2017 ACC/AHA Practice Guideline for the Management of Hypertension
Common CVD Risk Factors in Patients With Hypertension
Modifiable
Relatively Fixed
Current cigarette smoking, secondhand smoking
CKD
Diabetes mellitus
Family history
Dyslipidemia/hypercholesterolemia
Increased age
Overweight/obesity
Low socioeconomic/educational status
Physical inactivity/low fitness
Male sex
Unhealthy diet
Obstructive sleep apnea
Psychosocial stress
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Adult patients with hypertension have other CVD risk factors
Higher percentage of adults with CVD risk factors have hypertension (i.e. 71% of US adults with
diagnosed DM have hypertension)
CVD risk factors affect BP through over activation of the renin-angiotensin-aldosterone system,
activation of the sympathetic nervous system, inhibition of the cardiac natriuretic peptide
system, endothelial dysfunction, and other mechanisms
o Treating some of the other modifiable risk factors may reduce BP through modification
of shared pathology
Causes of Secondary
Hypertension
Sleep apnea
Renal disease/CKD
Primary aldosteronism
Drug/alcohol-induced
Cushing’s syndrome
Pheochromocytoma
Thyroid dysfunction
Aortic Coarctation
Alcohol
Amphetamines
MAOI, SNRI, TCA
Atypical antipsychotics
(clozapine, olanzapine)
Caffeine
Decongestants
(phenylephrine,
pseudoephedrine)
Immunosuppressants
(cyclosporine)
Oral contraceptives
NSAIDs
Recreational drugs
(bath salts, cocaine,
meth)
Systemic corticosteroids
Drug Induced HTN
1/day F and 2/d M
D/C or decrease dose
Consider SSRI, avoid tyramine with MAOI
D/C or limit use, consider alt agents with
lower weight gain/DM/dyslipidemia
(ziprasidone, aripiprazole)
Limit to <300 mg/d
Use for shorted duration possible, consider
alt. therapies
Consider converting to tacrolimus
Use low dose (20-30 mg ethinyl estradiol) or
progestin-only, consider alternative forms of
birth control (IUD)
Avoid systemic NSAIDs, consider alternative
analgesics
D/C
Avoid or limit use, consider alternate routes
of administration when possible
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
Step 1: Properly prepare the
patient
Step 2: Use proper
technique for BP
measurements
Step 3: Take the proper
measurements needed for
diagnosis and treatment of
elevated BP/hypertension
Step 4: Properly document
accurate BP readings
Step 5: Average the readings
Step 6: Provide BP readings
to patient
Accurate Blood Pressure Measurement
1. Have the patient relax, sitting in a chair (feet on floor, back
supported) for >5 min.
2. The patient should avoid caffeine, exercise, and smoking for at
least 30 min before measurement.
3. Ensure patient has emptied his/her bladder.
4. Neither the patient nor the observer should talk during the rest
period or during the measurement.
5. Remove all clothing covering the location of cuff placement.
6. Measurements made while the patient is sitting or lying on an
examining table do not fulfill these criteria.
1. Use a BP measurement device that has been validated, and ensure
that the device is calibrated periodically.
2. Support the patient’s arm (eg, resting on a desk).
3. Position the middle of the cuff on the patient’s upper arm at the
level of the right atrium (the midpoint of the sternum).
4. Use the correct cuff size, such that the bladder encircles 80% of the
arm, and note if a larger- or smaller-than-normal cuff size is used.
5. Either the stethoscope diaphragm or bell may be used for
auscultatory readings.
1. At the first visit, record BP in both arms. Use the arm that gives the
higher reading for subsequent readings.
2. Separate repeated measurements by 1–2 min.
3. For auscultatory determinations, use a palpated estimate of radial
pulse obliteration pressure to estimate SBP. Inflate the cuff 20–30
mm Hg above this level for an auscultatory determination of the BP
level.
4. For auscultatory readings, deflate the cuff pressure 2 mm Hg per
second, and listen for Korotkoff sounds.
1. Record SBP and DBP. If using the auscultatory technique, record
SBP and DBP as onset of the first Korotkoff sound and disappearance
of all Korotkoff sounds, respectively, using the nearest even number.
2. Note the time of most recent BP medication taken before
measurements.
Use an average of ≥2 readings obtained on ≥2 occasions to estimate
the individual’s level of BP.
Provide patients the SBP/DBP readings both verbally and in writing.
Out-of-Office Blood Pressure Measurements
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
Recommended to confirm HTN diagnosis and to titrate medications
Training should occur for home blood pressure monitoring(HBPM)
o Automated devices, appropriate cuff size
o Remain still, avoid smoking, caffeine, exercise for 30m prior; feet on the floor; keep arm
supported on flat surface
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
o
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Take at least 2 readings 1 min apart before taking medications and in the evening before
dinner
o Optimally measure daily
o Record all readings
Ambulatory blood pressure monitoring (ABPM) is preferred method for out-of-office
measurements
o Monitors usually programmed to obtain readings every 15-30m during the day and
every 15m-1h during the night
o Can determine the nocturnal “dipping” of blood pressure and daily/nighttime patterns
o Machine may be reimbursable to patients with suspected white-coat HTN and masked
HTN
 White-coat HTN - office BP elevated (>130/80 and <160/100) but daytime ABPM
or HBPM is not
 Masked HTN – office BP 120-129/<80 but ABPM or HBPM >130/80
Clinic
120/80
130/80
140/90
160/100
Corresponding SBP/DBP Values for Measurement Kinds
HBPM
Daytime ABPM
Nighttime ABPM
120/80
120/80
100/65
130/80
130/80
110/65
135/85
135/85
120/70
145/90
145/90
140/85
Category
Normal
Elevated
Hypertension
Stage 1
Stage 2
Hypertensive Crisis
Hypertensive
Emergency
Population
Uncomplicated HTN
Diabetes
CKD
Older Adults
Blood Pressure Classification
SBP (mmHg)
< 120
And
120 – 129
And
24-hour ABPM
115/75
125/75
130/80
145/90
DBP (mmHg)
< 80
< 80
130 – 139
Or
80 – 89
≥ 140
Or
≥ 90
> 180
And/or
> 120
Hypertensive crisis + evidence of acute target organ damage
Blood Pressure Goals Across Guidelines
ACC/AHA
Other Guideline Recommendations
< 130 / 80
< 130 / 80
ADA 2023
< 130 / 80
< 130 / 80
KDIGO 2021
< 120 SBP
< 130 SBP
ACP/AAFP 2017
General: < 150 SBP
Stroke/TIA or high CV risk: < 140 SBP
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
Non-Pharmacologic Treatment
Treatment
Weight loss
DASH diet
Dietary Sodium
Dietary Potassium
Aerobic exercise
Dynamic resistance exercise
Alcohol
Intervention
Goal: IBW; expect 1 mmHg reduction for every
1-kg lost
Fruits, vegetables, wholegrains, low-fat dairy
with reduced saturated and trans fats
Goal: < 1500 mg/d (aim for < 1000)
Goal: 3500 – 5000 mg/d
90 – 150 min/wk of 65 – 75% heart rate reserve
90 – 150 min/wk: 6 exercises at 50 – 80% 1 rep
max, 3 exercises/sets with 10 reps/set
M < 2; F < 1
Pharmacologic Treatment
Stage 1 HTN (clinical ASCVD, 10-yr
ASCVD risk > 10%, DM, CKD)
 Monotherapy
Stage 2 HTN
BP > 20/10 above goal combination
therapy with 2 first-line agents
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
Initial Medication Selection:
First line therapies:
General: Thiazide diuretics, CCB, ACE, ARB
- ALLHAT: chlorthalidone, amlodipine, lisinopril no difference found in primary outcome
(CVD death, nonfatal MI); chlorthalidone showed CVD benefit compared to amlodipine,
lisinopril
- ACCOMPLISH – benazepril/amlodipine significantly decreased primary (CV death,
nonfatal MI) and secondary outcomes
African American patients (w/o HF or CKD): thiazide, CCB
- lower RAAS efficacy (lower circulating renin concentrations)
Comorbidity specific (below)
*most patients will require 2 or more medications to achieve their BP goal
Recommended therapy for comorbid conditions & Special Populations
Diabetes AND CKD
- Albuminuria: ACE or ARB
- ≥ 300 mg/d or mg/g albumin-creatinine ratio or equivalent
- No albuminuria: thiazide, CCB, ACE, ARB
- Kidney transplant: CCB
- AVOID: non-DHP CCB
HFrEF
- carvedilol, metoprolol XR, bisoprolol (GDMT BB), ACE, ARB, ARNI, mineral corticoid RA,
diuretics
- AVOID: non-DHP CCB
HFpEF
- diuretic (initiate first to control volume overload), BB, ACE, ARB
Stable Ischemic Heart Disease (SIHD)
- ACE, ARB, BB (continue x3 year if has MI or ACS)
- CCB (esp. if angina and uncontrolled HTN), thiazide or MRA can be added PRN
- AVOID ISA BB
Secondary Stroke Prevention
- thiazide, ACE, ARB; combination thiazide + ACE
A fib
- ARB
Aortic disease
- BB
PREGNANCY
- Methyldopa, nifedipine, labetalol
- CI : ACE, ARB, renin inhibitors
- GOAL: < 120 – 160 / 80 – 105 (American College of Ob and Gyn)
Resistant Hypertension
- ≥ 130 / 80 despite concurrent use of 3 antihypertensives from different classes
(including long acting CCB, RAAS blocker and diuretic at max tolerated doses)
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
- drug-induced, nonadherence, volume overload, co-morbid conditions, secondary THN
cause
- optimizing drug regimens (in order)
- substitute thiazide diuretic for loop diuretics
- add MRA
- add BB
- add hydralazine
- sub minoxidil for hydralazine
FRIST LINE DRUGS (ACE, ARB, thiazide, CCB)
Benazepril
Captopril
Enalapril
Fosinopril
Lisinopril
Quinapril
Ramipril
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ACE INHIBITORS
Usual Dose Range (mg/d)
10–40
12.5–150
5–40
10–40
10–40
10–80
2.5–20
Daily Frequency
1 or 2
2 or 3
1 or 2
1
1
1 or 2
1 or 2
MOA – inhibit conversion of angiotensin I to II (angiotensin II = vasoconstrictor)
Do not use in combination with ARB or direct renin inhibitor (aliskiren) (hyperkalemia risk)
DDI – NSAIDs
o NSAIDs constrict afferent arteriole (PG dilates), ACE/ARB dilate (ANGII constrict)efferent
arteriole  together filtrate does not stay in the glomerulus to be filtered when
administered concomitantly
DDI – may increase lithium concentrations
Nephroprotective
o To much circulating renin  increased angiotensin II  increased vasoconstriction of
efferent arteriole  increased glomerular pressure and damage
36h Entresto washout
Benign increase in SCr (20-30% acceptable)
Hyperkalemia
Angioedema (less with ARBs)
Cough (increased bradykinin)
CI: bilateral renal artery stenosis, AKI, pregnancy
(teratogenic), Hx angioedema (BBW)
Ok in gout (lipid and uric acid neutral)
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
Candesartan
Irbesartan
Losartan
Olmesartan
Telmisartan
Valsartan
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ANGIOTENSIN II RECEPTOR BLOCKERS (ARB)
Usual Dose Range (mg/d)
Daily Frequency
8–32
1
150–300
1
50–100
1 or 2
20–40
1
20–80
1
80–320
1
MOA – selectively antagonize angiotensin II AT1 receptors
Do not use in combination with ACE or direct renin inhibitor (aliskiren) (hyperkalemia risk)
Olmesartan – diarrhea causing weight loss
Benign increase in SCr (20-30%) acceptable
Hyperkalemia
Angioedema
o Less than ACE
o 6 week washout if angioedema with ACE before starting ARB
o Normal transition = 36 h washout
CI: bilateral renal artery stenosis, AKI, pregnancy (teratogenic), Hx angioedema with ARB
DIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS
Usual Dose Range (mg/d)
Daily Frequency
Amlodipine
2.5–10
1
Felodipine
2.5–10
1
Nicardipine SR
60–120
2
Nifedipine LA
30–90
1
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MOA – inhibits smooth muscle calcium channels (more in vasculature than myocardium)
AVOID in patients with HErEF (can use amlodipine or felodipine if required)
Nicardipine XR – ghost tablet, preferred formulation (IR  profound SE)
Dose-related pedal/peripheral edema (more common in women)
Headache, flushing, Reflex tachycardia (vasodilatory SE)
Gingival hyperplasia
Orthostasis
Greater benefit in the African American population than RAAS inhibitors/BB
Can be used in Raynaud syndrome
CI: Nicardipine in aortic stenosis
DDI: grapefruit (3A4)
Clevidipine (IV)
o Increases TG (2kcal/mL)
o 3A4 DDI
o CI: soy/egg allergy
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
THIAZIDE/THIAZIDE-LIKE DIURETICS
Usual Dose Range (mg/d)
Chlorthalidone
12.5–25
Hydrochlorothiazide
25–50
Indapamide
1.25–2.5
Metolazone
2.5–5
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Daily Frequency
1
1
1
1
MOA – inhibits Na/Cl reabsorption in the distal convoluted tubule
Chlorthalidone currently preferred to HCTZ (longer t1/2 and proven to decrease CV death
(ALLHAT))
HYPO – K, Na, Mg
HYPER – Ca, BG, UA, TG/LDL
CI: Anuria, sulfa
Not effective with GFR < 30
CAUTION: gout or DM
Osteoporosis protective (prevents urine Ca loss)
OTHER AGENTS
NON-DIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS
Usual Dose Range (mg/d)
Daily Frequency
Diltiazem ER
120–360
1
Verapamil IR
120–360
3
Verapamil SR
120–360
1 or 2
Verapamil-delayed onset ER
100–300
1 (in the evening)
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MOA – more inhibition of calcium channels in myocardium/conduction tissue than vasculature
smooth muscle
Useful in patients with concomitant A Fib
May be useful in migraine prophylaxis
AVOID in patients with HErEF
3A4CYP INHIBITOR and SUBSTRATE
o DDI - statins
Bradycardia
Heart/AV block
Constipation
Gingival hyperplasia
CI: heart/AV block; sick sinus syndrome
Caution: concomitant BB (increased risk of heart/AV block and bradycardia)
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
Bumetanide
Furosemide
Torsemide
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Conversion
Daily Frequency
2
2
1
PO
1 mg
40 mg
20 mg
IV
1 mg
20 mg
-
MOA – inhibit the reabsorption of Na and Cl in the ascending loop of Henle and distal tubule
Preferred diuretics in persons with symptomatic HF
Preferred over thiazides in persons with moderate-severe CKD (GFR < 30)
Bumetanide - myalgias
HYPO – Ca, K, Mg, Na
HYPER – BG, UA, TG
Dehydration
Ototoxic
Orthostasis
CI: Anuria
Ethacrynic acid if sulfa allergy
Amiloride
Triamterene

LOOP DIURETICS
Usual Dose Range (mg/d)
0.5–2
20–80
5–10
POTASSIUM-SPARING DIURETICS
Usual Dose Range (mg/d)
Daily Frequency
5–10
1 or 2
50–100
1 or 2
MOA – interferes with K/Na exchange in the distal convoluted tubule ( decrease in water
reabsorption and increases potassium retention)
Used in combination with thiazide in patients with hypokalemia on thiazide monotherapy
o Minimally effective as an antihypertensive as monotherapy
HYPER – K, BG, UA
AVOID: GFR < 45
CI: Anuria, hyperkalemia, severe renal or hepatic disease
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
Eplerenone
Spironolactone
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ALDOSTERONE ANTAGONISTS
Usual Dose Range (mg/d)
50–100
25–100
MOA – antagonize specific aldosterone receptors ( decreased Na and water reabsorption and
increased potassium retention)
Preferred in primary aldosteronism and resistant HTN (add-on)
Eplerenone often requires BID dosing for adequate BP control
Hyperkalemia; greater risk if with an ACE; D/C if K > 5.5
Gynecomastia, impotence (spironolactone)
Hirsutism (eplerenone – lower binding affinity for progesterone/androgen receptors, increased
for MRA)
CI: GFR < 30, Anuria, SCr > 2 for F and SCr > 2.5 M
Atenolol
Bisoprolol
Metoprolol tartrate
Metoprolol succinate

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Daily Frequency
1 or 2
1
BETA BLOCKERS
Usual Dose Range (mg/d)
25–100
2.5–10
100–200
50–200
Daily Frequency
2
1
2
1
Not first line unless HF or ischemic heart disease
Bradycardia
Caution: bronchospastic disease, Raynaud’s disease
Carvedilol – edema, weight gain
Exercise intolerance
Sexual dysfunction
Fatigue
Depression
Cold extremities
Metoprolol IV: PO 1:2.5
May mask symptoms of hypoglycemia
Metoprolol XL, carvedilol – take with food, 2D6 substrates
CI: AV block/dysfunction, decompensated HF, severe bronchospastic disease
CI: carvedilol in severe hepatic impairment
Warning: carvedilol – intraoperative floppy iris syndrome (cataract surgery)
Cautions: asthma or COPD (especially non-selective; use cardio-selective agents)
TAPER over 2 weeks to discontinue
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
Cardio-selective (Beta 1)
Alpha, non-selective beta
Cardio-non-selective (beta 1
and 2)
Atenolol
Metoprolol
Bisoprolol
Nebivolol
Renally cleared
Succinate preferred in HFrEF
Preferred in HFrEF
Nitric oxide inhibition/vasodilatory  no
sexual dysfunction
Esmolol
Carvedilol
Labetalol
Propranolol
Nadolol
Sotalol
Timolol
Pindolol
Preferred in HFrEF
ISA, generally avoid
DIRECT RENIN INHIBITORS
Aliskiren
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Daily Frequency
150–300
1
MOA – directly inhibits renin
High fat meals decrease absorption
Unknown efficacy in renal insufficiency (excluded group in trials)
hyperkalemia
CI: pregnancy, in combinations with ACE or ARB (hyperkalemia increase), bilateral renal artery
stenosis
Doxazosin
Prazosin
Terazosin
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Usual Dose Range (mg/d)
Alpha-1 blockers
Usual Dose Range (mg/d)
1–16
2–20
1–20
Daily Frequency
1
2 or 3
1 or 2
MOA – antagonize peripheral alpha-1 adrenergic receptors
Can be used in BPH (second line antihypertensive in patients with concomitant BPH)
Dizziness and orthostasis
BEER’s List
Crosses BBB
Start low and titrate
Consider taking at bedtime (1st dose orthostasis)
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
Clonidine oral
Clonidine patch
Methyldopa
Guanfacine
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Daily Frequency
2
1 weekly
2
1
MOA – agonize alpha-2 in the brain ( decreased sympathetic output from vasomotor center
and increased vagal tone)
o Also works in the periphery ( decreased sympathetic tone = decreased HR, CO, total
peripheral resistance)
Generally reserved last line for HTN due to significant CNS SE (especially in elderly)
Guanfacine is alpha-2a selective
o ADHD
Do NOT abruptly D/C (rebound hypertension) – esp. clonidine
Methyldopa – DOC HTN in pregnancy
Beneficial for hypertensive urgency
Anticholinergic SE
Dizziness and orthostasis
Drowsiness
Dry mouth
BEER’s List
Rare hepatitis (methyldopa)
Avoid in PT with HF
Hydralazine
Minoxidil
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CENTRAL ALPHA-2 AGONISTS
Usual Dose Range (mg/d)
0.1–0.8
0.1–0.3
250–1000
0.5–2
DIRECT VASODILATORS
Usual Dose Range (mg/d)
100–200
5–100
Daily Frequency
2 or 3
1-3
Hydralazine – tachycardia (use with BB), DILI, fluid retention (use with loop diuretic), HA
Minoxidil – fluid retention, pericardial effusion (use with loop diuretic), hirsutism
BEER’s List
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2017 ACC/AHA Practice Guideline for the Management of Hypertension
HYPERTENSIVE CRISISES
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Crisis/urgency: > 180 / 120
o Usually do not require hospitalization
o Should receive immediate combination oral therapy
 Captopril, clonidine, and labetalol
o Decrease SBP by no more than 25% in the 1st hour then decrease to < 160 / 100 within
the next 2-6 hours
Emergency: > 180 / 20 with signs of target end organ damage
o Requires hospitalization
 IV antihypertensives
 Nicardipine, clevidipine, sodium nitroprusside, nitroglycerin, esmolol,
labetalol, hydralazine, fenoldopam
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