JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 73, NO.

23, 2019

ª 2019 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

JACC GUIDELINE COMPARISON

ACC/AHA Versus ESC/ESH on

Hypertension Guidelines
JACC Guideline Comparison

George Bakris, MD,a Waleed Ali, MD,a Gianfranco Parati, MDb

ABSTRACT

This study compares the recommendations of the most recent American College of Cardiology (ACC)/American Heart
Association (AHA) and European Society of Cardiology (ESC)/European Society of Hypertension (ESH) blood pressure
guidelines. Both guidelines represent updates of previous guidelines and reinforce previous concepts of prevention
regarding elevated blood pressure. Specifically, a low-sodium diet, exercise, body weight reduction, low to moderate
alcohol intake, and adequate potassium intake are emphasized. Overall, both guidelines agree on the proper method of
blood pressure measurement, the use of home blood pressure and ambulatory monitoring, and restricted use of beta-
blockers as first-line therapy. The major disagreements are with the level of blood pressure defining hypertension,
flexibility in identifying blood pressure targets for treatment, and the use of initial combination therapy. Although initial
single-pill combination therapy is strongly recommended in both guidelines, the ESC/ESH guideline recommends it as
initial therapy in patients at $140/90 mm Hg. The ACC/AHA guideline recommends its use in patients >20/10 mm Hg
above blood pressure goal. Thus, the only real disagreement is that the ACC/AHA guidelines maintain that all people with
blood pressure >130/80 mm Hg have hypertension, and blood pressure should be lowered to <130/80 mm Hg in all. In
contrast, the ESC/ESH guidelines state that hypertension is defined as >140/90 mm Hg, with the goal being a
level <140/90 mm Hg for all targeting to <130/80 mm Hg only in those at high cardiovascular risk, but always
considering individual tolerability of the proposed goal. (J Am Coll Cardiol 2019;73:3018–26)
© 2019 by the American College of Cardiology Foundation.

T he 2017 American College of Cardiology

(ACC)/American Heart Association
guidelines for the prevention, detection,
evaluation, and management of high blood pressure
(AHA)
Before discussing practical implications
implementation of the guidelines, one is reminded
that one definition of a guideline is “a cord or rope to
aid a passer over a difficult point or to permit
and

(BP) in adults and the 2018 European Society of Car-
diology (ESC)/European Society of Hypertension
(ESH) guidelines for management of BP represent
the most recent guidance regarding assessment,
measurement, and approach to treat hypertension
(1,2).
retracing a course,” which ensures that climbers stay
on the safest path while ascending a mountain (3).
Given this definition, written guidelines produced by
experts and those who review them before publica-
tion are recommendations in each field by knowl-
edgeable people in the field, not edicts or laws. Put

Listen to this manuscript’s

audio summary by
Editor-in-Chief
Dr. Valentin Fuster on
JACC.org.
From the aDepartment of Medicine, AHA Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Meta-
bolism, University of Chicago Medicine, Chicago, Illinois; and the bDepartment of Medicine and Surgery, University of Milano-
Bicocca and Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, Milan, Italy. Dr.
Bakris is a consultant for Merck, Vascular Dynamics, Bayer, and Novo Nordisk; is a member of the steering committees of
CREDENCE (Janssen) and CALM-2 (Vascular Dynamics); and is principal investigator of the FIDELIO trial (Bayer). Dr. Parati has
received honoraria for lectures from Pfizer, Sanofi, and Omron HealthCare. Dr. Ali has reported that he has no relationships
relevant to the contents of this paper to disclose.

Manuscript received March 4, 2019; accepted March 26, 2019.

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2019.03.507

JACC VOL. 73, NO. 23, 2019
JUNE 18, 2019:3018–26
HIGHLIGHTS

Blood pressure guidelines are updated as
new data from clinical trials emerge.

The 2018 ACC/AHA and ESC/ESH guide-
lines interpreted similar data with a
fundamental difference of 2 different
blood pressure goals: <130/80 mm Hg
for ACC/AHA and <140/90 mm Hg for
ESC/ESH.

Other differences include the approach to
assess risk and goals in older people at
130/70 to 139/79 mm Hg for ESC/ESH
but <130/80 mm Hg for ACC/AHA.

Guideline implementation should include
patient participation and cooperation.
This is a large part of the ESC/ESH
guideline and mentioned but not
emphasized in the ACC/AHA guideline.
simply, guidelines should facilitate decision making
by health professionals in their daily practice without
imposing any choice, leaving the final decisions
concerning individual patients to the professionals,
in consultation with their patients and caregivers as
appropriate.
In the United States, BP guidelines were initiated
in 1977 with the first Joint National Committee report
(4). European guidelines appeared later, but the
intent of both was to inform practicing physicians
about available data regarding BP in the context of
cardiovascular (CV) risk and how to manage both BP
and CV risk. Since the late 1980s, an updated guide-
line from each group has been published every 5 to 6
years, incorporating the growing spectrum of data
regarding BP management. In 2013, the National
Heart, Lung, and Blood Institute of the National In-
stitutes of Health relinquished its leadership role in
producing Joint National Committee BP reports and
invited the AHA to assume guideline-writing re-
sponsibilities. The 2017 ACC/AHA report on BP man-
agement is the first to be generated by this group.
Both the ACC/AHA and ESC/ESH guidelines
address a variety of topics related to the diagnosis
and treatment of hypertension. In this regard, there is
overwhelming agreement on more than 90% of the
concepts between guidelines and general agreement
on the approach to reduce BP. The significant simi-
larities of both guidelines are summarized in Table 1.
One of the major issues both guidelines emphasize
is the use of lifestyle modifications as part of all
antihypertensive education and initial treatment. The
Bakris et al. 3019
Hypertension Guideline Comparison
current ACC/AHA BP guideline has expanded ABBREVIATIONS
AND ACRONYMS
the lifestyle modification table initially pub-
lished in the Joint National Committee 7
ACC = American College of
report (1); Table 2 places lifestyle modifica- Cardiology
tions as the cornerstone of all CV risk reduc-
AHA = American Heart
tion and BP prevention and treatment Association
regardless of CV risk. This table can be given ASCVD = atherosclerotic
to all patients, with a short explanation by a cardiovascular disease
nurse, a nutritionist, or another health care BP = blood pressure
professional as to the impact of each inter- CV = cardiovascular
vention on BP. Unfortunately, many physi- ESC = European Society of
cians do not have time to provide patients Cardiology
with lifestyle modification education, and on ESH = European Society of
this issue, we offer an approach later in this Hypertension
paper. SBP = systolic blood pressure
The approach to BP measurement is consistent
between guidelines. This is the methodology used to
assess BP in a patient; if this is flawed, then all de-
cisions about therapy will be flawed. The proper
approach is summarized in Table 3. It is a similar
methodology used in ACCORD (Action to Control
Cardiovascular Risk in Diabetes) and SPRINT (Systolic
Blood Pressure Intervention Trial), in which auto-
mated office BP measurements were used with proper
cuff size assessed before measurement. Although
most measurements were unattended in SPRINT,
many were attended. The difference in BP between
attended and unattended was thought to be as much
as 7 mm Hg (5), but this was recently examined, and
no significant BP difference was seen between these
approaches (6). This emphasizes that both guidelines
stress the importance of out-of-office BP monitoring
for better hypertension management, including the
possibility to detect and manage white-coat hyper-
tension and masked hypertension. In this context,
the ACC/AHA BP guidelines propose different out-of-
office BP thresholds (corresponding to a lower office
BP threshold), a suggestion, however, that needs
further support by outcome studies.
Although there are some differences regarding the
level to which BP should be reduced in specific sub-
sets of patients with hypertension (i.e., older per-
sons), there are 2 distinctive and vital differences
between guidelines. The first important difference
concerns the risk stratification process for patients
with hypertension. The ACC/AHA guidelines empha-
size individualized CV risk assessment using the
atherosclerotic CV disease (ASCVD) risk calculator
available for Android and iPhone before defining
treatment goals and options.
The ASCVD risk calculator uses data from the
pooled cohort equation to generate individualized
data on CV risk for patients so that patients under-
stand the risk and the benefits of achieving BP goals
3020 Bakris et al. JACC VOL. 73, NO. 23, 2019

Hypertension Guideline Comparison JUNE 18, 2019:3018–26

T A B L E 1 Comparison of American and European Guidelines

ACC/AHA BP 2017 ESC/ESH BP 2018

Similarities

More emphasis on home BP monitoring and patient
empowerment

Single-pill combination in those 20/10 mm Hg above goal

More attention to detail of BP measurement

Focus on improving adherence

Restriction of beta-blockers to patients with comorbidities
or compelling indications

BP telemonitoring and digital health solutions recom-
mended during follow-up (strong support)
Differences

Emphasis on absolute CV risk computed through ASCVD risk
calculator with >10% 10-year risk more aggressive

Focus on prevention of hypertension

Detailed guidance for ethnic/racial groups (i.e., black and
Hispanic)

New definition of hypertension >130/80 mm Hg for
everyone, with threshold and target the same, regardless of
age

No discussion of isolated systolic hypertension

Concise mention of organ damage assessment

Similar SBP targets for all patients

No mention of environmental and altitude effects on BP

Wider use of home BP monitoring to confirm diagnosis

Initial single-pill combination as initial therapy

More attention to detail of BP measurement

Detection of poor adherence

Restriction of beta-blockers to patients with comorbidities or
compelling indications

BP telemonitoring and digital health solutions recommended during
follow-up (mild support)

Emphasis on absolute CV risk computed using SCORE system coupled
with risk modifiers and assessment of HMOD, with >10% 10-year CV
risk more aggressive

No specific attention to prevention as BP approaches 130/80 mm Hg

Much less attention to specific ethnic/racial groups

Retained definition of hypertension >140/90 mm Hg and encour-
aged patient discussion and education to achieve <130/80 mm Hg in
those who require it by the evidence (<140/90 mm Hg in older
persons)

Limits on BP reduction, not <120/70 mm Hg

Detailed discussion of isolated systolic hypertension

Detailed description of HMOD

Personalized approach to definition of SBP targets

Environmental and altitude effects on BP mentioned

ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; ASCVD ¼ atherosclerotic cardiovascular disease; BP ¼ blood pressure; CV ¼ cardiovascular;
ESC ¼ European Society of Cardiology; ESH ¼ European Society of Hypertension; HMOD ¼ hypertension-mediated organ damage; SBP ¼ systolic blood pressure;
SCORE ¼ Systematic Coronary Risk Evaluation.

T A B L E 2 Best Proven Nonpharmacologic Interventions for Prevention and Treatment of Hypertension

Approximate Impact on SBP

Nonpharmacologic Intervention Dose Hypertension Normotension

Physical activity
Aerobic
90–150 min/week 5/8 mm Hg 2/4 mm Hg

65%–75% heart rate reserve
Dynamic resistance
90–150 min/week 4 mm Hg 2 mm Hg

50%–80% 1 repetition maximum

6 exercises, 3 sets/exercise, 10 repetitions/set
Isometric resistance
4  2 min (hand grip), 1 min rest between exercises, 30%–40% 5 mm Hg 4 mm Hg
maximum voluntary contraction, 3 sessions/week,

8–10 weeks
Healthy diet
DASH dietary pattern Diet rich in fruits, vegetables, whole grains, and low-fat dairy products 11 mm Hg 3 mm Hg
with reduced content of saturated and total fat
Weight loss
Weight/body fat Ideal body weight is best goal but $1 kg reduction in body weight for 5 mm Hg 2/3 mm Hg
most adults who are overweight
Reduced intake of dietary [Naþ]
Dietary sodium <1,500 mg/day is optimal goal but $1,000 mg/day reduction in most 5/6 mm Hg 2/3 mm Hg
adults
Enhanced intake of dietary [Kþ]
Dietary potassium 3,500–5,000 mg/day, preferably by consumption of a diet rich in 4/5 mm Hg 2 mm Hg
potassium
Moderation in alcohol intake
Alcohol consumption In individuals who drink alcohol, reduce alcohol to 4 mm Hg 3 mm Hg

Men: <2 drinks/day

Women: <1 drink/day

DASH ¼ Dietary Approaches to Stop Hypertension; SBP ¼ systolic blood pressure.

JACC VOL. 73, NO. 23, 2019
JUNE 18, 2019:3018–26
T A B L E 3 Key Steps for Proper Blood Pressure Measurement
1. Properly prepare the patient (e.g., quiet area, seated in chair, back
firmly supported and feet flat on the ground, arm supported with
appropriate size cuff placed). Wait 5 min, then check BP 3 times
1 min apart. Eliminate the first reading and average the next 2
readings.
2. Provide BP readings to patient.
3. Selection of proper cuff size as a function of arm circumference:
Arm circumference (cm)
22–26
27–34
35–44
45–52
BP ¼ blood pressure.
(7). This risk assessment approach has also been
adopted by the American Diabetes Association and
other groups (8). The U.S. guidelines using the ASCVD
risk calculator showcase recommendations based on a
>10%, 10-year risk. In contrast, the ESC/ESH guide-
lines recommend the use of the Systematic Coronary
Risk Evaluation system, based on large, representa-
tive European cohort datasets, which estimates the
10-year risk for a first fatal atherosclerotic event in
the context of age, sex, smoking habit, total choles-
terol level, and systolic BP (SBP). The Systematic
Coronary Risk Evaluation system has recently been
adapted for patients older than 65 years (9).
A detailed discussion of factors influencing CV risk
factors in patients with hypertension is presented in
the ESC/ESH guidelines. These guidelines recom-
mend that risk estimation be complemented by an
assessment of hypertension-mediated organ damage,
which can increase CV risk to a higher level, even
when asymptomatic. Indeed, the ESC/ESH guidelines
devote considerable space to the assessment of
different types of hypertension-mediated
damage and their impact on global CV risk level. The
impact of general as well as specific modifiers of CV
risk for patients with hypertension is also acknowl-
edged (2).
A second important difference between the U.S.
and European BP guidelines is the level that defines
hypertension requiring treatment: 130/80 mm Hg in
the United States and 140/90 mm Hg in Europe
(Table 1). In fact, in patients with “high-normal BP”
(130/85 to 139/89 mm Hg), the ESC/ESH guidelines
recommend lifestyle changes, with drug treatment
considered only when their CV risk is very high
because of established CV disease, especially coro-
nary artery disease (2). Additionally, one ramification
of the new definition in the ACC/AHA guidelines is
the identification of about 14% more U.S. adults as
Bakris et al. 3021
Hypertension Guideline Comparison
having primary hypertension. This translates into
greater insurance costs for patients and increased
unreimbursed physician time for visits. The ACC/AHA
guideline authors argue that most patients newly
diagnosed with hypertension using the new criteria
can be managed with lifestyle modification. Although
we agree, most physicians fail to appropriately
Usual cuff size counsel patients on lifestyle modification, because of
Small adult time constraints related to workload and no
Adult
compensation for extra time. Moreover, insurance
Large adult
companies will not hesitate to increase the rates of
Adult thigh
these newly diagnosed patients irrespective of
treatment.
The risk of extrapolation to lower levels recom-
mended in the guidelines, therefore, could result in
overtreatment. Data from trials of lower risk subjects,
such as HOPE3 (Heart Outcomes Prevention Evalua-
tion), demonstrated no benefit of BP lowering if
initial BP is <140/90 mm Hg in subjects with low to
intermediate CV risk (10). Additionally, many studies
of patients with diabetes demonstrate increased CV
risk if BP is lowered to <120/80 mm Hg (11–13). A
recently published post hoc analysis of the EXAMINE
(Examination of Cardiovascular Outcomes With
Alogliptin Versus Standard of Care) trial demon-
strated that in patients with type 2 diabetes
mellitus and recent acute coronary syndromes, BP
<130/80 mm Hg was associated with worse CV out-
comes (14). A recent meta-analysis focusing on the
effects on CV outcomes of BP-lowering treatment in
subjects with ESC/ESH-defined “normal” or “high-
normal” BP in the absence of baseline antihyperten-
sive drugs and free from recent myocardial infarction,
left ventricular dysfunction, and heart failure showed
that when initial SBP is #130 mm Hg or between 130
and 139 mm Hg, BP-lowering treatment appears to
reduce stroke risk in those with very high CV risk due
organ to symptomatic CV disease (11).
The benefit/harm ratio for overtreatment of BP was
shown in recent analyses demonstrating that only
those with >18% 10-year CV risk derived more benefit
than harm from aggressive BP-lowering treatment
(15,16). A more evidence-based statement for the
guideline would have been to set the lower BP target
for treatment at >15% 10-year CV risk, because all
trials had cohorts with >15% CV risk.
One major change in both guidelines in pharma-
cological therapy is restriction of the use of beta-
blockers only to patients with comorbidities or
compelling indications requiring their use. The ESC/
ESH guidelines recommend combining beta-blockers
with any of the other major drug classes when there
are specific clinical indications (e.g., angina, post–
myocardial infarction, heart failure, heart rate
3022 Bakris et al.
Hypertension Guideline Comparison
control). Note that although hypertension outcome
trials using beta-blockers have failed to show a mor-
tality benefit, the agent chosen in these trials (i.e.,
atenolol, a beta-1-selective blocker) requires twice
daily dosing, while trials dosed once daily (17). The
ESC/ESH guidelines acknowledge that beta-blockers
are not a homogeneous class and that vasodilating
beta-blockers have more favorable effects and a bet-
ter side effect profile, although there is no outcome-
based evidence on a possible difference between
classical and vasodilator beta-blockers for hyperten-
sion treatment (2).
An individualized approach for the spectrum of all
patients with hypertension, although not in the pur-
view of general guidelines, can help determine the
best choice for first-line therapy to lower BP in most
people. There are some minor differences between
the ESC/ESH and U.S. BP guidelines. The ESC/ESH
guidelines strongly recommend the use of initial
combination therapy combining a blocker of the
renin-angiotensin system with either a thiazide
diuretic agent or a calcium antagonist in a single pill
(2). This guidance is consistent with the ACC/AHA
guidelines, which also recommend initial combina-
tion therapy. However, the ACC/AHA guidance per-
tains to persons who are 20/10 mm Hg above their BP
targets, so in the United States, all those at
150/90 mm Hg should be prescribed single-pill com-
bination therapy for BP control (Table 1). Both
guidelines provide an algorithm that applies to many
patients in this regard (1). The strong push for an
initial single-pill combination comes from years of
research on medication adherence, which has been
shown to be much better with single-pill combina-
tions, with a higher likelihood of achieving BP goals
with fewer adverse effects (18–20).
Although both guidelines agree on many things,
including the use of home and ambulatory BP moni-
toring, proper measurement of BP, and therapeutic
approaches, they differ in their definitions of hyper-
tension and goals to be achieved (Central Illustration).
Both guidelines agree that in persons at high CV risk,
the goal is <130/80 mm Hg, but the European guide-
lines mandate that everyone achieve a goal of <140/
90 mm Hg initially and then discuss the risks and
benefits of reaching a lower goal, as this approach
should be individualized. The ACC/AHA guideline
authors argue that a focus on calculating the absolute
risk to guide the prescription of pharmacological
therapy has yielded mixed results historically and
that recommending a universal BP goal simplifies
decisions regarding therapy. This assertion is under-
standable. However, the concept of “one size fits all”
for a BP goal, implied with a single value goal, is a
JACC VOL. 73, NO. 23, 2019
JUNE 18, 2019:3018–26
significant problem (21). Although there is a clear
rationale to assess ASCVD risk, there is no clear
rationale to change the BP thresholds previously used
to define hypertension as >140/90 mm Hg other than
to eliminate the term “pre-hypertension” and
mandate more aggressive therapy (2,22). Other
guidelines distinguish BP thresholds used to diagnose
hypertension from those used for treatment targets
(2,22). The primary difference of the ACC/AHA
guideline is that its aim is to meld prevention with
treatment and hence propose a goal formally
accepted as pre-hypertension.
ESC/ESH guidelines generally recommend a target
of <140/90 mm Hg and close to 130/80 mm Hg, while
the indication to achieve lower targets must be indi-
vidualized on the basis of treatment tolerance by
critically addressing both the benefits and the bur-
dens of reaching a lower BP level in each patient to
prevent treatment discontinuation (23). Moreover,
and this is an absolute novelty in the ESC/ESH
guidelines, it is also recommended to focus on BP
ranges to be achieved by treatment, by emphasizing
that SBP should be pushed at least <140 mm Hg and
close to or <130 mm Hg, but not <120 mm Hg. Similar
recommendations are given for most types of patients
with hypertension, including common conditions
such as kidney disease and stroke, with ACC/AHA
guidelines recommending a goal of <130/80 mm Hg
and ESC/ESH guidelines indicating an SBP
target <140 mm Hg and close to 130 mm Hg (1,2).
To further amplify the point of one size not fitting
all, the ACC/AHA BP guideline lowered the BP goal for
older people, suggesting that a 30-year-old and an 80-
year-old should have the same BP goal (i.e., <130/
80 mm Hg). They point to data from SPRINT to sup-
port this assertion. Although this goal is possible for
some older people, it is not for others, as emphasized
by the ESC/ESH guidelines, especially those with poor
vascular compliance and high pulse pressures, which
the guideline ignored because such patients studied
in previous systolic hypertension trials were
excluded from SPRINT, as were people with ortho-
static hypotension (24–26).
Another difference between guidelines is that the
ESC/ESH guideline discusses in detail the goals and
management of isolated systolic hypertension, while
the ACC/AHA guideline has no substantive discussion
of this topic (Table 1). This is a significant problem
among many people older than 70 years. The ESC/
ESH guideline for isolated systolic hypertension was
discussed in the context of 3 randomized prospective
trials in such groups, with the goal being <140 mm Hg
systolic to define CV risk reduction (2,25,27,28).
Additionally, the ESC/ESH guidelines discuss
JACC VOL. 73, NO. 23, 2019 Bakris et al. 3023
JUNE 18, 2019:3018–26 Hypertension Guideline Comparison

C ENTR AL I LL U STRA T I O N Comparison of American and European Society Definitions and

Management of Hypertension

American College European Society

of Cardiology/American of Cardiology/European
Heart Association (ACC/AHA) Society of Hypertension (ESC/ESH)

Level of blood pressure (BP) Systolic and/ Diastolic Systolic and/ Diastolic
(mm Hg) or (mm Hg) (mm Hg) or (mm Hg)

≥ 130 ≥ 80 ≥ 140 ≥ 90

Daytime mean ≥ 130 ≥ 80 ≥ 135 ≥ 85

Nighttime mean ≥ 110 ≥ 65 ≥ 120 ≥ 70

24-hour mean ≥ 125 ≥ 75 ≥ 130 ≥ 80

Home BP mean ≥ 130 ≥ 80 ≥ 135 ≥ 85

BP targets for treatment < 130/80 mm Hg Systolic targets < 140 mm Hg

and close to 130 mm Hg

Initial Combination Therapy Initial single-pill combination Initial single-pill combination

therapy in patients > 20/10 mm Hg therapy in patients ≥ 140/90 mm Hg
above BP goal

Hypertensive requiring > 130/80 mm Hg ≥ 140/90 mm Hg

intervention

Guideline Similarities ACC/AHA ESC/ESH

Importance of home BP • Take BP at home, twice in the morning and twice in the evening,
monitoring in the week before clinic
• Bring the BP machine in annually for validation

Therapy • Restrict beta blockers to patients with comorbidities or other indications

• Initial single pill combination as initial therapy

Follow-up • Detect poor adherence and focus on improvement

• BP telemonitoring and digital health solutions recommended

Bakris, G. et al. J Am Coll Cardiol. 2019;73(23):3018–26.

ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; BP ¼ blood pressure; ESC ¼ European Society of Cardiology; ESH ¼ European Society of
Hypertension.
3024 Bakris et al.
Hypertension Guideline Comparison
T A B L E 4 Blood Pressure Goals in Patients With Hypertension According to
Clinical Conditions
Category ESC/ESH 2018
Age $65 yrs 130 to <140/70 to 79 mm Hg
Diabetes Close to 130 (or lower if tolerated/
70 to 79 mm Hg
Coronary artery disease Close to 130 (or lower if tolerated/
70 to 79 mm Hg
Chronic kidney disease 130 to <140/70 to 79 mm Hg
(eGFR <60 ml/min/1.73 m2)
Post-stroke Close to 130 (or lower if tolerated/
70 to 79 mm Hg
eGFR ¼ estimated glomerular filtration rate; other abbreviations as in Table 1.
predominant systolic and diastolic BP in younger
people (age <40 years) and its management. These
topics are not discussed in the ACC/AHA guideline.
Numerous trials have assessed BP lowering in older
patients with predominant systolic hypertension.
Many subjects in these trials were unable to tolerate
SBP levels <140 mm Hg, let alone <130 mm Hg.
Nevertheless, older people did have a clear reduction
in CV events, even at BP levels between 140 and
150 mm Hg, compared with the placebo groups
(26–28). The ESC/ESH guideline supports a BP be-
tween 130/70 and 139/79 mm Hg, while the ACC/AHA
guideline recommends <130/80 mm Hg for those
older than 65 years (Table 4).
Given that there are more similarities than differ-
ences between the guidelines, how should a clinician
implement these recommendations in daily practice?
F I G U R E 1 Option to Achieve Blood Pressure Guidelines Approach
BP measurement according to guidelines-7-8 min
BP meds review and updates-3-4 min
Lifestyle review and discussion-7-10 min
CV risk assessment via ASCVD app-1 min
All information presented to physician at visit start-
TOTAL time 23-28 min
Premise: patient arrives 30 min prior to visit. Nurse or physician assistant does as shown.
ASCVD ¼ atherosclerotic cardiovascular disease; BP ¼ blood pressure;
CV ¼ cardiovascular.
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JUNE 18, 2019:3018–26
As we noted at the beginning of this paper, guidelines
simply offer guidance to approach different patient
types with different risk profiles. Outcomes of trials
AHA/ACC 2017
do not always translate into “real-world” practice
<130/<80 mm Hg
settings, as results are not driven by protocols and
<130/<80 mm Hg
study coordinators’ hounding patients. Hence, there
<130/<80 mm Hg is no substitute for clinical judgment and discussion
of risk and the suggested approach with an individual
<130/<80 mm Hg
patient. The primary issue is how to properly achieve
<130/<80 mm Hg the high quality required to assess BP, council and
educate patients, and get patients involved in their
care in the short time allowed by payers. One effec-
tive way to do so given the current constraints of
billing and time is additional request time on pa-
tients’ part and use of the existing workforce. The
proposed approach maximizes time and labor while
minimizing increased cost to a practice (Figure 1).
As noted earlier, BP measurement is critical
because it provides the data used for treatment. Thus,
it must be standardized (Table 3). Patients must be
taught how to measure BP at home and when to do so,
namely, twice in the morning and twice in the eve-
ning over the week preceding a clinic visit, as indi-
cated by ESH home BP monitoring guidelines (29), but
each patient might need individualization depending
on his or her schedule. Also, patients must be
reminded to bring their BP monitors in annually for
validation.
Second, time to discuss lifestyle modifications and
determine 10-year CV risk is needed during initial and
possibly subsequent visits. This can be done with a
dietitian, an allied health provider, or a nurse facili-
tating data collection. This is critical because failure
to adhere to a low-sodium diet (<2,300 mg/day) or 1
level teaspoon of salt, as suggested by the preventive
task force, is a significant cause of resistant hyper-
tension and renders renin-angiotensin system
blockers ineffective. Many patients believe that not
adding salt to their food translates into a low-salt
diet. Hence, they need education on how to choose
foods that are lower in salt, how to check labels, and
how much salt they need during the day. Discharge
instruction sheets are available on some electronic
health records and AHA web sites such as targetbp.
org.
Third, a nurse or an allied health worker should
collect data on overall CV risk and provide this in-
formation along with other data to the physician at
the start of the visit. The ASCVD risk calculator data
or the Systematic Coronary Risk Evaluation risk chart
should be shown to patients so that they are aware of
their current CV risk and how it will be reduced by
following the suggestions for treatment. A team
approach will improve time efficiency and patient
JACC VOL. 73, NO. 23, 2019 Bakris et al. 3025
JUNE 18, 2019:3018–26 Hypertension Guideline Comparison

education and allow physicians to explain and answer
questions posed by patients (Figure 1).
In summary, although both the ACC/AHA and ESC/
ESH guidelines have many positive and concordant
features (Table 1), changing the definition of hyper-
tension to >130/80 mm Hg, as suggested in the ACC/
AHA guidelines, is problematic (Central Illustration).
However, what is consistent in both guidelines is that
patients at high CV risk need more aggressive
lowering of BP to levels <130/80 mm Hg. The ESC/
ESH, ease into this gradually by stating that all per-
sons’ BP should be <140/90 mm Hg, followed by
discussion with individual patients about their CV
risk and the benefits of further lowering BP to <130/
80 mm Hg whenever this is needed; using this
approach coupled with the tools of measurement and
lifestyle education can result in higher proportions of
people achieving BP goals. This approach is also
embraced by the Canadian and Latin American BP
guidelines. To fully implement current guidelines
appropriately, physicians and/or health
personnel need more time with patients to educate
them on approaches to lifestyle modifications and the
importance of how and when to assess their BP. This
will require appropriate and additional funding from
payers (insurance companies, governments, and
others) to achieve this quality improvement.
To be clear, there is no fundamental problem with
any of the guidelines, as the data used are of high
quality. It is not even their strict interpretation but
rather the disconnect between a given culture’s
willingness to adopt a healthy lifestyle as well as
governments’ and insurance companies’ willingness
to support physicians and health care providers to
implement these changes. There are many examples
of countries, through government intervention,
modifying sodium levels in their food supplies over
decades, resulting in significant reductions in CV
events (30,31). We fully agree with others who argue
that funders, the government, and the health care
profession need to spend more time educating pa-
tients and reinforcing lifestyle modification rather
than simply writing prescriptions for more BP medi-
cations (32).
care ADDRESS FOR CORRESPONDENCE: Dr. George
Bakris, AHA Comprehensive Hypertension Center,
University of Chicago Medicine, 5841 S. Maryland
Avenue, MC 1027, Chicago, Illinois 60637. E-mail:
gbakris@uchicago.edu. Twitter: @UChicagoMed.

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KEY WORDS blood pressure, guidelines,
hypertension, lifestyle, mortality, outcomes