Written by Thomas Davis, MD.
The AHA has published new guidelines replacing the JNC guidelines for management of hypertension. Here is what you need to know.
Why does this matter?
Following the publication of several recent RCTs, the AHA has published new guidelines that address both the emergencies and chronic HTN referrals to the ED. While some still debate whether or not to initiate antihypertensive therapy in the ED, managing hypertension is a bread-and-butter skill of all good clinicians. When a patient on beta-blocker monotherapy gets referred to the ED for a hypertensive urgency, we want you to look like a pro. The answers on what to do are below. Thankfully, the AHA is now on our side when it comes to emergent referral to the ED. You won't regret skimming the Guidelines Made Simple version the AHA released. It helps a lot.
“Doc, my blood pressure is 190/120. I’m afraid I’m going to stroke out.”
- The new BP goal is < 130/80 mmHg.
- Measure BP using the arm with the higher read. Use the average BP from at least 2 separate occasions.
- Start therapy if BP is above 130/80 and patient meets either indication:
- Primary prevention: 10-year risk of atherosclerotic cardiovascular disease (ASCVD) is above 10%. If patient is older than 65 or has DM/CKD, you can assume risk is > 10%
- Secondary prevention: Patient has CAD, CHF, or prior CVA.
- Start therapy if BP is above 140/90 for all other lower risk patients.
- First line agents are thiazides, calcium channel blockers, and ACEi/ARB.
- For stage 2 HTN (>140/90), start with two agents.
- Thiazides seem to be the most health protective drug class followed by CCB. In particular, thiazides are superior at decreasing the risk of developing heart failure compared to other agents.
- If you use a thiazide, chlorthalidone (12.5-25mg daily) is preferred over HCTZ, as it is more potent and has a longer half life.
- Do NOT use beta-blockers unless there is another compelling indication, such as heart failure or prior MI.
- Clonidine is the last line agent.
“There is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for such patients.” Instead, these patients are “treated by reinstitution or intensification of antihypertensive drug therapy and treatment of anxiety as applicable.” See this from last year. These folks do well and have very low 90-day mortality.
- For adults with a compelling condition (i.e., aortic dissection, severe preeclampsia/eclampsia, or pheochromocytoma crisis), SBP should be reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection.
- For adults without a compelling condition, SBP should be reduced by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours.
- The only RCT data exist for intracerebral hemorrhage. Per AHA, do NOT lower SBP below 140 mmHg within 6 hours of the acute event if initial systolic blood pressure is 150-220mmHg. If above 220mmHg, it is reasonable to lower but optimal goals are unknown.
- For acute stroke patients receiving tPA, keep BP < 180/105 for 24 hours.
- If stroke patients do not receive tPA, only treat if BP > 220/110. Lower by 15% for first 24 hours. Otherwise, permissive hypertension for the first 48-72 hours is preferred.
Peer reviewed by Clay Smith, MD. Comment - This summary condenses a 38 page paper, which consists of 3 systematic reviews in one.
Systematic Review for the 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. 2017 Nov 7. pii: S0735-1097(17)41517-8. doi: 10.1016/j.jacc.2017.11.004. [Epub ahead of print]