New Blood Pressure Guideline Sets Lower 130/80 Threshold

Expanded guideline means more than 100 million people have high blood pressure.

The new US blood pressure guideline lowers the definition of high blood pressure to 130/80 mm Hg. This means that more than 100 million adults will now have high blood pressure, though many will be unaware of the diagnosis.

Paul Whelton

The 192 page guideline (the executive summary is only 112 pages) is the long-awaited update of the US hypertension guideline. The last “official” guideline was the NIH’s seventh Joint National Commission, which was published in 2003. In 2013 the NIH announced that it would no longer be responsible for developing influential guidelines like the JNC guideline for hypertension and the Adult Treatment Panel (ATP) guideline for cholesterol.

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure was released today at the American Heart Association meeting in Anaheim and published simultaneously in Hypertension and the Journal of the American College of Cardiology.

The new guideline eliminates the category of prehypertension. The new blood pressure categories are:

• Normal:<120/80 mm Hg;
• Elevated:Systolic between 120-129 and diastolic less than 80;
• Stage 1: Systolic between 130-139 or diastolic between 80-89;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic >180 and/or diastolic >120.

The guideline authors said that the the impact of the new guideline will be greatest among younger people. They said the prevalence of hypertension in people under the age of 45 would triple among men and double among women.

At a news conference, Paul Whelton the chair of the writing committee, said that the new guideline contains 106 recommendations. The first hypertension guideline contained only 6 recommendations, “so we’ve come a long way,” he said.

In an accompanying paper published in Circulation, Paul Munter (University of Alabama at Birmingham) and colleagues used national survey data to estimate the impact of the new guideline. The prevalence of hypertension will increase from 31.9% under JNC7 criteria to 45.6%. This works out to 103.3 million people who will be categorized as having high blood pressure.

In the new guideline antihypertensive drug therapy is recommended for 36.2% of US adults, or 81.9 million adults, while 21.4 million are recommended for nonpharmacologic therapy only. The new guideline increases the number of US adults recommended for drug therapy by 4.2 million.

The new definition also mean that a greater percentage of adults taking antihypertensive drugs have failed to reach goal, rising from 39% in JNC7 to 53.4% in the new guideline. Intensification of drug therapy is recommended for those who fail to reach goal.

The new guideline adopts a key component of the 2013 cholesterol guideline and incorporates overall cardiovascular risk. Many people newly defined as hypertensive because they have a systolic blood pressure between 130-139 mm Hg or a diastolic blood pressure between 80-89 mm Hg do not need to take drugs. Adults in this range who are at low cardiovascular risk and who are less than 65 years of age should be treated with lifestyle changes while those at high cardiovascular risk or who are 65 or older should receive drug therapy.

The new guideline also places a strong emphasis on improving blood pressure measurement both in the office and at home. Use of an automated measurement system, similar to that used in clinical trials, is recommended in the office. Blood pressure measurements taken at home are also endorsed, particularly to help identify people with white coat hypertension.

The new guideline represents a partial but not complete acceptance of the 2015 SPRINT trial, which initially appeared to support a radically more aggressive systolic target of 120 mm Hg. SPRINT tested an antihypertensive strategy using the conventional goal of 140 mm Hg against the more aggressive goal of 120 mm Hg in high risk patients. The results favored the more aggressive treatment, but many hypertension experts were critical of the trial and said the 120 goal should not be broadly adopted.

The 130 systolic blood pressure goal in the guideline suggests that the writing committee found a middle ground or compromise.

Harlan Krumholz (Yale University) said that the guideline represents “a major change in the recommendations, opting for more people being labeled with hypertension and recommended for treatment. The challenge now is immense; how to communicate the change, the strength of the evidence behind it; and the options available to patients – and ensure that patients’   goals and preferences are steering the clinical course. Otherwise we will have what we do today, many prescriptions that are unfilled and untaken; many people who clear knowledge of their risk and risk factors; and too many preventable events in people who otherwise would have chosen pharmacological and non-pharmacological strategies to reduce risk.

The AHA went to extraordinary efforts to control the flow of information about the new guideline. An embargoed copy of the guideline was only made available to the media 7 hours before the publication time, leaving little opportunity for journalists to obtain outside opinion or perspective.