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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

2017; Lippincott Williams & Wilkins; Volume: 71; Issue: 6 Linguagem: Inglês

10.1161/hyp.0000000000000065

ISSN

1524-4563

Autores

Paul K. Whelton, Robert M. Carey, Wilbert S. Aronow, Donald E. Casey, Karen J. Collins, Cheryl Dennison Himmelfarb, Sondra M. DePalma, Samuel S. Gidding, Kenneth Jamerson, Daniel W. Jones, Eric J. MacLaughlin, Paul Muntner, Bruce Ovbiagele, Sidney C. Smith, Crystal C. Spencer, Randall S. Stafford, Sandra J. Taler, Randal J. Thomas, Kim A. Williams, Jeff D. Williamson, Jackson T. Wright,

Tópico(s)

Hemodynamic Monitoring and Therapy

Resumo

HomeHypertensionVol. 71, No. 62017 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 Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUB2017 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 Paul K. Whelton, MB, MD, MSc, FAHA, Robert M. Carey, MD, FAHA, Wilbert S. Aronow, MD, FACC, FAHA, Donald E. CaseyJr, 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. SmithJr, 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. WilliamsSr, MD, MACC, FAHA, Jeff D. Williamson, MD, MHS and Jackson T. WrightJr, MD, PhD, FAHA Paul K. WheltonPaul K. Whelton , Robert M. CareyRobert M. Carey , Wilbert S. AronowWilbert S. Aronow , Donald E. CaseyJrDonald E. CaseyJr , Karen J. CollinsKaren J. Collins , Cheryl Dennison HimmelfarbCheryl Dennison Himmelfarb , Sondra M. DePalmaSondra M. DePalma , Samuel GiddingSamuel Gidding , Kenneth A. JamersonKenneth A. Jamerson , Daniel W. JonesDaniel W. Jones , Eric J. MacLaughlinEric J. MacLaughlin , Paul MuntnerPaul Muntner , Bruce OvbiageleBruce Ovbiagele , Sidney C. SmithJrSidney C. SmithJr , Crystal C. SpencerCrystal C. Spencer , Randall S. StaffordRandall S. Stafford , Sandra J. TalerSandra J. Taler , Randal J. ThomasRandal J. Thomas , Kim A. WilliamsSrKim A. WilliamsSr , Jeff D. WilliamsonJeff D. Williamson and Jackson T. WrightJrJackson T. WrightJr Originally published13 Nov 2017https://doi.org/10.1161/HYP.0000000000000065Hypertension. 2018;71:e13–e115is corrected byCorrection to: 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 GuidelinesOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2017: Previous Version 1 Table of ContentsPreamble e151.Introduction e161.1.Methodology and Evidence Review e161.2.Organization of the Writing Committee e171.3.Document Review and Approval e181.4.Scope of the Guideline e181.5.Abbreviations and Acronyms e182.BP and CVD Risk e192.1.Observational Relationship e192.2.BP Components e202.3.Population Risk e202.4.Coexistence of Hypertension and Related Chronic Conditions e203.Classification of BP e213.1.Definition of High BP e213.2.Lifetime Risk of Hypertension e223.3.Prevalence of High BP e223.4.Awareness, Treatment, and Control e224.Measurement of BP e234.1.Accurate Measurement of BP in the Office e234.2.Out-of-Office and Self-Monitoring of BP e244.3.Ambulatory BP Monitoring e254.4.Masked and White Coat Hypertension e265.Causes of Hypertension e285.1.Genetic Predisposition e285.2.Environmental Risk Factors e285.2.1.Overweight and Obesity e285.2.2.Sodium Intake e295.2.3.Potassium e295.2.4.Physical Fitness e295.2.5.Alcohol e295.3.Childhood Risk Factors and BP Tracking e315.4.Secondary Forms of Hypertension e325.4.1.Drugs and Other Substances With Potential to Impair BP Control e325.4.2.Primary Aldosteronism e325.4.3.Renal Artery Stenosis e345.4.4.Obstructive Sleep Apnea e346.Nonpharmacological Interventions e356.1.Strategies e356.2.Nonpharmacological Interventions e357.Patient Evaluation e387.1.Laboratory Tests and Other Diagnostic Procedures e387.2.Cardiovascular Target Organ Damage e388.Treatment of High BP e398.1.Pharmacological Treatment e398.1.1.Initiation of Pharmacological BP Treatment in the Context of Overall CVD Risk e398.1.2.BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension e408.1.3.Follow-Up After Initial BP Evaluation e428.1.4.General Principles of Drug Therapy e428.1.5.BP Goal for Patients With Hypertension e438.1.6.Choice of Initial Medication e468.2.Achieving BP Control in Individual Patients e478.3.Follow-Up of BP During Antihypertensive Drug Therapy e488.3.1.Follow-Up After Initiating Antihypertensive Drug Therapy e488.3.2.Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP e489.Hypertension in Patients With Comorbidities e489.1.Stable Ischemic Heart Disease e499.2.Heart Failure e509.2.1.Heart Failure With Reduced Ejection Fraction e509.2.2.Heart Failure With Preserved Ejection Fraction e519.3.Chronic Kidney Disease e519.3.1.Hypertension After Renal Transplantation e539.4.Cerebrovascular Disease e539.4.1.Acute Intracerebral Hemorrhage e549.4.2.Acute Ischemic Stroke e549.4.3.Secondary Stroke Prevention e569.5.Peripheral Artery Disease e579.6.Diabetes Mellitus e589.7.Metabolic Syndrome e599.8.Atrial Fibrillation e599.9.Valvular Heart Disease e609.10.Aortic Disease e6010.Special Patient Groups e6010.1.Race and Ethnicity e6010.1.1.Racial and Ethnic Differences in Treatment e6110.2.Sex-Related Issues e6110.2.1.Women e6210.2.2.Pregnancy e6210.3.Age-Related Issues e6310.3.1.Older Persons e6310.3.2.Children and Adolescents e6411.Other Considerations e6411.1.Resistant Hypertension e6411.2.Hypertensive Crises—Emergencies and Urgencies e6511.3.Cognitive Decline and Dementia e6811.4.Sexual Dysfunction and Hypertension e6911.5.Patients Undergoing Surgical Procedures e6912.Strategies to Improve Hypertension Treatment and Control e7112.1.Adherence Strategies for Treatment of Hypertension e7112.1.1.Antihypertensive Medication Adherence Strategies e7112.1.2.Strategies to Promote Lifestyle Modification e7112.1.3.Improving Quality of Care for Resource-Constrained Populations e7212.2.Structured, Team-Based Care Interventions for Hypertension Control e7312.3.Health Information Technology–Based Strategies to Promote Hypertension Control e7312.3.1.EHR and Patient Registries e7312.3.2.Telehealth Interventions to Improve Hypertension Control e7412.4.Improving Quality of Care for Patients With Hypertension e7412.4.1.Performance Measures e7412.4.2.Quality Improvement Strategies e7412.5.Financial Incentives e7513.The Plan of Care for Hypertension e7513.1.Health Literacy e7613.2.Access to Health Insurance and Medication Assistance Plans e7613.3.Social and Community Services e7614.Summary of BP Thresholds and Goals for Pharmacological Therapy e7715.Evidence Gaps and Future Directions e77References e79Appendix 1: Author Relationships With Industry and Other Entities (Relevant) e108Appendix 2: Reviewer Relationships With Industry and Other Entities (Comprehensive) e110PreambleSince 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines (guidelines) with recommendations to improve cardiovascular health. In 2013, the National Heart, Lung, and Blood Institute (NHLBI) Advisory Council recommended that the NHLBI focus specifically on reviewing the highest-quality evidence and partner with other organizations to develop recommendations.P-1,P-2 Accordingly, the ACC and AHA collaborated with the NHLBI and stakeholder and professional organizations to complete and publish 4 guidelines (on assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults) to make them available to the widest possible constituency. In 2014, the ACC and AHA, in partnership with several other professional societies, initiated a guideline on the prevention, detection, evaluation, and management of high blood pressure (BP) in adults. Under the management of the ACC/AHA Task Force, a Prevention Subcommittee was appointed to help guide development of the suite of guidelines on prevention of cardiovascular disease (CVD). These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA.Intended UsePractice guidelines provide recommendations applicable to patients with or at risk of developing CVD. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations can have a global impact. Although guidelines may be used to inform regulatory or payer decisions, they are intended to improve patients' quality of care and align with patients' interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.Clinical ImplementationManagement in accordance with guideline recommendations is effective only when followed by both practitioners and patients. Adherence to recommendations can be enhanced by shared decision making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities.Methodology and ModernizationThe ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations, including the Institute of Medicine,P-3,P-4 and on the basis of internal reevaluation. Similarly, the presentation and delivery of guidelines are reevaluated and modified on the basis of evolving technologies and other factors to facilitate optimal dissemination of information to healthcare professionals at the point of care.Toward this goal, this guideline continues the introduction of an evolved format of presenting guideline recommendations and associated text called the "modular knowledge chunk format." Each modular "chunk" includes a table of related recommendations, a brief synopsis, recommendation-specific supportive text, and when appropriate, flow diagrams or additional tables. References are provided within the modular chunk itself to facilitate quick review. Additionally, this format will facilitate seamless updating of guidelines with focused updates as new evidence is published, as well as content tagging for rapid electronic retrieval of related recommendations on a topic of interest. This evolved approach format was instituted when this guideline was near completion; therefore, the present document represents a transitional format that best suits the text as written. Future guidelines will fully implement this format, including provisions for limiting the amount of text in a guideline.Recognizing the importance of cost–value considerations in certain guidelines, when appropriate and feasible, an analysis of the value of a drug, device, or intervention may be performed in accordance with the ACC/AHA methodology.P-5To ensure that guideline recommendations remain current, new data are reviewed on an ongoing basis, with full guideline revisions commissioned in approximately 6-year cycles. Publication of new, potentially practice-changing study results that are relevant to an existing or new drug, device, or management strategy will prompt evaluation by the Task Force, in consultation with the relevant guideline writing committee, to determine whether a focused update should be commissioned. For additional information and policies regarding guideline development, we encourage readers to consult the ACC/AHA guideline methodology manualP-6 and other methodology articles.P-7–P-10Selection of Writing Committee MembersThe Task Force strives to avoid bias by selecting experts from a broad array of backgrounds. Writing committee members represent different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice. The Task Force may also invite organizations and professional societies with related interests and expertise to participate as partners, collaborators, or endorsers.Relationships With Industry and Other EntitiesThe ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without bias or improper influence. The complete relationships with industry and other entities (RWI) policy can be found online. Appendix 1 of the present document lists writing committee members' relevant RWI. For the purposes of full transparency, writing committee members' comprehensive disclosure information is available online. Comprehensive disclosure information for the Task Force is available online.Evidence Review and Evidence Review CommitteesIn developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data.P-6–P-9 Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited.An independent evidence review committee (ERC) is commissioned when there are 1 or more questions deemed of utmost clinical importance that merit formal systematic review. The systematic review will determine which patients are most likely to benefit from a drug, device, or treatment strategy and to what degree. Criteria for commissioning an ERC and formal systematic review include: a) the absence of a current authoritative systematic review, b) the feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline, c) the relevance to a substantial number of patients, and d) the likelihood that the findings can be translated into actionable recommendations. ERC members may include methodologists, epidemiologists, healthcare providers, and biostatisticians. The recommendations developed by the writing committee on the basis of the systematic review are marked with "SR."Guideline-Directed Management and TherapyThe term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm the dosage by reviewing product insert material and evaluate the treatment regimen for contraindications and interactions. The recommendations are limited to drugs, devices, and treatments approved for clinical use in the United States.Class of Recommendation and Level of EvidenceThe Class of Recommendation (COR) indicates the strength of the recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence that supports the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1).P-6–P-8Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)Glenn N. Levine, MD, FACC, FAHAChair, ACC/AHA Task Force on Clinical Practice Guidelines1. IntroductionAs early as the 1920s, and subsequently in the 1959 Build and Blood Pressure StudyS1.5-1 of almost 5 million adults insured between 1934 and 1954, a strong direct relationship was noted between level of BP and risk of clinical complications and death. In the 1960s, these findings were confirmed in a series of reports from the Framingham Heart Study.S1.5-2 The 1967 and 1970 Veterans Administration Cooperative Study Group reports ushered in the era of effective treatment for high BP.S1.5-3,S1.5-4 The first comprehensive guideline for detection, evaluation, and management of high BP was published in 1977, under the sponsorship of the NHLBI.S1.5-5 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.S1.5-5–S1.5-7 The present guideline updates prior JNC reports.1.1. Methodology and Evidence ReviewAn extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted between February and August 2015. Key search words included but were not limited to the following: adherence; aerobic; alcohol intake; ambulatory care; antihypertensive: agents, drug, medication, therapy; beta adrenergic blockers; blood pressure: arterial, control, determination, devices, goal, high, improve, measurement, monitoring, ambulatory; calcium channel blockers; diet; diuretic agent; drug therapy; heart failure: diastolic, systolic; hypertension: white coat, masked, ambulatory, isolated ambulatory, isolated clinic, diagnosis, reverse white coat, prevention, therapy, treatment, control; intervention; lifestyle: measures, modification; office visits; patient outcome; performance measures; physical activity; potassium intake; protein intake; renin inhibitor; risk reduction: behavior, counseling; screening; sphygmomanometers; spironolactone; therapy; treatment: adherence, compliance, efficacy, outcome, protocol, regimen; weight. Additional relevant studies published through June 2016, during the guideline writing process, were also considered by the writing committee and added to the evidence tables when appropriate. The final evidence tables included in the Online Data Supplement summarize the evidence used by the writing committee to formulate recommendations.As noted in the preamble, an independent ERC was commissioned to perform a formal systematic review of 4 critical clinical questions related to hypertension (Table 2), the results of which were considered by the writing committee for incorporation into this guideline. Concurrent with this process, writing committee members evaluated other published data relevant to the guideline. The findings of the ERC and the writing committee members were formally presented and discussed, and then guideline recommendations were developed. The systematic review report, "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," is published in conjunction with this guideline,S1.5-8 and its respective data supplements are available online. No writing committee member reported a RWI. Drs. Whelton, Wright, and Williamson had leadership roles in SPRINT (Systolic Blood Pressure Intervention Trial). Dr. Carey chaired committee discussions in which the SPRINT results were considered.Table 2. Systematic Review Questions on High BP in AdultsQuestion NumberQuestionSection Number1Is there evidence that self-directed monitoring of BP and/or ambulatory BP monitoring are superior to office-based measurement of BP by a healthcare worker for 1) preventing adverse outcomes for which high BP is a risk factor and 2) achieving better BP control?4.22What is the optimal target for BP lowering during antihypertensive therapy in adults?8.1.59.39.63In adults with hypertension, do various antihypertensive drug classes differ in their comparative benefits and harms?8.1.68.24In adults with hypertension, does initiating treatment with antihypertensive pharmacological monotherapy versus initiating treatment with 2 drugs (including fixed-dose combination therapy), either of which may be followed by the addition of sequential drugs, differ in comparative benefits and/or harms on specific health outcomes?8.1.6.1BP indicates blood pressure.1.2. Organization of the Writing CommitteeThe writing committee consisted of clinicians, cardiologists, epidemiologists, internists, an endocrinologist, a geriatrician, a nephrologist, a neurologist, a nurse, a pharmacist, a physician assistant, and 2 lay/patient representatives. It included representatives from the ACC, AHA, American Academy of Physician Assistants (AAPA), Association of Black Cardiologists (ABC), American College of Preventive Medicine (ACPM), American Geriatrics Society (AGS), American Pharmacists Association (APhA), American Society of Hypertension (ASH), American Society for Preventive Cardiology (ASPC), National Medical Association (NMA), and Preventive Cardiovascular Nurses Association (PCNA).1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers nominated by the ACC and AHA; 1 reviewer each from the AAPA, ABC, ACPM, AGS, APhA, ASH, ASPC, NMA, and PCNA; and 38 individual content reviewers. Reviewers' RWI information was distributed to the writing committee and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC, AHA, AAPA, ABC, ACPM, AGS, APhA, ASH, ASPC, NMA, and PCNA.1.4. Scope of the GuidelineThe present guideline is intended to be a resource for the clinical and public health practice communities. It is designed to be comprehensive but succinct and practical in providing guidance for prevention, detection, evaluation, and management of high BP. It is an update of the NHLBI publication, "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure" (JNC 7).S1.5-7 It incorporates new information from studies of office-based BP-related risk of CVD, ambulatory blood pressure monitoring (ABPM), home blood pressure monitoring (HBPM), telemedicine, and various other areas. This guideline does not address the use of BP-lowering medications for the purposes of prevention of recurrent CVD events in patients with stable ischemic heart disease (SIHD) or chronic heart failure (HF) in the absence of hypertension; these topics are the focus of other ACC/AHA guidelines.S1.5-9,S1.5-10 In developing the present guideline, the writing committee reviewed prior published guidelines, evidence reviews, and related statements. Table 3 contains a list of publications and statements deemed pertinent to this writing effort and is intended for use as a resource, thus obviating the need to repeat existing guideline recommendations.Table 3. Associated Guidelines and StatementsTitleOrganizationPublication YearGuidelines Lower-extremity peripheral artery diseaseAHA/ACC2016S1.5-11 Management of primary aldosteronism: case detection, diagnosis, and treatmentEndocrine Society2016S1.5-12 Stable ischemic heart diseaseACC/AHA/AATS/PCNA/SCAI/STS2014S1.5-13* 2012S1.5-9 Pheochromocytoma and paragangliomaEndocrine Society2014S1.5-14 Atrial fibrillationAHA/ACC/HRS2014S1.5-15 Valvular heart diseaseACC/AHA2017S1.5-16 Assessment of cardiovascular riskACC/AHA2013S1.5-17 Hypertension in pregnancyACOG2013S1.5-18 Heart failureACC/AHA2017S1.5-19 2013S1.5-10 Lifestyle management to reduce cardiovascular riskAHA/ACC2013S1.5-20 Management of arterial hypertensionESH/ESC2013S1.5-21 Management of overweight and obesity in adultsAHA/ACC/TOS2013S1.5-22 ST-elevation myocardial infarctionACC/AHA2013S1.5-23 Treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adultsACC/AHA2013S1.5-24 Cardiovascular diseases during pregnancyESC2011S1.5-25 Effectiveness-based guidelines for the prevention of cardiovascular disease in womenAHA/ACC2011S1.5-26 Secondary prevention and risk-reduction therapy for patients with coronary and other atherosclerotic vascular diseaseAHA/ACC2011S1.5-27 Assessment of cardiovascular risk in asymptomatic adultsACC/AHA2010S1.5-28 Thoracic aortic diseaseACC/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM2010S1.5-29 Diagnosis, evaluation, and treatment of high blood pressure in children and adolescentsNHLBI2004S1.5-30Statements Salt sensitivity of blood pressureAHA2016S1.5-31 Cardiovascular team-based care and the role of advanced practice providersACC2015S1.5-32 Treatment of hypertension in patients with coronary artery diseaseAHA/ACC/ASH2015S1.5-33 Ambulatory blood pressure monitoring in children and adolescentsAHA2014S1.5-34 An effective approach to high blood pressure controlAHA/ACC/CDC2014S1.5-35 Ambulatory blood pressure monitoringESH2013S1.5-36 Performance measures for adults with coronary artery disease and hypertensionACC/AHA/AMA-PCPI2011S1.5-37 Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adultsAHA2010S1.5-38 Resistant hypertension: diagnosis, evaluation, and treatmentAHA2008S1.5-39*The full-text SIHD guideline is from 2012.S1.5-9 A focused update was published in 2014.S1.5-13AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ACOG, American College of Obstetricians and Gynecologists; ACR, American College of Radiology; AHA, American Heart Association; AMA, American Medical Association; ASA, American Stroke Association; ASH, American Society of Hypertension; CDC, Centers for Disease Control and Prevention; ESC, European Society of Cardiology; ESH, European Society of Hypertension; HRS, Heart Rhythm Society; NHLBI, National Heart, Lung, and Blood Institute; PCNA, Preventive Cardiovascular Nurses Association; PCPI, Physician Consortium for Performance Improvement; SCA, Society of Cardiovascular Anesthesiologists; SCAI, Society for Cardiovascular Angiography and Interventions; SIHD, stable ischemic heart disease; SIR, Society of Interventional Radiology; STS, Society of Thoracic Surgeons; SVM, Society for Vascular Medicine; and TOS, The Obesity Society.1.5. Abbreviations and AcronymsAbbreviation/AcronymMeaning/PhraseABPMambulatory blood pressure monitoringACEangiotensin-converting enzymeAFatrial fibrillationARBangiotensin receptor blockerBPblood pressureCCBcalcium channel blockerCHDcoronary heart diseaseCKDchronic kidney diseaseCPAPcontinuous positive airway pressureCVDcardiovascular diseaseDBPdiastolic blood pressureDMdiabetes mellitusECGelectrocardiogramESRDend-stage renal diseaseGDMTguideline-directed management and therapyGFRglomerular filtration rateHBPMhome blood pressure monitoringEHRelectronic health recordHFheart failureHFpEFheart failure with preserved ejection fractionHFrEFheart failure with reduced ejection fractionICHintracerebral hemorrhageJNCJoint National CommissionLVleft ventricularLVHleft ventricular hypertrophyMImyocardial infarctionMRImagnetic resonance imagingPADperipheral artery diseaseRASrenin-angiotensin systemRCTrandomized controlled trialSBPsystolic blood pressureSIHDstable ischemic heart diseaseTIAtransient ischemic attack2. BP and CVD Risk2.1. Observational RelationshipObservational studies have demonstrated graded associations between higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) and increased CVD risk.S2.1-1,S2.1-2 In a meta-analysis of 61 prospective studies, the risk of CVD increased in a log-linear fashion from SBP levels 180 mm Hg and from DBP levels 105 mm Hg.S2.1-1 In that analysis, 20 mm Hg higher SBP and 10 mm Hg higher DBP were each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. In a separate observational study including >1 million adult patients ≥30 years of age, higher SBP and DBP were associated with increased risk of CVD incidence and angina, myocardial infarction (MI), HF, stroke, peripheral artery disease (PAD), and abdominal aortic aneurysm, each evaluated separately.S2.1-2 An increased risk of CVD associated with higher SBP and DBP has been reported across a broad age spectrum, from 30 years to >80 years of age. Although the relative risk of incident CVD associated with higher SBP and DBP is smaller at older ages, the corresponding high BP–related increase in absolute risk is larger in older persons (≥65 years) given the higher absolute risk of CVD at an older age.S2.1-12.2. BP ComponentsEpidemiological studies have evaluated associations of SBP and DBP, as well as derived components of BP measurements (including pulse pressure, mean BP, and mid-BP), with CVD outcomes (Table 4). When considered separately, higher levels of both SBP and DBP have been associated with increased CVD risk.S2.2-1,S2.2-2 Higher SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, DBP.S2.2-3–S2.2-5 In contrast, after consideration of SBP through adjustment or stratification, DBP has not been consistently associated with CVD risk.S2.2-6,S2.2-7 Although pulse pressure and mid-BP have been associated with increased CVD risk independent of SBP and DBP in some studies, SBP (especially) and DBP are prioritized in the present document because of the robust evidence base for these measures in both observational studies and clinical trials and because of their ease of measurement in practice settings.S2.2-8–S2.2-11Table 4. BP Measurement DefinitionsBP MeasurementDefinitionSBPFirst Korotkoff sound*DBPFifth Korotkoff

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