Hypertension | Guidelines and Management

Hypertension is a life-threatening condition that affects 1.13 billion people worldwide, according to the world health organization (WHO). It’s a leading cause of premature death around the world. Thus, we should know more about it; we will discuss the hypertension guidelines that show the different systems of classification and management.

• Guidelines are useful to know the best way to evaluate and deal with hypertension cases.

We will discuss guidelines issued by some organizations, including the European society of hypertension (ESH), European society of cardiology (ESC), American college of cardiology (ACC), American Heart Association (AHA), and the Joint National Committee (JNC).

We will discuss the guidelines for hypertension classifications, targeting blood pressure management, hypertensive emergencies, and hypertension in pregnancy.

Guidelines for hypertension classifications

European society of hypertension (ESH), and the European society of cardiology (ESC) issued this classification system:

• • Optimal blood pressure is lower than 120/80 mmHg.
  • Normal blood pressure is between 120/80 mmHg and 129/84 mmHg.
  • High normal blood pressure ranges between 130/85 mmHg and 139/89 mmHg.
  • Grade 1 hypertension ranges between 140/90 mmHg and 159/99 mmHg.
  • Grade 2 hypertension ranges between 160/100 mmHg and 179/109 mmHg.
  • Grade 3 hypertension is 180/110 mmHg or higher.
  • Isolated systolic hypertension can be diagnosed after a systolic blood pressure of 140 mmHg or higher, with a diastolic blood pressure lower than 90 mmHg.

American college of cardiology (ACC) and American heart association (AHA) issued this classification system:

• • Normal blood pressure is lower than 120/80 mmHg.
  • Elevated blood pressure equals 120-129/80 mmHg
  • Stage 1 hypertension ranges between 130/80 mmHg and 139/89 mmHg.
  • Stage 2 hypertension is higher than 140/90 mmHg.
  • Hypertensive crisis occurs when blood pressure is higher than 180/120 mmHg.

According to the 7th report of the joint national committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure:

• • Normal blood pressure is lower than 120/80 mmHg.
  • Prehypertension ranges between 120/80 mmHg and139/89 mmHg.
  • Stage 1 hypertension: It occurs when blood pressure is between 140/90 mmHg and 159/99 mmHg.
  • Stage 2 hypertension is higher than 160/100 mmHg.

This classification is the most used in the United States for adults (≥18 years).

» Now, let’s know the guideline for target blood pressure to know at which level we should keep our blood pressure.

Guidelines for target blood pressure

Joint national committee (JNC) issued two reports about the target blood pressure:

1. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2003): It determined target blood pressure as less than 140/90 mmHg in healthy adults and less than 130/80 mmHg in those with other conditions like diabetes or kidney diseases.
2. Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2014): It determined target blood pressure as less than 140/90 mmHg in adults between 18 and 60 years old with other conditions like diabetes or kidney diseases. But for those who are above 60 years old, this report determined target blood pressure as less than 150/90 mmHg.

American college of cardiology (ACC) and American heart association (AHA), in 2017, determined target blood pressure as less than 130/80 mmHg for all adults.

» Because hypertension is an asymptomatic and dangerous condition, it’s useful to screen your blood pressure continuously. Thus, we will discuss the guidelines for blood pressure screening.

Guidelines for blood pressure screening

The European society of hypertension (ESH), and the European society of cardiology (ESC) guidelines (2018) recommended blood pressure screening for all adults as following:

• • Every five years for those with optimal blood pressure (less than 120/80 mmHg)
  • Every three years for those with normal blood pressure (between 120/80 mmHg and129/84 mmHg)
  • Every year for those with high normal blood pressure (between 130/85 mmHg and 139/89 mmHg)

According to these guidelines, the diagnosis should be after, at least, 2 measurements on two separate occasions.

The 7th report of the joint national committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2003) recommended blood pressure screening every two years for adults with normal blood pressure (less than 120/80 mmHg) and every year for those in the prehypertension stage (between 120/80 mmHg and 139/89 mmHg).

According to this report, the diagnosis should depend on 2 or more measurements on 2 or more doctor visits.

» Now, we will discuss the guidelines for hypertension management to know the different systems for hypertension management.

Guidelines for hypertension management

There are many guidelines for hypertension management, but we will discuss the most used ones. The guidelines of the Joint national committee (JNC 7), and the American Diabetes Association (ADA) are the most used.

Joint national committee (JNC 7) recommended the following guidelines:

• • Treatment of hypertension aims to reduce the risk of cardiovascular, renal, and cerebral complications, which may be fatal.
  • People in the prehypertension stage (between 120/80 mmHg and139/89 mmHg) should follow a healthy lifestyle to avoid a further increase in blood pressure and reduce the risk of cardiovascular complications.
  • Thiazide diuretics are the first-line treatment for hypertensive patients without complications. Treating doctors can use it alone or combined with other antihypertensive medications.
  • For patients with a high risk of complications, we should use stronger classes of antihypertensive medications like calcium channel blockers, beta-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers.
  • For patients with diabetes or kidney disease, we should use two or more antihypertensive drugs.
  • Regardless of the number of used antihypertensive drugs, one of them should be thiazide diuretic.

American Diabetes Association (ADA) guidelines (2017):

• • It’s better to reduce blood pressure to less than 130/80 mmHg with a healthy lifestyle only if you can do it.
  • If blood pressure becomes higher than 140/90 mmHg, we should add a pharmacologic treatment to the lifestyle plan.
  • We can use several classes of antihypertensive drugs: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics.
  • The first-line treatment for diabetic patients is the angiotensin-converting enzyme inhibitors or angiotensin receptor blockers; the doctor chooses the drug that the patient can tolerate.

♦ The most critical component of the treatment plan is the adherence to it. Thus, the patients must be compliant with their treatment plan to avoid complications.

Lifestyle modification has great benefits for hypertensive patients. Thus, we will discuss some recommendations issued by Joint national committee (JNC 7) and American heart association (AHA):

• • Weight reduction lowers the risk of hypertension; each 10 kg loss reduces blood pressure by 5-10 mmHg.
  • The diet should contain less sodium and fats, more potassium, calcium, and magnesium, and should be rich in fruits and vegetables.
  • Physical exercise for at least 30 minutes per day lowers the risk of hypertension and its cardiovascular complications; it can lower blood pressure by 4-9 mmHg.
  • Reduction of alcohol intake to less than 30mg ethanol for men and 15mg ethanol for women reduces blood pressure by 2-4 mmHg.
  • 30mg ethanol= 720ml of beer, 60ml of 100-proof whiskey, or 300ml of wine.
  • Cessation of smoking has remarkable benefits for hypertensive patients; it reduces the risk of cardiovascular complications.

» Now, we will discuss the guidelines for cases of hypertensive emergencies, issued by the American College of Emergency Physicians (ACEP) in 2013, and the American College of Cardiology/American Heart Association (ACC/AHA) in 2017.

Guidelines for cases of hypertensive emergencies

The American College of Emergency Physicians (ACEP), in 2013, issued guidelines for hypertensive patients in the emergency department, which focus on cases of hypertensive urgency (asymptomatic severe high blood pressure).

• • Cases of hypertensive urgency, in the emergency department, should have routine examination for multi-organ damage.
  • In the emergency department, doctors may treat high blood pressure and start a long-term treatment plan to control hypertension.
  • Doctors should refer their patients to regular follow-ups at outpatient clinics.

The American College of Cardiology/American Heart Association (ACC/AHA) in 2017 guidelines focuses on cases of hypertensive emergency (severe high blood pressure with symptoms of multi-organ damage).

• • In cases of hypertensive emergency, doctors should start intravenous therapy and continuous evaluation of blood pressure and multi-organ damage, at the intensive care unit (ICU).
  • Our initial goal, in these cases, is to lower blood pressure by less than 25% in the first hour. If the patient is still stable, we will lower blood pressure to 160/110 mmHg in the next 2-6 hours. If the patient is still stable after these reductions, we will lower blood pressure to a normal level in the next 24-48 hours.

» Now, we will discuss the guidelines for the management of hypertension in pregnancy to know the different ways to protect the pregnant mother and her baby.

Management of hypertension in pregnancy

• Joint national committee (JNC 7) recommended the treatment of the pregnant females with chronic (preexisting) hypertension who have blood pressure higher than 150/100 mmHg or 160/110 mmHg, regardless of the presence of organ damage.
• American College of Obstetricians and Gynecologists (ACOG) recommended considering fetal safety in the treatment plan. These guidelines recommended the alpha-methyl dopa as the first-line antihypertensive in pregnancy. Also, diuretics and beta-blockers are safe in pregnancy. These guidelines recommended avoiding the angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and renin inhibitors.