to achieve SBP ˂ 140 mmHg (weak recommendation, moderate quality evidence)
In some patients with high cardiovascular (CV) risk, consider initiating or intensifying drug treatment to achieve SBP ˂ 140 mmHg (weak recommendation, low quality evidence)
Qaseem A et al. Ann Intern Med 2017;166:430-7.

11. Accurate BP Measurement The 3 Necessary Pillars
Validated Device
Measurement Techniques
Measurement Conditions
The above is true irrespective of the location
of BP measurement (clinic, home)

12. Listings of Validated Home and Office BP Monitors
British and Irish Hypertension Society

13. Seven Steps to Obtaining Accurate Blood Pressure Readings
Do NOT have a conversation (talking or active listening adds 10 mmHg)
Empty bladder first (a full bladder adds 10 mmHg)
Use correct cuff size (cuff too small adds 2-10 mmHg)
Place cuff on bare arm (cuff over clothing adds 5-50 mmHg)
Support arm at heart level (unsupported arm adds 10 mmHg)
Keep legs uncrossed (crossed legs add 2-8 mmHg)
Support back and feet (unsupported back and feet adds 6 mmHg)
Adapted from Target: BP/ American Heart Association and American Medical Association

14. How Inaccurate Blood Pressure Readings Undermine the Practice of High Quality Medicine
Over-diagnosis of hypertension
(most poor measurement techniques bias BP readings upward)
Over-prescribing of BP lowering medications
Underestimation of hypertension control rates

16. Home BP Readings
Home BP readings are typically lower than single BP readings obtained in ambulatory clinical settings
Encourage purchase of validated devices (eg, Omron) and instruct patients on how to accurately measure their BP at home
Observe them taking their own BP in clinic and ensure that the device they use produces readings close to those obtained in your office
Twelve home BP readings taken at various times of the day, including prior to taking morning medications, should be obtained over and extended period of time (1 – 2 weeks)
Clinical decisions should not be made on isolated readings but rather the average of at least 12 readings
Ideally, the morning BP reading prior to taking medication should also be controlled (<135/85 mm Hg)
Organ transplantation
CV event, procedure or hospitalization for unstable angina (prior 3 months)