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January 15, 2018.

New clinical guidelines for high blood pressure (hypertension) from the American College of Cardiology (ACC) and the American Heart Association (AHA) define much lower targets for acceptable blood pressure levels. According to the new guidelines, high blood pressure is considered anything exceeding 130/80 mm Hg, down from the previous 140/90 mm Hg standard. According to an analysis published in Circulation, this new definition raises the percentage of U.S. adults with hypertension from 32% to 46%—with rates tripling for men and doubling for women under the age of 45.

The ACC/AHA guidelines, published in November 2017, are an update to the 2003 "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure."

Blood pressure readings measure two pressures: systolic pressure is the force exerted on the blood vessel walls when the heart is pumping blood (e.g., the heart is contracting) and diastolic pressure is the force present when the heart relaxes between beats. These pressures are recorded as systolic over diastolic pressure in millimeters of mercury (e.g., 130/80 mm Hg). A single measurement of elevated blood pressure is not diagnostic for hypertension. Typically, multiple readings are taken on different days and, if the measurements are consistently high, the diagnosis of high blood pressure is made.

The new ACC/AHA guidelines are supported by data from the National Heart Lung and Blood Institute's 9,361-participant Systolic Blood Pressure Intervention Trial (SPRINT). In 2015, SPRINT administrators reported that intensive management of systolic blood pressure to a more aggressive target of less than 120 mm Hg systolic compared to a conventional target of less than 140 mm Hg systolic reduced rates of high blood-pressure complications—including heart attacks, heart failure, and stroke—by 25% and lowered the risk of death by 27%.

One of the biggest recommended changes in the "language" of hypertension is the elimination of the term pre-hypertension for blood pressures of 120 to 139/80 to 89 mm Hg. Paul K. Whelton, chair of the guideline writing committee, says the term pre-hypertension gives people "a false sense that everything's OK, but in reality, they aren't. At these levels, you are at double the risk of a heart attack compared to someone with normal blood pressure." Instead, the new guidelines recommend the following blood pressure categories:

  • Normal—Less than 120/80 mm Hg
  • Elevated—120 to 129/less than 80 mm Hg
  • Hypertension stage 1—Systolic pressure 130 to 139 mm Hg; or diastolic pressure 80 to 89 mm Hg
  • Hypertension stage 2—Systolic pressure at or over 140 mm Hg; or diastolic pressure at or over 90 mm Hg
  • Hypertensive crisis—Systolic pressure over 180 mm Hg and/or diastolic pressure over 120 mm Hg

The guidelines emphasize proper technique for measuring blood pressure, including the value of home blood-pressure monitoring, and the appropriate training of healthcare practitioners to reveal "white-coat" hypertension in their patients (high blood pressure that occurs during doctor visits but not in other settings).

While the new ACC/AHA guidelines increase the number of people labeled with high blood pressure, they don't necessarily recommend that all of these people receive medication to manage their hypertension. Treatment is based on the hypertension categories and the 10-year risk of developing cardiovascular disease using the ACC/AHA risk calculator.

  • For most people with early-stage hypertension, the guidelines recommend lifestyle changes, such as improved diet, more exercise, lower alcohol and sodium intake, and lowering stress levels.
  • For those with hypertension stage 1 and above, treatment may also include drug therapy to lower blood pressure. (For details on treatment and the ACC/AHA risk calculator, see the links in Related Content.)

The medical community has not yet reached consensus on the new blood-pressure cutoffs defined by the ACC/AHA guidelines. Some hypertension experts have been critical of the SPRINT study results, saying that the under-120 goal is too aggressive and should not be applied so broadly. Experts also point out that the SPRINT blood-pressure measurements were taken using methods different than those commonly used in clinical practice. In the study, patients were seated for 5 minutes before their blood pressure was taken. In clinical practice, blood pressure is usually taken as soon as the patient sits down, which could lead to higher blood pressures being recorded. Allan S. Brett, editor-in-chief of the New England Journal of Medicine's Journal Watch, has commented that "several studies have suggested that the ACC/AHA risk calculator overestimates risk in certain populations."

Other clinicians have voiced their concern over the major changes in the new ACC/AHA guidelines, saying that it will be a huge challenge to translate the recommendations into practice. Currently, only half of people labeled with high blood pressure have their hypertension under control—which suggests that the percentage of people with uncontrolled hypertension under these new, tighter guidelines, will be even higher.

View Sources

Greenland, P., and Peterson E. (20 November 2017) The New 2017 ACC/AHA Guidelines "Up the Pressure" on Diagnosis and Treatment of Hypertension. JAMA. Available online at http://dx.doi.org/10.1001/jama.2017.18605. Accessed on November 28, 2017.

Brett, A. S. (16 November 2017). New Multisociety Hypertension Guideline Is Released. NEJM Journal Watch. Available online at www.jwatch.org/na45488/2017/11/16/new-multisociety-hypertension-guideline-released. Accessed on November 28, 2017.

(14 November 2017) National Heart, Lung and Blood Institute. Fact Sheet: Systolic Blood Pressure Intervention Trial (SPRINT) OVERVIEW. Available online at www.nhlbi.nih.gov/news/spotlight/fact-sheet/systolic-blood-pressure-intervention-trial-sprint-overview. Accessed on November 28, 2017.

Elia, J. (14 November 2017). New BP Guidelines Expand Hypertension Definition to 130 Systolic or Above. NEJM Journal Watch. Available online at www.jwatch.org/fw113530/2017/11/14/new-bp-guidelines-expand-hypertension-definition-130. Accessed on November 28, 2017.

Bernstein, L., and Cha, A. E. (13 November 2017). Blood Pressure of 130 is the New ‘High,’ According to First Update of Guidelines in 14 Years. The Washington Post. Available online at www.washingtonpost.com/news/to-your-health/wp/2017/11/13/blood-pressure-of-130-is-the-new-high-according-to-first-update-of-guidelines-in-14-years/?utm_term=.8e22889663db. Accessed on November 28, 2017.

Husten, L. (13 November 2017) CARDIOBRIEF. New Blood Pressure Guideline Sets Lower 130/80 Threshold. Available online at www.cardiobrief.org/2017/11/13/new-blood-pressure-guideline-sets-lower-13080-threshold/ Accessed on November 28, 2017.

Munter, P., et al. (13 November 2017). Potential U.S. Population Impact of the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline. Circulation. Available online at https://doi.org/10.1161/CIRCULATIONAHA.117.032582. Accessed on November 28, 2017.

Whelton P. K., et al. (13 November 2017) ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. Available online at http://dx.doi.org/10.1016/j.jacc.2017.11.006. Accessed on November 28, 2017.