-
CV dz hx (CAD, HF, CVA/TIA, etc)
Choose BP target for pts w/ existing CV dz1,2 - Target <130/80, per ACC/AHA (if safely attainable,2 per ADA2)
- If DM + chronic HTN + pregnant, initiation/titration tx for BP threshold of 140/90 assoc w/ better outcomes and no ↑ in risk of small-for-gestational-age birth than reserving tx for severe HTN; target 110-135/85 for ↓ the risk of accelerated HTN in pregnant pt, per ADA2
Choose 1st-line drug1,2 (thiazide diuretic, ACEI/ARB, CCB), factoring conditions, plus lifestyle.1 If SBP ≥140 or DBP ≥90 while >20/10 over target, use 2 drugs w/ differing1 actions, per ACC/AHA; ADA2 2-drug threshold ≥160/100 - CAD. Certain BB, ACEI/ARB. If angina, add dihydropyridine CCB to BB if needed. If hx MI/ACS: Continue BB and use ACEI/ARB; if still not at goal, add dihydropyridine CCB, thiazide diuretics (eg, chlorthalidone), and/or MRA1
- HF. Treat volume overload w/ loop diuretics, plus more agents if needed. HFrEF: Use ACEI/ARB1 or ARNI, along w/ certain BBs,3 MRAs;3 don’t use nondihydropyridine CCB.1 HFpEF: ACE/ARB;1 certain BBs,3 MRAs3
- CVA/TIA. Thiazide diuretic, ACEI/ARB, or thiazide diuretic + ACEI combo; if still not at individualized goal, may add CCB and/or MRA1
- DM. ACEI/ARB,1 dihydropyridine CCB,1 thiazide-like diuretics (chlorthalidone, indapamide preferred), per ADA2
- CKD. If Stage 3+ CKD or Stage 1/2 w/ albuminuria:1,2 ACEI (or ARB).1 For diuretics: If GFR <30 mL/min, loop preferred over thiazide; if GFR <45 mL/min, avoid K+-sparing diuretics,1 per ACC/AHA. Post-txp: special recs apply,1 per ACC/AHA
- Afib: ARB,1 per ACC/AHA
- Bronchospastic dz. Cardioselective1 BB preferred over nonselective BB
- Black. If no HF/CKD: thiazide-type diuretic (esp chlorthalidone) or CCB;1 2+ drugs recommended, per ACC/AHA
- Pregnancy current/planned: methyldopa, nifedipine, and/or labetalol while pregnant; don’t use ACEI, ARB, DRI, per ACC/AHA. If DM + pregnant, use methyldopa, labetalol, long-acting nifedipine. Hydralazine may be considered for acute tx in pts w/ HTN + pregnancy/severe preeclampsia,2 per ADA
- Adherence. Once-daily & combo pills preferred
Footnotes 1 ACC (Hypertension) 2017. 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. Whelton PK, et al. J Am Coll Cardiol. 2018 May 15;71(19)e127-e248. PDF
• CVD defined as CHD, CHF, CVA. If PAD only: Tx same as non-PAD pt.
• Lifestyle: Tobacco cessation, wt↓, physical activity, ↓sodium intake, healthy diet (DASH), EtOH moderation.
• Don’t combine among ACEI, ARB, DRI. OK to combine thiazide, K+-sparing, loop diuretics. OK to combine dihydropyridine + nondihydropyridine CCBs. Use caution starting 2 drugs in older pts (↓BP, orthostatic hypotension risks).
• BB in CAD: bisoprolol, carvedilol, metoprolol tartrate or succinate, nadolol, propranolol, timolol. Don’t use atenolol for reducing CV events. If s/p MI/ACS: continuing BB beyond 3y after event for HTN reasonable.
• CCB. Dihydropyridine: amlodipine, felopdipine, isradipine, nicardipine, nifedipine, nisoldipine. Nondihydropyridine: verapamil, diltiazem.
• If hx MI w/ HTN + angina: OK to use CCB (including w/ BB) starting 3y post-MI.
• BP goal <130/80 may be reasonable. If BP >140/90, or if previously treated for HTN, start/restart antihypertensives a few days post-CVA/TIA. However, if previously untreated HTN w/ BP <140/<90; usefulness of starting antihypertensives not well established.
• Albuminuria in CKD: ≥300 mg/d, or ≥300 mg/g albumin-to-Cr ratio or equivalent in 1st morning void. If ACEI not tolerated, ARB is reasonable.
• BP target <130/80 reasonable, but 1st mo post-txp less stringent (eg, <160/90); CCBs favored; reserve ACEI for those w/ specific indications (eg, proteinuria or HF post-txp).
• Cardioselective BB: atenolol, betaxolol, bisoprolol, metoprolol tartrate, metoprolol succinate, nebivolol.
• For Black pts (including w/ DM) w/o HF or CKD: Initial tx should include a thiazide-type diuretic or CCB. RAS inhibitors are recommended in Black pts w/ DM + nephropathy, but aren’t better than diuretics or CCBs in those w/ DM w/o nephropathy.
2 ADA (CV dz) 2023. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2023. American Diabetes Association. Diabetes Care. 2023. Jan 1;46(Suppl 1):S158-S190. Free full-text article
• ASCVD defined as coronary heart dz, cerebrovascular dz, PAD that’s presumed atherosclerotic.
• Pts w/ DM+HTN w/ BP persistently ≥130/80 qualify for antihypertensive tx; on-tx target goal <130/80, if it can be safely attained.
• If hx adverse effects of intensive BP control, or high risk of adverse effects (orthostatic hypotension, comorbidity, polypharmacy, functional limits), pts may choose higher BP targets to improve their quality of life. Presence of low DBP is not necessarily a contraindication to intensive BP tx in the context of standard care.
• Drugs that reduce CV events in DM: ACEI, ARB, thiazide-like diuretics, dihydropyridine CCBs. Don’t combine ACEI + ARB; don’t combine ACEI or ARB w/ DRIs. If prior MI, active angina, HF: beta-blockers may be used, but haven’t been shown to reduce mortality absent these conditions.
• Albuminuria in pts w/ DM: If urinary albumin-creatinine ratio ≥300 mg/g creatinine OR urinary albumin-creatinine ratio 30-299 mg/g creatinine: 1st line is ACE/ARB at max-tolerated dose; switch to other class if 1 class not tolerated.
• If DM + HTN + pregnancy: Target 110-135/85. Contraindicated in pregnancy: ACEI/ARB, spironolactone. Safe in pregnancy: methyldopa, labetalol, long-acting nifedipine. If HTN + pregnancy/severe preeclampsia: hydralazine may be considered for acute tx. Diuretics not recommended for BP control; may be used during late-stage pregnancy for volume control.
3 ACC (Heart Failure Mgmt) 2022. 2022 AHA/ACC/HFSA Guideline for
the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Heidenreich PA, et al. Circulation. 2022 May 3;145(18):e895-e1032. Free full-text article
• Mineralocorticoid receptor antagonists (aldosterone antagonists) eplerenone, spironolactone: Use only if established eGFR >30 mL/min/1.73 m 2 w/ K+ <5 mEq/L.
• BBs in HF: bisoprolol, carvedilol, carvedilol CR, metoprolol succinate CR/XL. May be used for pts w/ hx of MI, symptomatic CAD, or AF w/ rapid ventricular response. Balance w/ potential contribution of chronotropic incompetence to exercise intolerance. In the RATE-AF trial, among older pts w/ AF and sx of HF (most w/ HFpEF), QOL was similar between bisoprolol and digoxin at 6mo, but several secondary QOL endpoints, functional capacity, and ↓ in NT-proBNP favored digoxin at 12mo. HR↓ was similar in both groups, but adverse events (e.g., dizziness, lethargy, hypotension) were more common w/ BBs.
Individualize BP target based on age & health status including CV dz,1,2 via shared decision-making - ACC/AHA. For ambulatory community-dweller,1 target <130. However, if ≥65 yo w/ high comorbidity burden or limited life expectancy, use judgment, pt preference
- ACP/AAFP. Target <140 for pts ≥60 yo w/ hx stroke/TIA and other CV dz3
- ADA. Generally for pts ≥65 yo w/ DM: target <130/80 for healthy/intermediate complex pts; <140/90 for very complex or poor-health-status older pts4
Choose 1st-line drug,1,2 (thiazide diuretic, ACEI/ARB,1 CCB), factoring conditions, plus lifestyle.1 If SBP ≥140 or DBP ≥90 while >20/10 over target, use 2 drugs w/ differing1 actions, but caution in older pts (↓BP, orthostatic hypotension risks) per ACC/AHA; ADA2 2-drug threshold ≥160/100 - CAD. Certain BB, ACEI/ARB. If angina, add dihydropyridine CCB to BB if needed. If hx MI/ACS: Continue BB and use ACEI/ARB; if still not at goal, add dihydropyridine CCB, thiazide diuretics (eg, chlorthalidone), and/or MRA1
- HF. Treat volume overload w/ loop diuretics, plus more agents if needed. HFrEF: Use ACEI/ARB1 or ARNI, along w/ certain BBs,5 MRAs;5 don’t use nondihydropyridine CCB.1 HFpEF: ACE/ARB;1 certain BBs,5 MRAs5
- CVA/TIA. Thiazide diuretic, ACEI/ARB, or thiazide diuretic + ACEI combo; if still not at individualized goal, may add CCB and/or MRA1
- DM. ACEI/ARB,1 dihydropyridine CCB,1 thiazide-like diuretics (chlorthalidone, indapamide preferred), per ADA2
- CKD. If Stage 3+ CKD or Stage 1/2 w/ albuminuria:1,2 ACEI (or ARB).1 For diuretics: If GFR <30 mL/min, loop preferred over thiazide; if GFR <45 mL/min, avoid K+-sparing diuretics,1 per ACC/AHA. Post-txp: special recs apply,1 per ACC/AHA
- Afib: ARB,1 per ACC/AHA
- Bronchospastic dz. Cardioselective1 BB preferred over nonselective BB
- Black. If no HF/CKD: thiazide-type diuretic (esp chlorthalidone) or CCB;1 2+ drugs recommended, per ACC/AHA
- Adherence. Once-daily & combo pills preferred
Footnotes 1 ACC (Hypertension) 2017. 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. Whelton PK, et al. J Am Coll Cardiol. 2018 May 15;71(19)e127-e248. PDF
• CVD defined as CHD, CHF, CVA. If PAD only: Tx same as non-PAD pt.
• Don’t combine among ACEI, ARB, DRI. OK to combine thiazide, K+-sparing, loop diuretics. OK to combine dihydropyridine + nondihydropyridine CCBs. Use caution starting 2 drugs in older pts (↓BP, orthostatic hypotension risks).
• Lifestyle: Tobacco cessation, wt↓, physical activity, ↓sodium intake, healthy diet (DASH), EtOH moderation.
• BB in CAD: bisoprolol, carvedilol, metoprolol tartrate or succinate, nadolol, propranolol, timolol. Don’t use atenolol for reducing CV events.
• If hx MI w/ HTN + angina: OK to use CCB (including w/ BB) starting 3y post-MI.
• CCB. Dihydropyridine: amlodipine, felopdipine, isradipine, nicardipine, nifedipine, nisoldipine. Nondihydropyridine: verapamil, diltiazem.
• CVA/TIA. BP goal <130/80 may be reasonable; use judgment/pt preferences if high comorbidities. If BP >140/90, or if previously treated for HTN, start/restart antihypertensives a few days post-CVA/TIA. However, if previously untreated HTN w/ BP <140/<90, usefulness of starting antihypertensives not well established.
• Albuminuria in CKD: ≥300 mg/d, or ≥300 mg/g albumin-to-Cr ratio or equivalent in 1st morning void. If ACEI not tolerated, ARB is reasonable.
• CKD post-txp. BP target <130/80 reasonable, but 1st mo post-txp less stringent (eg, <160/90); CCBs favored; reserve ACEI for those w/ specific indications (eg, proteinuria or HF post-txp).
• Cardioselective BB: atenolol, betaxolol, bisoprolol, metoprolol tartrate, metoprolol succinate, nebivolol.
• For Black pts (including w/ DM) w/o HF or CKD: Initial tx should include a thiazide-type diuretic or CCB. RAS inhibitors are recommended in Black pts w/ DM + nephropathy, but aren’t better than diuretics or CCBs in those w/ DM w/o nephropathy.
2 ADA (CV dz) 2023. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2023. American Diabetes Association. Diabetes Care. 2023. Jan 1;46(Suppl 1):S158-S190. Free full-text article
• ASCVD defined as coronary heart dz, cerebrovascular dz, PAD that’s presumed atherosclerotic.
• Pts w/ DM+HTN w/ BP persistently ≥130/80 qualify for antihypertensive tx; on-tx target goal <130/80, if it can be safely attained.
• If hx adverse effects of intensive BP control, or high risk of adverse effects (orthostatic hypotension, comorbidity, polypharmacy, functional limits), pts may choose higher BP targets to improve their quality of life. Presence of low DBP is not necessarily a contraindication to intensive BP tx in the context of standard care.
• Drugs that reduce CV events in DM: ACEI, ARB, thiazide-like diuretics, dihydropyridine CCBs. Don’t combine ACEI + ARB; don’t combine ACEI or ARB w/ DRIs. If prior MI, active angina, HF: beta-blockers may be used, but haven’t been shown to reduce mortality absent these conditions.
• Albuminuria in pts w/ DM: If urinary albumin-creatinine ratio ≥300 mg/g creatinine OR urinary albumin-creatinine ratio 30-299 mg/g creatinine: 1st-line is ACE/ARB at max-tolerated dose; switch to other class if 1 class not tolerated.
3 ACP/AAFP (Hypertension Older Adults) 2017. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017;166:430-437. Accessed online 11/15/19
• If 60+ yo w/ hx stroke/TIA: Target SBP <140 to reduce recurrent stroke risk. (Grade: weak recommendation, moderate-quality evidence). Periodically discuss benefits/harms.
• Some pts 60+ yo w/ high/increased CV risk (eg, known vasc dz, DM, CKD/ eGFR <45 mL/min/1.73 m2, metabolic syndrome): Target SBP <140 when initiating/intensifying (Grade: weak recommendation, low-quality evidence). Periodically discuss benefits/harms.
• Regarding DBP: Insufficient evidence for DBP-based targeting.
4 ADA (Older Adults) 2023. 13. Older Adults: Standards of Care in Diabetes—2023. American Diabetes Association. Diabetes Care. 2023. Jan 1;46(Suppl 1):S216-S229. Free full-text article
• Healthy=few coexisting chronic diseases, intact cognition/fxn.
• Complex/Intermediate=multiple chronic illnesses OR 2+ instrumental ADL impairments OR mild to mod cognitive impairment.
• Very complex/poor health=long-term care or end-stage chronic illness OR mod to severe cognitive impairment OR 2+ ADL dependencies.
5 ACC (Heart Failure Mgmt) 2022. 2022 AHA/ACC/HFSA Guideline for
the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Heidenreich PA, et al. Circulation. 2022 May 3;145(18):e895-e1032. Free full-text article
• Mineralocorticoid receptor antagonists (aldosterone antagonists) eplerenone, spironolactone: Use only if established eGFR >30 mL/min/1.73 m 2 w/ K+ <5 mEq/L.
• BBs in HF: bisoprolol, carvedilol, carvedilol CR, metoprolol succinate CR/XL. May be used for pts w/ hx of MI, symptomatic CAD, or AF w/ rapid ventricular response. Balance w/ potential contribution of chronotropic incompetence to exercise intolerance. In the RATE-AF trial, among older pts w/ AF and sx of HF (most w/ HFpEF), QOL was similar between bisoprolol and digoxin at 6mo, but several secondary QOL endpoints, functional capacity, and ↓ in NT-proBNP favored digoxin at 12mo. HR↓ was similar in both groups, but adverse events (e.g., dizziness, lethargy, hypotension) were more common w/ BBs.
-
No CV dz hx (CAD, HF, CVA/TIA, etc)
Select individualized BP target in pts w/o CVD1,2 - ACC/AHA. Target for DM2 and/or CKD <130/80; use judgment, pt preference if ≥65 yo w/ high comorbidity burden or limited life expectancy
- ADA. Targets in DM: <130/80 if safely attainable;2 pts w/ hx/high risk of adverse events from intensive BP control may choose higher BP targets to improve their quality of life. Presence of low DBP is not necessarily a contraindication to intensive BP tx in the context of standard care. ≥65 yo: <130/80 for healthy/intermediate complex pts; <140/90 for very complex or poor-health-status older pts;3 110-135/85 for ↓ the risk of accelerated HTN in pregnant pts
- ACP/AAFP.Targets for ≥60 yo: <140 reasonable if increased CV risk (most pts w/ DM, CKD pts, older pts, metabolic syndrome, etc)4
Choose 1st-line drug1,2 (thiazide diuretic, ACEI/ARB,1 CCB), factoring conditions, plus lifestyle.1 If SBP ≥140 or DBP ≥90 while >20/10 over target, use 2 drugs w/ differing1 actions per ACC/AHA (caution in older pts);3 ADA2 2-drug threshold ≥160/100 - DM. ACEI/ARB,1 thiazide-like diuretics (chlorthalidone, indapamide preferred), dihydropyridine CCB, per ADA;2 if albuminuria,1,2 then ACEI or ARB, per ACC/AHA, ADA
- CKD. If Stage 3+ CKD or Stage 1/2 w/ albuminuria:1,2ACEI or ARB1 per ACC/AHA, ADA. For diuretics: If GFR <30 mL/min, loop preferred over thiazide; if GFR <45 mL/min, avoid K+-sparing diuretics.1 Post-txp: special recs apply,1 per ACC/AHA
- Bronchospastic dz. Prefer cardioselective1 BB over nonselective BB
- Pregnancy current/planned: methyldopa, nifedipine, and/or labetalol while pregnant; don’t use ACEI, ARB, DRI2
- Black. 1 If no HF/CKD: thiazide-type diuretic (esp chlorthalidone) or CCB; 2+ drugs recommended. RAS inhibitors are recommended in Black pts w/ DM + nephropathy but aren’t better than diuretics or CCBs in those w/ DM w/o nephropathy, per ACC/AHA
- Adherence. Once-daily & combo pills preferred
Footnotes 1 ACC (Hypertension) 2017. 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. Whelton PK, et al. J Am Coll Cardiol. 2018 May 15;71(19)e127-e248. PDF
• CVD defined as CHD, CHF, CVA. If PAD only: Tx same as non-PAD pt.
• For individualized risk in pts 40-79 yo not on statins: Use 10-yr ASCVD risk calc.
Per US population studies:
• For people ≥65 yo, 88% (98% men, 80% women) have CVD hx or ≥10% ASCVD risk score.
• For people ≥75 yo, 100% have CVD hx or ≥10% ASCVD risk score.
• Don’t combine among ACEI, ARB, DRI. OK to combine thiazide, K+-sparing, loop diuretics. OK to combine dihydropyridine + nondihydropyridine CCBs. Use caution starting 2 drugs in older pts (↓BP, orthostatic hypotension risks).
• Albuminuria in CKD: ≥300 mg/d, or ≥300 mg/g albumin-to-Cr ratio or equivalent in 1st morning void. If ACEI not tolerated, ARB is reasonable.
• Lifestyle: Tobacco cessation, wt↓, physical activity, ↓sodium intake, healthy diet (DASH), EtOH moderation.
• CKD post-txp. BP target <130/80 reasonable, but 1st mo post-txp less stringent (eg, <160/90); CCBs favored; reserve ACEI for those w/ specific indications (eg, proteinuria or HF post-txp).
• Cardioselective BB: atenolol, betaxolol, bisoprolol, metoprolol tartrate, metoprolol succinate, nebivolol.
• For Black pts (including w/ DM) w/o HF or CKD: Initial tx should include a thiazide-type diuretic or CCB. RAS inhibitors are recommended in Black pts w/ DM + nephropathy but aren’t better than diuretics or CCBs in those w/ DM w/o nephropathy.
• CCB. Dihydropyridine: amlodipine, felopdipine, isradipine, nicardipine, nifedipine, nisoldipine. Nondihydropyridine: verapamil, diltiazem.
2 ADA (CV dz) 2023. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2023. American Diabetes Association. Diabetes Care. 2023. Jan 1;46(Suppl 1):S158-S190. Free full-text article
• ASCVD defined as coronary heart dz, cerebrovascular dz, PAD that’s presumed atherosclerotic.
• Pts w/ DM+HTN w/ BP persistently ≥130/80 qualify for antihypertensive tx; on-tx target goal <130/80, if it can be safely attained.
• If hx adverse effects of intensive BP control, or high risk of adverse effects (orthostatic hypotension, comorbidity, polypharmacy, functional limits), pts may choose higher BP targets to improve their quality of life. Presence of low DBP is not necessarily a contraindication to intensive BP tx in the context of standard care.
• Drugs that reduce CV events in DM: ACEI, ARB, thiazide-like diuretics, dihydropyridine CCBs. Don’t combine ACEI + ARB; don’t combine ACEI or ARB w/ DRIs. If prior MI, active angina, HF: beta-blockers may be used, but haven’t been shown to reduce mortality absent these conditions.
• Albuminuria in pts w/ DM: If urinary albumin-creatinine ratio ≥300 mg/g creatinine OR urinary albumin-creatinine ratio 30-299 mg/g creatinine: 1st line is ACE/ARB at max-tolerated dose; switch to other class if 1 class not tolerated.
• If DM + HTN + pregnancy: Target 110-135/85. Contraindicated in pregnancy: ACEI/ARB, spironolactone. Safe in pregnancy: methyldopa, labetalol, long-acting nifedipine. If HTN + pregnancy/severe preeclampsia: hydralazine may be considered for acute tx. Diuretics not recommended for BP control; may be used during late-stage pregnancy for volume control.
3 ADA (Older Adults) 2023. 13. Older Adults: Standards of Care in Diabetes—2023. American Diabetes Association. Diabetes Care. 2023. Jan 1;46(Suppl 1):S216-S229. Free full-text article
• Healthy=few coexisting chronic diseases, intact cognition/fxn.
• Complex/Intermediate=multiple chronic illnesses OR 2+ instrumental ADL impairments OR mild to mod cognitive impairment.
• Very complex/poor health=long-term care or end-stage chronic illness OR mod to severe cognitive impairment OR 2+ ADL dependencies.
4 AAACP/AAFP (Hypertension Older Adults) 2017. Pharmacological Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017;166:430-437. Accessed online 11/15/19
• Some pts 60+ yo w/ high/increased CV risk (eg, known vasc dz, DM, CKD/ eGFR <45 mL/min/1.73 m2, metabolic syndrome): Target SBP <140 when initiating/intensifying (Grade: weak recommendation, low-quality evidence). Periodically discuss benefits/harms.
• Regarding DBP: Insufficient evidence for DBP-based targeting.
Select targets for primary prevention in pts w/o DM/CKD/CVD,1 per ACC/AHA - If BP 120-129/<80: Lifestyle1 mod
- If BP 130-139/80-89: If 10-yr ASCVD risk1 <10%, lifestyle1 mod. If 10-yr ASCVD risk ≥10%, target <130/80 w/ drug + lifestyle1 mod
- If BP ≥140/90: Treat w/ drug(s) + lifestyle1 mod. If 10-yr ASCVD risk ≥10%, target <130/80 (same target reasonable for ASCVD risk <10%, but underrepresented in studies)
Choose 1st-line drug1 (thiazide diuretic, ACEI/ARB,1 CCB), factoring conditions, plus lifestyle.1 If SBP ≥140 or DBP ≥90 while >20/10 over target, use 2 drugs w/ differing1 actions per ACC/AHA - Afib: ARB
- Bronchospastic dz. Prefer cardioselective1 BB over nonselective BB
- Pregnancy current/planned: methyldopa, nifedipine, and/or labetalol while pregnant; don’t use ACEI, ARB, DRI
- Black.1 Thiazide-type diuretic (esp chlorthalidone) or CCB; 2+ drugs recommended
- Adherence. Once-daily & combo pills preferred
Footnotes 1 ACC (Hypertension) 2017. 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. Whelton PK, et al. J Am Coll Cardiol. 2018 May 15;71(19)e127-e248. PDF
• CVD defined as CHD, CHF, CVA. If PAD only: Tx same as non-PAD pt.
• Lifestyle: Tobacco cessation, wt↓, physical activity, ↓sodium intake, healthy diet (DASH), EtOH moderation.
• For individualized risk in pts 40-79 yo not on statins: Use 10-yr ASCVD risk calc
• Don’t combine among ACEI, ARB, DRI. OK to combine thiazide, K+-sparing, loop diuretics. OK to combine dihydropyridine + nondihydropyridine CCBs. Use caution starting 2 drugs in older pts (↓BP, orthostatic hypotension risks).
• Cardioselective BB: atenolol, betaxolol, bisoprolol, metoprolol tartrate, metoprolol succinate, nebivolol.
• For Black pts w/o HF or CKD: Initial tx should include a thiazide-type diuretic or CCB.
Individualize primary prevention for pts w/o DM/CKD/CVD.1 ACC/AHA targets differ from ACP/AAFP for older pts; both recommend lifestyle mod1 - ACC/AHA. For ambulatory community-dwelling adult ≥65 yo, target <130 recommended, as vast majority have 10-yr ASCVD risk ≥10%.1 If ≥65 yo w/ high comorbidity burden + limited life expectancy, use judgment + shared decision-making
- ACP/AAFP. For ≥60 yo: Target SBP <140 reasonable if increased CV risk (eg, older pts, metabolic syndrome pts, etc); otherwise, target SBP <1502
Choose 1st-line drug1,2 (thiazide diuretic, ACEI/ARB,1 CCB), factoring conditions, plus lifestyle.1 If SBP ≥140 or DBP ≥90 while >20/10 over target, consider 2 drugs w/ differing1 actions per ACC/AHA, but use caution in older pts (↓BP, orthostatic hypotension risks) - Bronchospastic dz. Prefer cardioselective1 BB over nonselective BB
- Afib: ARB, per ACC/AHA
- Black.1 If no HF/CKD: thiazide-type diuretic (esp chlorthalidone) or CCB; 2+ drugs recommended
- Adherence. Once-daily & combo pills preferred
Footnotes 1 ACC (Hypertension) 2017. 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. Whelton PK, et al. J Am Coll Cardiol. 2018 May 15;71(19)e127-e248. PDF
• CVD defined as CHD, CHF, CVA. If PAD only: Tx same as non-PAD pt.
• Lifestyle: Tobacco cessation, wt↓, physical activity, ↓sodium intake, healthy diet (DASH), EtOH moderation.
• For individualized risk in pts 40-79 yo not on statins: Use 10-yr ASCVD risk calc.
Per US population studies:
• For people ≥65 yo, 88% (98% men, 80% women) have CVD hx or ≥10% ASCVD risk score.
• For people ≥75 yo, 100% have CVD hx or ≥10% ASCVD risk score.
• Don’t combine among ACEI, ARB, DRI. OK to combine thiazide, K+-sparing, loop diuretics. OK to combine dihydropyridine + nondihydropyridine CCBs. Use caution starting 2 drugs in older pts (↓BP, orthostatic hypotension risks).
• Cardioselective BB: atenolol, betaxolol, bisoprolol, metoprolol tartrate, metoprolol succinate, nebivolol.
• For Black pts w/o HF or CKD: Initial tx should include a thiazide-type diuretic or CCB.
2 AAACP/AAFP (Hypertension Older Adults) 2017. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017;166:430-437. Accessed online 11/15/19
• If 60+ yo w/ SBP persistently ≥150: Initiate tx (including lifestyle/diet) targeting SBP <150 to reduce risk for stroke, CV events, and possibly mortality. (Grade: strong recommendation, high-quality evidence). Periodically discuss benefits/harms.
• Some pts 60+ yo w/ high/increased CV risk (eg, known vasc dz, DM, CKD/ eGFR <45 mL/min/1.73 m2, metabolic syndrome): Target SBP <140 when initiating/intensifying (Grade: weak recommendation, low-quality evidence). Periodically discuss benefits/harms.
• Regarding DBP: Insufficient evidence for DBP-based targeting.
|
