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Opinion

VIEWPOINT
The 2017 Clinical Practice Guideline
for High Blood Pressure
Paul K. Whelton, MB, mended for the management of prehypertension and for
Clinical practice guidelines (CPGs) are well suited to the
MD, MSc management of high blood pressure (BP) because it is a initial treatment of hypertension. Antihypertensive drug
Department of condition that is common, costly for patients and soci- therapy was recommended for adults with hyperten-
Epidemiology, Tulane
ety,exhibitsconsiderablevariationinpracticepatternsand sion whose SBP and DBP remained above a treatment
University School of
Public Health and hypertension control rates by geographic region and so- goal of less than 140 and 90 mm Hg, respectively (<130
Tropical Medicine, cioeconomic status, and has a substantial body of scien- and 80 mm Hg, respectively, in patients with diabetes
New Orleans, tific evidence available to support recommendations.1 BP-or chronic kidney disease). Thiazide-type diuretics were
Louisiana; and
Department of
related CPGs have long been a part of routine clinical recommended as initial agents for BP lowering but sev-
Medicine, Tulane practice, beginning with the 1977 Report of the Joint Na-eral antihypertensive drug classes were recognized as
University School of tional Committee (JNC) on Detection, Evaluation, and effective in reducing the risk of CVD. JNC 7 also acknowl-
Medicine, New Orleans,
Treatment of High Blood Pressure.2 edged that most patients with hypertension would re-
Louisiana.
The 1977 committee members, appointed by the quire more than 1 BP-lowering drug.
Robert M. Carey, MD National Heart, Lung, and Blood Institute (NHLBI), in- In 2008, the NHLBI appointed panel members to the
Division of cluded representatives from major professional soci- Eighth Joint National Committee (JNC 8) to update 3
Endocrinology and eties, the Veterans Administration, and the US Public treatment-related questions in an evidence-based guide-
Metabolism,
Health Service. They produced a consensus document line. However, in 2013, before the report was completed
Department of
Medicine, University of that resulted in 6 principal recommendations, includ- and published,5 the NHLBI transferred responsibility for
Virginia School of ing use of a stepped-care approach for antihyperten- sponsorship of CVD prevention CPGs to the American
Medicine, sive therapy in virtually all adults with a diastolic BP (DBP)
Heart Association (AHA) and American College of Cardi-
Charlottesville.
of 105 mm Hg or greater. An individualized approach to ology (ACC).6 In 2014, the ACC and AHA, in partnership
treatment, considering other cardiovascular disease with 9 other professional societies (representing the ma-
(CVD) risk factors, was recommended for patients with jor professional organizations who agreed to provide rep-
Editorial resentatives), appointed a writing com-
mittee to develop a new BP CPG. The
“Successful implementation of the new writing committee’s recently published
Related article
guideline will likely result in a substantially guideline7,8 was developed over a 3-year
period by a multidisciplinary team, includ-
lower average BP in the general population ing 2 lay participants, all of whom had no
with a commensurate reduction in relationships with industry involving di-
morbidity and mortality from CVD…” agnosis or treatment of BP. Although sev-
eral BP CPGs have been published since
a DBP of 90 to 104 mm Hg but no specific action was 2003, the 2017 guideline is the most comprehensive US
necessary unless the DBP was 105 mm Hg or greater.3 adult BP CPG since the JNC 7 report.
There were no recommendations for classification or The new guideline7,8 includes 15 sections and 106
treatment based on systolic BP (SBP) because “if both recommendations addressing different aspects of care.
systolic and diastolic pressures were used as guide- Each recommendation is accompanied by a Class of
lines, the recommendations would be far too complex.”2 Recommendation and Level of Evidence based on pre-
The 1977 report was followed by a series of NHLBI- defined ACC/AHA Task Force methods. An indepen-
sponsored BP CPGs, culminating in the 2003 publica- dent external review committee conducted systematic
tion of the Seventh Report of the Joint National Commit- reviews and meta-analyses for 3 questions of special
tee on Prevention, Detection, Evaluation, and Treatment interest to the writing committee. The guideline was
ofHighBloodPressure(JNC7).4 Progressively,theseCPGs then opened for commentary to 14 representatives
became more comprehensive and benefited from an ex- from the 11 professional societies who sponsored it and
Corresponding
panding array of observational and clinical trial evi- 38 external content reviewers. The writing committee
Author: Paul K.
Whelton, MB, MD, MSc, dence. The emphasis shifted to SBP, although cutpoints responded to each of the approximately 1000 com-
Department of for DBP were still included. The 2003 JNC 7 report used ments generated as a result of this review process.
Epidemiology, Tulane a BP classification system in which adults with an aver- So what is the same and what is different in the new
University School of
Public Health and age SBP of 140 mm Hg or greater or DBP of 90 mm Hg or guideline? The 2017 guideline retains a focus on SBP but
Tropical Medicine, greater were designated as having hypertension and in addition continues to provide recommendations based
1440 Canal St, those with an SBP of 130 to 139 mm Hg or DBP of 80 to on DBP. This recognizes the fact that recent studies, es-
Room 2018,
89 mm Hg as having prehypertension. pecially randomized clinical trials, have used SBP cut-
New Orleans, LA
70112 (pkwhelton Attention was devoted to proper methods for points but there is a strong body of preexisting evidence
@gmail.com). BP measurement. Lifestyle modification was recom- from older studies that relied on DBP. In general, the levels

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Opinion Viewpoint

of evidence supporting SBP recommendations are stronger than cor- In contrast to JNC 7,4 the new guideline7,8 identifies the overall
responding recommendations for DBP. The new guideline uses a dif- goal of treatment as a reduction in BP to a SBP target of less than
ferent system for classification of BP compared with JNC 7. Adults with 130 mm Hg and a DBP target of less than 80 mm Hg in most adults
an average SBP of 130 to 139 mm Hg or DBP of 80 to 89 mm Hg are and concludes that most adults with BP sufficiently elevated to
categorized as having stage 1 hypertension (included the prehyper- warrant drug therapy should be treated initially with 2 agents, es-
tension category in JNC 7). Adults in this BP range have about a 2-fold pecially those who are black or have stage 2 hypertension (average
increase in CVD risk compared with their counterparts with a normal SBP ⱖ 140 mm Hg or average DBP ⱖ 90 mm Hg). When initiation
BP (SBP < 120 mm Hg and DBP < 80 mm Hg) and recent random- of pharmacological therapy with a single medication is appropri-
ized clinical trials, in select populations, have shown benefit in achiev- ate, the guideline suggests that primary consideration be given to
ing an SBP of less than 130 mm Hg. The change in classification is ex- comorbid conditions for which specific classes of BP-lowering
pected to result in a substantial increase in prevalence of hypertension medication are indicated. If there are no compelling indications for
(about 14% higher than estimates based on JNC 7). choice of a particular drug class, the guideline suggests a diuretic,
In contrast to JNC 7,4 the new guideline7,8 recommends esti- angiotensin-converting enzyme inhibitor, angiotensin receptor
mation of underlying atherosclerotic CVD (ASCVD) risk and use of blocker, or calcium channel blocker as acceptable first-step agents
this information to guide drug treatment decisions. Nonpharmaco- but identifies thiazide diuretics (especially chlorthalidone) and cal-
logical interventions are recommended as the treatment of choice cium channel blockers as good options for monotherapy.
for adults newly classified as having stage 1 hypertension but oth- In addition to careful BP measurement, the new guideline high-
erwise at low risk for ASCVD. Antihypertensive drug therapy, in ad- lights the increasingly important role of out-of-office BP readings for
dition to nonpharmacological therapy, is recommended for adults confirming hypertension and recognizing white-coat and masked
with stage 1 hypertension who are considered to be at high risk for hypertension. It also emphasizes contemporary strategies to im-
ASCVD because they have already had a CVD complication or have prove BP control, including ways to successfully implement and sus-
a combination of CVD risk factors that result in a high calculated risk. tain nonpharmacological interventions, improve medication adher-
Although estimation of ASCVD risk is recommended for all adults with ence, use a structured team-based approach to care, and take
hypertension, those with diabetes and chronic kidney disease are advantage of health information technology.
accepted as being at high risk and antihypertensive drug therapy is Since publication of the landmark 1977 JNC report,2 there has
recommended when their average SBP is 130 mm Hg or greater or been progressive improvement in awareness, treatment, and con-
their average DBP is 80 mm Hg or greater. trol of high BP.10 Application of the recommendations in the 2017
Similar to JNC 7,4 the 2017 guideline7,8 recommends antihyper- guideline will hopefully increase recognition of those at risk from
tensive drug therapy for all adults, irrespective of ASCVD risk, with hypertension, allow for identification of adults most likely to ben-
an average SBP of 140 mm Hg or greater or DBP of 90 mm Hg or efit from drug therapy by incorporating global ASCVD risk assess-
greater. It also recommends use of BP-lowering drugs for older adults ment in treatment decisions, and should result in more intensive
(ⱖ65 years) with an average SBP of 130 mm Hg or greater. An analy- BP-lowering therapy in those being treated. Successful implemen-
sis based on the 2011-2014 National Health and Nutrition Examina- tation of the new guideline will likely result in a substantially lower
tion Survey,9 estimates that application of the new guideline rec- average BP in the general population with a commensurate reduc-
ommendations would result in antihypertensive drug therapy for an tion in morbidity and mortality from CVD, in line with the mission
additional 1.9% of US adults (4.2 million) compared with JNC 7. of the organizations that sponsored this guideline.

ARTICLE INFORMATION 4. Chobanian AV, Bakris GL, Black HR, et al; of Cardiology/American Heart Association Task
Published Online: November 20, 2017. National Heart, Lung, and Blood Institute Joint Force on Clinical Practice Guidelines [published
doi:10.1001/jama.2017.18209 National Committee on Prevention, Detection, online November 13, 2017]. Hypertension.
Evaluation, and Treatment of High Blood Pressure; doi:10.1161/HYP.0000000000000065
Conflict of Interest Disclosures: The authors have National High Blood Pressure Education Program
completed and submitted the ICMJE Form for 8. Whelton PK, Carey RM, Aronow WS, et al. 2017
Coordinating Committee. The Seventh Report of ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/
Disclosure of Potential Conflicts of Interest. the Joint National Committee on Prevention,
Dr Whelton was chair of the 2017 American College NMA/PCNA guideline for the prevention, detection,
Detection, Evaluation, and Treatment of High Blood evaluation, and management of high blood
of Cardiology/American Heart Association blood Pressure: the JNC 7 report. JAMA. 2003;289(19):
pressure clinical practice guideline. No other pressure in adults: a report of the American College
2560-2572. of Cardiology/American Heart Association Task
disclosures were reported.
5. James PA, Oparil S, Carter BL, et al. 2014 Force on Clinical Practice Guidelines [published
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