The last months of 2017 have brought to the attention of the medical community the problem of arterial hypertension, as the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults of the American College of Cardiology/American Heart Association (ACC/AHA) has been pub-lished. The guideline is an update of the „Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure“ (JNC 7), that was pub-lished in 2003. The new American guideline came with a „surprise“: normal blood pressure is defined now as a value < 120/80 mm Hg. Elevated blood pressure is considered 120-129/<80 mm Hg, hy-pertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥ 140 or ≥ 90 mm Hg. The term „prehypertension“ has been eliminat-ed by the new guideline. The guideline’s authors tried to incorporate all the new information from epidemiologic studies regarding the cardiovascular risks of high blood pressure patients.
What are the recommendations of this guide-line, besides the decreased cut-off values of the blood pressure? A strong emphasis is put on blood pressure measurement. The authors recommend that the physicians follow the standards for accu-rate blood pressure measurement. For the diag-nosis of arterial hypertension, at least two read-ings obtained on at least two occasions should be used. To confirm the diagnosis, out-of-office and self-monitoring of the blood pressure are recom-mended. For the screening of white coat hyper-tension or the diagnosis of masked hypertension (in individuals with elevated office blood pressure values, but not meeting the criteria for hyperten-sion), ambulatory blood pressure monitoring or home blood pressure monitoring should be used. Screening of other cardiovascular risk factors is very important in hypertensive patients: diabe-tes, dyslipidemia, smoking, excessive weight, lack of physical activity, psychosocial stress, unhealthy diet, obstructive sleep apnea. Patients with a di-agnosis of primary hypertension should have an initial evaluation of complete blood cell count, lipid profile, thyroid stimulating hormone (TSH), uric acid, basic metabolic panel, urine analysis, al-bumin-to-creatinine ratio, electrocardiogram and echocardiography (optional). Screening for second-ary causes of hypertension is necessary for patients with new-onset or uncontrolled hypertension, in-cluding drug -resistant, abrupt onset, age <30 years, target organ damage or for the onset of diastolic hypertension in older adults or in the presence of unprovoked or excessive hypokalemia. Lifestyle changes are of cornerstone importance in reduc-ing blood pressure and decreasing the cardiovas-cular risk: weight loss, heart-healthy diet, physical exercise, no excessive alcohol consumption, a diet low in sodium (< 1500 mg/day) and saturated fat, consumption of vegetables, fruits and grains.
Antihypertensive drugs are used for secondary prevention in patients with clinically manifest car-diovascular diseases and an average systolic blood pressure ≥ 130 mm Hg or a diastolic blood pres-sure ≥ 80 mm Hg. The guideline recommends a new approach to decision-making for treatment, that incorporates underlying cardiovascular risk. To assess the need for antihypertensive medica-tion, the 10-year atherosclerotic cardiovascular risk (ASCVD) is used.
Regarding the treatment, initial first- line therapy for stage 1 hypertension may include thi-azide diuretics, calcium channel blockers, angio-tensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs), with a tar-get blood pressure less than 130/80 mm Hg. In patients with stage 2 hypertension and an average blood pressure value of 20/10 mm Hg above the target, two first-line drugs of different classes are recommended. A better adherence to treatment may be obtained with once-daily drug adminis-tration or combination therapy. For patients with confirmed arterial hypertension and known car-diovascular disease or 10- year ASCVD risk ≥10%, a blood pressure target of <130/80 mm Hg is recommended. In diabetic patients with arterial hypertension, antihypertensive drug treatment should be initiated at a blood pressure ≥130/80 mm Hg, with a treatment goal of <130/80 mm Hg; all first-line classes of antihypertensive agents are useful.
In the future, it will be interesting to see if the changes of the ACC/AHA guideline will have an impact on the next European Society of Hypertension guideline
International Secretary General of the Balkan Medical Union
President of the Romanian National Section