Hypertension Management (ACC/AHA 2017)

Algorithm Steps

1. ▶

   Start

   Blood Pressure Measurement

   Average of ≥2 readings on ≥2 occasions

   1. ◆

      Decision

      BP Classification

      Classify based on systolic/diastolic readings

      • Normal: <120/<80 mmHg
      • Elevated: 120-129/<80 mmHg
      • Stage 1 HTN: 130-139 or 80-89 mmHg
      • Stage 2 HTN: ≥140 or ≥90 mmHg
      1. ✓

         Outcome

         Normal BP (<120/80)

         Promote healthy lifestyle, reassess annually

      2. ●

         Action

         Elevated BP (120-129/<80)

         Nonpharmacologic therapy

         • Weight loss if overweight
         • DASH diet
         • Sodium reduction <1500mg/day
         • Physical activity 90-150 min/week
         • Limit alcohol
         1. ●

            Action

            ASCVD Risk <10%

            Lifestyle modification, reassess in 3-6 months

            • Nonpharmacologic therapy alone initially
            • If BP still elevated at 3-6 months, add medication
            • Consider medication if compelling indication
            1. ●

               Action

               First-Line Antihypertensive Agents

               Choose based on compelling indications

               • Thiazide diuretics (chlorthalidone preferred)
               • ACE inhibitors (if DM, CKD, HF, post-MI)
               • ARBs (alternative to ACE-I)
               • Calcium channel blockers (DHP preferred)
               • Avoid: ACE-I + ARB combination
               1. ●

                  Action

                  Compelling Indications

                  Specific drug classes recommended

                  • CKD: ACE-I or ARB
                  • Diabetes: ACE-I or ARB
                  • Heart Failure: ACE-I/ARB + BB + diuretic
                  • Post-MI: BB + ACE-I
                  • Recurrent stroke: Thiazide + ACE-I
                  • Stable CAD: BB, CCB, ACE-I
                  1. ●

                     Action

                     Monthly Follow-Up

                     Titrate until goal achieved

                     • Goal: <130/80 for most patients
                     • Increase dose or add agent monthly if not at goal
                     • If 3 agents needed, add spironolactone
                     • Consider specialist referral if resistant
                     1. ✓

                        Outcome

                        BP Goal Achieved (<130/80)

                        Continue therapy, follow-up every 3-6 months

                     2. ⚠

                        Warning

                        Resistant Hypertension

                        BP above goal on ≥3 agents including diuretic

                        • Confirm true resistance (adherence, technique)
                        • Screen for secondary causes
                        • Consider specialist referral
                        • Add spironolactone 25-50mg
      3. ◆

         Decision

         Stage 1 HTN (130-139/80-89)

         Assess 10-year ASCVD risk

         • Use ACC/AHA ASCVD Risk Calculator
         • Consider clinical ASCVD, DM, CKD
         • Risk ≥10% = high risk
         1. ●

            Action

            ASCVD Risk ≥10% or Clinical CVD/DM/CKD

            Lifestyle + pharmacotherapy

            • Start single first-line agent
            • Titrate to goal <130/80
            • Follow up in 1 month
      4. ●

         Action

         Stage 2 HTN (≥140/90)

         Initiate pharmacotherapy + lifestyle

         • Start with 2 first-line agents
         • Consider single-pill combination
         • BP goal <130/80 for most patients