2017 Guideline for the Prevention, Detection, Evaluation, and

2017 Guideline for the Prevention,

Detection, Evaluation, and Management

of High Blood Pressure in Adults

GUIDELINES MADE SIMPLE

A Selection of Tables and Figure

ACC.org/GMSHBP

2017 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

Paul K. Whelton, MB, MD, MSc, FAHA, Chair

Robert M. Carey, MD, FAHA, Vice Chair

Wilbert S. Aronow, MD, FACC, FAHA

Donald E. Casey, Jr, MD, MPH, MBA, FAHA

Karen J. Collins, MBA

Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA

Sondra M. DePalma, MHS, PA-C, CLS, AACC

Samuel Gidding, MD, FAHA

Kenneth A. Jamerson, MD

Daniel W. Jones, MD, FAHA

Eric J. MacLaughlin, PharmD

Paul Muntner, PhD, FAHA

Bruce Ovbiagele, MD, MSc, MAS, MBA FAHA

Sidney C. Smith, Jr, MD, MACC, FAHA

Crystal C. Spencer, JD

Randall S. Stafford, MD, PhD

Sandra J. Taler, MD, FAHA

Randal J. Thomas, MD, MS, FACC, FAHA

Kim A. Williams, Sr, MD, MACC, FAHA

Jeff D. Williamson, MD, MHS

Jackson T. Wright, Jr, MD, PhD, FAHA

CITATION: J Am Coll Cardiol. Sep 2017, 23976; DOI: 10.1016/j.jacc.2017.07.745

Writing Committee:

The ACC and AHA convened this writing committee to address the prevention, detection, evaluation,

and management of high blood pressure in adults. The rst comprehensive guideline for detection,

evaluation, and management of high BP was published in 1977, under the sponsorship of the

NHLBI. In subsequent years, a series of Joint National Committee (JNC) BP guidelines were

published to assist the practice community and improve prevention, awareness, treatment, and

control of high BP. The present guideline updates prior JNC reports.

The following resource contains Figures and Tables from 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. The resource is only an excerpt from the

Guideline and the full publication should be reviewed for more gures and tables as well as

important context.

Categories of BP in Adults ……………………………………………………………………………………… 4

Corresponding Values of Systolic BP/Diastolic BP for Clinic, Home (HBPM), Daytime, Nighttime, and

24-Hour Ambulatory (ABPM) Measurement …………………………………………………………………… 4

Detection of White Coat Hypertension or Masked Hypertension in Patients Not on Drug Therapy ……… 5

Detection of White Coat Hypertension or Masked Hypertension in Patients on Drug Therapy …………… 6

Screening for Secondary Hypertension ………………………………………………………………………… 7

Causes of Secondary Hypertension with Clinical Indications and Diagnostic Screening Tests (1 of 3) …… 8

Causes of Secondary Hypertension with Clinical Indications and Diagnostic Screening Tests (2 of 3) …… 9

Causes of Secondary Hypertension with Clinical Indications and Diagnostic Screening Tests (2 of 3) … 10

Frequently Used Medications and Other Substances That May Cause Elevated BP ……………………… 11

Best Proven Nonpharmacologic Interventions for Prevention and Treatment of Hypertension ………… 12

Basic and Optional Laboratory Tests for Primary Hypertension …………………………………………… 13

Blood Pressure (BP) Thresholds and Recommendations for Treatment and Follow-Up ………………… 14

BP Thresholds for and Goals of Pharmacologic Therapy in Patients with Hypertension According to

Clinical Conditions ……………………………………………………………………………………………… 15

Oral Antihypertensive Drugs (1 of 3) ………………………………………………………………………… 16

Oral Antihypertensive Drugs (2 of 3) ………………………………………………………………………… 17

Oral Antihypertensive Drugs (3 of 3) ………………………………………………………………………… 18

Heart Failure with Reduced Ejection Fraction (HFrEF) ……………………………………………………… 19

Heart Failure with Preserved Ejection Fraction (HFpEF) …………………………………………………… 19

DIabetes Mellitus ……………………………………………………………………………………………… 19

Management of Hypertension in Speciﬁc Patient Populations

Stable Ischemic Heart Disease (SIHD) …………………………………………………………………… 20

Chronic Kidney Disease ... …………………………………………………………………………………… 21

Acute Intercerebral Hemorrhage …………………………………………………………………………… 22

Acute ischemic Stroke ……………………………………………………………………………………… 23

Previous History of Stroke (Secondary Stroke Prevention) ……………………………………………… 24

Resistant Hypertension: Diagnosis, Evaluation, and Treatment ………………………………………… 25

Diagnosis and Management of a Hypertensive Crisis …………………………………………………… 26

Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies (1 of 2) …………… 27

Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies (2 of 2) …………… 28

Selected Tables or Figure Page

2017 Guideline for the Prevention, Detection, Evaluation,

and Management of High Blood Pressure in Adults

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*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.

Table 6

Table 11

BP Category SBP DBP

Normal <120 mm Hg and <80 mm Hg

Elevated 120–129 mm Hg and <80 mm Hg

Hypertension

Stage 1 130–139 mm Hg or 80–89 mm Hg

Stage 2 ≥140 mm Hg or ≥90 mm Hg

Clinic HBPM Daytime ABPM Nighttime ABPM 24-Hour ABPM

120/80 120/80 120/80 100/65 115/75

130/80 130/80 130/80 110/65 125/75

140/90 135/85 135/85 120/70 130/80

160/100 145/90 145/90 140/85 145/90

Categories of BP in Adults*

Corresponding Values of Systolic BP/Diastolic BP for Clinic, Home (HBPM),

Daytime, Nighttime, and 24-Hour Ambulatory (ABPM) Measurements.

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Ofce BP:

≥130/80 mm Hg but <160/100 mm Hg

after 3 mo trial of lifestyle modication and suspect

white coat hypertension

Yes

Daytime ABPM

or HBPM

BP <130/80 mm Hg

White Coat Hypertension

• Lifestyle modication

• Annual ABPM or HBPM

to detect progression

(Class IIa)

Elevated BP

• Lifestyle modication

• Annual ABPM or HBPM to

detect MH or progression

(Class IIa)

Hypertension

• Continue lifestyle

modication and

start antihypertensive

drug therapy

(Class IIa)

Masked Hypertension

• Continue lifestyle

modication and

start antihypertensive

drug therapy

(Class IIa)

Ofce BP:

120–129/<80 mm Hg

after 3 mo trial of lifestyle modication and suspect

masked hypertension

Yes

Daytime ABPM

or HBPM

BP ≥ 130/80 mm Hg

Detection of White Coat Hypertension or Masked Hypertension

in Patients Not on Drug Therapy

Figure 1

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Screen for

masked uncontrolled

hypertension with HBPM

(Class IIb)

Screening

not necessary

(No Benet)

Increased CVD risk

or target organ damage

Ofce BP

at goal

ABPM BP

above goal

HBPM BP

above goal

Yes

Screen for

white coat effect

with HBPM

(Class IIb)

Screening

not necessary

(No Benet)

Ofce BP

≥5–10 mm Hg

above goal on

≥3 agents

HBPM BP

at goal

Yes

Masked

Uncontrolled Hypertension:

Intensify therapy

(Class IIb)

Continue

current therapy

Yes

White Coat Effect:

Conrm with ABPM

(Class IIa)

Continue

titrating therapy

Yes

Detection of White Coat Effect or

Masked Uncontrolled Hypertension

in Patients on Drug Therapy

Detection of White Coat Hypertension or Masked Hypertension

in Patients on Drug Therapy

Figure 2

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Screen for

secondary hypertension

(Class I)

(see Table 13)

Screening

not indicated

(No benet)

New Onset or Uncontrolled Hypertension in Adults

Conditions

• Drug-resistant/induced hypertension

• Abrupt onset of hypertension

• Onset of hypertension at <30 y

• Exacerbation of previously controlled hypertension

• Disproportionate TOD for degree of hypertension

• Accelerated/malignant hypertension

• Onset of diastolic hypertension in older adults (≥ 65 y)

• Unprovoked or excessive hypokalemia

Yes

Positive

screening test

Refer to clinician

with specic

expertise

(Class IIb)

Referral

not necessary

(No benet)

Screening for Secondary Hypertension

Figure 3

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Renal

parenchymal

disease

Renovascular

disease

Primary

aldosteronism

Obstructive

sleep apnea‡

Drug- or

alcohol-

induced

Common Causes

Urinary tract infections;

obstruction, hematuria;

urinary frequency and nocturia;

analgesic abuse; family history

of polycystic kidney disease;

elevated serum creatinine;

abnormal urinalysis

Resistant hypertension;

hypertension of abrupt onset

or worsening or increasingly

difcult to control; ash

pulmonary edemam

(atherosclerotic); early onset

hypertension, especially in

women (bromuscular

hyperplasia)

Resistant hypertension;

hypertension with hypokalemia

(spontaneous or diuretic-

induced); hypertension and

muscle cramps or weakness;

hypertension and incidentally

discovered adrenal mass;

hypertension and obstructive

sleep apnea; hypertension

and family history of early

onset hypertension or stroke

Resistant hypertension; snoring

tful sleep; breathing pauses

during sleep; daytime

sleepiness

Sodium-containing antacids;

caffeine; nicotine (smoking);

alcohol; NSAIDs; oral

contraceptives; cyclosporine or

tacrolimus; sympathomimetics

(decongestants, anorectics);

cocaine, amphetamines and

other illicit drugs; neuro

psychiatric agents; erythro-

poiesis stimulating agents;

clonidine withdrawal; herbal

agents (MaHuang, ephedra)

Abdominal mass

(polycystic kidney

disease); skin pallor

Abdominal systolic-

diastolic bruit; bruits

over other arteries

(carotid –

atherosclerotic or

bromuscular

dysplasia), femoral

Arrhythmias (with

hypokalemia);

especially atrial

brillation

Obesity, Mallampati

class III–IV; loss of

normal nocturnal BP

fall

Fine tremor,

tachycardia,

sweating (cocaine,

ephedrine, MAO

inhibitors); acute

abdominal pain

(cocaine)

Renal ultrasound

Renal Duplex

Doppler ultrasound;

MRA; abdominal CT

Plasma aldosterone/

renin ratio under

standardized

conditions

(correction of

hypokalemia and

withdrawal of

aldosterone

antagonists for

4–6 wk)

Berlin Questionnaire

(8); Epworth

Sleepiness Score (9);

overnight oximetry

Urinary drug screen

(illicit drugs)

Tests to evaluate

cause of renal

disease

Bilateral selective

renal intraarterial

angiography

Oral sodium loading

test (prior to 24 h

urine aldosterone)

or IV saline infusion

test with plasma

aldosterone at 4 h

of infusion. Adrenal

CT scan, Adrenal

vein sampling. Trial

of mineralocorticoid

receptor blockers§

Polysomnography

Response to

withdrawal of

suspected agent

1%–2%

5%-34%*

8%–20%†

25%–50%

2%–4%

Clinical Physical Screening

Additional/

Prevalence

Indications Exam Tests

Conrmatory

Tests

Uncommon Causes will be listed in the next two pages

Causes of Secondary Hypertension

with Clinical Indications and Diagnostic Screening Tests (1 of 3)

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Pheochromo-

cytoma/

paraganglioma

Cushing’s

syndrome

Hypothyroid-

ism

Hyperthyroid-

ism

Aortic

coarctation

(undiagnosed

or repaired)

Primary

hyperpara-

thyroidism

Uncommon Causes

Resistant hypertension;

paroxysmal hypertension or

crisis superimposed on

sustained hypertension;

“spells”, BP lability, headache,

sweating, palpitations, pallor;

positive family history of

pheochromocytoma/

paraganglioma; adrenal

incidentaloma

Rapid weight gain, especially

with central distribution;

proximal muscle weakness;

depression; hyperglycemia

Dry skin; cold intolerance;

constipation; hoarseness;

weight gain

Warm, moist skin; heat

intolerance; nervousness;

tremulousness; insomnia;

weight loss; diarrhea; proximal

muscle weakness

Young patient with

hypertension (<30 y of age)

Hypercalcemia

Skin stigmata of

neurobromatosis

(café-au-lait spots;

neurobromas);

orthostatic

hypotension

Central obesity,

“moon” face, dorsal

and supraclavicular

fat pads, wide

(1 cm) violaceous

striae, hirsutism

Delayed ankle reex;

periorbital pufness;

coarse skin; cold

skin; slow

movement; goiter

Lid lag; ne tremor

of the outstretched

hands; warm, moist

skin

BP higher in upper

extremities

compared to lower

extremities; absent

femoral pulses;

continuous murmur

over patient’s back,

chest, or abdominal

bruit; left

thoracotomy scar

(postoperative)

Usually none

24-h urinary

fractionated

metanephrines or

plasma

metanephrines under

standard conditions

(30’ supine position

with indwelling IV

cannula)

Overnight 1 mg

dexamethasone

suppression test

Thyroid stimulating

hormone; free

thyroxine

Thyroid stimulating

hormone, free

thyroxine

Echocardiogram

Serum calcium

CT or MRI scan of

abdomen/pelvis

24-h urinary free

cortisol excretion

(preferably multiple);

midnight salivary

cortisol

None

Radioactive iodine

uptake and scan

Thoracic and

abdominal CT or

MRA

Serum parathyroid

hormone

0.1%–0.6%

<0.1%

<1%

0.1%

Rare

Clinical Physical Screening

Additional/

Prevalence

Indications Exam Tests

Conrmatory

Tests

Uncommon Causes will continue in the next page

Causes of Secondary Hypertension

with Clinical Indications and Diagnostic Screening Tests (2 of 3)

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*Depending on the clinical situation (hypertension alone, 5%; hypertension starting dialysis, 22%; hypertension and peripheral

vascular disease, 28%; hypertension in the elderly with congestive heart failure, 34%).

†8% in general population with hypertension; up to 20% in patients with resistant hypertension.

‡Although obstructive sleep apnea is listed as a cause of secondary hypertension, RCTs on the effects of continuous positive airway

pressure on lowering BP in patients with hypertension have produced mixed results

For a list of frequently used drugs causing hypertension and accompanying evidence, see Table 14 on the next page.

Table 13

Congenital

adrenal

hyperplasia

Mineralo-

corticoid

excess

syndromes

other than

primary

aldosteronism

Acromegaly

Uncommon Causes (continued from previous page)

Hypertension and

hypokalemia; virilization

(11-beta-hydroxylase

deciency [11-beta-OH])

incomplete masculinization in

males and primary amenorrhea

in females (17-alpha-

hydroxylase deciency

[17-alpha-OH])

Early onset hypertension;

resistant hypertension;

hypokalemia or hyperkalemia

Acral features, enlarging shoe,

glove or hat size; headache,

visual disturbances; diabetes

mellitus

Signs of virilization

(11-beta-OH) or

incomplete

masculinization

(17-alpha-OH)

Arrhythmias (with

hypokalemia)

Acral features; large

hands and feet;

frontal bossing

Hypertension and

hypokalemia with

low or normal

aldosterone and

renin

Low aldosterone and

renin

Serum growth

hormone ≥1 ng/mL

during oral glucose

load

11-beta-OH:

elevated deoxycorti-

costerone (DOC),

11-deoxycortisol and

androgens 17-alpha-

OH: decreased

androgens and

estrogen; elevated

deoxycorticosterone

and corticosterone

Urinary cortisol

metabolites; genetic

testing

Elevated age- and

sex-matched IGF-1

level; MRI scan of

the pituitary

Rare

Clinical Physical Screening

Additional/

Prevalence

Indications Exam Tests

Conrmatory

Tests

Causes of Secondary Hypertension

with Clinical Indications and Diagnostic Screening Tests (3 of 3)

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Alcohol

Amphetamines (e.g., amphetamine, methylphenidate

dexmethylphenidate, dextroamphetamine)

Antidepressants (e.g., MAOIs, SNRIs, TCAs)

Atypical antipsychotics (e.g., clozapine, olanzapine)

Caffeine

Decongestants (e.g., phenylephrine,

pseudoephedrine)

Herbal supplements (e.g., Ma Huang [ephedra],

St. John’s wort [with MAO inhibitors, yohimbine])

Immunosuppressants (e.g., cyclosporine)

Oral contraceptives

NSAIDs

Recreational drugs (e.g., “bath salts” [MDPV],

cocaine, methamphetamine, etc.)

Systemic corticosteroids (e.g., dexamethasone,

udrocortisone, methylprednisolone, prednisone,

prednisolone)

Angiogenesis inhibitor (eg. bevacizumab) and

tyrosine kinase inhibitors (eg. sunitinib, sorafenib)

• Limit alcohol to ≤1 drink daily for women and ≤2 drinks for men

• Discontinue or decrease dose

• Consider behavioral therapies for ADHD

• Consider alternative agents (e.g., SSRIs,) depending on indication

• Avoid tyramine containing foods with MAOIs

• Discontinue or limit use when possible

• Consider behavior therapy where appropriate

• Lifestyle modication (Section 6.2)

• Consider alternative agents associated with lower risk of weight gain,

diabetes mellitus, and dyslipidemia (e.g., aripiprazole, ziprasidone).

• Generally limit caffeine intake to <300 mg/d

• Avoid use in patients with uncontrolled hypertension

• Coffee use in patients with hypertension associated with acute increases

in BP; long-term use not associated with increased BP or CVD

• Use for shortest duration possible and avoid in severe or uncontrolled

hypertension

• Consider alternative therapies (e.g., nasal saline, intranasal

corticosteroids, antihistamines) as appropriate

• Avoid use

• Consider converting to tacrolimus, which may be associated with less

effects on BP

• Use low-dose (e.g., 20–30 mcg ethinyl estradiol) agents or a

progestin-only form of contraception and/or consider alternative forms

of birth control where appropriate (e.g., barrier, abstinence, IUD)

• Avoid use in women with uncontrolled hypertension

• Avoid systemic NSAIDs when possible

• Consider alternative analgesics (e.g., acetaminophen, tramadol, topical

NSAIDs,) depending on indication and risk

• Discontinue and/or avoid use

• Avoid or limit use when possible

• Consider alternative modes of administration (e.g., inhaled, topical)

when feasible

• Initiate or intensify antihypertensive therapy

Agent Possible Management Strategy

Frequently Used Medications and Other Substances That May Cause Elevated BP*

*List is not all-inclusive.

Table 14

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Weight loss

Healthy diet

Reduced intake

of dietary sodium

Enhanced intake

of dietary potassium

Physical activity

Moderation in alcohol

intake

Weight/body fat

DASH dietary pattern

Dietary sodium

Dietary potassium

Aerobic

Dynamic Resistance

Isometric Resistance

Alcohol consumption

Ideal body weight is best goal but at

least 1 kg reduction in body weight for

most adults who are overweight. Expect

about 1 mm Hg for every 1 kg reduction

in body weight.

Diet rich in fruits, vegetables, whole

grains, and low-fat dairy products with

reduced content of saturated and trans

l fat

<1,500 mg/d is optimal goal but at

least 1,000 mg/d reduction in most

adults

3,500–5,000 mg/d, preferably by

consumption of a diet rich in potassium

• 90–150 min/wk

• 65%–75% heart rate reserve

• 90–150 min/wk

• 50%–80% 1 rep maximum

• 6 exercises, 3 sets/exercise,

10 repetitions/set

• 4 x 2 min (hand grip), 1 min rest

between exercises, 30%–40%

maximum voluntary contraction,

3 sessions/wk

• 8–10 wk

In individuals who drink alcohol, reduce

alcohol

†

to:

• Men: ≤2 drinks daily

• Women: ≤1 drink daily

-5 mm Hg

-11 mm Hg

-5/6 mm Hg

-4/5 mm Hg

-5/8 mm Hg

-4 mm Hg

-5 mm Hg

-4 mm Hg

-2/3 mm Hg

-3 mm Hg

-2/3 mm Hg

-2 mm Hg

-2/4 mm Hg

-2 mm Hg

-4 mm Hg

-3 mm Hg

Nonpharmacologic

Dose

Approximate Impact on SBP

Intervention

Hypertension Normotension

Best Proven Nonpharmacologic Interventions for Prevention

and Treatment of Hypertension*

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.

†In the United States, one “standard” drink contains roughly 14 grams of pure alcohol, which is typically found in 12 ounces of regular beer

(usually about 5% alcohol), 5 ounces of wine (usually about 12% alcohol) and 1.5 ounces of distilled spirits (usually about 40% alcohol).

Table 15

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Basic Testing

Optional Testing

Fasting blood glucose*

Complete blood count

Lipid prole

Serum creatinine with eGFR*

Serum sodium, potassium, calcium*

Thyroid-stimulating hormone

Urinalysis

Electrocardiogram

Echocardiogram

Uric acid

Urinary albumin to creatinine ratio

Basic and Optional Laboratory Tests for Primary Hypertension

*May be included in a comprehensive metabolic panel

Table 17

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BP Thresholds and Recommendations for Treatment and Follow-up

Normal BP

(BP <120/80

mm Hg)

Elevated BP

(BP 120–129/<80

mm Hg)

Stage 1 Hypertension

(BP 130–139/80-89

mm Hg)

Stage 2 Hypertension

(BP ≥ 140/90 mm Hg)

No Yes

Promote optimal

lifestyle habits

Nonpharmacologic

therapy

(Class I)

Clinical ASCVD

or estimated 10-y CVD risk

≥10%*

Reassess in

1 y

(Class IIa)

Reassess in

3–6 mo

(Class I)

Reassess in

3–6 mo

(Class I)

Reassess in

3–6 mo

(Class I)

Assess and

optimize

adherence

to therapy

Consider

intensication

of therapy

Reassess in

1 mo

(Class I)

BP goal met

Nonpharmacologic

therapy

(Class I)

Nonpharmacologic

therapy and

BP-lowering medication

(Class I)

Nonpharmacologic

therapy and

BP-lowering medication

†

(Class I)

Blood Pressure (BP) Thresholds

and Recommendations for Treatment and Follow-Up

*Using the ACC/AHA Pooled Cohort Equations. Note that patients with DM

or CKD are automatically placed in the high-risk category. For initiation

of RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and

renal function 2 to 4 weeks after initiating therapy.

†Consider initiation of pharmacological therapy for stage 2 hypertension

with 2 antihypertensive agents of different classes. Patients with stage

2 hypertension and BP ≥160/100 mm Hg should be promptly treated,

carefully monitored, and subject to upward medication dose adjustment

as necessary to control BP. Reassessment includes BP measurement,

detection of orthostatic hypotension in selected patients (e.g., older or

with postural symptoms), identication of white coat hypertension or a

white coat effect, documentation of adherence, monitoring of the

response to therapy, reinforcement of the importance of adherence,

reinforcement of the importance of treatment, and assistance with

treatment to achieve BP target.

Figure 4

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Table 23

General

Clinical CVD or 10 year ASCVD risk ≥ 10%

No clinical CVD and 10 year ASCVD risk <10%

Older persons (≥65 years of age; non-institutionalized,

ambulatory, community-living adults)

Specic Comorbidities

Diabetes mellitus

Chronic kidney disease

Chronic kidney disease post-renal transplantation

Heart failure

Stable ischemic heart disease

Secondary stroke prevention

Peripheral arterial disease

Clinical Condition (s) BP Threshold mm Hg BP Goal mm Hg

≥130/80

≥140/90

≥130 (SBP)

≥130/80

≥140/90

≥130/80

<130/80

<130 (SBP)

<130/80

BP Thresholds for and Goals of Pharmacologic Therapy

in Patients with Hypertension According to Clinical Conditions

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Primary Agents

Usual Dose,

Daily

Class Drug Range

Frequency

Comments

(mg per day)*

• Chlorthalidone preferred based on prolonged

half-life and proven trial reduction of CVD

• Monitor for hyponatremia and hypokalemia, uric

acid and calcium levels.

• Use with caution in patients with history of acute

gout unless patient is on uric acid-lowering therapy.

• Do not use in combination with ARBs or direct

renin inhibitor

• Increased risk of hyperkalemia, especially in

patients with CKD or in those on K+ supplements

or K+-sparing drugs

• May cause acute renal failure in patients with

severe bilateral renal artery stenosis

• Do not use if history of angioedema with ACE

inhibitors.

• Avoid in pregnancy

• Do not use in combination with ACE inhibitors or

direct renin inhibitor

• Increased risk of hyperkalemia in CKD or in those

on K+ supplements or K+-sparing drugs

• May cause acute renal failure in patients with

severe bilateral renal artery stenosis

• Do not use if history of angioedema with ARBs.

Patients with a history of angioedema with an

ACEI can receive an ARB beginning 6 weeks after

ACEI discontinued.

• Avoid in pregnancy

• Avoid use in patients with HFrEF; amlodipine or

felodipine may be used if required

• Associated with dose-related pedal edema, which

is more common in women than men

• Avoid routine use with beta blockers due to

increased risk of bradycardia and heart block

• Do not use in patients with HFrEF

• Drug interactions with diltiazem and verapamil

(CYP3A4 major substrate and moderate inhibitor)

1 or 2

2 or 3

1 or 2

1 (in the

evening)

12.5–25

25–50

1.25–2.5

2.5–5

10–40

12.5–150

5–40

10–40

7.5–30

4–16

10–80

2.5–20

1–4

40–80

8–32

600–800

150–300

50–100

20–40

20–80

80–320

2.5–10

5–10

60–120

30–90

17–34

120–360

120-360

120–360

100–300

Chlorthalidone

Hydrochlorothiazide

Indapamide

Metolazone

Benazepril

Captopril

Enalapril

Fosinopril

Lisinopril

Moexipril

Perindopril

Quinapril

Ramipril

Trandolapril

Azilsartan

Candesartan

Eprosartan

Irbesartan

Losartan

Olmesartan

Telmisartan

Valsartan

Amlodipine

Felodipine

Isradipine

Nicardipine SR

Nifedipine LA

Nisoldipine

Diltiazem ER

Verapamil IR

Verapamil SR

Verapamil-delayed

onset ER

Thiazide or

thiazide-type

diuretics

ACE Inhibitors

ARBs

CCB—

dihydropyridines

CCB—

nondihydropyridines

Table is continued in the next two pages

Oral Antihypertensive Drugs (1 of 3)

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Secondary Agents

Usual Dose,

Daily

Class Drug Range

Frequency

Comments

(mg per day)*

• Preferred diuretics in patients with symptomatic

HF. Preferred over thiazides in patients with

moderate-to-severe CKD (e.g., GFR <30 mL/min)

• Monotherapy agents minimally effective

antihypertensives

• Combination therapy of potassium sparing

diuretic with a thiazide can be considered in

patients with hypokalemia on thiazide

monotherapy

• Avoid in patients with signicant CKD (e.g.,

GFR <45 mL/min)

• Preferred agents in primary aldosteronism and

resistant hypertension

• Spironolactone associated with greater risk of

gynecomastia and impotence compared to

eplerenone

• Common add-on therapy in resistant hypertension

• Avoid use with K+ supplements, other K+-sparing

diuretics or signicant renal dysfunction

• Eplerenone often requires twice daily dosing for

adequate BP lowering

• Beta blockers are not recommended as rst-line

agents unless the patient has IHD or HF

• Preferred in patients with bronchospastic airway

disease requiring a beta blocker

• Bisoprolol and metoprolol succinate preferred in

patients with HFrEF

• Avoid abrupt cessation

• Induces nitric oxide-induced vasodilation

• Avoid abrupt cessation

• Avoid in patients with reactive airways disease

• Avoid abrupt cessation

• Generally avoid, especially in patients with IHD or HF

• Avoid abrupt cessation

1 or 2

0.5–2

20–80

5–10

50–100

25–100

5–20

2.5–10

100–200

50–200

5–40

40–120

80–160

200–800

10–40

10–60

Bumetanide

Furosemide

Torsemide

Amiloride

Triamterene

Eplerenone

Spironolactone

Atenolol

Betaxolol

Bisoprolol

Metoprolol tartrate

Metoprolol

succinate

Nebivolol

Nadolol

Propranolol IR

Propranolol LA

Acebutolol

Penbutolol

Pindolol

Diuretics—loop

Diuretics—

potassium sparing

Diuretics—

aldosterone

antagonists

Beta blockers—

cardioselective

Beta blockers—

cardioselective

and vasodilatory

Beta blockers—

noncardioselective

Beta blockers—

intrinsic

sympathomimetic

activity

Table is continued in the next page

Oral Antihypertensive Drugs (2 of 3)

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Secondary Agents (continued from previous page)

Usual Dose,

Daily

Class Drug Range

Frequency

Comments

(mg per day)*

• Carvedilol preferred in patients with HFrEF

• Avoid abrupt cessation

• Do not use in combination with ACE inhibitors

or ARBs

• Aliskiren is very long acting

• Increased risk of hyperkalemia in CKD or in those

on K+ supplements or K+ sparing drugs

• May cause acute renal failure in patients with

severe bilateral renal artery stenosis

• Avoid in pregnancy

• Associated with orthostatic hypotension,

especially in older adults

• May consider as second-line agent in patients

with concomitant BPH

• Generally reserved as last-line due to signicant

CNS adverse effects, especially in older adults

• Avoid abrupt discontinuation of clonidine, which

may induce hypertensive crisis; clonidine must be

tapered to avoid rebound hypertension

• Associated with sodium and water retention and

reex tachycardia; use with a diuretic and bet

a blocker

• Hydralazine associated with drug-induced lupus-

like syndrome at higher doses

• Minoxidil associated with hirsutism and requires

a loop diuretic. Can induce pericardial effusion

2 or 3

1 or 2

1 weekly

2 or 3

1 -3

12.5–50

20–80

200–800

150–300

1–16

2-20

1–20

0.1–0.8

0.1–0.3

250–1000

0.5–2

100-200

5–100

Carvedilol

phosphate

Labetalol

Aliskiren

Doxazosin

Prazosin

Terazosin

Clonidine oral

Clonidine patch

Methyldopa

Guanfacine

Hydralazine

Minoxidil

Beta blockers—

combined

alpha- and

beta-receptor

Direct renin

inhibitor

Alpha-1 blockers

Central Alpha2-

agonists and other

centrally acting

drugs

Direct vasodilators

Oral Antihypertensive Drugs (3 of 3)

*Dosages may vary from those listed in the FDA approved labeling (available at http://dailymed.nlm.nih.gov/dailymed/index.cfm).

Adapted with permission from Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003; 289:2560-72

Table 18

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COR LOE Recommendations

1. Adults with HFrEF and hypertension should be prescribed GDMT*

titrated to attain a BP less than 130/80 mm Hg.

2. Nondihydropyridine CCBs are not recommended in the treatment

of hypertension in adults with HFrEF.

III:

No Benet

C-EO

B-R

Recommendations for Treatment of Hypertension

in Patients with Heart Failure with Reduced Ejection Fraction (HFrEF)

Referenced studies that support recommendations are summarized in

online Data Supplement 34

Heart Failure with Reduced Ejection Fraction (HFrEF)

COR LOE Recommendations

1. In adults with HFpEF who present with symptoms of volume

overload, diuretics should be prescribed to control hepertension.

2. Adults with HFpEF and persistent hypertension after management

of volume overload should be prescribed ACE inhibitors or ARB

and beta blockers titrated to attain systolic BP less than 130 mm Hg.

C-EO

C-LD

Recommendations for Treatment of Hypertension

in Patients with Heart Failure with Preserved Ejection Fraction (HFpEF)

Referenced studies that support recommendations are summarized in

online Data Supplement 35, 36

COR LOE Recommendations

1. In adults with DM and hypertension, antihypertensive drug

treatment should be initiated at a BP of 130/80 mm Hg or higher

with a treatment goal of less than 130/80 mm Hg.

SBP:

B-R

3. In adults with DM and hypertension, ACE inhibitors or ARBs may

be considered in the presence of albuminuria.

IIb B-NR

2. In adults with DM and hypertension, all rst-line classes of

antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and

CCBs) are useful and effective.

I A

DBP:

C-EO

Recommendations for Treatment of Hypertension in Patients With DM

Heart Failure with Preserved Ejection Fraction (HFpEF)

Diabetes Mellitus

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Reduce BP to <130/80 mm Hg with

GDMT beta blockers*, ACE inhibitor, or ARB

†

(Class I)

Hypertension With SIHD

Yes

BP goal not met

Angina

pectoris

Add

dihydropyridine CCBs

if needed

(Class I)

Add

dihydropyridine CCBs,

thiazide-type diuretics,

and/or MRAs

as needed

(Class I)

Management of Hypertension in Patients with

Stable Ischemic Heart Disease (SIHD)

*GDMT beta blockers for BP control or relief of angina include carvedilol, metoprolol tartrate, metoprolol succinate,

nadolol, bisoprolol, propranolol, and timolol. Avoid beta blockers with intrinsic sympathomimetic activity. The beta

blocker atenolol should not be used because it is less effective than placebo in reducing cardiovascular events.

†If needed for BP control.

Figure 5

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BP goal <130/80 mm Hg

(Class I)

Treatment of Hypertension in Patients with CKD

Yes

Albuminuria

(≥ 300 mg/d or ≥300 mg/g

creatinine)

ACE inhibitor

(Class IIa)

Usual “rst line”

medication choices

Yes

ACE inhibitor

intolerant

ACE inhibitor*

(Class IIa)

ARB*

(Class IIb)

Management of Hypertension in Patients with

Chronic Kidney Disease

*CKD stage 3 or higher or stage 1 or 2 with albuminuria

≥300 mg/d or ≥300 mg/g creatinine.

Figure 6

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Acute (<6 h from symptom onset)

Spontaneous ICH

SBP lowering to

<140 mm Hg

(Class III)

Harm

SBP lowering with

continuous IV infusion

& close BP monitoring

(Class IIa)

SBP

150–220 mm Hg

SBP

>220 mm Hg

Management of Hypertension in Patients with

Acute Intercerebral Hemorrhage

Figure 7

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Lower SBP to <185 mm Hg and DBP <110 mm Hg

before initiation of IV thrombolysis

(Class I)

Maintain BP <180/105 mm Hg

for rst 24 h after IV thrombosis

(Class I)

For pre-existing hypertension, reinitiate

antihypertensive drugs after neurological stability

(Class IIa)

Lower BP 15%

during rst 24 h

(Class IIb)

Initiating or reinitiating treatment of

hypertension within the rst 48-72 hours

after an acute ischemic stroke is not

effective to prevent death or dependency

(Class III: ineffective)

Acute (<72 h from symptom onset)

Ischemic Stroke and Elevated BP

Yes

And

Patient qualies for IV

thrombolysis therapy

≤220/110 mm Hg

>220/110 mm Hg

Management of Hypertension in Patients with

Acute ischemic Stroke

Figure 8

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Restart

antihypertensive

treatment

(Class I)

Aim for

SBP <130/80 mm Hg

(Class IIb)

Initiate antihypertensive treatment

(Class I)

Aim for SBP <130/80 mm Hg

(Class IIb)

Stroke ≥72 h from symptom onset

and stable neurological status or TIA

Yes

Previous diagnosed

or treated hypertension

Established

SBP ≥140 mm Hg

or DBP ≥90 mm Hg

Usefulness of starting antihypertensive

treatment is not well established

(Class IIb)

Established

SBP <140 mm Hg

and DBP <90 mm Hg

Management of Hypertension in Patients with

a Previous History of Stroke (Secondary Stroke Prevention)

Figure 9

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Adapted with permission from Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis,

evaluation, and treatment. A scientic statement from the American Heart Association Professional

Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008; 51:1403-19

Figure 10

Conrm Treatment Resistance

Ofce SBP/DBP ≥130/80 mm Hg

and

Patient prescribed ≥3 antihypertensive medications at optimal doses, including a diuretic, if possible

Ofce SBP/DBP <130/80 mm Hg but patient requires ≥4 antihypertensive medications

Exclude Pseudo-Resistance

Ensure accurate ofce BP measurements

Assess for nonadherence with prescribed regimen

Obtain home, work, or ambulatory BP readings to exclude white coat effect

Identify and Reverse Contributing Lifestyle Factors

Obesity

Physical Inactivity

Excessive alcohol ingestion

High salt, low-ber diet

Discontinue or Minimize Interfering Substances

NSAIDs

Sympathomimetic (e.g., amphetamines, decongestants)

Stimulants

Oral contraceptives

Licorice

Ephedra

Screen for Secondary Causes of Hypertension

Primary aldosteronism (elevated aldosterone/renin ratio)

CKD (eGFR <60 mL/min/1.73 m

)

Renal artery stenosis (young female, known atherosclerotic disease, worsening kidney function)

Pheochromocytoma (episodic hypertension, palpitations, diaphoresis, headache)

Obstructive sleep apnea (snoring, witnessed apnea, excessive daytime sleepiness)

Pharmacologic Treatment

Maximize diuretic therapy

Add a mineralocorticoid receptor antagonist

Add other agents with different mechanisms of actions

Use loop diuretics in patients with CKD

and/or patients receiving potent vasodilators (e.g., minoxidil)

Refer to Specialist

Refer to appropriate specialist for known or suspected secondary cause(s) of hypertension

Refer to hypertension specialist if BP remains uncontrolled after 6 mo of treatment

Resistant Hypertension: Diagnosis, Evaluation, and Treatment

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Hypertensive

emergency

Admit to ICU

(Class I)

Markedly

elevated BP

Reinstitute/intensify oral

antihypertensive drug therapy

and arrange follow-up

Reduce SBP to <140 mm Hg

during 1

h*and to <120 mm Hg

in aortic dissection

†

(Class I)

Reduce BP by max 25% over 1

†

then to 160/100–110 mm Hg over next 2–6 h,

then to normal over next 24–48 h

(Class I)

SBP >180 mm Hg and/or DBP >120 mm Hg

Yes

Target organ damage new/

progressive/worsening

Conditions

• Aortic dissection;

• Severe pre-eclampsia or eclampsia;

• Pheochromocytoma crisis

Diagnosis and Management of a Hypertensive Crisis

*Use drug(s) specied in Table 19.

†If other comorbidities are present, select a drug specied in Table 20.

Figure 11

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Intravenous Antihypertensive Drugs

for Treatment of Hypertensive Emergencies (1 of 2)

Contraindicated in advanced aortic stenosis; no dose

adjustment needed for elderly.

Contraindicated in pts with soybean, soy product,

egg, and egg product allergy and in pts with defective

lipid metabolism (e.g., pathological hyperlipidemia,

lipoid nephrosis or acute pancreatitis). Use low-end

dose range for elderly pts.

Intra-arterial BP monitoring recommended to prevent

“overshoot”. Lower dosing adjustment required for

elderly. Tachyphylaxis common with extended use.

Cyanide toxicity with prolonged use can result in

irreversible neurologic changes and cardiac arrest.

Use only in pts with acute coronary syndrome and/

or acute pulmonary edema. Do not use in volume-

depleted pts.

BP begins to decrease within 10–30 min and the

fall lasts 2–4 h. Unpredictability of response and

prolonged duration of action do not make hydralazine

a desirable rst-line agent for acute treatment in

most pts.

Contraindicated in pts with concurrent beta-blocker

therapy, bradycardia and/or decompensated HF

Monitor for bradycardia.

May worsen HF.

Higher doses may block beta2 receptors and impact

lung function in reactive airway disease.

Initial 5 mg/h,

increasing every 5 min by 2.5 mg/h to

maximum 15 mg/h.

Initial 1–2 mg/h, doubling every 90 s

until BP approaches target, then

increasing by < double every 5–10

min; maximum dose 32 mg/h;

maximum duration 72 h.

Initial 0.3–0.5 mcg/kg/min; increase

in increments of 0.5 mcg/kg/min to

achieve BP target; maximum dose

10 mcg/kg/min; duration of treatment

as short as possible. For infusion rates

≥4–10 mcg/kg/min or duration >30

min, thiosulfate can be coadministered

to prevent cyanide toxicity.

Initial 5 mcg/min; increase in incre-

ments of 5 mcg/min every 3–5 min to

a maximum of 20 mcg/min.

Initial 10 mg via slow IV infusion

(maximum initial dose 20 mg); repeat

every 4–6 h as needed.

Loading dose 500–1,000 mcg/

kg/min over 1 min followed by a 50

mcg/kg/min infusion. For additional

dosing, the bolus dose is repeated

and the infusion increased in 50

mcg/kg/min increments as needed to

a maximum of 200 mcg/kg/ min.

Nicardipine

Clevidipine

Sodium

nitroprusside

Nitroglycerin

Hydralazine

Esmolol

CCB-

dihydropyridines

Vasodilators-

nitric oxide

dependent

Vasodilators-

direct

Adrenergic

blockers

beta1 receptor

selective

antagonist

Agent Drugs Usual Dose Range Comments

Table will be continued in the next page

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Intravenous Antihypertensive Drugs

for Treatment of Hypertensive Emergencies (2 of 2)

Contraindicated in reactive airways disease or chronic

obstructive pulmonary disease. Especially useful in

hyperadrenergic syndromes. May worsen HF and

should not be given in pts with 2nd or 3rd degree

heart block or bradycardia.

Used in hypertensive emergencies induced by

catecholamine excess (pheochromocytoma,

interactions between monamine oxidase inhibitors

and other drugs or food, cocaine toxicity,

amphetamine overdose or clonidine withdrawal).

Contraindicated in pts at risk for increased

intraocular pressure (glaucoma) or intracranial

pressure and those with sulte allergy.

Contraindicated in pregnancy and should not be

used in acute MI or bilateral renal artery stenosis.

Mainly useful in hypertensive emergencies

associated with high plasma renin activity.

Dose not easily adjusted.

Relatively slow onset of action (15 min) and

unpredictability of BP response.

Initial 0.3–1.0 mg/kg dose

(maximum 20 mg) slow IV injection

every 10 min or 0.4–1.0 mg/kg/h IV

infusion up to 3 mg/kg/h. Adjust

rate up to total cumulative dose of

300 mg. This dose can be repeated

every 4–6 h.

IV bolus dose 5 mg. Additional bolus

doses every 10 min as needed to

lower BP to target.

Initial 0.1–0.3 mcg/kg/min; may be

increased in increments of 0.05–0.1

mcg/kg/min every 15 min until target

BP is reached. Maximum infusion rate

1.6 mcg/kg/min.

Initial 1.25 mg over a 5 min period.

Doses can be increased up to 5 mg

every 6 h as needed to achieve BP

target.

Labetalol

Phentolamine

Fenoldopam

Enalaprilat

Adrenergic

blockers-

combined

alpha1 and

nonselective

beta receptor

antagonist

Adrenergic

blockers-

non-selective

alpha receptor

antagonist

Dopamine1-

receptor

selective

agonist

Angiotensin

converting

enzyme

inhibitor

Agent Drugs Usual Dose Range Comments

Table 19