Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 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 WRITING COMMITTEE MEMBERS Paul K. Whelton, MB, MD, MSc, FAHA, Chair Robert M. Carey, MD, FAHA, Vice Chair Wilbert S. Aronow, MD, FACC, FAHA* Bruce Ovbiagele, MD, MSc, MAS, MBA, FAHA† Donald E. Casey, Jr, MD, MPH, MBA, FAHA† Sidney C. Smith, Jr, MD, MACC, FAHA†† DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo Karen J. Collins, MBA‡ Crystal C. Spencer, JD‡ wwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwww nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn lololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololololo Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA§ Randall S. Stafford, MD, PhD‡‡ aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa ddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee Sondra M. DePalma, MHS, PA-C, CLS, AACC║ Sandra J. Taler, MD, FAHA§§ ddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro fro Samuel Gidding, MD, FACC, FAHA¶ Randal J. Thomas, MD, MS, FACC, FAHA║║ mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h Kenneth A. Jamerson, MD# Kim A. Williams, Sr, MD, MACC, FAHA† ttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttpttp ://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h://h Daniel W. Jones, MD, FAHA† Jeff D. Williamson, MD, MHS¶¶ ypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypypyp Eric J. MacLaughlin, PharmD** Jackson T. Wright, Jr, MD, PhD, FAHA## eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee r.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.ar.a Paul Muntner, PhD, FAHA† hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa 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ls.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.ols.o ACC/AHA TASK FORCE MEMBERS rgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrgrg b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ b/ Glenn N. Levine, MD, FACC, FAHA, Chair yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g g Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect uuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee st ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost ost o Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N Sana M. Al-Khatib, MD, MHS, FACC, FAHA Federico Gentile, MD, FACC ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo veveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveveve Joshua A. Beckman, MD, MS, FAHA Samuel Gidding, MD, FAHA*** mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm bebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebebe Kim K. Birtcher, MS, PharmD, AACC Zachary D. Goldberger, MD, MS, FACC, FAHA r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20r 20 Biykem Bozkurt, MD, PhD, FACC, FAHA*** Mark A. Hlatky, MD, FACC, FAHA , 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2 000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 Ralph G. Brindis, MD, MPH, MACC*** John Ikonomidis, MD, PhD, FAHA 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777 Joaquin E. Cigarroa, MD, FACC José A. Joglar, MD, FACC, FAHA Lesley H. Curtis, PhD, FAHA*** Laura Mauri, MD, MSc, FAHA Anita Deswal, MD, MPH, FACC, FAHA Susan J. Pressler, PhD, RN, FAHA*** Lee A. Fleisher, MD, FACC, FAHA Barbara Riegel, PhD, RN, FAHA Duminda N. Wijeysundera, MD, PhD *American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ║American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ║║Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative. ***Former Task Force member; current member during the writing effort. Page 1 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline This document was approved by the American College of Cardiology Clinical Policy Approval Committee and the American Heart Association Science Advisory and Coordinating Committee in September 2017, and by the American Heart Association Executive Committee in October 2017. The Comprehensive RWI Data Supplement table is available with this article at http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYP.0000000000000065/-/DC1. The online Data Supplement is available with this article at http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYP.0000000000000065/-/DC2. The American Heart Association requests that this document be cited as follows: Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 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. Hypertension. D ow 2017;:e–e. n lo ad This article has been copublished in the Journal of the American College of Cardiology. e d from Copies: This document is available on the World Wide Web sites of the American College of Cardiology http (www.acc.org) and the American Heart Association (professional.heart.org). A copy of the document is available at ://h http://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by y pe Topic” area. To purchase additional reprints, call 843-216-2533 or e-mail [email protected]. r.a h a jo Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more u rn on AHA statements and guidelines development, visit http://professional.heart.org/statements. Select the a ls .o “Guidelines & Statements” drop-down menu, then click “Publication Development.” rg b/ y Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not g u e permitted without the express permission of the American Heart Association. Instructions for obtaining permission s t on are located at http://www.heart.org/HEARTORG/General/Copyright-Permission- N o Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side v e m of the page. b e r 2 0 (Hypertension. 2017;00:e000-e000.) , 2 0 1 7 © 2017 by the American College of Cardiology Foundation and the American Heart Association, Inc. Hypertension is available at http://hyper.ahajournals.org Page 2 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table of Contents Preamble .................................................................................................................................................. 6 1. Introduction ................................................................................................................................. 10 1.1. Methodology and Evidence Review ................................................................................................ 10 1.2. Organization of the Writing Committee ......................................................................................... 10 1.3. Document Review and Approval..................................................................................................... 11 1.4. Scope of the Guideline .................................................................................................................... 12 1.5. Abbreviations and Acronyms .......................................................................................................... 14 2. BP and CVD Risk ........................................................................................................................... 17 2.1. Observational Relationship ............................................................................................................. 17 2.2. BP Components ............................................................................................................................... 17 2.3. Population Risk ................................................................................................................................ 18 2.4. Coexistence of Hypertension and Related Chronic Conditions ...................................................... 19 3. Classification of BP ....................................................................................................................... 21 D o 3.1. Definition of High BP ....................................................................................................................... 21 w n lo 3.2. Lifetime Risk of Hypertension ......................................................................................................... 23 a de 3.3. Prevalence of High BP ..................................................................................................................... 23 d fro 3.4. Awareness, Treatment, and Control ............................................................................................... 26 m h 4. Measurement of BP ...................................................................................................................... 27 ttp ://h 4.1. Accurate Measurement of BP in the Office .................................................................................... 27 yp 4.2. Out-of-Office and Self-Monitoring of BP ........................................................................................ 29 e r.a 4.3. Ambulatory BP Monitoring ............................................................................................................. 31 h a jo 4.4. Masked and White Coat Hypertension ........................................................................................... 33 u rna 5. Causes of Hypertension ................................................................................................................ 39 ls .o 5.1. Genetic Predisposition .................................................................................................................... 39 rg b/ 5.2. Environmental Risk Factors ............................................................................................................. 39 y gu 5.2.1. Overweight and Obesity .............................................................................................................. 40 e s t o 5.2.2. Sodium Intake ........................................................................................................................... 40 n N 5.2.3. Potassium .................................................................................................................................. 40 o v e 5.2.4. Physical Fitness ......................................................................................................................... 41 m b e 5.2.5. Alcohol ...................................................................................................................................... 41 r 2 0, 2 5.3. Childhood Risk Factors and BP Tracking ......................................................................................... 43 01 5.4. Secondary Forms of Hypertension .................................................................................................. 43 7 5.4.1. Drugs and Other Substances With Potential to Impair BP Control ........................................... 49 5.4.2. Primary Aldosteronism ............................................................................................................. 51 5.4.3. Renal Artery Stenosis ................................................................................................................ 53 5.4.4. Obstructive Sleep Apnea ........................................................................................................... 54 6. Nonpharmacological Interventions ............................................................................................... 55 6.1. Strategies ........................................................................................................................................ 55 6.2. Nonpharmacological Interventions................................................................................................. 56 7. Patient Evaluation ........................................................................................................................ 56 7.1. Laboratory Tests and Other Diagnostic Procedures ...................................................................... 66 7.2. Cardiovascular Target Organ Damage ............................................................................................ 67 8. Treatment of High BP ................................................................................................................... 69 8.1. Pharmacological Treatment ............................................................................................................ 69 8.1.1. Initiation of Pharmacological BP Treatment in the Context of Overall CVD Risk ..................... 69 Page 3 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 8.1.2. BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension ....................................................................................................................................... 71 8.1.3. Follow-Up After Initial BP Evaluation ........................................................................................ 77 8.1.4. General Principles of Drug Therapy .......................................................................................... 78 8.1.5. BP Goal for Patients With Hypertension ................................................................................... 82 8.1.6. Choice of Initial Medication ...................................................................................................... 83 8.2. Achieving BP Control in Individual Patients .................................................................................... 88 8.3. Follow-Up of BP During Antihypertensive Drug Therapy ............................................................ 89 8.3.1. Follow-Up After Initiating Antihypertensive Drug Therapy ...................................................... 89 8.3.2. Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP ..... 90 9. Hypertension in Patients With Comorbidities ................................................................................ 90 9.1. Stable Ischemic Heart Disease ........................................................................................................ 91 9.2. Heart Failure.................................................................................................................................... 91 9.2.1. Heart Failure With Reduced Ejection Fraction .......................................................................... 96 D 9.2.2. Heart Failure With Preserved Ejection Fraction ....................................................................... 97 o wn 9.3. Chronic Kidney Disease ................................................................................................................. 100 lo a 9.3.1. Hypertension After Renal Transplantation ............................................................................. 105 d e d fro 9.4. Cerebrovascular Disease ............................................................................................................... 106 m 9.4.1. Acute Intracerebral Hemorrhage ............................................................................................ 107 h ttp 9.4.2. Acute Ischemic Stroke ............................................................................................................. 109 ://h 9.4.3. Secondary Stroke Prevention .................................................................................................. 112 y p er.a 9.5. Peripheral Arterial Disease............................................................................................................ 115 h a 9.6. Diabetes Mellitus .......................................................................................................................... 116 jo urn 9.7. Metabolic Syndrome ..................................................................................................................... 119 a ls 9.8. Atrial Fibrillation ............................................................................................................................ 120 .o brg/ 9.9. Valvular Heart Disease .................................................................................................................. 121 y g 9.10. Aortic Disease .............................................................................................................................. 122 u es 10. Special Patient Groups .............................................................................................................. 123 t o n 10.1. Race and Ethnicity ....................................................................................................................... 123 N ov 10.1.1 Racial and Ethnic Differences in Treatment ........................................................................... 125 e m b 10.2. Sex-Related Issues ....................................................................................................................... 127 e r 2 10.2.1. Women .................................................................................................................................. 127 0 , 2 10.2.2. Pregnancy .............................................................................................................................. 127 0 1 7 10.3. Age-Related Issues ...................................................................................................................... 130 10.3.1. Older Persons ........................................................................................................................ 130 10.3.2. Children and Adolescents ..................................................................................................... 132 11. Other Considerations ................................................................................................................ 133 11.1. Resistant Hypertension ............................................................................................................... 133 11.2. Hypertensive Crises—Emergencies and Urgencies..................................................................... 137 11.3. Cognitive Decline and Dementia ................................................................................................. 143 11.4. Sexual Dysfunction and Hypertension ........................................................................................ 145 11.5. Patients Undergoing Surgical Procedures ................................................................................... 146 12. Strategies to Improve Hypertension Treatment and Control ...................................................... 149 12.1. Adherence Strategies for Treatment of Hypertension ............................................................... 149 12.1.1. Antihypertensive Medication Adherence Strategies ............................................................ 150 12.1.2. Strategies to Promote Lifestyle Modification ....................................................................... 151 12.1.3. Improving Quality of Care for Resource-Constrained Populations ....................................... 152 Page 4 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 12.2. Structured, Team-Based Care Interventions for Hypertension Control ..................................... 153 12.3. Health Information Technology–Based Strategies to Promote Hypertension Control .............. 155 12.3.1. EHR and Patient Registries .................................................................................................... 155 12.3.2. Telehealth Interventions to Improve Hypertension Control ................................................ 155 12.4. Improving Quality of Care for Patients With Hypertension ........................................................ 157 12.4.1. Performance Measures ......................................................................................................... 157 12.4.2. Quality Improvement Strategies ........................................................................................... 158 12.5. Financial Incentives ..................................................................................................................... 159 13. The Plan of Care for Hypertension ............................................................................................. 160 13.1. Health Literacy ............................................................................................................................ 161 13.2. Access to Health Insurance and Medication Assistance Plans.................................................... 161 13.3. Social and Community Services .................................................................................................. 162 14. Summary of BP Thresholds and Goals for Pharmacological Therapy ........................................... 164 15. Evidence Gaps and Future Directions ........................................................................................ 165 D Appendix 1. Author Relationships With Industry and Other Entities (Relevant) ................................ 168 o wn Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) .................. 174 lo a d e d fro m http ://h y p e r.a h a jo u rn a ls .o rg b/ y g u e s t o n N o v e m b e r 2 0 , 2 0 1 7 Page 5 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Preamble Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines (guidelines) with recommendations to improve cardiovascular health. In 2013, the National Heart, Lung, and Blood Institute (NHLBI) Advisory Council recommended that the NHLBI focus specifically on reviewing the highest-quality evidence and partner with other organizations to develop recommendations (1, 2). Accordingly, the ACC and AHA collaborated with the NHLBI and stakeholder and professional organizations to complete and publish 4 guidelines (on assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults) to make them available to the widest possible constituency. In 2014, the ACC and AHA, in partnership with several other professional societies, initiated a guideline on the prevention, detection, evaluation, and management of high blood pressure (BP) in adults. Under the management of the ACC/AHA Task Force, a Prevention Subcommittee was appointed to help guide development of the suite of guidelines on prevention of cardiovascular disease (CVD). These guidelines, which are based on systematic methods to D o evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA w n lo sponsor the development and publication of guidelines without commercial support, and members of a de each organization volunteer their time to the writing and review efforts. Guidelines are official policy of d fro the ACC and AHA. m h ttp Intended Use ://hy Practice guidelines provide recommendations applicable to patients with or at risk of developing CVD. The p e r.a focus is on medical practice in the United States, but guidelines developed in collaboration with other h ajo organizations can have a global impact. Although guidelines may be used to inform regulatory or payer u rn decisions, they are intended to improve patients’ quality of care and align with patients’ interests. a ls.o Guidelines are intended to define practices meeting the needs of patients in most, but not all, rg b/ circumstances and should not replace clinical judgment. y g u e Clinical Implementation s t on Management in accordance with guideline recommendations is effective only when followed by both N o practitioners and patients. Adherence to recommendations can be enhanced by shared decision making v e m between clinicians and patients, with patient engagement in selecting interventions on the basis of b e r 2 individual values, preferences, and associated conditions and comorbidities. 0 , 2 01 Methodology and Modernization 7 The ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations, including the Institute of Medicine (3, 4), and on the basis of internal reevaluation. Similarly, the presentation and delivery of guidelines are reevaluated and modified on the basis of evolving technologies and other factors to facilitate optimal dissemination of information to healthcare professionals at the point of care. Toward this goal, this guideline continues the introduction of an evolved format of presenting guideline recommendations and associated text called the “modular knowledge chunk format.” Each modular “chunk” includes a table of related recommendations, a brief synopsis, recommendation-specific supportive text, and when appropriate, flow diagrams or additional tables. References are provided within the modular chunk itself to facilitate quick review. Additionally, this format will facilitate seamless updating of guidelines with focused updates as new evidence is published, as well as content tagging for rapid electronic retrieval of related recommendations on a topic of interest. This evolved approach format was instituted when this guideline was near completion; therefore, the present document represents a Page 6 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline transitional format that best suits the text as written. Future guidelines will fully implement this format, including provisions for limiting the amount of text in a guideline. Recognizing the importance of cost–value considerations in certain guidelines, when appropriate and feasible, an analysis of the value of a drug, device, or intervention may be performed in accordance with the ACC/AHA methodology (5). To ensure that guideline recommendations remain current, new data are reviewed on an ongoing basis, with full guideline revisions commissioned in approximately 6-year cycles. Publication of new, potentially practice-changing study results that are relevant to an existing or new drug, device, or management strategy will prompt evaluation by the Task Force, in consultation with the relevant guideline writing committee, to determine whether a focused update should be commissioned. For additional information and policies regarding guideline development, we encourage readers to consult the ACC/AHA guideline methodology manual (6) and other methodology articles (7-10). Selection of Writing Committee Members The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds. Writing D ow committee members represent different geographic regions, sexes, ethnicities, races, intellectual n lo perspectives/biases, and scopes of clinical practice. The Task Force may also invite organizations and a d ed professional societies with related interests and expertise to participate as partners, collaborators, or fro endorsers. m h ttp://h Relationships With Industry and Other Entities yp The ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without e r.a bias or improper influence. The complete relationships with industry and other entities (RWI) policy can h a jo be found at http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with- u rna industry-policy. Appendix 1 of the present document lists writing committee members’ relevant RWI. For ls .o the purposes of full transparency, writing committee members’ comprehensive disclosure information is rg b/ available online (http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYP.0000000000000065/- y gu /DC1). Comprehensive disclosure information for the Task Force is available at e s t o http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/guidelines-and-documents- n N task-forces. o v e m b Evidence Review and Evidence Review Committees e r 2 In developing recommendations, the writing committee uses evidence-based methodologies that are 0 , 20 based on all available data (6-9). Literature searches focus on randomized controlled trials (RCTs) but also 1 7 include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited. An independent evidence review committee (ERC) is commissioned when there are 1 or more questions deemed of utmost clinical importance that merit formal systematic review. The systematic review will determine which patients are most likely to benefit from a drug, device, or treatment strategy and to what degree. Criteria for commissioning an ERC and formal systematic review include: a) the absence of a current authoritative systematic review, b) the feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline, c) the relevance to a substantial number of patients, and d) the likelihood that the findings can be translated into actionable recommendations. ERC members may include methodologists, epidemiologists, healthcare providers, and biostatisticians. The recommendations developed by the writing committee on the basis of the systematic review are marked with “SR”. Page 7 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Guideline-Directed Management and Therapy The term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm the dosage by reviewing product insert material and evaluate the treatment regimen for contraindications and interactions. The recommendations are limited to drugs, devices, and treatments approved for clinical use in the United States. Class of Recommendation and Level of Evidence The Class of Recommendation (COR) indicates the strength of the recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence that supports the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1) (6-8). Glenn N. Levine, MD, FACC, FAHA Chair, ACC/AHA Task Force on Clinical Practice Guidelines D o w n lo ad e d fro m h ttp ://h y p e r.a h a jo u rn a ls .o rg b/ y g u e s t o n N o v e m b e r 2 0 , 2 0 1 7 Page 8 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015) D o w n lo a d e d fro m h ttp ://h y p e r.a h a jo u rn a ls .o rg b/ y g u e s t o n N o v e m b e r 2 0 , 2 0 1 7 References 1. Gibbons GH, Harold JG, Jessup M, et al. The next steps in developing clinical practice guidelines for prevention. Circulation. 2013;128:1716-7. 2. Gibbons GH, Shurin SB, Mensah GA, et al. Refocusing the agenda on cardiovascular guidelines: an announcement from the National Heart, Lung, and Blood Institute. Circulation. 2013;128:1713-5. 3. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine (U.S.). Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011. Page 9 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 4. Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Institute of Medicine (U.S.). Finding What Works in Health Care: Standards for Systematic Reviews. Washington, DC: National Academies Press; 2011. 5. Anderson JL, Heidenreich PA, Barnett PG, et al. ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Circulation. 2014;129:2329-45. 6. ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. American College of Cardiology and American Heart Association, 2010. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf and http://professional.heart.org/idc/groups/ahamah- public/@wcm/@sop/documents/downloadable/ucm_319826.pdf. Accessed September 15, 2017. 7. Halperin JL, Levine GN, Al-Khatib SM, et al. Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2016;133:1426-8. 8. Jacobs AK, Kushner FG, Ettinger SM. ACCF/AHA clinical practice guideline methodology summit report: a D o report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice w n lo Guidelines. Circulation. 2013;127:268-310. a de 9. Jacobs AK, Anderson JL, Halperin JL. The evolution and future of ACC/AHA clinical practice guidelines: a 30- d fro year journey: a report of the American College of Cardiology/American Heart Association Task Force on m Practice Guidelines. Circulation. 2014;130:1208-17. h ttp 10. Arnett DK, Goodman RA, Halperin JL, et al. AHA/ACC/HHS strategies to enhance application of clinical practice ://h guidelines in patients with cardiovascular disease and comorbid conditions: from the American Heart y p e Association, American College of Cardiology, and U.S. Department of Health and Human Services. Circulation. r.a h 2014;130:1662-7. a jo u rn a ls .o rg b/ 1. Introduction y g u As early as the 1920s, and subsequently in the 1959 Build and Blood Pressure Study (1) of almost 5 million e s t o adults insured between 1934 and 1954, a strong direct relationship was noted between level of BP and n N risk of clinical complications and death. In the 1960s, these findings were confirmed in a series of reports o v em from the Framingham Heart Study (2). The 1967 and 1970 Veterans Administration Cooperative Study b er 2 Group reports ushered in the era of effective treatment for high BP (3, 4). The first comprehensive 0, 2 guideline for detection, evaluation, and management of high BP was published in 1977, under the 0 1 sponsorship of the NHLBI (5). In subsequent years, a series of Joint National Committee (JNC) BP guidelines 7 were published to assist the practice community and improve prevention, awareness, treatment, and control of high BP (5-7). The present guideline updates prior JNC reports. 1.1. Methodology and Evidence Review An extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted between February and August 2015. Key search words included but were not limited to the following: adherence; aerobic; alcohol intake; ambulatory care; antihypertensive: agents, drug, medication, therapy; beta adrenergic blockers; blood pressure: arterial, control, determination, devices, goal, high, improve, measurement, monitoring, ambulatory; calcium channel blockers; diet; diuretic agent; drug therapy; heart failure: diastolic, systolic; hypertension: white coat, masked, ambulatory, isolated ambulatory, isolated clinic, diagnosis, reverse white coat, prevention, therapy, treatment, control; Page 10