They include updated treatment recommendations and the addition of prevention strategies for all adults.
Important changes to US blood pressure (BP) guidelines have been made, including how cardiovascular risk is assessed, health lifestyle goals and the inclusion of fixed-dose combinations (FDCs) as first-line hypertension medication.
The American Heart Association, American College of Cardiology, American Medical Association and many others collaborated to update their previous 2017 version.
Many new recommendations are for all adults regardless of BP, with the aim of hypertension prevention as well as treatment.
Lifestyle interventions included in the guideline are adopting heart-healthy eating patterns including the DASH diet, initiating a moderate physical activity program, achieving a healthy weight, limiting stress and eliminating alcohol.
Cardiovascular risk was changed from assessment using the ASCVD tool with a threshold of 10% to using the PREVENT equation, with treatment recommendations dependent on whether a person is above or below 7.5%.
The guideline is now also more specific about weight loss, including a goal of at least a 5% reduction in body weight for overweight and obese individuals.
Sodium reduction has been clarified and, regardless of BP, adults should initially reduce their intake to 2300mg per day with the long-term aim of less than 1500mg/day.
Potassium-based salt supplementation was described as a useful tool for all adults, except for those with CKD or medications that require serum potassium monitoring.
The previous guideline’s daily alcohol intake recommendation for people with elevated BP or hypertension was no more than one standard drink per day for women and two standards for men.
The recommended goal is now alcohol abstinence for all, regardless of BP, with those reductions to one and two standards as the minimum acceptable aim.
Stress reduction was not mentioned in the previous version of the guideline, but is now recommended for all adults through meditation, breathing control techniques and yoga as an adjunct to lifestyle changes and medication.
As the most prevalent modifiable risk factor for CVD, chronic kidney disease, dementia and all-cause mortality, the guideline confirms that the goal of treatment should be a BP of less than 130/80mmHg.
Exceptions are people who require institutional care, have a limited predicted lifespan or are pregnant, as they require additional considerations.
Their classification framework defined 120-129mmHg SBP as elevated, 130-139/80-89mmHg as stage one hypertension and stage two as starting at 140/90mmHg. A BP greater than 180/120mmHg in nonpregnant individuals is considered severe hypertension.
For adults with an average elevated BP and a 10-year CVD risk of less than 7.5% as defined by PREVENT, first line treatment should be a three-to-six-month trial of lifestyle modification.
However, if average BP remains 130/80mmHg or higher after lifestyle changes, initiation of medication therapy is recommended.
Adults who present with stage two hypertension, or stage one hypertension along with clinical CVD, a history of stroke, diabetes, CKD or a 10-year CVD risk over 7.5%, should have medication therapy initiated as well as lifestyle intervention.
For all adults with stage two hypertension, antihypertensive drug therapy should be initiated with fixed-dose combinations. The AHA said this is preferred over two separate medications to improve adherence and reduce the time needed to achieve BP control.
For those with severe hypertension without evidence of acute target organ damage, evaluation and treatment should be conducted in a timely manner in an outpatient setting.
Home blood pressure monitoring is an important integrated tool to improve blood pressure control, the guideline explained.
However, this should be used in combination with frequent interactions with multidisciplinary team members and using standardised measurement and treatment protocols.
Reliance on cuffless devices such as smartwatches for accurate blood pressure measurements should be avoided until greater precision and reliability from these devices have been demonstrated, they said.
The guidelines emphasised the need for a collaborative effort between clinicians, community leaders, health systems and practices to implement adult screening and guideline-based recommendations in their communities to prevent and manage HBP.
