IN PRACTICE

women's health

A Primer on the New Guideline for the

Prevention, Detection, Evaluation, and
Management of Hypertension
Carina Katigbak & Holly B. Fontenot

ABSTRACT: Hypertension is a leading risk factor for the development of cardiovascular disease. In 2017, the American College of
Cardiology and the American Heart Association published a new guideline for the prevention, detection, evaluation, and management
of hypertension. The guideline adjusts the clinical parameters for diagnosis and management of hypertension. In this article we
summarize the updates and provide some background on these changes as they relate to nursing practice implications, with specific
implications for women’s health.
doi: 10.1016/j.nwh.2018.06.003 Accepted May 2018
KEYWORDS: blood pressure, cardiovascular disease, guideline, hypertension, pre-hypertension, Stage 1 hypertension, Stage 2
hypertension, stroke
Photo ª geckophotos / iStockphoto.com

U
ncontrolled hypertension is a critical modifiable risk
factor in the development and progression of a
number of conditions, including cerebrovascular
disease and cardiovascular disease. Approximately 75 million
Americans, or one third of the U.S. adult population, have high
blood pressure (Centers for Disease Control and Prevention,
2016), and only slightly more than half (54%) of them have the
condition under control (Yoon, Fryar, & Carroll, 2015),
increasing their risk for cardiovascular disease and stroke. For
women, cardiovascular disease is the leading cause of death,
accounting for one out of every three female deaths (Garcia,
Mulvagh, Merz, Buring, & Manson, 2016). Epidemiologic
evidence shows that although hypertension prevalence is
lower among adult women compared with men from ages 18

346 ª 2018 AWHONN; doi: 10.1016/j.nwh.2018.06.003 nwhjournal.org

 Katigbak & Fontenot

CLINICAL IMPLICATIONS
n Uncontrolled hypertension is a critical modifiable risk factor in the
development and progression of cerebrovascular disease and
cardiovascular disease.
n The American College of Cardiology and the American Heart
Association have released a new guideline for the prevention,
detection, evaluation, and management of hypertension.
n The new guideline emphasizes early detection of high blood
pressure and adoption of nonpharmacologic lifestyle
interventions such as losing weight, increasing physical activity,
moderating alcohol consumption, and quitting smoking.
n Nurses play a critical role in disease prevention by assessing for
risk and providing education and counseling.
n Nurses are ideally positioned to screen for high blood pressure
and to initiate therapeutic options at any point in a woman’s life
span.

to 59 years, this trend reverses itself for older adults ($60

years old) such that high blood pressure is more prevalent
among women than men in this age group (Yoon, Fryar, &
Carroll, 2015).
In 2017, the American College of Cardiology (ACC) and the
American Heart Association (AHA) published new a guideline
for the prevention, detection, evaluation, and treatment of
hypertension—the first comprehensive update to the blood
pressure guideline since the 2003 Joint National Committee
on the Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure (JNC7). In this article we review the
updated ACC/AHA Hypertension Guideline, summarizing key
changes and their implications for nursing practice, and
women’s health.
History and Overview of Hypertension
Treatment Guidelines
In response to the growing burden of cardiovascular dis-
ease and its known links to hypertension, the National
Heart, Lung, and Blood Institute began producing a series
of hypertension guidelines in 1977. These guidelines
evolved over time to become, in 2003, the JNC7. Its most
recent iteration, JNC8, was published in 2014 and
emphasized greater control of systolic blood pressure and
diastolic blood pressure, along with age- and comorbidity-
specific treatment cutoffs (James et al., 2014). In 2014,
the ACC and the AHA collaborated with nine other profes-
sional associations to develop the new hypertension clinical
Photo ª LordHenriVoton / iStockphoto.com
Approximately 75 million Americans
have high blood pressure, and only
slightly more than half of them have
the condition under control
(meta-analyses were performed where possible) to deter-
mine the following: (a) whether self-directed blood pressure
monitoring/ambulatory blood pressure monitoring is more
effective than office-based blood pressure monitoring by a
health care provider in achieving better blood pressure
control and preventing adverse outcomes for those with
hypertension risks, (b) the optimal blood pressure target for
people being treated with antihypertensive medication, (c)
whether various antihypertensive medications vary in terms
of their comparative harms and benefits, and (d) whether
initiating antihypertensive medication treatment with one
drug is more beneficial than starting with two drugs.
Although it is beyond the scope of this clinical summary to
discuss the methodologies used in conducting the review of
the evidence, a thorough description was given by P. K.
Whelton et al. (2018).
The new guideline recommends an aggressive approach to
blood pressure management and advocates for a risk-based
approach to prevention and treatment. It emphasizes the
importance of accurate blood pressure measurement, lowers

practice guideline (P. K. Whelton et al., 2018). A team of
multidisciplinary experts oversaw four systematic reviews
Carina Katigbak, PhD, RN, ANP-BC, is an assistant professor, William F.
Connell School of Nursing at Boston College in Chestnut Hill, MA. Holly B.
Fontenot, PhD, RN, WHNP-BC, is an associate professor, William F. Connell
School of Nursing at Boston College in Chestnut Hill, MA. The authors report
no conflicts of interest or relevant financial relationships. Address
correspondence to: katigbac@bc.edu.
the blood pressure threshold for defining hypertension, and
recategorizes blood pressure into normal, elevated, Stage 1
hypertension, and Stage 2 hypertension. Shared decision
making between providers and patients and team-based care
are further emphasized in terms of establishing an evidence-
based plan of care that incorporates self-management, timely
follow-up, home-based blood pressure monitoring, and greater
attention to lifestyle interventions to prevent disease
progression.

August 2018 Nursing for Women’s Health 347

New Hypertension Guideline
TABLE 1 OLD AND NEW BLOOD PRESSURE CATEGORIES
Blood Pressure JNC7
<120/80 mm Hg Normal blood pressure
120–129/<80 mm Hg Prehypertension
130–139/80–89 mm Hg Prehypertension
‡140/‡90 mm Hg Stage 1 hypertension
‡160/‡100 Stage 2 hypertension
Blood Pressure Classification
The most impactful change in the new guideline is the new
definition and reclassification of stages of high blood pres-
sure. A normal blood pressure, as defined by both the JNC7
and the new guideline, remains less than 120/80 mm Hg.
Prehypertension is reclassified into two new categories:
elevated blood pressure (120–129/<80 mm Hg) and Stage 1
hypertension (130–139 mm Hg systolic pressure or 80–
89 mm Hg diastolic pressure), effectively lowering the
threshold by which clinicians diagnose hypertension to
130 mm Hg or greater systolic blood pressure and 80 mm Hg
or greater diastolic blood pressure. Stage 2 hypertension is
classified as 140/90 mm Hg or greater (see Table 1).
The rationale for these new definitions is based on evi-
dence from several meta-analyses in which researchers re-
ported a gradient in cardiovascular disease risk that rises as
blood pressure increases from normal to elevated to hyper-
tension (Guo, Zhang, Guo, et al., 2013; Guo, Zhang, Zheng,
et al., 2013; Huang et al., 2014; Shen, Ma, Xiang, & Wang,
2013), in addition to observational data (Lewington et al.,
2002) and randomized trials of lifestyle interventions to lower
blood pressure (S. P. Whelton, Chin, Xin, & He, 2002). As
systolic blood pressure exceeds 120 mm Hg, cardiovascular
disease risk increases, and this risk doubles with systolic
blood pressure of 130 mm Hg or greater.
This change to the definition of hypertension substantially
increases the proportion of U.S. adults with hypertension from
one third to one half of the U.S. adult population (Muntner
et al., 2018). However, this growth in newly diagnosed hy-
pertension cases translates to a small increase (1.9%) in the
number of U.S. adults for whom antihypertensive medications
would be prescribed. It is projected that most people newly
diagnosed with hypertension according to the updated criteria
would fall into the Stage 1 hypertension category, for which
nonpharmacologic lifestyle interventions and counseling only
are recommended as treatment. An accurate diagnosis
should be based on an average of two or more blood pressure
readings obtained on two or more occasions to estimate an
individual’s blood pressure category.
Accurate Blood Pressure Measurement
Accurate blood pressure measurement is critical to properly
categorize blood pressure and identify risk of hypertension.
348 Volume 22 Issue 4
ACC/AHA 2017 Guideline
Normal blood pressure
Elevated blood pressure
Stage 1 hypertension
Stage 2 hypertension
Stage 2 hypertension
The new guideline provides seven tips for health care pro-
viders to accurately measure blood pressure. Improper patient
preparation (e.g., not emptying bladder, caffeine consumption
before measurement), improper patient positioning, and
inappropriate cuff size/cuff placement all can lead to inac-
curate blood pressure measurements with inaccuracies
ranging from 5 to 50 mm Hg (Kallioinen, Hill, Horswill, Ward, &
Watson, 2017; Ringrose, Wong, Yousefi, & Padwal, 2017;
Ozone et al., 2016).
The new guideline recommends out-of-office/home-based
blood pressure measurement and self-monitoring to confirm
hypertension diagnosis when an elevated blood pressure has
been detected in health care settings and to guide titration of
blood pressure–lowering medication; or alternately, to screen
for white coat hypertension or masked hypertension before
providing a diagnosis of hypertension. Providers must educate
and work with patients on proper at-home blood pressure
measurement techniques and documentation practices.
Numerous tools and resources are available for providers and
patients to use toward achieving blood pressure goals, such
as “Target:BP” (2016), a recent collaboration between the
AHA and American Medical Association that provides free
online resources for clinicians and patient tools such as self-
care tips and checklists for at-home blood pressure moni-
toring to promote engaged decision making (see Box 1).
Risk-Based Treatment Approach
The new guideline includes a risk-based approach to treat-
ment. The authors recommend that health care providers
consider an individual’s risk for experiencing events related to
atherosclerotic cardiovascular disease—defined as family
history of death related to coronary heart disease, nonfatal
myocardial infarction, or fatal/nonfatal stroke—when deciding
whether to prescribe nonpharmacologic therapies, medica-
tions, or both (see Figure 1). The risk estimation developed by
the ACC/AHA estimates the 10-year risk of atherosclerotic
cardiovascular disease, with low risk defined as less than
10% and high risk defined as greater than 10%. Clinicians can
use online risk estimators, such as that provided by the ACC
(see http://tools.acc.org/ASCVD-Risk-Estimator-Plus/
#!/calculate/estimate). Information that is used to estimate
this risk includes age, sex, race, cholesterol (total and high-
density lipoproteins), blood pressure, antihypertensive
doi: 10.1016/j.nwh.2018.06.003
 Katigbak & Fontenot

FIGURE 1 BLOOD PRESSURE THRESHOLDS AND RECOMMENDATIONS FOR TREATMENT AND

FOLLOW-UP

Note. From “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,” by P. K. Whelton, R. M.
Carey, W. S. Aronow, D. E. Casey Jr., K. J. Collins, C. Dennison Himmelfarb, . J. T. Wright Jr., 2018, Hypertension, 71, 1269–1324, doi:10.1161/
HYP.0000000000000066. ª 2017 American Heart Association, Inc. Reprinted with permission. ASCVD ¼ atherosclerotic cardiovascular disease; BP ¼ blood
pressure; CVD ¼ cardiovascular disease; mo ¼ month; y ¼ year.

medication use, diabetes status, and smoking status (Goff
et al., 2014). Using a risk-based approach focuses treatment
on those who are more likely to have cardiac events, thereby
reducing cardiovascular risk and preventing cardiovascular
events (Carey et al., 2018).
Treatment
Lifestyle Changes
Clinicians are encouraged to work with individuals to assess
and evaluate their cardiovascular risk, accurately classify
their blood pressure, and to make appropriate treatment rec-
ommendations. A combination of lifestyle changes and anti-
hypertensive medications is essential to lowering blood
pressure and decreasing risk of atherosclerotic cardiovascular
disease. The target blood pressure for adults with a confirmed
hypertension diagnosis is less than 130/80 mm Hg. Primary
cardiovascular disease prevention through nonpharmacologic
therapy is recommended for adults at low risk (e.g., those with
elevated blood pressure or Stage 1 hypertension with low
atherosclerotic cardiovascular disease risk [<10% 10-year
risk]), with follow-up within 3 to 6 months of instituting lifestyle

August 2018 Nursing for Women’s Health 349

New Hypertension Guideline

BOX 1 EXAMPLES OF RESOURCES

AVAILABLE FROM “TARGET:BP”
Clinician Resources
 Blood Pressure Positioning Challenge: Resolve
Positioning Issues to Get an Accurate Reading
 Technique Quick Check: Checklist to ensure that blood
pressure readings are accurate
 Collaborative Communication Strategies to Manage
Blood Pressure
Patient Resources
 7-Day Blood Pressure Recording Log (2 times/day—
average)
 How Do I Manage My Medicines?
 Why Should I Limit Sodium?

Note. Resources can be accessed at https://targetbp.

org/tools-downloads.

changes. The treatment algorithm depicted in Figure 1 illustrates

recommendations for treatment and follow-up according to the
various blood pressure classifications.
The guideline emphasizes early detection of high blood
pressure and instituting nonpharmacologic lifestyle interventions
such as losing weight, increasing physical activity, moderating
alcohol consumption, and quitting smoking. Implementing these
lifestyle changes is known to reduce systolic blood pressure by 4
to 5 mm Hg and diastolic blood pressure by 2 to 4 mm Hg
(Cornelissen & Smart, 2013; Neter, Stam, Kok, Grobbee, &
Geleijnse, 2003; Roerecke et al., 2017; S. P. Whelton et al.,
2002; Xin et al., 2001). Dietary changes, however, such as
consuming less sodium, saturated fat, and total fat and more Women with moderately elevated
fruits, vegetables, and whole grains may decrease systolic blood
pressure by as much as 11 mm Hg (Aburto et al., 2013; Appel
blood pressure during pregnancy
et al., 2003; He, Li, & Macgregor, 2013; P. K. Whelton et al., have about twice the odds of
1997). Strategies for applying these interventions includes using developing hypertension later in life
a team-based approach composed of various providers (e.g.,
physicians, nurses, nurse practitioners, registered dietitians,
pharmacists, and social workers), using telemedicine, and lifestyle changes should be implemented, along with antihy-
encouraging use of health information technology for self- pertensive drug therapy using two drugs from different clas-
monitoring and increased engagement in self-care. ses. Prompt initiation of antihypertensive medication using
dual therapy should occur in patients with Stage 2 hyperten-
Pharmacologic Treatment
Photo ª KatarzynaBialasiewicz / iStockphoto.com

sion whose blood pressure is 160/100 mm Hg or greater.

Antihypertensive medication is recommended for adults with
Stage 1 hypertension (systolic blood pressure $130 mm Hg
or diastolic blood pressure $80 mm Hg), no cardiovascular
disease history, and high atherosclerotic cardiovascular dis-
ease risk ($10% 10-year risk). Lifestyle changes are also
recommended, and a repeat blood pressure measurement
should be performed within 1 month. For adults with Stage 2
hypertension (systolic blood pressure $140 mm Hg or dia-
stolic blood pressure $90 mm Hg), no cardiovascular disease
history, and low atherosclerotic cardiovascular disease risk,
Additional recommendations include close monitoring and
upward dose adjustment as necessary to control blood pres-
sure (see Table 2).
General Guidance on Drug Therapy
The following summarizes the broad recommendations for
pharmacologic treatment; comprehensive information related
to specific drugs and special populations can be found in the
article by P. K. Whelton et al. (2018). First-line initial therapy
for Stage 1 hypertension includes the use of thiazide

350 Volume 22 Issue 4 doi: 10.1016/j.nwh.2018.06.003

 Katigbak & Fontenot

TABLE 2 SUMMARY OF TREATMENT RECOMMENDATIONS BY BLOOD PRESSURE CATEGORY

Blood Pressure Category Treatment and Recommendations
Normal Yearly evaluation, promote healthful lifestyle changes to maintain normal BP
 Systolic blood pressure < 120 mm Hg and
 Diastolic blood pressure < 80 mm Hg
Elevated Promote health lifestyle change and re-evaluate in 3–6 months
 Systolic blood pressure 120–129 mm Hg and
 Diastolic blood pressure < 80 mm Hg
Stage 1 hypertension Assess 10-year risk for heart disease and stroke (e.g., ASCVD risk calculator)
 Systolic blood pressure [ 130–139 mm Hg  If ASCVD risk < 10%:
or diastolic blood pressure [ 80–89 mm Hg B Recommend healthful lifestyle changes and re-evaluate in 3–6 months

 If ASCVD risk > 10% with comorbidities:

B Recommend healthful lifestyle changes and one blood pressure–lowering
medication, then reassess in 1 month
B If blood pressure goal is met in 1 month: reassess in 3–6 months
B If blood pressure goal is not met in 1 month: titrate medication, or switch
B Monthly follow-up until blood pressure goal is met
Stage 2 hypertension Recommend healthful lifestyle changes and initiate antihypertensive drug
 Systolic blood pressure ‡ 140 mm Hg or therapy using two drugs from different classes
diastolic blood pressure ‡ 90 mm Hg B If blood pressure goal is met in 1 month: reassess in 3–6 months

B If blood pressure goal is not met in 1 month: titrate medication, or switch

B Monthly follow-up until blood pressure goal is met

 Systolic blood pressure ‡ 160 mm Hg or Promptly treat, monitor, and titrate medications for better blood pressure control.
diastolic blood pressure ‡ 100 mm Hg B Reassess blood pressure, document adherence and response to therapy,

reinforce importance of treatment and adherence, and screen for

orthostatic (or white coat) hypertension.
Note. ASCVD ¼ atherosclerotic cardiovascular disease.

diuretics, calcium channel blockers, angiotensin-converting
enzyme inhibitors, or angiotensin receptor blockers, with a
blood pressure goal of less than 130/80 mm Hg. Dosages
should be titrated accordingly, and additional agents may be
added to the treatment regimen to achieve target blood
pressure. For adults with Stage 2 hypertension, two first-line
drugs from different classes are recommended (separately or
combined as a fixed dose) when the average systolic blood
pressure and diastolic blood pressure are more than
20 mm Hg and more than 10 mm Hg, respectively, greater
than the target blood pressure. Follow-up should occur on a
monthly basis to monitor for treatment response and adher-
ence, and the medication dose should be titrated until blood
pressure control is achieved.
Implications for Women’s Health
Before age 50 years, hypertension prevalence is lower among
women than men, but women’s risk increases with age (Benjamin
et al., 2018). Despite evidence that hypertension prevalence in-
creases among women with age, the new guideline does not
provide sex-based recommendations for treatment targets or
thresholds for initiating drug therapy or recommendations on
selecting medications to lower blood pressure, because no sig-
nificant between-sex differences were identified by the guideline
authors through their review of the literature.
Specific recommendations, however, are provided for
treating hypertension during pregnancy. Women with hyper-
tension who are pregnant or planning to become pregnant
should be transitioned to methyldopa, nifedipine, or labetalol
(P. K. Whelton et al., 2018). Conversely, during preconception
and pregnancy, health care providers should not prescribe
antihypertensive medications from the following drug classes:
angiotensin-converting enzyme inhibitors, angiotensin recep-
tor blockers, or direct renin inhibitors (P. K. Whelton et al.,
2018), which are associated with adverse fetal outcomes;
these medications should be avoided in all women of repro-
ductive age (American College of Obstetricians and
Gynecologists, 2013).
Implications for Nursing Practice
The new guideline presents unique ways for nurses and
advanced practice nurses to become more actively involved in

August 2018 Nursing for Women’s Health 351

New Hypertension Guideline

Association and the Amer-

ican Society for Preventive
Cardiology, others such as
the American Association of
Family Physicians and the
American College of Physi-
cians have declined to
endorse the guideline. There
is controversy around a num-
ber of factors, including the
increased number of people
who would be classified as
hypertensive, the potential
that greater pharmacologic
treatment will be enacted
without considering individual
risk status, potential
increased profits for the
pharmaceutical industry, and
the notion that the new blood
pressure thresholds may
lead to less individualized
care planning for varying de-
grees of hypertension (Bakris
& Sorrentino, 2018; Darrah,
2018).

preventing and treating high blood pressure in women. Nurses Conclusion

play a critical role in disease prevention by assessing for risk
and providing education and counseling, and they are ideally
positioned to screen for blood pressure and to initiate thera-
peutic options at any point in a woman’s life span.
Although hypertension rates increase for women as they
age, it is important for nurses to educate, screen, and treat
blood pressure abnormalities in adolescent and young adult
women as well. According to Zang and Moran (2017),
approximately 7% of U.S. young adults ages 18 to 39 years
have hypertension. Abnormalities in blood pressure have
health implications for contraceptive decision making, pre-
conception counseling, and pregnancy.
Pregnancy in particular can be a window of opportunity
for behavior and lifestyle changes. Nurses can counsel
women about associated health implications of hyperten-
sion on imminent maternal/fetal health and health later in
life. It is important to facilitate and support lifestyle in-
terventions and referrals for exercise and/or nutrition
counseling for all young women. Women need to be aware
that if they have moderately elevated blood pressure during
With the first comprehensive update to hypertension man-
agement guidance in more than 10 years, authors of a new
ACC/AHA guideline recommend an aggressive approach to
preventing and managing hypertension. The new, lower
threshold that defines hypertension increases the number of
U.S. adults who will be classified as having hypertension, and
the guideline authors emphasize the importance of non-
pharmacologic lifestyle interventions to prevent hypertension
disease progression. This new guidance promotes a holistic
approach to illness management that nurses are well poised
to undertake. In doing so, there is great potential to address
the long-standing public health issue of cardiovascular dis-
ease and to improve outcomes for women with hypertension
across various stages of the life span. NWH
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Photo ª kali9 / iStockphoto.com

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