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Latest guideline addresses the gap in managing adult stage 1 hypertension with a low 10-year ASCVD risk

28 Jun 2021

The 2017 Hypertension Clinical Practice Guideline issued by the American College of Cardiology/American Heart Association (ACC/AHA) Task Force outlined the general blood pressure (BP) management approach to adults with stage 1 hypertension and a 10-year risk for atherosclerotic cardiovascular disease (ASCVD) of <10%, but not specified the follow-up management strategies for patients who fail to meet the BP target of <130/80mmHg despite practicing the recommended lifestyle changes for 6 months.1,2 To address this guidance gap, the AHA issued another hypertension guideline as a supplementary update, recommending clinicians to consider pharmacological therapies for hypertensive patients on top of ongoing lifestyle changes to better augment BP control for the improvement of goal attainment and risk reduction of cardiovascular disease (CVD).2

Globally, hypertension is one of the leading causes of CVD and premature mortality, with approximately 1.4 billion adults worldwide living with this condition in 2010.3 Yet, the emergence of antihypertensives such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), and thiazide diuretics, as well as the publication of different clinical guidelines enabled clinicians to better manage hypertensive patients for improving BP control and CVD prevention.1,4,5 As a result, the global mean BP actually remains on a constant to a slightly declining level over the past couple decades.3

Per the ACC/AHA 2017 guidelines, patients with a BP of ≥140/≥90mmHg, i.e., stage 2 hypertension, warrant the use of both pharmacological and lifestyle interventions for BP control.1 For those with BP ranges between 130-139/80-89mmHg, i.e., stage 1 hypertension, and an estimated 10-year ASCVD risk of <10%, the condition can be simply managed with lifestyle interventions alone, together with a repeated BP evaluation within 3 to 6 months.1 The recommended lifestyle therapies can be multifold, ranging from weight loss, a heart-healthy diet, sodium restriction, potassium supplementation, increased physical activity to alcohol reduction.1 However, due to the lack of randomized controlled trials (RCTs) that specifically target this relatively low-risk patient population, the 2017 guideline did not provide any further recommendations for patients not achieving the BP goal following 6 months of lifestyle interventions.2 To better support this patient population, the AHA therefore published a supplementary guideline that aims to address these previously missed recommendations based on evidence from observation data as opposed to RCTs.2

According to this recently published 2021 supplementary guideline, the AHA now recommends all patients with stage 1 hypertension and an estimated 10-year ASCVD risk of <10% who fail to achieve a target BP of <130/80mmHg within 6 months despite practicing vigorous lifestyle changes to consider the addition of antihypertensives while maintaining lifestyle changes.1,2 In addition, for patients who are diagnosed with hypertension during adolescence or childhood and are on antihypertensive medications, clinicians should consider the original indications for treatment initiation as well as the need to continue the medications and lifestyle therapy as the patients mature into young adults.2 For young adults with stage 1 hypertension uncontrolled with lifestyle modifications alone, the 2021 guideline also recommends the consideration of antihypertensive medications if the patient has a family history of premature CVD, a history of hypertension during pregnancy, or a personal history of premature birth.2

Together with the previously published 2017 guideline, the 2021 supplementary guideline helps provide a more comprehensive treatment guidance for managing hypertension, particularly for patients with stage 1 hypertension and an estimated ASCVD risk of <10%. Overall, Dr. Daniel W. Jones, Chair of the Statement Writing Group and Past President of the AHA, commented that there were no treatment recommendations in the 2017 guidelines for patients who are at relatively low and short-term risk of heart disease when BP does not drop below 130mmHg after 6 months of recommended lifestyle changes. With this 2021 supplementary guideline filling the gap, Dr. Jones summarized that, “We want clinicians to advise patients to make healthy lifestyle changes seriously and do their best. We certainly prefer to achieve BP goals without adding medication [as] successfully treating high BP does extend both [survival] and quality of life."

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