New ACC/AHA guidelines dramatically increase the number of patients with hypertension, but that doesn’t mean they all need drugs. While the new normal is lower and the prehypertensive category has gone away, most people who were not considered to have hypertension under previous guidelines are encouraged to manage their blood pressure through lifestyle changes rather than medication. Individuals with diabetes and certain other comorbidities or at high risk of cardiovascular disease, however, need to be managed differently.

The first comprehensive revision to guidelines for the diagnosis and management of hypertension since 2003 changed the definition of high blood pressure (BP), putting 46% of the adult U.S. population in the category. The new standard will triple the number of men—and double the number of women—under age 45 years considered to have the condition. Does that mean that prescriptions for antihypertensives should also rise sharply? Probably not.

“If you already have a doubling of risk, you need to know about it. It doesn’t mean you need medication, but it’s a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches,” said lead author Paul K. Whelton, MB, MD, MSc, in a press release.

The ACC/AHA guidelines establish normal BP as less than 120/80 mm Hg. They also eliminate the prehypertensive category present in previous guidelines with an elevated blood pressure category that includes a systolic between 120 and 129 and diastolic less than 80 mm Hg and Stage 1 hypertension for systolic of 130 to 139 or diastolic between 80 and 89 mm Hg.

Patients with elevated or stage I hypertension should only be prescribed medication if they have already experienced myocardial infarction or stroke or are at high risk for either event, have diabetes mellitus, chronic kidney disease, or have a 10-year 10% or higher risk of high risk of atherosclerotic cardiovascular disease (ASCVD) using a recommended risk calculator.

The former Stage 1 hypertension is now classified as Stage 2, with a systolic of 140 or more and diastolic of at least 90 mm Hg. Physicians should consider prescribing antihypertensives to these patients as well as urging lifestyle changes known to reduce the risk of heart disease.

Patients should be considered to be in hypertensive crisis if their systolic exceeds 180 or their diastolic is over 120 mm Hg. Crisis indicates an immediate need for a change in medication, if asymptomatic, and hospitalization if accompanied by signs of organ damage.

The guidelines recommend that patients with known cardiovascular disease and those at high risk of atherosclerotic cardiovascular disease target a blood pressure of less than 130/80 mm Hg. The guidelines make a weaker recommendation for the same level for other individuals as well.

“The 2017 guideline strategy of tailoring treatment to a combination of both BP and underlying 10-year estimated risk of ASCVD is a huge step forward for hypertension management,“ said Philip Greenland, MD, and Eric Peterson, MD, MPH, in an editorial accompanying the guidelines in JAMA. “This change reflects epidemiologic data showing that both underlying risk and change in BP while receiving treatment determine one’s absolute benefit from BP lowering.”

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