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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

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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†† Karen J. Collins, MBA‡ Crystal C. Spencer, JD‡ Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA§ Randall S. Stafford, MD, PhD‡‡ Sondra M. DePalma, MHS, PA-C, CLS, AACC║ Sandra J. Taler, MD, FAHA§§ Samuel Gidding, MD, FACC, FAHA¶ Randal J. Thomas, MD, MS, FACC, FAHA║║ Kenneth A. Jamerson, MD# Kim A. Williams, Sr, MD, MACC, FAHA† Daniel W. Jones, MD, FAHA† Jeff D. Williamson, MD, MHS¶¶ Eric J. MacLaughlin, PharmD** Jackson T. Wright, Jr, MD, PhD, FAHA## Paul Muntner, PhD, FAHA†

ACC/AHA TASK FORCE MEMBERS

Glenn N. Levine, MD, FACC, FAHA, Chair Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair Sana M. Al-Khatib, MD, MHS, FACC, FAHA Federico Gentile, MD, FACC Joshua A. Beckman, MD, MS, FAHA Samuel Gidding, MD, FAHA*** Kim K. Birtcher, MS, PharmD, AACC Zachary D. Goldberger, MD, MS, FACC, FAHA Biykem Bozkurt, MD, PhD, FACC, FAHA*** Mark A. Hlatky, MD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC*** John Ikonomidis, MD, PhD, FAHA 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.

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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.

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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. 2017;:e–e. This article has been copublished in the Journal of the American College of Cardiology. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional.heart.org). A copy of the document is available at http://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 843-216-2533 or e-mail [email protected] Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.” Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-PermissionGuidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page. (Hypertension. 2017;00:e000-e000.) © 2017 by the American College of Cardiology Foundation and the American Heart Association, Inc. Hypertension is available at http://hyper.ahajournals.org

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table of Contents

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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 3.1. Definition of High BP ....................................................................................................................... 21 3.2. Lifetime Risk of Hypertension ......................................................................................................... 23 3.3. Prevalence of High BP ..................................................................................................................... 23 3.4. Awareness, Treatment, and Control ............................................................................................... 26 4. Measurement of BP...................................................................................................................... 27 4.1. Accurate Measurement of BP in the Office .................................................................................... 27 4.2. Out-of-Office and Self-Monitoring of BP ........................................................................................ 29 4.3. Ambulatory BP Monitoring ............................................................................................................. 31 4.4. Masked and White Coat Hypertension ........................................................................................... 33 5. Causes of Hypertension ................................................................................................................ 39 5.1. Genetic Predisposition .................................................................................................................... 39 5.2. Environmental Risk Factors ............................................................................................................. 39 5.2.1. Overweight and Obesity .............................................................................................................. 40 5.2.2. Sodium Intake ........................................................................................................................... 40 5.2.3. Potassium .................................................................................................................................. 40 5.2.4. Physical Fitness ......................................................................................................................... 41 5.2.5. Alcohol ...................................................................................................................................... 41 5.3. Childhood Risk Factors and BP Tracking ......................................................................................... 43 5.4. Secondary Forms of Hypertension .................................................................................................. 43 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

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline

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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 9.2.2. Heart Failure With Preserved Ejection Fraction ....................................................................... 97 9.3. Chronic Kidney Disease ................................................................................................................. 100 9.3.1. Hypertension After Renal Transplantation ............................................................................. 105 9.4. Cerebrovascular Disease ............................................................................................................... 106 9.4.1. Acute Intracerebral Hemorrhage ............................................................................................ 107 9.4.2. Acute Ischemic Stroke ............................................................................................................. 109 9.4.3. Secondary Stroke Prevention.................................................................................................. 112 9.5. Peripheral Arterial Disease............................................................................................................ 115 9.6. Diabetes Mellitus .......................................................................................................................... 116 9.7. Metabolic Syndrome ..................................................................................................................... 119 9.8. Atrial Fibrillation............................................................................................................................ 120 9.9. Valvular Heart Disease .................................................................................................................. 121 9.10. Aortic Disease.............................................................................................................................. 122 10. Special Patient Groups.............................................................................................................. 123 10.1. Race and Ethnicity ....................................................................................................................... 123 10.1.1 Racial and Ethnic Differences in Treatment........................................................................... 125 10.2. Sex-Related Issues ....................................................................................................................... 127 10.2.1. Women.................................................................................................................................. 127 10.2.2. Pregnancy.............................................................................................................................. 127 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

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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 Appendix 1. Author Relationships With Industry and Other Entities (Relevant)................................ 168 Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) .................. 174

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline

Preamble

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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 evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA.

Intended Use

Practice guidelines provide recommendations applicable to patients with or at risk of developing CVD. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations can have a global impact. Although guidelines may be used to inform regulatory or payer decisions, they are intended to improve patients’ quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.

Clinical Implementation

Management in accordance with guideline recommendations is effective only when followed by both practitioners and patients. Adherence to recommendations can be enhanced by shared decision making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities.

Methodology and Modernization

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

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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 Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds. Writing committee members represent different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice. The Task Force may also invite organizations and professional societies with related interests and expertise to participate as partners, collaborators, or endorsers.

Relationships With Industry and Other Entities

The ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without bias or improper influence. The complete relationships with industry and other entities (RWI) policy can be found at http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-withindustry-policy. Appendix 1 of the present document lists writing committee members’ relevant RWI. For the purposes of full transparency, writing committee members’ comprehensive disclosure information is available online (http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYP.0000000000000065//DC1). Comprehensive disclosure information for the Task Force is available at http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/guidelines-and-documentstask-forces.

Evidence Review and Evidence Review Committees

In developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data (6-9). Literature searches focus on randomized controlled trials (RCTs) but also 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”.

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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 Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

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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)

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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.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 4.

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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/ahamahpublic/@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 report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:268-310. 9. Jacobs AK, Anderson JL, Halperin JL. The evolution and future of ACC/AHA clinical practice guidelines: a 30year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:1208-17. 10. Arnett DK, Goodman RA, Halperin JL, et al. AHA/ACC/HHS strategies to enhance application of clinical practice guidelines in patients with cardiovascular disease and comorbid conditions: from the American Heart Association, American College of Cardiology, and U.S. Department of Health and Human Services. Circulation. 2014;130:1662-7.

1. Introduction

As early as the 1920s, and subsequently in the 1959 Build and Blood Pressure Study (1) of almost 5 million adults insured between 1934 and 1954, a strong direct relationship was noted between level of BP and risk of clinical complications and death. In the 1960s, these findings were confirmed in a series of reports from the Framingham Heart Study (2). The 1967 and 1970 Veterans Administration Cooperative Study Group reports ushered in the era of effective treatment for high BP (3, 4). The first comprehensive guideline for detection, evaluation, and management of high BP was published in 1977, under the sponsorship of the NHLBI (5). In subsequent years, a series of Joint National Committee (JNC) BP guidelines 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;

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intervention; lifestyle: measures, modification; office visits; patient outcome; performance measures; physical activity; potassium intake; protein intake; renin inhibitor; risk reduction: behavior, counseling; screening; sphygmomanometers; spironolactone; therapy; treatment: adherence, compliance, efficacy, outcome, protocol, regimen; weight. Additional relevant studies published through June 2016, during the guideline writing process, were also considered by the writing committee and added to the evidence tables when appropriate. The final evidence tables included in the Online Data Supplement (http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYP.0000000000000065/-/DC2) summarize the evidence used by the writing committee to formulate recommendations. As noted in the preamble, an independent ERC was commissioned to perform a formal systematic review of 4 critical clinical questions related to hypertension (Table 2), the results of which were considered by the writing committee for incorporation into this guideline. Concurrent with this process, writing committee members evaluated other published data relevant to the guideline. The findings of the ERC and the writing committee members were formally presented and discussed, and then guideline recommendations were developed. The systematic review report, “Systematic Review for the 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,” is published in conjunction with this guideline (8), and its respective data supplements are available online (http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYP.0000000000000067/-/DC2). No writing committee member reported a RWI. Drs. Whelton, Wright, and Williamson had leadership roles in SPRINT (Systolic Blood Pressure Intervention Trial). Dr. Carey chaired committee discussions in which the SPRINT results were considered. Table 2. Systematic Review Questions on High BP in Adults Question Number 1

2

Question Is there evidence that self-directed monitoring of BP and/or ambulatory BP monitoring are superior to office-based measurement of BP by a healthcare worker for 1) preventing adverse outcomes for which high BP is a risk factor and 2) achieving better BP control? What is the optimal target for BP lowering during antihypertensive therapy in adults?

3

In adults with hypertension, do various antihypertensive drug classes differ in their comparative benefits and harms? 4 In adults with hypertension, does initiating treatment with antihypertensive pharmacological monotherapy versus initiating treatment with 2 drugs (including fixeddose combination therapy), either of which may be followed by the addition of sequential drugs, differ in comparative benefits and/or harms on specific health outcomes? BP indicates blood pressure.

Section Number 4.2

8.1.5 9.3 9.6 8.1.6 8.2 8.1.6.1

1.2. Organization of the Writing Committee The writing committee consisted of clinicians, cardiologists, epidemiologists, internists, an endocrinologist, a geriatrician, a nephrologist, a neurologist, a nurse, a pharmacist, a physician assistant, and 2 lay/patient representatives. It included representatives from the ACC, AHA, American Academy of Physician Assistants (AAPA), Association of Black Cardiologists (ABC), American College of Preventive Medicine (ACPM), American Geriatrics Society (AGS), American Pharmacists Association (APhA), American

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Society of Hypertension (ASH), American Society for Preventive Cardiology (ASPC), National Medical Association (NMA), and Preventive Cardiovascular Nurses Association (PCNA).

1.3. Document Review and Approval This document was reviewed by 2 official reviewers nominated by the ACC and AHA; 1 reviewer each from the AAPA, ABC, ACPM, AGS, APhA, ASH, ASPC, NMA, and PCNA; and 38 individual content reviewers. Reviewers’ RWI information was distributed to the writing committee and is published in this document (Appendix 2). This document was approved for publication by the governing bodies of the ACC, AHA, AAPA, ABC, ACPM, AGS, APhA, ASH, ASPC, NMA, and PCNA.

1.4. Scope of the Guideline Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

The present guideline is intended to be a resource for the clinical and public health practice communities. It is designed to be comprehensive but succinct and practical in providing guidance for prevention, detection, evaluation, and management of high BP. It is an update of the NHLBI publication, “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7) (7). It incorporates new information from studies of office-based BP-related risk of CVD, ambulatory blood pressure monitoring (ABPM), home blood pressure monitoring (HBPM), telemedicine, and various other areas. This guideline does not address the use of BP-lowering medications for the purposes of prevention of recurrent CVD events in patients with stable ischemic heart disease (SIHD) or chronic heart failure (HF) in the absence of hypertension; these topics are the focus of other ACC/AHA guidelines (9, 10). In developing the present guideline, the writing committee reviewed prior published guidelines, evidence reviews, and related statements. Table 3 contains a list of publications and statements deemed pertinent to this writing effort and is intended for use as a resource, thus obviating the need to repeat existing guideline recommendations. Table 3. Associated Guidelines and Statements Title Guidelines Lower-extremity peripheral artery disease Management of primary aldosteronism: case detection, diagnosis, and treatment Stable ischemic heart disease Pheochromocytoma and paraganglioma Atrial fibrillation Valvular heart disease Assessment of cardiovascular risk Hypertension in pregnancy Heart failure

Organization

Publication Year

AHA/ACC

2016 (11)

Endocrine Society

2016 (12)

ACC/AHA/AATS/PCNA/SCAI/STS Endocrine Society

2014 (13)*2012 (9) 2014 (14)

AHA/ACC/HRS ACC/AHA ACC/AHA ACOG ACC/AHA AHA/ACC

2014 (15) 2017 (16) 2013 (17) 2013 (18) 2017 (19) 2013 (10) 2013 (20)

ESH/ESC

2013 (21)

Lifestyle management to reduce cardiovascular risk Management of arterial hypertension

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Management of overweight and obesity in adults ST-elevation myocardial infarction Treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults Cardiovascular diseases during pregnancy Effectiveness-based guidelines for the prevention of cardiovascular disease in women Secondary prevention and riskreduction therapy for patients with coronary and other atherosclerotic vascular disease Assessment of cardiovascular risk in asymptomatic adults Thoracic aortic disease

AHA/ACC/TOS

2013 (22)

ACC/AHA ACC/AHA

2013 (23) 2013 (24)

ESC

2011 (25)

AHA/ACC

2011 (26)

AHA/ACC

2011 (27)

ACC/AHA

2010 (28)

ACC/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/ STS/SVM NHLBI

2010 (29)

Diagnosis, evaluation, and 2004 (30) treatment of high blood pressure in children and adolescents Statements Salt sensitivity of blood pressure AHA 2016 (31) Cardiovascular team-based care and ACC 2015 (32) the role of advanced practice providers Treatment of hypertension in AHA/ACC/ASH 2015 (33) patients with coronary artery disease Ambulatory blood pressure AHA 2014 (34) monitoring in children and adolescents An effective approach to high blood AHA/ACC/CDC 2014 (35) pressure control Ambulatory blood pressure ESH 2013 (36) monitoring Performance measures for adults ACC/AHA/AMA-PCPI 2011 (37) with coronary artery disease and hypertension Interventions to promote physical AHA 2010 (38) activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults Resistant hypertension: diagnosis, AHA 2008 (39) evaluation, and treatment *The full-text SIHD guideline is from 2012 (9). A focused update was published in 2014 (13). AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ACOG, American College of Obstetricians and Gynecologists; ACR, American College of Radiology; AHA, American Heart Association; AMA, American Medical Association; ASA, American Stroke Association; ASH, American Society of Hypertension; CDC, Centers for Disease Control and Prevention; ESC, European Society of Cardiology; ESH, European Society of

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Hypertension; HRS, Heart Rhythm Society; NHLBI, National Heart, Lung, and Blood Institute; PCNA, Preventive Cardiovascular Nurses Association; PCPI, Physician Consortium for Performance Improvement; SCA, Society of Cardiovascular Anesthesiologists; SCAI, Society for Cardiovascular Angiography and Interventions; SIHD, stable ischemic heart disease; SIR, Society of Interventional Radiology; STS, Society of Thoracic Surgeons; SVM, Society for Vascular Medicine; and TOS, The Obesity Society.

1.5. Abbreviations and Acronyms

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Abbreviation/Acronym ABPM ACE AF ARB BP CCB CHD CKD CPAP CVD DBP DM ECG ESRD GDMT GFR HBPM EHR HF HFpEF HFrEF ICH JNC LV LVH MI MRI PAD RAS RCT SBP SIHD TIA

Meaning/Phrase ambulatory blood pressure monitoring angiotensin-converting enzyme atrial fibrillation angiotensin receptor blocker blood pressure calcium channel blocker coronary heart disease chronic kidney disease continuous positive airway pressure cardiovascular disease diastolic blood pressure diabetes mellitus electrocardiogram end-stage renal disease guideline-directed management and therapy glomerular filtration rate home blood pressure monitoring electronic health record heart failure heart failure with preserved ejection fraction heart failure with reduced ejection fraction intracerebral hemorrhage Joint National Commission left ventricular left ventricular hypertrophy myocardial infarction magnetic resonance imaging peripheral artery disease renin-angiotensin system randomized controlled trial systolic blood pressure stable ischemic heart disease transient ischemic attack

References 1. Society of Actuaries. Build and Blood Pressure Study. Vol 1. Ann Arbor, MI: The University of Michigan; 1959. 2. Dawber TR. The Framingham Study: The Epidemiology of Atherosclerotic Disease. Cambridge, MA: Harvard University Press; 1980. 3. Effects of treatment on morbidity in hypertension. I. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA. 1967;202:1028-34.

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10. 11. 12. 13.

14. 15. 16.

17. 18. 19.

Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA. 1970;213:1143-52. Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. A cooperative study. JAMA. 1977;237:255-61. Moser M, Roccella EJ. The treatment of hypertension: a remarkable success story. J Clin Hypertens (Greenwich). 2013;15:88-91. Chobanian AV, Bakris GL, Black HR, et al; the National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52. Reboussin DM, Allen NB, Griswold ME, et al. Systematic review for the 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. Circulation. 2017. In press. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126:e354-471. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240-327. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e726-79. Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2016;101:1889-916. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014;130:174967. Lenders JWM, Duh Q-Y, Eisenhofer G, et al. Pheochromocytoma and paraganglioma: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014;99:1915-42. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014;130:e199-267. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e1159-95. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S49-73. American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122:1122-31. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136:e137-61.

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20. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S76-99. 21. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. 22. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014;129(suppl 2):S102-38. 23. O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362-425. 24. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S145. 25. Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147-97. 26. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243-62. 27. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. Circulation. 2011;124:2458-73. 28. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010;122:e584-636. 29. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266-369. 30. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114:555-76. 31. Elijovich F, Weinberger MH, Anderson CAM, et al. Salt sensitivity of blood pressure: a scientific statement from the American Heart Association. Hypertension. 2016;68:e7-46. 32. Brush JE Jr, Handberg EM, Biga C, et al. 2015 ACC health policy statement on cardiovascular team-based care and the role of advanced practice providers. J Am Coll Cardiol. 2015;65:2118-36. 33. Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Circulation. 2015;131:e435-70. 34. Flynn JT, Daniels SR, Hayman LL, et al. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63:1116-35. 35. Go AS, Bauman MA, Coleman King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension. 2014;63:878-85. 36. O'Brien E, Parati G, Stergiou G, et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31:1731-68.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 37. Drozda J Jr, Messer JV, Spertus J, et al. ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement. Circulation. 2011;124:248-70. 38. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 2010;122:406-41. 39. Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment:a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008;51:1403-19.

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2.1. Observational Relationship Observational studies have demonstrated graded associations between higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) and increased CVD risk (1, 2). In a meta-analysis of 61 prospective studies, the risk of CVD increased in a log-linear fashion from SBP levels <115 mm Hg to >180 mm Hg and from DBP levels <75 mm Hg to >105 mm Hg (1). In that analysis, 20 mm Hg higher SBP and 10 mm Hg higher DBP were each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. In a separate observational study including >1 million adult patients ≥30 years of age, higher SBP and DBP were associated with increased risk of CVD incidence and angina, myocardial infarction (MI), HF, stroke, peripheral artery disease (PAD), and abdominal aortic aneurysm, each evaluated separately (2). An increased risk of CVD associated with higher SBP and DBP has been reported across a broad age spectrum, from 30 years to >80 years of age. Although the relative risk of incident CVD associated with higher SBP and DBP is smaller at older ages, the corresponding high BP–related increase in absolute risk is larger in older persons (≥65 years) given the higher absolute risk of CVD at an older age (1). References 1. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-13. 2. Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet. 2014;383:1899-911.

2.2. BP Components Epidemiological studies have evaluated associations of SBP and DBP, as well as derived components of BP measurements (including pulse pressure, mean BP, and mid-BP), with CVD outcomes (Table 4). When considered separately, higher levels of both SBP and DBP have been associated with increased CVD risk (1, 2). Higher SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, DBP (3-5). In contrast, after consideration of SBP through adjustment or stratification, DBP has not been consistently associated with CVD risk (6, 7). Although pulse pressure and mid-BP have been associated with increased CVD risk independent of SBP and DBP in some studies, SBP (especially) and DBP are prioritized in the present document because of the robust evidence base for these measures in both observational studies and clinical trials and because of their ease of measurement in practice settings (8-11).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 4. BP Measurement Definitions BP Measurement Definition SBP First Korotkoff sound* DBP Fifth Korotkoff sound* Pulse pressure SBP minus DBP Mean arterial pressure DBP plus one third pulse pressure† Mid-BP Sum of SBP and DBP, divided by 2 *See Section 4 for a description of Korotkoff sounds. †Calculation assumes normal heart rate. BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure.

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References 1. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-13. 2. Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet. 2014;383:1899-911. 3. Rutan GH, Kuller LH, Neaton JD, et al. Mortality associated with diastolic hypertension and isolated systolic hypertension among men screened for the Multiple Risk Factor Intervention Trial. Circulation. 1988;77:504-14. 4. Sesso HD, Stampfer MJ, Rosner B, et al. Systolic and diastolic blood pressure, pulse pressure, and mean arterial pressure as predictors of cardiovascular disease risk in men. Hypertension. 2000;36:801-7. 5. Stamler J, Stamler R, Neaton JD. Blood pressure, systolic and diastolic, and cardiovascular risks. US population data. Arch Intern Med. 1993;153:598-615. 6. Benetos A, Thomas F, Bean K, et al. Prognostic value of systolic and diastolic blood pressure in treated hypertensive men. Arch Intern Med. 2002;162:577-81. 7. Lindenstrom E, Boysen G, Nyboe J. Influence of systolic and diastolic blood pressure on stroke risk: a prospective observational study. Am J. Epidemiol. 1995;142:1279-90. 8. Zhao L, Song Y, Dong P, et al. Brachial pulse pressure and cardiovascular or all-cause mortality in the general population: a meta-analysis of prospective observational studies. J Clin Hypertens (Greenwich). 2014;16:678-85. 9. Mosley WJ, Greenland P, Garside DB, et al. Predictive utility of pulse pressure and other blood pressure measures for cardiovascular outcomes. Hypertension. 2007;49:1256-64. 10. Franklin SS, Lopez VA, Wong ND, et al. Single versus combined blood pressure components and risk for cardiovascular disease: the Framingham Heart Study. Circulation. 2009;119:243-50. 11. Kodama S, Horikawa C, Fujihara K, et al. Meta-analysis of the quantitative relation between pulse pressure and mean arterial pressure and cardiovascular risk in patients with diabetes mellitus. Am J Cardiol. 2014;113:1058-65.

2.3. Population Risk In 2010, high BP was the leading cause of death and disability-adjusted life years worldwide (1, 2). In the United States, hypertension (see Section 3.1 for definition) accounted for more CVD deaths than any other modifiable CVD risk factor and was second only to cigarette smoking as a preventable cause of death for any reason (3). In a follow-up study of 23,272 U.S. NHANES (National Health and Nutrition Examination Survey) participants, >50% of deaths from coronary heart disease (CHD) and stroke occurred among individuals with hypertension (4). Because of the high prevalence of hypertension and its associated increased risk of CHD, stroke, and end-stage renal disease (ESRD), the populationattributable risk of these outcomes associated with hypertension is high (4, 5). In the population-based ARIC (Atherosclerosis Risk in Communities) study, 25% of the cardiovascular events (CHD, coronary revascularization, stroke, or HF) were attributable to hypertension. In the Northern Manhattan study, the percentage of events attributable to hypertension was higher in women (32%) than in men (19%) and higher in blacks (36%) than in whites (21%) (6). In 2012, hypertension was the second leading assigned cause of ESRD, behind diabetes mellitus (DM), and accounted for 34% of incident ESRD cases in the U.S. population (7).

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References 1. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2224-60. 2. Forouzanfar MH, Liu P, Roth GA, et al. Global burden of hypertension and systolic blood pressure of at Least 110 to 115 mm Hg, 1990-2015. JAMA. 2017;317:165-82. 3. Danaei G, Ding EL, Mozaffarian D, et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009;6:e1000058. 4. Ford ES. Trends in mortality from all causes and cardiovascular disease among hypertensive and nonhypertensive adults in the United States. Circulation. 2011;123:1737-44. 5. Cheng S, Claggett B, Correia AW, et al. Temporal trends in the population attributable risk for cardiovascular disease: the Atherosclerosis Risk in Communities Study. Circulation. 2014;130:820-8. 6. Willey JZ, Moon YP, Kahn E, et al. Population attributable risks of hypertension and diabetes for cardiovascular disease and stroke in the northern Manhattan study. J Am Heart Assoc. 2014;3:e001106. 7. Saran R, Li Y, Robinson B, et al. US Renal Data System 2014 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2015;66 Svii:S1-305.

2.4. Coexistence of Hypertension and Related Chronic Conditions Recommendation for Coexistence of Hypertension and Related Chronic Conditions References that support the recommendation are summarized in Online Data Supplement 1. COR

LOE

I

B-NR

Recommendation 1. Screening for and management of other modifiable CVD risk factors are recommended in adults with hypertension (1, 2).

Synopsis Many adult patients with hypertension have other CVD risk factors; a list of such modifiable and relatively fixed risk factors is provided in Table 5. Among U.S. adults with hypertension between 2009 and 2012, 15.5% were current smokers, 49.5% were obese, 63.2% had hypercholesterolemia, 27.2% had DM, and 15.8% had chronic kidney disease (CKD; defined as estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2 and/or urine albumin:creatinine ≥300 mg/g) (3). Not only are CVD risk factors common among adults with hypertension, a higher percentage of adults with CVD risk factors have hypertension. For example, 71% of U.S. adults with diagnosed DM have hypertension (4). In the Chronic Renal Insufficiency Cohort (CRIC), 86% of the participants had hypertension (5). Also, 28.1% of adults with hypertension and CKD in the population-based REGARDS (Reasons for Geographic and Racial Differences in Stroke) study had apparent resistant hypertension (6). In NHANES 1999– 2010, 35.7% of obese individuals had hypertension (7). The presence of multiple CVD risk factors in individuals with hypertension results in high absolute risks for CHD and stroke in this population. For example, among U.S. adults with hypertension between 2009 and 2012, 41.7% had a 10-year CHD risk >20%, 40.9% had a risk of 10% to 20%, and only 18.4% had a risk <10% (3). Modifiable risk factors for CVD that are common among adults with hypertension include cigarette smoking/tobacco smoke exposure, DM, dyslipidemia (including high levels of low-density lipoprotein cholesterol or hypercholesterolemia, high levels of triglycerides, and low levels of high-density lipoprotein cholesterol), overweight/obesity, physical inactivity/low fitness level, and unhealthy diet (8). The relationship between hypertension and other modifiable risk factors is complex and interdependent, with several sharing mechanisms of action and pathophysiology. CVD risk factors affect BP through over activation of the reninangiotensin-aldosterone system, activation of the sympathetic nervous system, inhibition of the cardiac natriuretic peptide system, endothelial dysfunction, and other mechanisms (9-11). Treating some of the other modifiable risk factors may reduce BP through modification of shared pathology, and CVD risk may be reduced by treating global risk factor burden.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Recommendation-Specific Supportive Text 1. Observational studies have demonstrated that CVD risk factors frequently occur in combination, with ≥3 risk factors present in 17% of patients (1). A meta-analysis from 18 cohort studies involving 257,384 patients identified a lifetime risk of CVD death, nonfatal MI, and fatal or nonfatal stroke that was substantially higher in adults with ≥2 CVD risk factors than in those with only 1 risk factor (1, 2). Table 5. CVD Risk Factors Common in Patients With Hypertension Modifiable Risk Factors* • Current cigarette smoking, secondhand smoking • Diabetes mellitus • Dyslipidemia/hypercholesterolemia • Overweight/obesity • Physical inactivity/low fitness • Unhealthy diet

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Relatively Fixed Risk Factors† • CKD • Family history • Increased age • Low socioeconomic/educational status • Male sex • Obstructive sleep apnea • Psychosocial stress *Factors that can be changed and, if changed, may reduce CVD risk. †Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive sleep apnea (12)), cannot be changed (family history, increased age, male sex), or, if changed through the use of current intervention techniques, may not reduce CVD risk (psychosocial stress) (12). CKD indicates chronic kidney disease; and CVD, cardiovascular disease. References 1. Wilson PW, Kannel WB, Silbershatz H, et al. Clustering of metabolic factors and coronary heart disease. Arch Intern Med. 1999;159:1104-9. 2. Berry JD, Dyer A, Cai X, et al. Lifetime risks of cardiovascular disease. N Engl J Med. 2012;366:321-9. 3. Egan BM, Li J, Hutchison FN, et al. Hypertension in the United States, 1999 to 2012: progress toward Healthy People 2020 goals. Circulation. 2014;130:1692-9. 4. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States. Atlanta, GA: U.S. Department of Health and Human Services; 2014. 5. Muntner P, Anderson A, Charleston J, et al. Hypertension awareness, treatment, and control in adults with CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis. 2010;55:441-51. 6. Tanner RM, Calhoun DA, Bell EK, et al. Prevalence of apparent treatment-resistant hypertension among individuals with CKD. Clin J Am Soc Nephrol. 2013;8:1583-90. 7. Saydah S, Bullard KM, Cheng Y, et al. Trends in cardiovascular disease risk factors by obesity level in adults in the United States, NHANES 1999-2010. Obesity (Silver Spring). 2014;22:1888-95. 8. Castelli WP. Epidemiology of coronary heart disease: the Framingham study. Am J Med. 1984;76:4-12. 9. Sarzani R, Salvi F, Dessi-Fulgheri P, et al. Renin-angiotensin system, natriuretic peptides, obesity, metabolic syndrome, and hypertension: an integrated view in humans. J Hypertens. 2008;26:831-43. 10. Grassi G, Seravalle G, Cattaneo BM, et al. Sympathetic activation in obese normotensive subjects. Hypertension. 1995;25:560-3. 11. Kim J, Montagnani M, Koh KK, et al. Reciprocal relationships between insulin resistance and endothelial dysfunction: molecular and pathophysiological mechanisms. Circulation. 2006;113:1888-904. 12. McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016;375:919-31.

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3. Classification of BP 3.1. Definition of High BP Recommendation for Definition of High BP References that support the recommendation are summarized in Online Data Supplement 2. COR LOE Recommendation 1. BP should be categorized as normal, elevated, or stage 1 or 2 hypertension I B-NR to prevent and treat high BP (Table 6) (1-20). Synopsis Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Although a continuous association exists between higher BP and increased CVD risk (see Section 2.1), it is useful to categorize BP levels for clinical and public health decision making. In the present document, BP is categorized into 4 levels on the basis of average BP measured in a healthcare setting (office pressures): normal, elevated, and stage 1 or 2 hypertension (Table 6). Online Data Supplement C illustrates schematically the SBP and DBP categories defining normal BP, elevated BP, and stages 1 and 2 hypertension. This categorization differs from that previously recommended in the JNC 7 report, with stage 1 hypertension now defined as an SBP of 130–139 or a DBP of 80–89 mm Hg, and with stage 2 hypertension in the present document corresponding to stages 1 and 2 in the JNC 7 report (21). The rationale for this categorization is based on observational data related to the association between SBP/DBP and CVD risk, RCTs of lifestyle modification to lower BP, and RCTs of treatment with antihypertensive medication to prevent CVD. The increased risk of CVD among adults with stage 2 hypertension is well established. An increasing number of individual studies and meta-analyses of observational data have reported a gradient of progressively higher CVD risk going from normal BP to elevated BP and stage 1 hypertension (4-10, 12, 13, 16). In many of these meta-analyses, the hazard ratios for CHD and stroke were between 1.1 and 1.5 for the comparison of SBP/DBP of 120–129/80– 84 mm Hg versus <120/80 mm Hg and between 1.5 and 2.0 for the comparison of SBP/DBP of 130–139/85– 89 mm Hg versus <120/80 mm Hg. This risk gradient was consistent across subgroups defined by sex and race/ethnicity. The relative increase in CVD risk associated with higher BP was attenuated but still present among older adults (1). The prevalence of severe hypertension has been declining over time, but approximately 12.3% of U.S. adults with hypertension have an average SBP ≥160 mm Hg or average DBP ≥100 mm Hg (22). Lifestyle modification and pharmacological antihypertensive treatment recommendations for individuals with elevated BP and stages 1 and 2 hypertension are provided in Sections 6 and 8, respectively. The relationship of this classification schema with measurements obtained by ambulatory BP recording and home BP measurements is discussed in Section 4.2. Recommendation-Specific Supportive Text 1. As was the case in previous BP classification systems, the choice and the naming of the categories were based on a pragmatic interpretation of BP-related CVD risk and benefit of BP reduction in clinical trials. Metaanalyses of observational studies have demonstrated that elevated BP and hypertension are associated with increased risk of CVD, ESRD, subclinical atherosclerosis, and all-cause death (1-17). The recommended BP classification system is most valuable in untreated adults as an aid in decisions about prevention or treatment of high BP. However, it is also useful in assessing the success of interventions to reduce BP.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 6. Categories of BP in Adults* BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated 120–129 mm Hg and <80 mm Hg Hypertension Stage 1 130–139 mm Hg or 80–89 mm Hg Stage 2 ≥140 mm Hg or ≥90 mm Hg *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as detailed in Section 4); DBP, diastolic blood pressure; and SBP systolic blood pressure.

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References 1. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-13. 2. Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people. Lancet. 2014;383:1899-911. 3. Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957-67. 4. Guo X, Zhang X, Guo L, et al. Association between pre-hypertension and cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Curr Hypertens Rep. 2013;15:703-16. 5. Guo X, Zhang X, Zheng L, et al. Prehypertension is not associated with all-cause mortality: a systematic review and meta-analysis of prospective studies. PLoS ONE. 2013;8:e61796. 6. Huang Y, Cai X, Li Y, et al. Prehypertension and the risk of stroke: a meta-analysis. Neurology. 2014;82:1153-61. 7. Huang Y, Cai X, Liu C, et al. Prehypertension and the risk of coronary heart disease in Asian and Western populations: a meta-analysis. J Am Heart Assoc. 2015;4:e001519. 8. Huang Y, Cai X, Zhang J, et al. Prehypertension and incidence of ESRD: a systematic review and meta-analysis. Am J Kidney Dis. 2014;63:76-83. 9. Huang Y, Su L, Cai X, et al. Association of all-cause and cardiovascular mortality with prehypertension: a metaanalysis. Am Heart J. 2014;167:160-8.e1. 10. Huang Y, Wang S, Cai X, et al. Prehypertension and incidence of cardiovascular disease: a meta-analysis. BMC Med. 2013;11:177. 11. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. 12. Lee M, Saver JL, Chang B, et al. Presence of baseline prehypertension and risk of incident stroke: a meta-analysis. Neurology. 2011;77:1330-7. 13. Shen L, Ma H, Xiang M-X, et al. Meta-analysis of cohort studies of baseline prehypertension and risk of coronary heart disease. Am J Cardiol. 2013;112:266-71. 14. Sundstrom J, Arima H, Jackson R, et al. Effects of blood pressure reduction in mild hypertension: a systematic review and meta-analysis. Ann Intern Med. 2015;162:184-91. 15. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 2. Effects at different baseline and achieved blood pressure levels--overview and meta-analyses of randomized trials. J Hypertens. 2014;32:2296-304. 16. Wang S, Wu H, Zhang Q, et al. Impact of baseline prehypertension on cardiovascular events and all-cause mortality in the general population: a meta-analysis of prospective cohort studies. Int J Cardiol. 2013;168:4857-60. 17. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387:435-43. 18. Cushman WC, Ford CE, Cutler JA, et al. Success and predictors of blood pressure control in diverse North American settings: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). J Clin Hypertens (Greenwich). 2002;4:393-404.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 19. Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359:995-1003. 20. Wald DS, Law M, Morris JK, et al. Combination therapy versus monotherapy in reducing blood pressure: metaanalysis on 11,000 participants from 42 trials. Am J Med. 2009;122:290-300. 21. Chobanian AV, Bakris GL, Black HR, et al; the National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52. 22. Yoon SS, Gu Q, Nwankwo T, et al. Trends in blood pressure among adults with hypertension: United States, 2003 to 2012. Hypertension. 2015;65:54-61.

3.2. Lifetime Risk of Hypertension

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Observational studies have documented a relatively high incidence of hypertension over periods of 5 to 10 years of follow-up (1, 2). Thus, there is a much higher long-term population burden of hypertension as BP progressively increases with age. Several studies have estimated the long-term cumulative incidence of developing hypertension (3, 4). In an analysis of 1132 white male medical students (mean age: approximately 23 years at baseline) in the Johns Hopkins Precursors study, 0.3%, 6.5%, and 37% developed hypertension at age 25, 45, and 65 years, respectively (5). In MESA (Multi-Ethnic Study of Atherosclerosis), the percentage of the population developing hypertension over their lifetimes was higher for African Americans and Hispanics than for whites and Asians (3). For adults 45 years of age without hypertension, the 40-year risk of developing hypertension was 93% for African-American, 92% for Hispanic, 86% for white, and 84% for Chinese adults (3). In the Framingham Heart Study, approximately 90% of adults free of hypertension at age 55 or 65 years developed hypertension during their lifetimes (4). All of these estimates were based on use of the 140/90– mm Hg cutpoint for recognition of hypertension and would have been higher had the 130/80–mm Hg cutpoint been used. References 1. Muntner P, Woodward M, Mann DM, et al. Comparison of the Framingham Heart Study hypertension model with blood pressure alone in the prediction of risk of hypertension: the Multi-Ethnic Study of Atherosclerosis. Hypertension. 2010;55:1339-45. 2. Parikh NI, Pencina MJ, Wang TJ, et al. A risk score for predicting near-term incidence of hypertension: the Framingham Heart Study. Ann Intern Med. 2008;148:102-10. 3. Carson AP, Howard G, Burke GL, et al. Ethnic differences in hypertension incidence among middle-aged and older adults: the multi-ethnic study of atherosclerosis. Hypertension. 2011;57:1101-7. 4. Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: the Framingham Heart Study. JAMA. 2002;287:1003-10. 5. Shihab HM, Meoni LA, Chu AY, et al. Body mass index and risk of incident hypertension over the life course: the Johns Hopkins Precursors Study. Circulation. 2012;126:2983-9.

3.3. Prevalence of High BP Prevalence estimates are greatly influenced by the choice of cutpoints to categorize high BP, the methods used to establish the diagnosis, and the population studied (1, 2). Most general population prevalence estimates are derived from national surveys. Table 7 provides estimates for prevalence of hypertension in the U.S. general adult population (≥20 years of age) that are based on the definitions of hypertension recommended in the present guideline and in the JNC 7 report. The prevalence of hypertension among U.S. adults is substantially higher when the definition in the present guideline is used versus the JNC 7 definition (46% versus 32%). However, as described in Section 8.1, nonpharmacological treatment (not antihypertensive medication) is recommended for most U.S. adults who have hypertension as defined in the present guideline but who would not meet the JNC 7 definition for hypertension. As a consequence, the new definition results

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline in only a small increase in the percentage of U.S. adults for whom antihypertensive medication is recommended in conjunction with lifestyle modification. The prevalence of hypertension rises dramatically with increasing age and is higher in blacks than in whites, Asians, and Hispanic Americans. NHANES estimates of JNC 7–defined hypertension prevalence have remained fairly stable since the early 2000s (1). Most contemporary population surveys, including NHANES, rely on an average of BP measurements obtained at a single visit (2), which is likely to result in an overestimate of hypertension prevalence compared with what would be found by using an average of ≥2 readings taken on ≥2 visits (1), as recommended in current and previous BP guidelines (3-5). The extent to which guideline recommendations for use of BP averages from ≥2 occasions is followed in practice is unclear. Adding selfreport of previously diagnosed hypertension yields a 5% to 10% higher estimate of prevalence (1, 6, 7). Most individuals who were added by use of this expanded definition have been diagnosed as having hypertension by a health professional on >1 occasion, and many have been advised to change their lifestyle (2, 6).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 7. Prevalence of Hypertension Based on 2 SBP/DBP Thresholds*†

Overall, crude

SBP/DBP ≥130/80 mm Hg or SelfReported Antihypertensive Medication† 46% Men (n=4717) Women (n=4906) 48% 43%

SBP/DBP ≥140/90 mm Hg or SelfReported Antihypertensive Medication‡ 32% Men (n=4717) 31%

Women (n=4906) 32%

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Overall, age-sex adjusted Age group, y 20–44 30% 19% 11% 10% 45–54 50% 44% 33% 27% 55–64 70% 63% 53% 52% 65–74 77% 75% 64% 63% 75+ 79% 85% 71% 78% Race-ethnicity§ Non-Hispanic white 47% 41% 31% 30% Non-Hispanic black 59% 56% 42% 46% Non-Hispanic Asian 45% 36% 29% 27% Hispanic 44% 42% 27% 32% The prevalence estimates have been rounded to the nearest full percentage. *130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014. †BP cutpoints for definition of hypertension in the present guideline. ‡BP cutpoints for definition of hypertension in JNC 7. §Adjusted to the 2010 age-sex distribution of the U.S. adult population. BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health and Nutrition Examination Survey; and SBP, systolic blood pressure. References 1. Whelton PK. The elusiveness of population-wide high blood pressure control. Annu Rev Public Health. 2015;36:109-30. 2. Crim MT, Yoon SSS, Ortiz E, et al. National surveillance definitions for hypertension prevalence and control among adults. Circ Cardiovasc Qual Outcomes. 2012;5:343-51. 3. Chobanian AV, Bakris GL, Black HR, et al; the National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52. 4. Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. A cooperative study. JAMA. 1977;237:255-61. 5. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993;153:154-83. 6. Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension. 1995;25:305-13. 7. Gee ME, Campbell N, Sarrafzadegan N, et al. Standards for the uniform reporting of hypertension in adults using population survey data: recommendations from the World Hypertension League Expert Committee. J Clin Hypertens (Greenwich). 2014;16:773-81.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline

3.4. Awareness, Treatment, and Control

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Prevalence estimates for awareness, treatment, and control of hypertension are usually based on self-reports of the hypertension diagnosis (awareness), use of BP-lowering medications in those with hypertension (treatment), and achievement of a satisfactory SBP/DBP during treatment of hypertension (control). Before the present publication, awareness and treatment in adults were based on the SBP/DBP cutpoints of 140/90 mm Hg, and control was based on an SBP/DBP <140/90 mm Hg. In the U.S. general adult population, hypertension awareness, treatment, and control have been steadily improving since the 1960s (1-4), with NHANES 2009 to 2012 prevalence estimates for men and women, respectively, being 80.2% and 85.4% for awareness, 70.9% and 80.6% for treatment (88.4% and 94.4% in those who were aware), 69.5% and 68.5% for control in those being treated, and 49.3% and 55.2% for overall control in adults with hypertension (5). The NHANES experience may underestimate awareness, treatment, and control of hypertension because it is based on BP estimates derived from an average of readings obtained at a single visit, whereas guidelines recommend use of BP averages of ≥2 readings obtained on ≥2 occasions. In addition, the current definition of control excludes the possibility of control resulting from lifestyle change or nonpharmacological interventions. NHANES hypertension control rates have been consistently higher in women than in men (55.3% versus 38.0% in 2009–2012); in whites than in blacks and Hispanics (41.3% versus 31.1% and 23.6%, respectively, in men, and 57.2% versus 43.2% and 52.9%, respectively, in women, for 2009–2012); and in older than in younger adults (50.5% in adults ≥60 years of age versus 34.4% in patients 18 to 39 years of age for 2011–2012) up to the seventh decade (4, 5), although control rates are considerably lower for those ≥75 years (46%) and only 39.8% for adults ≥80 years (6) . In addition, control rates are higher for persons of higher socioeconomic status (43.2% for adults with an income >400% above the U.S. government poverty line versus 30.2% for those below this line in 2003 to 2006) (5). Research studies have repeatedly demonstrated that structured, goal-oriented BP treatment initiatives with feedback and provision of free medication result in a substantial improvement in BP control (7-9). Control rates that are much higher than noted in the general population have been reported in care settings where a systems approach (detailed in Sections 12.2 and 12.3) has been implemented for insured adults (10-12). References 1. Burt VL, Cutler JA, Higgins M, et al. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the Health Examination Surveys, 1960 to 1991. Hypertension. 1995;26:60-9. 2. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. 2003;290:199-206. 3. Egan BM, Li J, Hutchison FN, et al. Hypertension in the United States, 1999 to 2012: progress toward Healthy People 2020 goals. Circulation. 2014;130:1692-9. 4. Nwankwo T, Yoon SS, Burt V, et al. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief. 2013;1-8. 5. National Center for Health Statistics (U.S.). Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD: National Center for Health Statistics (U.S.); 2014. 6. Bromfield SG, Bowling CB, Tanner RM, et al. Trends in hypertension prevalence, awareness, treatment, and control among US adults 80 years and older, 1988-2010. J Clin Hypertens (Greenwich). 2014;16:270-6. 7. Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-85. 8. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-97. 9. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA. 2016;315:2673-82. 10. Fletcher RD, Amdur RL, Kolodner R, et al. Blood pressure control among US veterans: a large multiyear analysis of blood pressure data from the Veterans Administration health data repository. Circulation. 2012;125:2462-8.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 11. Jaffe MG, Lee GA, Young JD, et al. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310:699-705. 12. Jaffe MG, Young JD. The Kaiser Permanente Northern California story: improving hypertension control from 44% to 90% in 13 years (2000 to 2013). J Clin Hypertens (Greenwich). 2016;18:260-1.

4. Measurement of BP 4.1. Accurate Measurement of BP in the Office Recommendation for Accurate Measurement of BP in the Office COR

LOE

I

C-EO

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Recommendation 1. For diagnosis and management of high BP, proper methods are recommended for accurate measurement and documentation of BP (Table 8).

Synopsis Although measurement of BP in office settings is relatively easy, errors are common and can result in a misleading estimation of an individual’s true level of BP. There are various methods for measuring BP in the office. The clinical standard of auscultatory measures calibrated to a column of mercury has given way to oscillometric devices (in part because of toxicological issues with mercury). Oscillometric devices use a sensor that detects oscillations in pulsatile blood volume during cuff inflation and deflation. BP is indirectly calculated from maximum amplitude algorithms that involve population-based data. For this reason, only devices with a validated measurement protocol can be recommended for use (see Section 4.2 for additional details). Many of the newer oscillometric devices automatically inflate multiple times (in 1- to 2-minute intervals), allowing patients to be alone and undisturbed during measurement. Although much of the available BP-related risk information and antihypertensive treatment trial experience have been generated by using “traditional” office methods of BP measurement, there is a growing evidence base supporting the use of automated office BP measurements (1). Recommendation-Specific Supportive Text 1. Accurate measurement and recording of BP are essential to categorize level of BP, ascertain BP-related CVD risk, and guide management of high BP. Most systematic errors in BP measurement can be avoided by following the suggestions provided in Table 8, including having the patient sit quietly for 5 minutes before a reading is taken, supporting the limb used to measure BP, ensuring the BP cuff is at heart level, using the correct cuff size (Table 9), and, for auscultatory readings, deflating the cuff slowly (2). In those who are already taking medication that affects BP, the timing of BP measurements in relation to ingestion of the patient’s medication should be standardized. Because individual BP measurements tend to vary in an unpredictable or random fashion, a single reading is inadequate for clinical decision-making. An average of 2 to 3 BP measurements obtained on 2 to 3 separate occasions will minimize random error and provide a more accurate basis for estimation of BP. In addition to clinicians, other caregivers and patients who perform BP selfmonitoring should be trained to follow the checklist in Table 8. Common errors in clinical practice that can lead to inaccurate estimation of BP include failure to allow for a rest period and/or talking with the patient during or immediately before the recording, improper patient positioning (e.g., sitting or lying on an examination table), rapid cuff deflation (for auscultatory readings), and reliance on BPs measured at a single occasion.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 8. Checklist for Accurate Measurement of BP (3, 4) Key Steps for Proper BP Measurements Step 1: Properly prepare the patient

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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

Specific Instructions 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 (e.g., 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 (Table 9). 5. Either the stethoscope diaphragm or bell may be used for auscultatory readings (5, 6). 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.

Step 6: Provide BP readings to patient *See Section 4.2 for additional guidance. BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure. Adapted with permission from Mancia et al. (3) (Oxford University Press), Pickering et al. (2) (American Heart Association, Inc.), and Weir et al. (4) (American College of Physicians, Inc.).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 9. Selection Criteria for BP Cuff Size for Measurement of BP in Adults Arm Circumference Usual Cuff Size 22–26 cm Small adult 27–34 cm Adult 35–44 cm Large adult 45–52 cm Adult thigh Adapted with permission from Pickering et al. (2) (American Heart Association, Inc.). BP indicates blood pressure.

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References 1. Leung AA, Daskalopoulou SS, Dasgupta K, et al. Hypertension Canada's 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol. 2017;33:557-76. 2. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005;111:697-716. 3. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. 4. Weir MR. In the clinic: hypertension. Ann Intern Med. 2014;161:ITC1-15. 5. Liu C, Griffiths C, Murray A, et al. Comparison of stethoscope bell and diaphragm, and of stethoscope tube length, for clinical blood pressure measurement. Blood Press Monit. 2016;21:178-83. 6. Kantola I, Vesalainen R, Kangassalo K, et al. Bell or diaphragm in the measurement of blood pressure? J Hypertens. 2005;23:499-503.

4.2. Out-of-Office and Self-Monitoring of BP Recommendation for Out-of-Office and Self-Monitoring of BP

References that support the recommendation are summarized in Online Data Supplement 3 and Systematic Review Report. COR LOE Recommendation 1. Out-of-office BP measurements are recommended to confirm the diagnosis SR of hypertension (Table 11) and for titration of BP-lowering medication, in I A conjunction with telehealth counseling or clinical interventions (1-4). SR indicates systematic review.

Synopsis Out-of-office measurement of BP can be helpful for confirmation and management of hypertension. Selfmonitoring of BP refers to the regular measurement of BP by an individual at home or elsewhere outside the clinic setting. Among individuals with hypertension, self-monitoring of BP, without other interventions, has shown limited evidence for treatment-related BP reduction and achievement of BP control (1, 5, 6). However, with the increased recognition of inconsistencies between office and out-of-office BPs (see Section 4.4) and greater reduction in BP being recommended for hypertension control, increased attention is being paid to out-of-office BP readings. Although APBM is generally accepted as the best out-of-office measurement method, HBPM is often a more practical approach in clinical practice. Recommended procedures for the collection of HBPM data are provided in Table 10. If self-monitoring is used, it is important to ensure that the BP measurement device used has been validated with an internationally accepted protocol and the results have been published in a peer-reviewed journal (7). A guide to the relationship between HBPM BP readings

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline and corresponding readings obtained in the office and by ABPM is presented in Table 11. The precise relationships between office readings, ABPM, and HBPM are unsettled, but there is general agreement that office BPs are often higher than ABPM or HBPM BPs, especially at higher BPs. Recommendation-Specific Supportive Text

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1. Ambulatory BP monitoring (ABPM) is used to obtain out-of-office BP readings at set intervals, usually over a period of 24 hours. Home BP monitoring (HBPM) is used to obtain a record of out-of-office BP readings taken by a patient. Both ABPM and HBPM typically provide BP estimates that are based on multiple measurements. A systematic review conducted by the U.S. Preventive Services Task Force reported that ABPM provided a better method to predict long-term CVD outcomes than did office BPs. It incorporates new information from studies of home blood pressure monitoring (HBPM), ambulatory blood pressure monitoring (ABPM), the relationship of overall CVD risk to the effectiveness of blood pressure lowering, clinical outcomes related to different blood pressure goals, strategies to improve blood pressure control and various other areas.. A small body of evidence suggested, but did not confirm, that HBPM could serve as a similar predictor of outcomes (4). Meta-analyses of RCTs have identified clinically useful reductions in SBP and DBP and achievement of BP goals at 6 months and 1 year when self-monitoring of BP has been used in conjunction with other interventions, compared with usual care. Meta-analyses of RCTs have identified only small net reductions in SBP and DBP at 6 months and 1 year for use of self-monitoring of BP on its own, as compared with usual care (1, 5, 6). See Section 4.4 for additional details of diagnostic classification and Section 12 for additional details of telehealth and out-of-office BP measurement for management of high BP. Table 10. Procedures for Use of HBPM (8-10) Patient training should occur under medical supervision, including: • Information about hypertension • Selection of equipment • Acknowledgment that individual BP readings may vary substantially • Interpretation of results Devices: • Verify use of automated validated devices. Use of auscultatory devices (mercury, aneroid, or other) is not generally useful for HBPM because patients rarely master the technique required for measurement of BP with auscultatory devices. • Monitors with provision for storage of readings in memory are preferred. • Verify use of appropriate cuff size to fit the arm (Table 9). • Verify that left/right inter-arm differences are insignificant. If differences are significant, instruct patient to measure BPs in the arm with higher readings. Instructions on HBPM procedures: • Remain still: • Avoid smoking, caffeinated beverages, or exercise within 30 min before BP measurements. • Ensure ≥5 min of quiet rest before BP measurements. • Sit correctly: • Sit with back straight and supported (on a straight-backed dining chair, for example, rather than a sofa). • Sit with feet flat on the floor and legs uncrossed. • Keep arm supported on a flat surface (such as a table), with the upper arm at heart level. • Bottom of the cuff should be placed directly above the antecubital fossa (bend of the elbow). • Take multiple readings: • Take at least 2 readings 1 min apart in morning before taking medications and in evening before supper. Optimally, measure and record BP daily. Ideally, obtain weekly BP readings beginning 2 weeks after a change in the treatment regimen and during the week before a clinic visit. • Record all readings accurately: • Monitors with built-in memory should be brought to all clinic appointments. • BP should be based on an average of readings on ≥2 occasions for clinical decision making.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline The information above may be reinforced with videos available online: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/SymptomsDiagnosisMonitoringofHighBloodPr essure/Home-Blood-Pressure-Monitoring_UCM_301874_Article.jsp#.WcQNfLKGMnM See Table 11 for HBPM targets. BP indicates blood pressure; and HBPM, home blood pressure monitoring.

Table 11. Corresponding Values of SBP/DBP for Clinic, HBPM, Daytime, Nighttime, and 24-Hour ABPM Measurements

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Clinic HBPM Daytime ABPM Nighttime ABPM 24-Hour ABPM 120/80 120/80 120/80 100/65 115/75 130/80 130/80 130/80 110/65 125/75 140/90 135/85 135/85 120/70 130/80 160/100 145/90 145/90 140/85 145/90 ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; DBP diastolic blood pressure; HBPM, home blood pressure monitoring; and SBP, systolic blood pressure. References 1. Uhlig K, Balk EM, Patel K, et al. Self-Measured Blood Pressure Monitoring: Comparative Effectiveness. Rockville, MD: Agency for Healthcare Research and Quality (U.S.); 2012. 2. Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA. 2013;310:46-56. 3. McManus RJ, Mant J, Haque MS, et al. Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. JAMA. 2014;312:799-808. 4. Siu AL. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163:778-86. 5. Yi SS, Tabaei BP, Angell SY, et al. Self-blood pressure monitoring in an urban, ethnically diverse population: a randomized clinical trial utilizing the electronic health record. Circ Cardiovasc Qual Outcomes. 2015;8:138-45. 6. Agarwal R, Bills JE, Hecht TJW, et al. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension. 2011;57:29-38. 7. O'Brien E, Stergiou GS. The pursuit of accurate blood pressure measurement: a 35-year travail. J Clin Hypertens (Greenwich). 2017;19:746-52. 8. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. 9. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52:10-29. 10. National Clinical Guideline Centre (UK). Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34. London, UK: Royal College of Physicians (UK); 2011.

4.3. Ambulatory BP Monitoring All of the major RCTs have been based on use of clinic BP readings. However, ABPM is often used to supplement BP readings obtained in office settings (1). The monitors are usually programmed to obtain readings every 15 to 30 minutes throughout the day and every 15 minutes to 1 hour during the night. ABPM is conducted while individuals go about their normal daily activities. ABPM can a) provide estimates of mean BP over the entire monitoring period and separately during nighttime and daytime, b) determine the daytimeto-nighttime BP ratio to identify the extent of nocturnal “dipping,” c) identify the early-morning BP surge pattern, d) estimate BP variability, and e) allow for recognition of symptomatic hypotension. The U.S. Centers for Medicaid & Medicare Services and other agencies provide reimbursement for ABPM in patients with

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suspected white coat hypertension (2). Medicare claims for ABPM between 2007 and 2010 were reimbursed at a median of $52 and were submitted for <1% of beneficiaries (3, 4). A list of devices validated for ABPM is available (5, 6). ABPM and HBPM definitions of high BP use different BP thresholds than those used by the previously mentioned office-based approach to categorize high BP identified in Section 3.1. Table 11 provides best estimates for corresponding home, daytime, nighttime, and 24-hour ambulatory levels of BP, including the values recommended for identification of hypertension with office measurements. Typically, a clinic BP of 140/90 mm Hg corresponds to home BP values of 135/85 mm Hg and to ABPM values defined as a daytime SBP/DBP of 135/85 mm Hg, a nighttime SBP/DBP of 120/70 mm Hg, and a 24-hour SBP/DBP of 130/80 mm Hg (7, 8). These thresholds are based on data from European, Australian, and Asian populations, with few data available for establishing appropriate thresholds for U.S. populations (9-13). They are provided as a guide but should be interpreted with caution. Higher daytime SBP measurements from ABPM can be associated with an increased risk of CVD and all-cause death independent of clinic-measured BP (14). A meta-analysis of observational studies that included 13,844 individuals suggested nighttime BP is a stronger risk factor for CHD and stroke than either clinic or daytime BP (15). Methodological issues complicate the interpretation of data from studies that report office and outof-office BP readings. Definitions and diagnostic methods for identifying white coat hypertension and masked hypertension (see Section 4.4) have not been standardized. The available studies have differed with regard to number of office readings obtained, use of 24-hour ABPM, use of daytime-only ABPM, inclusion of daytime and nighttime BP readings as separate categories, HBPM for monitoring out-of-office BP levels, and even the BP thresholds used to define hypertension with ABPM or HBPM readings. In addition, there are few data that address reproducibility of these hypertension profiles over time, with several studies suggesting progression of white coat hypertension and especially of masked hypertension to sustained office-measured hypertension (16-22). References 1. Pickering TG, Shimbo D, Haas D. Ambulatory blood-pressure monitoring. N Engl J Med. 2006;354:2368-74. 2. Tunis SR. Decision Memo for Ambulatory Blood Pressure Monitoring (CAG-00067N). Centers for Medicare and Medicaid Services; October 17, 2001. 3. Shimbo D, Kent ST, Diaz KM, et al. The use of ambulatory blood pressure monitoring among Medicare beneficiaries in 2007-2010. J Am Soc Hypertens. 2014;8:891-7. 4. Kent ST, Shimbo D, Huang L, et al. Rates, amounts, and determinants of ambulatory blood pressure monitoring claim reimbursements among Medicare beneficiaries. J Am Soc Hypertens. 2014;8:898-908. 5. Dabl Educational Trust. Information on validated blood pressure devices and monitors. Available at: http://www.dableducational.org. Accessed September 17, 2017. 6. British Hypertension Society. BP Monitors. Available at: http://www.bhsoc.org/bp-monitors/bp-monitors. Accessed September 17, 2017. 7. Pickering TG, White WB, American Society of Hypertension Writing Group. ASH position paper: home and ambulatory blood pressure monitoring. When and how to use self (home) and ambulatory blood pressure monitoring. J Clin Hypertens (Greenwich). 2008;10:850-5. 8. O'Brien E, Parati G, Stergiou G, et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31:1731-68. 9. Kikuya M, Hansen TW, Thijs L, et al. Diagnostic thresholds for ambulatory blood pressure monitoring based on 10year cardiovascular risk. Circulation. 2007;115:2145-52. 10. Niiranen TJ, Asayama K, Thijs L, et al. Outcome-driven thresholds for home blood pressure measurement: international database of home blood pressure in relation to cardiovascular outcome. Hypertension. 2013;61:2734. 11. Head GA, Mihailidou AS, Duggan KA, et al. Definition of ambulatory blood pressure targets for diagnosis and treatment of hypertension in relation to clinic blood pressure: prospective cohort study. BMJ. 2010;340:c1104. 12. Hansen TW, Kikuya M, Thijs L, et al. Diagnostic thresholds for ambulatory blood pressure moving lower: a review based on a meta-analysis-clinical implications. J Clin Hypertens (Greenwich). 2008;10:377-81.

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13. Ravenell J, Shimbo D, Booth JN 3rd, et al. Thresholds for ambulatory blood pressure among African Americans in the Jackson Heart Study. Circulation. 2017;135:2470-80. 14. Hansen TW, Kikuya M, Thijs L, et al. Prognostic superiority of daytime ambulatory over conventional blood pressure in four populations: a meta-analysis of 7,030 individuals. J Hypertens. 2007;25:1554-64. 15. Roush GC, Fagard RH, Salles GF, et al. Prognostic impact from clinic, daytime, and night-time systolic blood pressure in nine cohorts of 13,844 patients with hypertension. J Hypertens. 2014;32:2332-40. 16. Mancia G, Bombelli M, Facchetti R, et al. Long-term risk of sustained hypertension in white-coat or masked hypertension. Hypertension. 2009;54:226-32. 17. Ben-Dov IZ, Ben-Arie L, Mekler J, et al. Reproducibility of white-coat and masked hypertension in ambulatory BP monitoring. Int J Cardiol. 2007;117:355-9. 18. Bidlingmeyer I, Burnier M, Bidlingmeyer M, et al. Isolated office hypertension: a prehypertensive state? J Hypertens. 1996;14:327-32. 19. Muxfeldt ES, Fiszman R, de Souza F, et al. Appropriate time interval to repeat ambulatory blood pressure monitoring in patients with white-coat resistant hypertension. Hypertension. 2012;59:384-9. 20. Palatini P, Winnicki M, Santonastaso M, et al. Prevalence and clinical significance of isolated ambulatory hypertension in young subjects screened for stage 1 hypertension. Hypertension. 2004;44:170-4. 21. Trudel X, Milot A, Brisson C. Persistence and progression of masked hypertension: a 5-year prospective study. Int J Hypertens. 2013;2013:836387. 22. Ugajin T, Hozawa A, Ohkubo T, et al. White-coat hypertension as a risk factor for the development of home hypertension: the Ohasama study. Arch Intern Med. 2005;165:1541-6.

4.4. Masked and White Coat Hypertension Recommendations for Masked and White Coat Hypertension

References that support recommendations are summarized in Online Data Supplements 4, 5, and 6. COR LOE Recommendation 1. In adults with an untreated SBP greater than 130 mm Hg but less than 160 mm Hg or DBP greater than 80 mm Hg but less than 100 mm Hg, it is IIa B-NR reasonable to screen for the presence of white coat hypertension by using either daytime ABPM or HBPM before diagnosis of hypertension (1-8). 2. In adults with white coat hypertension, periodic monitoring with either IIa C-LD ABPM or HBPM is reasonable to detect transition to sustained hypertension (2, 5, 7). 3. In adults being treated for hypertension with office BP readings not at goal IIa C- LD and HBPM readings suggestive of a significant white coat effect, confirmation by ABPM can be useful (9, 10). 4. In adults with untreated office BPs that are consistently between 120 mm Hg and 129 mm Hg for SBP or between 75 mm Hg and 79 mm Hg for DBP, IIa B-NR screening for masked hypertension with HBPM (or ABPM) is reasonable (3, 4, 6, 8, 11). 5. In adults on multiple-drug therapies for hypertension and office BPs within IIb C-LD 10 mm Hg above goal, it may be reasonable to screen for white coat effect with HBPM (or ABPM) (3, 7, 12). 6. It may be reasonable to screen for masked uncontrolled hypertension with IIb C-EO HBPM in adults being treated for hypertension and office readings at goal, in the presence of target organ damage or increased overall CVD risk. 7. In adults being treated for hypertension with elevated HBPM readings suggestive of masked uncontrolled hypertension, confirmation of the IIb C-EO diagnosis by ABPM might be reasonable before intensification of antihypertensive drug treatment.

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Table 12. BP Patterns Based on Office and Out-of-Office Measurements Office/Clinic/Healthcare Setting Home/Nonhealthcare/ABPM Setting Normotensive No hypertension No hypertension Sustained hypertension Hypertension Hypertension Masked hypertension No hypertension Hypertension White coat hypertension Hypertension No hypertension ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.

Synopsis

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The availability of noninvasive BP monitoring techniques has resulted in differentiation of hypertension into several clinically useful categories that are based on the place of BP measurement (Table 12) (1, 13, 14). These include masked hypertension and white coat hypertension, in addition to sustained hypertension. White coat hypertension is characterized by elevated office BP but normal readings when measured outside the office with either ABPM or HBPM. In contrast, masked hypertension is characterized by office readings suggesting normal BP but out-of-office (ABPM/HBPM) readings that are consistently above normal (15). In sustained hypertension, BP readings are elevated in both office and out-of-office settings. In patients treated for hypertension, both “white coat effect” (higher office BPs than out-of-office BPs) and “masked uncontrolled hypertension” (controlled office BPs but uncontrolled BPs in out-of-office settings) categories have been reported (5, 15, 16). The white coat effect (usually considered clinically significant when office SBP/DBPs are >20/10 mm Hg higher than home or ABPM SBP/DBPs) has been implicated in “pseudoresistant hypertension” (see Section 11.1) and results in an underestimation of office BP control rates (17, 18). The prevalence of masked hypertension varies from 10% to 26% (mean 13%) in population-based surveys and from 14% to 30% in normotensive clinic populations (6, 16, 19-21). The risk of CVD and all-cause mortality in persons with masked hypertension is similar to that noted in those with sustained hypertension and about twice as high as the corresponding risk in their normotensive counterparts (3, 4, 6, 8, 11). The prevalence of masked hypertension increases with higher office BP readings (20, 22, 23). The prevalence of white coat hypertension is higher with increasing age (24), female versus male sex, nonsmoking versus current smoking status, and routine office measurement of BP by clinician observers versus unattended BP measurements. Many, but not all, studies (4, 6, 8, 25, 26) have identified a minimal increase in risk of CVD complications or all-cause mortality in patients who have white coat hypertension. This has resulted in a recommendation by some panels to screen for white coat hypertension with ABPM (or HBPM) to avoid initiating antihypertensive drug treatment in such individuals (2, 5, 27). The white coat effect and masked uncontrolled hypertension appear to follow the risk profiles of their white coat hypertension and masked hypertension counterparts, respectively (3, 12). There are no data on the risks and benefits of treating white coat and masked hypertension. Despite these methodological differences, the data are consistent in indicating that masked hypertension and masked uncontrolled hypertension are associated with an increased prevalence of target organ damage and risk of CVD, stroke, and mortality compared with normotensive individuals and those with white coat hypertension. Figure 1 is an algorithm on the detection of white coat hypertension or masked hypertension in patients not on drug therapy. Figure 2 is an algorithm on detection of white coat effect or masked uncontrolled hypertension in patients on drug therapy. Table 12 is a summary of BP patterns based on office and out-ofoffice measurements.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Recommendation-Specific Supportive Text 1. White coat hypertension prevalence averages approximately 13% and as high as 35% in some hypertensive populations (1, 2), and ABPM and HBPM are better predictors of CVD risk due to elevated BP than are office BP measurements, with ABPM being the preferred measurement option. The major clinical relevance of white coat hypertension is that it has typically been associated with a minimal to only slightly increased risk of CVD and all-cause mortality risk (3, 4, 7, 11, 24). If ABPM resources are not readily available, HBPM provides a reasonable but less desirable alternative to screen for white coat hypertension, although the overlap with ABPM is only 60% to 70% for detection of white coat hypertension (5, 9, 27-30). 2. The incidence of white coat hypertension converting to sustained hypertension (justifying the addition of antihypertensive drug therapy to lifestyle modification) is 1% to 5% per year by ABPM or HBPM, with a higher incidence of conversion in those with elevated BP, older age, obesity, or black race (2, 7).

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3. The overlap between HBPM and both daytime and 24-hour ABPM in diagnosing white coat hypertension is only 60% to 70%, and the data for prediction of CVD risk are stronger with ABPM than with office measurements (5, 9, 27-30). Because a diagnosis of white coat hypertension may result in a decision not to treat or intensify treatment in patients with elevated office BP readings, confirmation of BP control by ABPM in addition to HBPM provides added support for this decision. 4. In contrast to white coat hypertension, masked hypertension is associated with a CVD and all-cause mortality risk twice as high as that seen in normotensive individuals, with a risk range similar to that of patients with sustained hypertension (3, 4, 6, 8, 11, 31). Therefore, out-of-office readings are reasonable to confirm BP control seen with office readings. 5. The white coat effect has been implicated in office-measured uncontrolled hypertension and pseudoresistant hypertension, which may result in BP control being underestimated when subsequently assessed by ABPM (17, 18). The risk of vascular complications in patients with office-measured uncontrolled hypertension with a white coat effect is similar to the risk in those with controlled hypertension (3, 4, 7, 11, 12). White coat hypertension and white coat effect raise the concern that unnecessary antihypertensive drug therapy may be initiated or intensified. Because a diagnosis of white coat hypertension or white coat effect would result in a decision to not treat elevated office BP readings, confirmation of BP control by HBPM (or ABPM) provides more definitive support for the decision not to initiate antihypertensive drug therapy or accelerate treatment. 6. Analogous to masked hypertension in untreated patients, masked uncontrolled hypertension is defined in treated patients with hypertension by office readings suggesting adequate BP control but out-of-office readings (HBPM) that remain consistently above goal (3, 15, 16, 32, 33). The CVD risk profile for masked uncontrolled hypertension appears to follow the risk profile for masked hypertension (3, 12, 34). Although the evidence is consistent in identifying the increased risk of masked uncontrolled hypertension, evidence is lacking on whether the treatment of masked hypertension or masked uncontrolled hypertension reduces clinical outcomes. A suggestion for assessing CVD risk is provided in Section 8. 7. Although both ABPM and HBPM are better predictors of CVD risk than are office BP readings, ABPM confirmation of elevated BP by HBPM might be reasonable because of the more extensive documentation of CVD risk with ABPM. However, unlike the documentation of a significant white coat effect to justify the decision to not treat an elevated clinic BP, it is not mandatory to confirm masked uncontrolled hypertension determined by HBPM.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 1. Detection of White Coat Hypertension or Masked Hypertension in Patients Not on Drug Therapy Office BP: ≥130/80 mm Hg but <160/100 mm Hg after 3 mo trial of lifestyle modification and suspected white coat hypertension

Office BP: 120–129/<80 mm Hg after 3 mo trial of lifestyle modification and suspected masked hypertension

Daytime ABPM or HBPM BP <130/80 mm Hg

Daytime ABPM or HBPM BP ≥130/80 mm Hg

Yes White Coat Hypertension • Lifestyle modification • Annual ABPM or HBPM to detect progression (Class IIa)

Yes

No Hypertension Continue lifestyle modification and start antihypertensive drug therapy (Class IIa)

Masked Hypertension Continue lifestyle modification and start antihypertensive drug therapy (Class IIb)

No Elevated BP • Lifestyle modification • Annual ABPM or ABPM to detect masked hypertension or progression (Class IIb)

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Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 2. Detection of White Coat Effect or Masked Uncontrolled Hypertension in Patients on Drug Therapy Detection of white coat effect or masked uncontrolled hypertension in patients on drug therapy

Office BP at goal Yes

No

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Increased CVD risk or target organ damage Yes Screen for masked uncontrolled hypertension with HBPM (Class IIb)

Office BP ≥5–10 mm Hg above goal on ≥3 agents Yes

No

Screen for white coat effect with HBPM (Class IIb)

Screening not necessary (No Benefit)

HBPM BP above goal

Masked uncontrolled hypertension: Intensify therapy (Class IIb)

Screening not necessary (No Benefit)

HBPM BP at goal Yes

ABPM BP above goal Yes

No

No

White coat effect: Confirm with ABPM (Class IIa)

No Continue titrating therapy

Continue current therapy (Class IIa)

Colors correspond to Class of Recommendation in Table 1. See Section 8 for treatment options. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; CVD, cardiovascular disease; and HBPM, home blood pressure monitoring. References 1. Pickering TG, James GD, Boddie C, et al. How common is white coat hypertension? JAMA. 1988;259:225-8. 2. Piper MA, Evans CV, Burda BU, et al. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2015;162:192-204. 3. Ohkubo T, Kikuya M, Metoki H, et al. Prognosis of "masked" hypertension and "white-coat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study. J Am Coll Cardiol. 2005;46:508-15.

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11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.

Fagard RH, Cornelissen VA. Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. J Hypertens. 2007;25:2193-8. National Clinical Guideline Centre (UK). Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34. London, UK: Royal College of Physicians (UK); 2011. Asayama K, Thijs L, Li Y, et al. Setting thresholds to varying blood pressure monitoring intervals differentially affects risk estimates associated with white-coat and masked hypertension in the population. Hypertension 2014;64:93542. Mancia G, Bombelli M, Brambilla G, et al. Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure measurements. Hypertension. 2013;62:168-74. Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens. 2011;24:52-8. Viera AJ, Hinderliter AL, Kshirsagar AV, et al. Reproducibility of masked hypertension in adults with untreated borderline office blood pressure: comparison of ambulatory and home monitoring. Am J Hypertens. 2010;23:11907. Viera AJ, Lin F-C, Tuttle LA, et al. Reproducibility of masked hypertension among adults 30 years or older. Blood Press Monit. 2014;19:208-15. Stergiou GS, Asayama K, Thijs L, et al. Prognosis of white-coat and masked hypertension: International Database of Home Blood Pressure in Relation to Cardiovascular Outcome. Hypertension. 2014;63:675-82. Tomiyama M, Horio T, Yoshii M, et al. Masked hypertension and target organ damage in treated hypertensive patients. Am J Hypertens. 2006;19:880-6. Perloff D, Sokolow M, Cowan R. The prognostic value of ambulatory blood pressures. JAMA. 1983;249:2792-8. Pickering TG, Davidson K, Gerin W, et al. Masked hypertension. Hypertension. 2002;40:795-6. Banegas JR, Ruilope LM, de la Sierra A, et al. High prevalence of masked uncontrolled hypertension in people with treated hypertension. Eur Heart J. 2014;35:3304-12. Gorostidi M, Vinyoles E, Banegas JR, et al. Prevalence of white-coat and masked hypertension in national and international registries. Hypertens Res. 2015;38:1-7. Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008;51:1403-19. O'Brien E, Parati G, Stergiou G, et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31:1731-68. Wang YC, Shimbo D, Muntner P, et al. Prevalence of masked hypertension among US Adults with nonelevated clinic blood pressure. Am J Epidemiol. 2017;185:194-202. Peacock J, Diaz KM, Viera AJ, et al. Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions. J Hum Hypertens. 2014;28:521-8. Conen D, Aeschbacher S, Thijs L, et al. Age-specific differences between conventional and ambulatory daytime blood pressure values. Hypertension. 2014;64:1073-9. Alwan H, Pruijm M, Ponte B, et al. Epidemiology of masked and white-coat hypertension: the family-based SKIPOGH study. PLoS ONE. 2014;9:e92522. Shimbo D, Newman JD, Schwartz JE. Masked hypertension and prehypertension: diagnostic overlap and interrelationships with left ventricular mass: the Masked Hypertension Study. Am J Hypertens. 2012;25:664-71. Franklin SS, Thijs L, Asayama K, et al. The cardiovascular risk of white-coat hypertension. J Am Coll Cardiol. 2016;68:2033-43. Tientcheu D, Ayers C, Das SR, et al. Target organ complications and cardiovascular events associated with masked hypertension and white-coat hypertension: analysis from the Dallas Heart Study. J Am Coll Cardiol. 2015;66:215969. Briasoulis A, Androulakis E, Palla M, et al. White-coat hypertension and cardiovascular events: a meta-analysis. J Hypertens. 2016;34:593-9. Siu AL, U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163:778-86. Bayo J, Cos FX, Roca C, et al. Home blood pressure self-monitoring: diagnostic performance in white-coat hypertension. Blood Press Monit. 2006;11:47-52.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 29. Nasothimiou EG, Tzamouranis D, Rarra V, et al. Diagnostic accuracy of home vs. ambulatory blood pressure monitoring in untreated and treated hypertension. Hypertens Res. 2012;35:750-5. 30. Sega R, Trocino G, Lanzarotti A, et al. Alterations of cardiac structure in patients with isolated office, ambulatory, or home hypertension: data from the general population (Pressione Arteriose Monitorate E Loro Associazioni [PAMELA] Study). Circulation. 2001;104:1385-92. 31. Hansen TW, Kikuya M, Thijs L, et al. Prognostic superiority of daytime ambulatory over conventional blood pressure in four populations: a meta-analysis of 7,030 individuals. J Hypertens. 2007;25:1554-64. 32. Diaz KM, Veerabhadrappa P, Brown MD, et al. Prevalence, determinants, and clinical significance of masked hypertension in a population-based sample of African Americans: the Jackson Heart Study. Am J Hypertens. 2015;28:900-8. 33. Andalib A, Akhtari S, Rigal R, et al. Determinants of masked hypertension in hypertensive patients treated in a primary care setting. Intern Med J. 2012;42:260-6. 34. Terawaki H, Metoki H, Nakayama M, et al. Masked hypertension determined by self-measured blood pressure at home and chronic kidney disease in the Japanese general population: the Ohasama study. Hypertens Res. 2008;31:2129-35. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

5. Causes of Hypertension 5.1. Genetic Predisposition Hypertension is a complex polygenic disorder in which many genes or gene combinations influence BP (1, 2). Although several monogenic forms of hypertension have been identified, such as glucocorticoid-remediable aldosteronism, Liddle’s syndrome, Gordon’s syndrome, and others in which single-gene mutations fully explain the pathophysiology of hypertension, these disorders are rare (3). The current tabulation of known genetic variants contributing to BP and hypertension includes more than 25 rare mutations and 120 singlenucleotide polymorphisms (3, 4). However, even with the discovery of multiple single-nucleotide polymorphisms influencing control of BP since completion of the Human Genome Project in 2003, the associated variants have only small effects. Indeed, at present, the collective effect of all BP loci identified through genome-wide association studies accounts for only about 3.5% of BP variability (4). The presence of a high number of small-effect alleles associated with higher BP results in a more rapid increase in BP with age (5). Future studies will need to better elucidate genetic expression, epigenetic effects, transcriptomics, and proteomics that link genotypes with underlying pathophysiological mechanisms. References 1. Kaplan NM. Primary hypertension: pathogenesis. In: Kaplan's Clinical Hypertension. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:50-121. 2. Padmanabhan S, Caulfield M, Dominiczak AF. Genetic and molecular aspects of hypertension. Circ Res. 2015;116:937-59. 3. Lifton RP, Gharavi AG, Geller DS. Molecular mechanisms of human hypertension. Cell. 2001;104:545-56. 4. Dominiczak AF, Kuo D. Hypertension: update 2017. Hypertension. 2017;69:3-4. 5. Ference BA, Julius S, Mahajan N, et al. Clinical effect of naturally random allocation to lower systolic blood pressure beginning before the development of hypertension. Hypertension. 2014;63:1182-8.

5.2. Environmental Risk Factors Various environmental exposures, including components of diet, physical activity, and alcohol consumption, influence BP. Many dietary components have been associated with high BP (1, 2). Some of the diet-related factors associated with high BP include overweight and obesity, excess intake of sodium, and insufficient intake of potassium, calcium, magnesium, protein (especially from vegetables), fiber, and fish fats. Poor diet, physical inactivity, and excess intake of alcohol, alone or in combination, are the underlying cause of a large proportion of hypertension. Gut microbiota have also been linked to hypertension, especially in experimental Page 39

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline animals. (3) Some of the best-proven environmental relationships with high BP are briefly reviewed below, and nonpharmacological interventions to lower BP are discussed in Section 6.2. References 1. Savica V, Bellinghieri G, Kopple JD. The effect of nutrition on blood pressure. Annu Rev Nutr. 2010;30:365-401. 2. Chan Q, Stamler J, Griep LMO, et al. An update on nutrients and blood pressure. J Atheroscler Thromb. 2016;23:276-89. 3. Tang WHW, Kitai T, Hazen SL. Gut microbiota in cardiovascular health and disease. Circ Res. 2017;120:1183-96.

5.2.1. Overweight and Obesity

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Insurance industry actuarial reports have identified a striking relationship between body weight and high BP (1) and a direct relationship between overweight/obesity and hypertension (2). Epidemiological studies, including the Framingham Heart Study (3) and the Nurses’ Health Study (4), have consistently identified a direct relationship between body mass index and BP that is continuous and almost linear, with no evidence of a threshold (5, 6). The relationship with BP is even stronger for waist-to-hip ratio and computed tomographic measures of central fat distribution (7). Attributable risk estimates from the Nurses’ Health Study suggest that obesity may be responsible for about 40% of hypertension, and in the Framingham Offspring Study, the corresponding estimates were even higher (78% in men and 65% in women) (8, 9). The relationship between obesity at a young age and change in obesity status over time is strongly related to future risk of hypertension. In combined data from 4 longitudinal studies begun in adolescence with repeat examination in young adulthood to early middle age, being obese continuously or acquiring obesity was associated with a relative risk of 2.7 for developing hypertension. Becoming normal weight reduced the risk of developing hypertension to a level similar to those who had never been obese (10).

5.2.2. Sodium Intake Sodium intake is positively associated with BP in migrant (11), cross-sectional (12-14), and prospective cohort studies (15) and accounts for much of the age-related increase in BP (11, 16). In addition to the well-accepted and important relationship of dietary sodium with BP, excessive consumption of sodium is independently associated with an increased risk of stroke (17, 18), CVD (19), and other adverse outcomes (20). Certain groups with various demographic, physiological, and genetic characteristics tend to be particularly sensitive to the effects of dietary sodium on BP (21-23). Salt sensitivity is a quantitative trait in which an increase in sodium load disproportionately increases BP (21, 24). Salt sensitivity is especially common in blacks, older adults, and those with a higher level of BP or comorbidities such as CKD, DM, or the metabolic syndrome (25). In aggregate, these groups constitute more than half of all U.S. adults (26). Salt sensitivity may be a marker for increased CVD and all-cause mortality risk independently of BP (27, 28), and the trait has been demonstrated to be reproducible (29). Current techniques for recognition of salt sensitivity are impractical in routine clinical practice, so salt sensitivity is best considered as a group characteristic.

5.2.3. Potassium Potassium intake is inversely related to BP in migrant (30), cross-sectional (13, 16, 31, 32), and prospective cohort (33) studies. It is also inversely related to stroke (34-36). A higher level of potassium seems to blunt the effect of sodium on BP (37), with a lower sodium–potassium ratio being associated with a lower level of BP than that noted for corresponding levels of sodium or potassium on their own (38). Likewise, epidemiological studies suggest that a lower sodium–potassium ratio may result in a reduced risk of CVD as compared with the pattern for corresponding levels of either cation on its own (39).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline

5.2.4. Physical Fitness

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Epidemiological studies have demonstrated an inverse relationship between physical activity and physical fitness and level of BP and hypertension (40). Even modest levels of physical activity have been associated with a decrease in the risk of incident hypertension (41). In several observational studies, the relationship between physical activity and BP has been most apparent in white men (40). With the advent of electronic activity trackers and ABPM, it has become increasingly feasible to conduct studies that relate physical activity and BP (42). Physical fitness, measured objectively by graded exercise testing, attenuates the rise of BP with age and prevents the development of hypertension. In the CARDIA (Coronary Artery Risk Development in Young Adults) study (43), physical fitness measured at 18 to 30 years of age in the upper 2 deciles of an otherwise healthy population was associated with one third the risk of developing hypertension 15 years later, and one half the risk after adjustment for body mass index, as compared with the lowest quintile. Change in fitness assessed 7 years later further modified risk (43). In a cohort of men 20 to 90 years of age who were followed longitudinally for 3 to 28 years, higher physical fitness decreased the rate of rise in SBP over time and delayed the time to onset of hypertension (44).

5.2.5. Alcohol The presence of a direct relationship between alcohol consumption and BP was first reported in 1915 (45) and has been repeatedly identified in contemporary cross-sectional and prospective cohort studies (46). Estimates of the contribution of alcohol consumption to population incidence and prevalence of hypertension vary according to level of intake. In the United States, it seems likely that alcohol may account for close to 10% of the population burden of hypertension (higher in men than in women). In contrast to its detrimental effect on BP, alcohol intake is associated with a higher level of high-density lipoprotein cholesterol and, within modest ranges of intake, a lower level of CHD than that associated with abstinence (35). References 1. Bray GA. Life insurance and overweight. Obes Res. 1995;3:97-9. 2. Harsha DW, Bray GA. Weight loss and blood pressure control (Pro). Hypertension. 2008;51:1420-5; discussion 1425. 3. Hubert HB, Feinleib M, McNamara PM, et al. Obesity as an independent risk factor for cardiovascular disease: a 26year follow-up of participants in the Framingham Heart Study. Circulation. 1983;67:968-77. 4. Huang Z, Willett WC, Manson JE, et al. Body weight, weight change, and risk for hypertension in women. Ann Intern Med. 1998;128:81-8. 5. Hall JE. The kidney, hypertension, and obesity. Hypertension. 2003;41:625-33. 6. Jones DW, Kim JS, Andrew ME, et al. Body mass index and blood pressure in Korean men and women: the Korean National Blood Pressure Survey. J Hypertens. 1994;12:1433-7. 7. Mertens IL, Van Gaal LF. Overweight, obesity, and blood pressure: the effects of modest weight reduction. Obes Res. 2000;8:270-8. 8. Garrison RJ, Kannel WB, Stokes J 3rd, et al. Incidence and precursors of hypertension in young adults: the Framingham Offspring Study. Prev Med. 1987;16:235-51. 9. Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA. 2009;302:401-11. 10. Juonala M, Magnussen CG, Berenson GS, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med. 2011;365:1876-85. 11. Klag MJ, He J, Coresh J, et al. The contribution of urinary cations to the blood pressure differences associated with migration. Am J Epidemiol. 1995;142:295-303. 12. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. BMJ. 1988;297:319-28. 13. Mente A, O'Donnell MJ, Rangarajan S, et al. Association of urinary sodium and potassium excretion with blood pressure. N Engl J Med. 2014;371:601-11.

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14. Elliott P, Stamler J, Nichols R, et al. Intersalt revisited: further analyses of 24 hour sodium excretion and blood pressure within and across populations. Intersalt Cooperative Research Group. BMJ. 1996;312:1249-53. 15. Takase H, Sugiura T, Kimura G, et al. Dietary sodium consumption predicts future blood pressure and incident hypertension in the Japanese normotensive general population. J Am Heart Assoc. 2015;4:e001959. 16. Stamler J. The INTERSALT study: background, methods, findings, and implications. Am J Clin Nutr. 1997;65:626S42S. 17. Strazzullo P, D'Elia L, Kandala NB, et al. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ. 2009;339:b4567. 18. Whelton PK. Sodium, potassium, blood pressure, and cardiovascular disease in humans. Curr Hypertens Rep. 2014;16:465. 19. Whelton PK, Appel LJ, Sacco RL, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation. 2012;126:2880-9. 20. Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: The National Academies Press; 2005. 21. Weinberger MH, Miller JZ, Luft FC, et al. Definitions and characteristics of sodium sensitivity and blood pressure resistance. Hypertension. 1986;8:II127-34. 22. Sanada H, Jones JE, Jose PA. Genetics of salt-sensitive hypertension. Curr Hypertens Rep. 2011;13:55-66. 23. Carey RM, Schoeffel CD, Gildea JJ, et al. Salt sensitivity of blood pressure is associated with polymorphisms in the sodium-bicarbonate cotransporter. Hypertension. 2012;60:1359-66. 24. Elijovich F, Weinberger MH, Anderson CAM. Salt sensitivity of blood pressure: a scientific statement from the American Heart Association. Hypertension. 2016;68:e7-46. 25. Weinberger MH. Salt sensitivity of blood pressure in humans. Hypertension. 1996;27:481-90. 26. Cogswell ME, Zhang Z, Carriquiry AL, et al. Sodium and potassium intakes among US adults: NHANES 2003-2008. Am J Clin Nutr. 2012;96:647-57. 27. Weinberger MH, Fineberg NS, Fineberg SE, et al. Salt sensitivity, pulse pressure, and death in normal and hypertensive humans. Hypertension. 2001;37:429-32. 28. Morimoto A, Uzu T, Fujii T, et al. Sodium sensitivity and cardiovascular events in patients with essential hypertension. Lancet. 1997;350:1734-7. 29. Gu D, Zhao Q, Chen J, et al. Reproducibility of blood pressure responses to dietary sodium and potassium interventions: the GenSalt study. Hypertension. 2013;62:499-505. 30. Poulter N, Khaw KT, Hopwood BE, et al. Blood pressure and associated factors in a rural Kenyan community. Hypertension. 1984;6:810-3. 31. He J, Tell GS, Tang YC, et al. Relation of electrolytes to blood pressure in men. The Yi people study. Hypertension. 1991;17:378-85. 32. Zhang Z, Cogswell ME, Gillespie C, et al. Association between usual sodium and potassium intake and blood pressure and hypertension among U.S. adults: NHANES 2005-2010. PLoS ONE. 2013;8:e75289. 33. Kieneker LM, Gansevoort RT, Mukamal KJ, et al. Urinary potassium excretion and risk of developing hypertension: the prevention of renal and vascular end-stage disease study. Hypertension. 2014;64:769-76. 34. D'Elia L, Barba G, Cappuccio FP, et al. Potassium intake, stroke, and cardiovascular disease a meta-analysis of prospective studies. J Am Coll Cardiol. 2011;57:1210-9. 35. D'Elia L, Iannotta C, Sabino P, et al. Potassium-rich diet and risk of stroke: updated meta-analysis. Nutr Metab Cardiovasc Dis. 2014;24:585-7. 36. Vinceti M, Filippini T, Crippa A, et al. Meta-analysis of potassium intake and the risk of stroke. J Am Heart Assoc. 2016;5:e004210. 37. Rodrigues SL, Baldo MP, Machado RC, et al. High potassium intake blunts the effect of elevated sodium intake on blood pressure levels. J Am Soc Hypertens. 2014;8:232-8. 38. Khaw KT, Barrett-Connor E. The association between blood pressure, age, and dietary sodium and potassium: a population study. Circulation. 1988;77:53-61. 39. Cook NR, Obarzanek E, Cutler JA, et al. Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the Trials of Hypertension Prevention follow-up study. Arch Intern Med. 2009;169:32-40. 40. Lesniak KT, Dubbert PM. Exercise and hypertension. Curr Opin Cardiol. 2001;16:356-9. 41. Hayashi T, Tsumura K, Suematsu C, et al. Walking to work and the risk for hypertension in men: the Osaka Health Survey. Ann Intern Med. 1999;131:21-6.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 42. Leary AC, Donnan PT, MacDonald TM, et al. The influence of physical activity on the variability of ambulatory blood pressure. Am J Hypertens. 2000;13:1067-73. 43. Carnethon MR, Gidding SS, Nehgme R, et al. Cardiorespiratory fitness in young adulthood and the development of cardiovascular disease risk factors. JAMA. 2003;290:3092-100. 44. Liu J, Sui X, Lavie CJ, et al. Effects of cardiorespiratory fitness on blood pressure trajectory with aging in a cohort of healthy men. J Am Coll Cardiol. 2014;64:1245-53. 45. Lian C. L'alcoholisme cause d'hypertension arterielle. Bull Acad Med (Paris). 1915;74:525-8. 46. Klatsky AL. Alcohol and cardiovascular mortality: common sense and scientific truth. J Am Coll Cardiol. 2010;55:1336-8.

5.3. Childhood Risk Factors and BP Tracking

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BP distribution in the general population increases with age. Multiple longitudinal studies have investigated the relationship of childhood BP to adult BP. A meta-analysis of 50 such studies showed correlation coefficients of about 0.38 for SBP and 0.28 for DBP, with BPs in the upper range of the pediatric distribution (particularly BPs obtained in adolescence) predicting hypertension in adulthood (1). Several factors, including genetic factors and development of obesity, increase the likelihood that a high childhood BP will lead to future hypertension (2). Premature birth is associated with a 4–mm Hg higher SBP and a 3–mm Hg higher DBP in adulthood, with somewhat larger effects in women than in men (3). Low birth weight from other causes also contributes to higher BP in later life (4). References 1. Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117:3171-80. 2. Juhola J, Oikonen M, Magnussen CG, et al. Childhood physical, environmental, and genetic predictors of adult hypertension: the cardiovascular risk in young Finns study. Circulation. 2012;126:402-9. 3. Parkinson JRC, Hyde MJ, Gale C, et al. Preterm birth and the metabolic syndrome in adult life: a systematic review and meta-analysis. Pediatrics. 2013;131:e1240-63. 4. de Jong F, Monuteaux MC, van Elburg RM, et al. Systematic review and meta-analysis of preterm birth and later systolic blood pressure. Hypertension. 2012;59:226-34.

5.4. Secondary Forms of Hypertension Recommendations for Secondary Forms of Hypertension COR

LOE

I

C-EO

IIb

C-EO

Recommendations 1. Screening for specific form(s) of secondary hypertension is recommended when the clinical indications and physical examination findings listed in Table 13 are present or in adults with resistant hypertension. 2. If an adult with sustained hypertension screens positive for a form of secondary hypertension, referral to a physician with expertise in that form of hypertension may be reasonable for diagnostic confirmation and treatment.

Synopsis A specific, remediable cause of hypertension can be identified in approximately 10% of adult patients with hypertension (1). If a cause can be correctly diagnosed and treated, patients with secondary hypertension can achieve a cure or experience a marked improvement in BP control, with reduction in CVD risk. All new patients with hypertension should be screened with a history, physical examination, and laboratory investigations, as recommended in Section 7, before initiation of treatment. Secondary hypertension can underlie severe elevation of BP, pharmacologically resistant hypertension, sudden onset of hypertension, increased BP in patients with hypertension previously controlled Page 43

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline on drug therapy, onset of diastolic hypertension in older adults, and target organ damage disproportionate to the duration or severity of the hypertension. Although secondary hypertension should be suspected in younger patients (<30 years of age) with elevated BP, it is not uncommon for primary hypertension to manifest at a younger age, especially in blacks (2), and some forms of secondary hypertension, such as renovascular disease, are more common at older age. Many of the causes of secondary hypertension are strongly associated with clinical findings or groups of findings that suggest a specific disorder. Figure 3 is an algorithm on screening for secondary hypertension. Table 13 is a detailed list of clinical indications and diagnostic screening tests for secondary hypertension, and Table 14 is a list of drugs that can induce secondary hypertension. Recommendation-Specific Supportive Text 1. The causes of secondary hypertension and recommended screening tests are provided in Table 13, and drugs that can induce secondary hypertension are provided in Table 14. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

2. Diagnosis of many of these disorders requires a complex set of measurements, specialized technical expertise, and/or experience in data interpretation. Similarly, specific treatment often requires a level of technical training and experience.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 3. Screening for Secondary Hypertension New-onset or uncontrolled hypertension in adults

Conditions • Drug-resistant/induced hypertension • Abrupt onset of hypertension • Onset of hypertension at <30 y • Exacerbation of previously controlled hypertension • Disproportionate TOD for degree of hypertension • Accelerated/malignant hypertension • Onset of diastolic hypertension in older adults (age ≥65 y) • Unprovoked or excessive hypokalemia Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Yes Screen for secondary hypertension (Class I) (see Table 13)

No Screening not indicated (No Benefit)

Positive screening test

Yes Refer to clinician with specific expertise (Class IIb)

No Referral not necessary (No Benefit)

Colors correspond to Class of Recommendation in Table 1. TOD indicates target organ damage (e.g., cerebrovascular disease, hypertensive retinopathy, left ventricular hypertrophy, left ventricular dysfunction, heart failure, coronary artery disease, chronic kidney disease, albuminuria, peripheral artery disease).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 13. Causes of Secondary Hypertension With Clinical Indications and Diagnostic Screening Tests

Common causes Renal parenchymal disease (1, 3)

Physical Examination

Screening Tests

Additional/ Confirmatory Tests

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Prevalence

Clinical Indications

1%–2%

Urinary tract infections; obstruction, hematuria; urinary frequency and nocturia; analgesic abuse; family history of polycystic kidney disease; elevated serum creatinine; abnormal urinalysis Resistant hypertension; hypertension of abrupt onset or worsening or increasingly difficult to control; flash pulmonary edema (atherosclerotic); early-onset hypertension, especially in women (fibromuscular hyperplasia) Resistant hypertension; hypertension with hypokalemia (spontaneous or diuretic induced); hypertension and muscle cramps or weakness; hypertension and incidentally discovered adrenal mass; hypertension and obstructive sleep apnea; hypertension and family history of early-onset hypertension or stroke Resistant hypertension; snoring; fitful sleep; breathing pauses during sleep; daytime sleepiness

Abdominal mass (polycystic kidney disease); skin pallor

Renal ultrasound

Tests to evaluate cause of renal disease

Abdominal systolic-diastolic bruit; bruits over other arteries (carotid – atherosclerotic or fibromuscular dysplasia), femoral Arrhythmias (with hypokalemia); especially atrial fibrillation

Renal Duplex Doppler ultrasound; MRA; abdominal CT

Bilateral selective renal intra-arterial angiography

Plasma aldosterone/r enin ratio under standardized conditions (correction of hypokalemia and withdrawal of aldosterone antagonists for 4–6 wk)

Oral sodium loading test (with 24-h urine aldosterone) or IV saline infusion test with plasma aldosterone at 4 h of infusion Adrenal CT scan, adrenal vein sampling.

Obesity, Mallampati class III–IV; loss of normal nocturnal BP fall

Polysomnograp hy

Sodium-containing antacids; caffeine; nicotine (smoking); alcohol; NSAIDs; oral contraceptives; cyclosporine or tacrolimus; sympathomimetics (decongestants, anorectics); cocaine, amphetamines and other illicit drugs; neuropsychiatric agents; erythropoiesis-stimulating

Fine tremor, tachycardia, sweating (cocaine, ephedrine, MAO inhibitors); acute abdominal pain (cocaine)

Berlin Questionnaire (8); Epworth Sleepiness Score (9); overnight oximetry Urinary drug screen (illicit drugs)

Renovascular disease (4)

5%–34%*

Primary aldosteronism (5, 6)

8%–20%†

Obstructive sleep apnea (7)‡

25%–50%

Drug or alcohol induced (10)§

2%–4%

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Response to withdrawal of suspected agent

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline

Uncommon causes Pheochromocytoma/pa raganglioma (11)

agents; clonidine withdrawal; herbal agents (Ma Huang, ephedra)

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0.1%–0.6%

Resistant hypertension; paroxysmal hypertension or crisis superimposed on sustained hypertension; “spells,” BP lability, headache, sweating, palpitations, pallor; positive family history of pheochromocytoma/ paraganglioma; adrenal incidentaloma

Skin stigmata of neurofibromato sis (café-au-lait spots; neurofibromas); Orthostatic hypotension

24-h urinary fractionated metanephrine s or plasma metanephrine s under standard conditions (supine position with indwelling IV cannula) Overnight 1mg dexamethaso ne suppression test

CT or MRI scan of abdomen/pelvis

Cushing’s syndrome (12)

<0.1%

Rapid weight gain, especially with central distribution; proximal muscle weakness; depression; hyperglycemia

Hypothyroidism (10)

<1%

Dry skin; cold intolerance; constipation; hoarseness; weight gain

Hyperthyroidism (10)

<1%

Aortic coarctation (undiagnosed or repaired) (13)

0.1%

Warm, moist skin; heat intolerance; nervousness; tremulousness; insomnia; weight loss; diarrhea; proximal muscle weakness Young patient with hypertension (<30 y of age)

Central obesity, “moon” face, dorsal and supraclavicular fat pads, wide (1-cm) violaceous striae, hirsutism Delayed ankle reflex; periorbital puffiness; coarse skin; cold skin; slow movement; goiter Lid lag; fine tremor of the outstretched hands; warm, moist skin

Thyroidstimulating hormone; free thyroxine

None

Thyroidstimulating hormone; free thyroxine

Radioactive iodine uptake and scan

Echocardiogra m

Thoracic and abdominal CT angiogram or MRA

Hypercalcemia

BP higher in upper extremities than in lower extremities; absent femoral pulses; continuous murmur over patient’s back, chest, or abdominal bruit; left thoracotomy scar (postoperative) Usually none

Primary hyperparathyroidism (14) Congenital adrenal hyperplasia (15)

Rare

Serum calcium

Hypertension and hypokalemia; virilization

Signs of virilization (11-

Hypertension and

Serum parathyroid hormone 11-beta-OH: elevated

Rare

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24-h urinary free cortisol excretion (preferably multiple); midnight salivary cortisol

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline (11-beta-hydroxylase deficiency [11-beta-OH]); incomplete masculinization in males and primary amenorrhea in females (17-alphahydroxylase deficiency [17-alpha-OH])

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Mineralocorticoid excess syndromes other than primary aldosteronism (15) Acromegaly (16)

Rare

beta-OH) or incomplete masculinization (17-alpha-OH)

hypokalemia with low or normal aldosterone and renin

deoxycorticoste rone (DOC), 11deoxycortisol, and androgens17alpha-OH; decreased androgens and estrogen; elevated deoxycorticoste rone and corticosterone Urinary cortisol metabolites; genetic testing

Early-onset hypertension; Arrhythmias Low resistant hypertension; (with aldosterone hypokalemia or hypokalemia) and renin hyperkalemia Rare Acral features, enlarging Acral features; Serum growth Elevated ageshoe, glove, or hat size; large hands and hormone ≥1 and sexheadache, visual feet; frontal ng/mL during matched IGF-1 disturbances; diabetes bossing oral glucose level; MRI scan mellitus load of the pituitary *Depending on the clinical situation (hypertension alone, 5%; hypertension starting dialysis, 22%; hypertension and peripheral vascular disease, 28%; hypertension in the elderly with congestive heart failure, 34%). †8% in general population with hypertension; up to 20% in patients with resistant hypertension. ‡Although obstructive sleep apnea is listed as a cause of secondary hypertension, RCTs on the effects of continuous positive airway pressure on lowering BP in patients with hypertension have produced mixed results (see Section 5.4.4 for details). §For a list of frequently used drugs causing hypertension and accompanying evidence, see Table 14. BP indicates blood pressure; CT, computed tomography; DOC, 11-deoxycorticosterone; IGF-1, insulin-like growth factor-1; IV, intravenous; MAO, monamine oxidase; MRI, magnetic resonance imaging; MRA, magnetic resonance arteriography; NSAIDs, nonsteroidal anti-inflammatory drugs; OH, hydroxylase; and RCT, randomized clinical trial.

References 1. Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008;51:1403-19. 2. Selassie A, Wagner CS, Laken ML, et al. Progression is accelerated from prehypertension to hypertension in blacks. Hypertension. 2011;58:579-87. 3. Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999;130:461-70. 4. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). Circulation. 2006;113:e463-654. 5. Funder JW, Carey RM, Fardella C, et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2008;93:3266-81. 6. Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2016;101:1889-916. 7. Pedrosa RP, Drager LF, Gonzaga CC, et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension. 2011;58:811-7. 8. Kump K, Whalen C, Tishler PV, et al. Assessment of the validity and utility of a sleep-symptom questionnaire. Am J. Respir Crit Care Med. 1994;150:735-41.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 9. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14:540-5. 10. Grossman E, Messerli FH. Drug-induced hypertension: an unappreciated cause of secondary hypertension. Am J Med. 2012;125:14-22. 11. Lenders JWM, Duh Q-Y, Eisenhofer G, et al. Pheochromocytoma and paraganglioma: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014;99:1915-42. 12. Nieman LK, Biller BMK, Findling JW, et al. The diagnosis of Cushing's syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2008;93:1526-40. 13. Lurbe E, Cifkova R, Cruickshank JK, et al. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens. 2009;27:1719-42. 14. Berglund G, Andersson O, Wilhelmsen L. Prevalence of primary and secondary hypertension: studies in a random population sample. Br Med J. 1976;2:554-6. 15. Hassan-Smith Z, Stewart PM. Inherited forms of mineralocorticoid hypertension. Curr Opin Endocrinol Diabetes Obes. 2011;18:177-85. 16. Katznelson L, Laws ER Jr, Melmed S, et al. Acromegaly: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014;99:3933-51. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

5.4.1. Drugs and Other Substances With Potential to Impair BP Control Numerous substances, including prescription medications, over-the-counter medications, herbals, and food substances, may affect BP (Table 14) (1-6). Changes in BP that occur because of drugs and other agents have been associated with the development of hypertension, worsening control in a patient who already has hypertension, or attenuation of the BP-lowering effects of antihypertensive therapy. A change in BP may also result from drug–drug or drug–food interactions (2, 4). In the clinical assessment of hypertension, a careful history should be taken with regard to substances that may impair BP control, with close attention paid to not only prescription medications, but also over-the-counter substances, illicit drugs, and herbal products. When feasible, drugs associated with increased BP should be reduced or discontinued, and alternative agents should be used. Table 14. Frequently Used Medications and Other Substances That May Cause Elevated BP* Agent Alcohol

Amphetamines (e.g., amphetamine, methylphenidate dexmethylphenidate, dextroamphetamine) Antidepressants (e.g., MAOIs, SNRIs, TCAs)

Atypical antipsychotics (e.g., clozapine, olanzapine)

Possible Management Strategy • Limit alcohol to ≤1 drink daily for women and ≤2 drinks for men (7) • Discontinue or decrease dose (8) • Consider behavioral therapies for ADHD (9) • • • • • •

Caffeine

• • •

Decongestants (e.g., phenylephrine, pseudoephedrine)



Consider alternative agents (e.g., SSRIs) depending on indication Avoid tyramine-containing foods with MAOIs Discontinue or limit use when possible Consider behavior therapy where appropriate Recommend lifestyle modification (see Section 6.2) Consider alternative agents associated with lower risk of weight gain, diabetes mellitus, and dyslipidemia (e.g., aripiprazole, ziprasidone) (10, 11) Generally limit caffeine intake to <300 mg/d Avoid use in patients with uncontrolled hypertension Coffee use in patients with hypertension is associated with acute increases in BP; long-term use is not associated with increased BP or CVD (12) Use for shortest duration possible, and avoid in severe or uncontrolled hypertension

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline • Herbal supplements (e.g., Ma Huang [ephedra], St. John’s wort [with MAO inhibitors, yohimbine]) Immunosuppressants (e.g., cyclosporine)



Oral contraceptives



NSAIDs

• • •



Consider alternative therapies (e.g., nasal saline, intranasal corticosteroids, antihistamines) as appropriate Avoid use

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Consider converting to tacrolimus, which may be associated with fewer effects on BP (13-15) Use low-dose (e.g., 20–30 mcg ethinyl estradiol) agents (16) or a progestin-only form of contraception, or consider alternative forms of birth control where appropriate (e.g., barrier, abstinence, IUD) Avoid use in women with uncontrolled hypertension (16) Avoid systemic NSAIDs when possible Consider alternative analgesics (e.g., acetaminophen, tramadol, topical NSAIDs), depending on indication and risk Discontinue or avoid use

Recreational drugs (e.g., “bath salts” • [MDPV], cocaine, methamphetamine, etc.) Systemic corticosteroids (e.g., • Avoid or limit use when possible dexamethasone, fludrocortisone, • Consider alternative modes of administration (e.g., inhaled, methylprednisolone, prednisone, topical) when feasible prednisolone) Angiogenesis inhibitor (e.g., bevacizumab) • Initiate or intensify antihypertensive therapy and tyrosine kinase inhibitors (e.g., sunitinib, sorafenif) *List is not all inclusive. ADHD indicates attention-deficit/hyperactivity disorder; BP, blood pressure; CVD, cardiovascular disease; IUD, intrauterine device; MAOI, monoamine-oxidase inhibitors; MDPV, methylenedioxypyrovalerone; NSAIDs, nonsteroidal antiinflammatory drugs; SNRI, serotonin norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; and TCA, tricyclic antidepressant. References 1. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993;153:154-83. 2. Grossman E, Messerli FH. Drug-induced hypertension: an unappreciated cause of secondary hypertension. Am J Med. 2012;125:14-22. 3. Ong SLH, Whitworth JA. How do glucocorticoids cause hypertension: role of nitric oxide deficiency, oxidative stress, and eicosanoids. Endocrinol Metab Clin North Am. 2011;40:393-407, ix. 4. Rossi GP, Seccia TM, Maniero C, et al. Drug-related hypertension and resistance to antihypertensive treatment: a call for action. J Hypertens. 2011;29:2295-309. 5. Tachjian A, Maria V, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular diseases. J Am Coll Cardiol. 2010;55:515-25. 6. Grossman E, Messerli FH. Secondary hypertension: interfering substances. J Clin Hypertens (Greenwich). 2008;10:556-66. 7. Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:51784. 8. Cortese S, Holtmann M, Banaschewski T, et al. Practitioner review: current best practice in the management of adverse events during treatment with ADHD medications in children and adolescents. J Child Psychol Psychiatry. 2013;54:227-46. 9. Wolraich M, Brown L, Brown RT, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128:1007-22.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 10. Newcomer JW. Metabolic considerations in the use of antipsychotic medications: a review of recent evidence. J Clin Psychiatry. 2007;68(suppl 1):20-7. 11. Willey JZ, Moon YP, Kahn E, et al. Population attributable risks of hypertension and diabetes for cardiovascular disease and stroke in the northern Manhattan study. J Am Heart Assoc. 2014;3:e001106. 12. Mesas AE, Leon-Munoz LM, Rodriguez-Artalejo F, et al. The effect of coffee on blood pressure and cardiovascular disease in hypertensive individuals: a systematic review and meta-analysis. Am J Clin Nutr. 2011;94:1113-26. 13. Liu Y, Yang M-S, Yuan J-Y. Immunosuppressant utilization and cardiovascular complications among Chinese patients after kidney transplantation: a systematic review and analysis. Int Urol Nephrol. 2013;45:885-92. 14. Penninga L, Penninga EI, Moller CH, et al. Tacrolimus versus cyclosporin as primary immunosuppression for lung transplant recipients. Cochrane Database Syst Rev. 2013;5:CD008817. 15. Xue W, Zhang Q, Xu Y, et al. Effects of tacrolimus and cyclosporine treatment on metabolic syndrome and cardiovascular risk factors after renal transplantation: a meta-analysis. Chin Med J. 2014;127:2376-81. 16. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

5.4.2. Primary Aldosteronism Recommendations for Primary Aldosteronism COR

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Recommendations 1. In adults with hypertension, screening for primary aldosteronism is recommended in the presence of any of the following concurrent conditions: resistant hypertension, hypokalemia (spontaneous or substantial, if diuretic induced), incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke at a young age (<40 years). 2. Use of the plasma aldosterone: renin activity ratio is recommended when adults are screened for primary aldosteronism (1). 3. In adults with hypertension and a positive screening test for primary aldosteronism, referral to a hypertension specialist or endocrinologist is recommended for further evaluation and treatment.

Synopsis Primary aldosteronism is defined as a group of disorders in which aldosterone production is inappropriately high for sodium status, is relatively autonomous of the major regulators of secretion (angiotensin II and potassium), and cannot be suppressed with sodium loading (2, 3). The increased production of aldosterone induces hypertension; cardiovascular and kidney damage; sodium retention; suppressed plasma renin activity; and increased potassium excretion, which, if prolonged and severe, may cause hypokalemia. However, hypokalemia is absent in the majority of cases and has a low negative predictive value for the diagnosis of primary aldosteronism (4). In about 50% of the patients, primary aldosteronism is due to increased unilateral aldosterone production (usually aldosterone-producing adenoma or, rarely, unilateral adrenal hyperplasia); in the remaining 50%, primary aldosteronism is due to bilateral adrenal hyperplasia (idiopathic hyperaldosteronism) (2, 3). Recommendation-Specific Supportive Text 1. Primary aldosteronism is one of the most frequent disorders (occurring in 5% to 10% of patients with hypertension and 20% of patients with resistant hypertension) that causes secondary hypertension (5, 6). The toxic tissue effects of aldosterone induce greater target organ damage in primary aldosteronism than in primary hypertension. Patients with primary aldosteronism have a 3.7-fold increase in HF, a 4.2-fold increase in stroke, a 6.5-fold increase in MI, a 12.1-fold increase in atrial fibrillation (AF), increased left ventricular

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline hypertrophy (LVH) and diastolic dysfunction, increased stiffness of large arteries, widespread tissue fibrosis, increased remodeling of resistance vessels, and increased kidney damage as compared with patients with primary hypertension matched for BP level (6-8). Because the deleterious effects of aldosterone overproduction are often reversible with unilateral laparoscopic adrenalectomy or treatment with mineralocorticoid receptor antagonists (i.e., spironolactone or eplerenone), screening of patients with hypertension at increased risk of primary aldosteronism is beneficial (2, 3). These include hypertensive patients with adrenal “incidentaloma,” an incidentally discovered adrenal lesion on a computed tomography or magnetic resonance imaging (MRI) scan performed for other purposes. Patients with hypertension and a history of early onset hypertension and/or cerebrovascular accident at a young age may have primary aldosteronism due to glucocorticoid-remediable aldosteronism (familial hyperaldosteronism type-1) and therefore warrant screening (2, 3).

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2. The aldosterone:renin activity ratio is currently the most accurate and reliable means of screening for primary aldosteronism (1). The most commonly used cutoff value is 30 when plasma aldosterone concentration is reported in nanograms per deciliter (ng/dL) and plasma renin activity in nanograms per milliliter per hour (ng/mL/h) (3). Because the aldosterone:renin activity ratio can be influenced by the presence of very low renin levels, the plasma aldosterone concentration should be at least 10 ng/dL to interpret the test as positive (3). Patients should have unrestricted salt intake, serum potassium in the normal range, and mineralocorticoid receptor antagonists (e.g., spironolactone or eplerenone) withdrawn for at least 4 weeks before testing (2, 3 ). 3. The diagnosis of primary aldosteronism generally requires a confirmatory test (intravenous saline suppression test or oral salt-loading test) (2, 3 ). If the diagnosis of primary aldosteronism is confirmed (and the patient agrees that surgery would be desirable), the patient is referred for an adrenal venous sampling procedure to determine whether the increased aldosterone production is unilateral or bilateral in origin. If unilateral aldosterone production is documented on adrenal venous sampling, the patient is referred for unilateral laparoscopic adrenalectomy, which improves BP in virtually 100% of patients and results in a complete cure of hypertension in about 50% (2, 3 ). If the patient has bilaterally increased aldosterone secretion on adrenal venous sampling or has a unilateral source of excess aldosterone production but cannot undergo surgery, the patient is treated with spironolactone or eplerenone as agent of choice (2, 3). Both adrenalectomy and medical therapy are effective in lowering BP and reversing LVH. Treating primary aldosteronism, either by mineralocorticoid receptor antagonists or unilateral adrenalectomy (if indicated), resolves hypokalemia, lowers BP, reduces the number of antihypertensive medications required, and improves parameters of impaired cardiac and kidney function (9, 10). References 1. Montori VM, Young WF Jr. Use of plasma aldosterone concentration-to-plasma renin activity ratio as a screening test for primary aldosteronism. A systematic review of the literature. Endocrinol Metab Clin North Am. 2002;31:619-32, xi. 2. Funder JW, Carey RM, Fardella C, et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2008;93:3266-81. 3. Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2016;101:1889-916. 4. Mulatero P, Stowasser M, Loh K-C, et al. Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. J Clin Endocrinol Metab. 2004;89:1045-50. 5. Hannemann A, Wallaschofski H. Prevalence of primary aldosteronism in patient's cohorts and in population-based studies--a review of the current literature. Horm Metab Res. 2012;44:157-62. 6. Rossi GP, Bernini G, Desideri G, et al. Renal damage in primary aldosteronism: results of the PAPY Study. Hypertension. 2006;48:232-8. 7. Milliez P, Girerd X, Plouin P-F, et al. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J Am Coll Cardiol. 2005;45:1243-8.

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Mulatero P, Monticone S, Bertello C, et al. Long-term cardio- and cerebrovascular events in patients with primary aldosteronism. J Clin Endocrinol Metab. 2013;98:4826-33. 9. Rossi GP, Cesari M, Cuspidi C, et al. Long-term control of arterial hypertension and regression of left ventricular hypertrophy with treatment of primary aldosteronism. Hypertension. 2013;62:62-9. 10. Fourkiotis V, Vonend O, Diederich S, et al. Effectiveness of eplerenone or spironolactone treatment in preserving renal function in primary aldosteronism. Eur J Endocrinol. 2013;168:75-81.

5.4.3. Renal Artery Stenosis Recommendations for Renal Artery Stenosis

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Recommendations 1. Medical therapy is recommended for adults with atherosclerotic renal artery stenosis (1, 2). 2. In adults with renal artery stenosis for whom medical management has failed (refractory hypertension, worsening renal function, and/or intractable HF) and those with nonatherosclerotic disease, including fibromuscular dysplasia, it may be reasonable to refer the patient for consideration of revascularization (percutaneous renal artery angioplasty and/or stent placement).

Synopsis Renal artery stenosis refers to a narrowing of the renal artery that can result in a restriction of blood flow. Atherosclerotic disease (90%) is by far the most common cause of renal artery stenosis, whereas nonatherosclerotic disease (of which fibromuscular dysplasia is the most common) is much less prevalent and tends to occur in younger, healthier patients (3). Renal artery stenosis is a common form of secondary hypertension. Relieving ischemia and the ensuing postischemic release of renin by surgical renal artery reconstruction is an invasive strategy with a postoperative mortality as high as 13% (4). With the advent of endovascular procedures to restore blood flow, several trials were designed to test the efficacy of these procedures against medical therapy, but they suggested no benefit over medical therapy alone (1, 2). Recommendation-Specific Supportive Text 1. Atherosclerotic disease in the renal arteries represents systemic disease and higher risk of both renal failure and cardiovascular morbidity and mortality. No RCT to date has demonstrated a clinical advantage of renal artery revascularization (with either angioplasty or stenting) over medical therapy (2). On the basis of the CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial, the recommended medical approach encompasses optimal management of hypertension with an antihypertensive regimen that includes a reninangiotensin system (RAS) blocker, in addition to low-density lipoprotein cholesterol reduction with a highintensity statin, smoking cessation, hemoglobin A1c reduction in patients with DM, and antiplatelet therapy (1). 2. Revascularization may be considered for those who do not respond to medical therapy and for those who have nonatherosclerotic disease (e.g., Takayasu arteritis in Asian populations, fibromuscular dysplasia in other populations). Fibromuscular dysplasia occurs over the lifespan of women (mean: 53 years of age) with almost equal frequency in the renal and carotid circulations (3). Percutaneous transluminal angioplasty alone (without stenting) can improve BP control and even normalize BP, especially in patients with recent onset of hypertension or resistant hypertension (5). References 1. Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014;370:13-22.

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Riaz IB, Husnain M, Riaz H, et al. Meta-analysis of revascularization versus medical therapy for atherosclerotic renal artery stenosis. Am J Cardiol. 2014;114:1116-23. Olin JW, Froehlich J, Gu X, et al. The United States Registry for Fibromuscular Dysplasia: results in the first 447 patients. Circulation. 2012;125:3182-90. Lamawansa MD, Bell R, House AK. Short-term and long-term outcome following renovascular reconstruction. Cardiovasc Surg. 1995;3:50-5. Trinquart L, Mounier-Vehier C, Sapoval M, et al. Efficacy of revascularization for renal artery stenosis caused by fibromuscular dysplasia: a systematic review and meta-analysis. Hypertension. 2010;56:525-32.

5.4.4. Obstructive Sleep Apnea Recommendation for Obstructive Sleep Apnea

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Recommendations 1. In adults with hypertension and obstructive sleep apnea, the effectiveness of continuous positive airway pressure (CPAP) to reduce BP is not well established (1-5).

Synopsis Obstructive sleep apnea is a common chronic condition characterized by recurrent collapse of upper airways during sleep, inducing intermittent episodes of apnea/hypopnea, hypoxemia, and sleep disruption (6). Obstructive sleep apnea is a risk factor for several CVDs, including hypertension, coronary and cerebrovascular diseases, HF, and AF (6-9). Observational studies have shown that the presence of obstructive sleep apnea is associated with increased risk of incident hypertension (10, 11). Obstructive sleep apnea is highly prevalent in adults with resistant hypertension (≥80%) (12, 13), and it has been hypothesized that treatment with CPAP may have more pronounced effects on BP reduction in resistant hypertension (6). Recommendation-Specific Supportive Text 1. CPAP is an efficacious treatment for improving obstructive sleep apnea. However, studies of the effects of CPAP on BP have demonstrated only small effects on BP (e.g., 2– to 3–mm Hg reductions), with results dependent on patient compliance with CPAP use, severity of obstructive sleep apnea, and presence of daytime sleepiness in study participants (1-5). Although many RCTs have been reported that address the effects of CPAP on BP in obstructive sleep apnea, most of the patients studied did not have documented hypertension, and the studies were too small and the follow-up period too short to allow for adequate evaluation. In addition, a well-designed RCT demonstrated that CPAP plus usual care, compared with usual care alone, did not prevent cardiovascular events in patients with moderate–severe obstructive sleep apnea and established CVD (14). References 1. Barbe F, Duran-Cantolla J, Capote F, et al. Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea. Am J Respir Crit Care Med. 2010;181:718-26. 2. Martinez-Garcia MA, Capote F, Campos-Rodriguez F, et al. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013;310:240715. 3. Lozano L, Tovar JL, Sampol G, et al. Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension: a randomized, controlled trial. J Hypertens. 2010;28:2161-8. 4. Muxfeldt ES, Margallo V, Costa LMS, et al. Effects of continuous positive airway pressure treatment on clinic and ambulatory blood pressures in patients with obstructive sleep apnea and resistant hypertension: a randomized controlled trial. Hypertension. Hypertension. 2015;65:736-42. 5. Pedrosa RP, Drager LF, de Paula LKG, et al. Effects of OSA treatment on BP in patients with resistant hypertension: a randomized trial. Chest. 2013;144:1487-94.

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12. 13. 14.

Parati G, Lombardi C, Hedner J, et al. Position paper on the management of patients with obstructive sleep apnea and hypertension: joint recommendations by the European Society of Hypertension, by the European Respiratory Society and by the members of European COST (COoperation in Scientific and Technological research) ACTION B26 on obstructive sleep apnea. J Hypertens. 2012;30:633-46. Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoeahypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046-53. Marshall NS, Wong KKH, Liu PY, et al. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep. 2008;31:1079-85. Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000;283:1829-36. Peppard PE, Young T, Palta M, et al. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000;342:1378-84. Marin JM, Agusti A, Villar I, et al. Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA. 2012;307:2169-76. Pedrosa RP, Drager LF, Gonzaga CC, et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension. 2011;58:811-7. Muxfeldt ES, Margallo VS, Guimaraes GM, et al. Prevalence and associated factors of obstructive sleep apnea in patients with resistant hypertension. Am J Hypertens. 2014;27:1069-78. McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016;375:919-31.

6. Nonpharmacological Interventions Correcting the dietary aberrations, physical inactivity, and excessive consumption of alcohol that cause high BP is a fundamentally important approach to prevention and management of high BP, either on their own or in combination with pharmacological therapy. Prevention of hypertension and treatment of established hypertension are complementary approaches to reducing CVD risk in the population, but prevention of hypertension provides the optimal means of reducing risk and avoiding the harmful consequences of hypertension (1-3). Nonpharmacological therapy alone is especially useful for prevention of hypertension, including in adults with elevated BP, and for management of high BP in adults with milder forms of hypertension (4, 5). References 1. Whelton PK, He J, Appel LJ, et al. Primary prevention of hypertension: clinical and public health advisory from the National High Blood Pressure Education Program. JAMA. 2002;288:1882-8. 2. National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Arch Intern Med. 1993;153:186-208. 3. Whelton PK. Hypertension curriculum review: epidemiology and the prevention of hypertension. J Clin Hypertens (Greenwich). 2004;6:636-42. 4. Whelton PK, Appel LJ, Espeland MA, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA. 1998;279:839-46. 5. Whelton PK. The elusiveness of population-wide high blood pressure control. Annu Rev Public Health. 2015;36:109-30.

6.1. Strategies Nonpharmacological interventions can be accomplished by means of behavioral strategies aimed at lifestyle change, prescription of dietary supplements, or implementation of kitchen-based interventions that directly modify elements of the diet. At a societal level, policy changes can enhance the availability of healthy foods and facilitate physical activity. The goal can be to modestly reduce BP in the general population or to

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline undertake more intensive targeted lowering of BP in adults with hypertension or at high risk of developing hypertension (1). The intent of the general population approach is to achieve a small downward shift in the general population distribution of BP, which would be expected to result in substantial health benefits (2). The targeted approach focuses on BP reduction in adults at greatest risk of developing BP-related CVD, including individuals with hypertension, as well as those at increased risk of developing hypertension, especially blacks and adults who are overweight, consume excessive amounts of dietary sodium, have a high intake of alcohol, or are physically inactive. The targeted approach tends to be intensive, with a more ambitious goal for BP reduction. Both approaches are complementary and mutually reinforcing, and modeling studies suggest they are likely to provide similar public health benefit (3, 4). However, as the precision of risk prediction tools increases, targeted prevention strategies that focus on high-risk individuals seem to become more efficient than population-based strategies (5).

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References 1. National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Arch Intern Med. 1993;153:186-208. 2. Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the Trials of Hypertension Prevention (TOHP). BMJ. 2007;334:885-8. 3. Rodgers A, MacMahon S. Blood pressure and the global burden of cardiovascular disease. Clin Exp Hypertens. 1999;21:543-52. 4. Qin X, Jackson R, Marshall R, et al. Modelling the potential impact of population-wide and targeted high-risk blood pressure-lowering strategies on cardiovascular disease in China. Eur J Cardiovasc Prev Rehabil. 2009;16:96-101. 5. Zulman DM, Vijan S, Omenn GS, et al. The relative merits of population-based and targeted prevention strategies. Milbank Q. 2008;86:557-80.

6.2. Nonpharmacological Interventions Recommendations for Nonpharmacological Interventions References that support recommendations are summarized in Online Data Supplements 9-21. COR LOE Recommendations 1. Weight loss is recommended to reduce BP in adults with elevated BP or I A hypertension who are overweight or obese (1-4). 2. A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is I A recommended for adults with elevated BP or hypertension (5-7). 3. Sodium reduction is recommended for adults with elevated BP or I A hypertension (8-12). 4. Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless I A contraindicated by the presence of CKD or use of drugs that reduce potassium excretion (13-17). 5. Increased physical activity with a structured exercise program is I A recommended for adults with elevated BP or hypertension (3, 4, 12, 18-22). 6. Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard I A drinks* per day, respectively (23-28).

*In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol) (29).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Synopsis

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Nonpharmacological interventions are effective in lowering BP, with the most important interventions being weight loss (1), the DASH (Dietary Approaches to Stop Hypertension) diet (5-7, 30), sodium reduction (8-11), potassium supplementation (13, 17), increased physical activity (18-20, 22, 31), and a reduction in alcohol consumption (23, 24). Various other nonpharmacological interventions have been reported to lower BP, but the extent and/or quality of the supporting clinical trial experience is less persuasive. Such interventions include consumption of probiotics (32, 33 , 34); increased intake of protein (35-37), fiber (38, 39), flaxseed (40), or fish oil (41); supplementation with calcium (42, 43) or magnesium (44, 45); and use of dietary patterns other than the DASH diet, including low-carbohydrate and vegetarian diets (5, 7, 46-49), (18-20, 22, 23, 31, 50). Stress reduction is intuitively attractive but insufficiently proved (51), as are several other interventions, including consumption of garlic (52), dark chocolate (53, 54), tea (55), or coffee (56). Behavioral therapies, including guided breathing, yoga, transcendental meditation, and biofeedback, lack strong evidence for their long-term BP-lowering effect (51, 57-61). The best proven nonpharmacological measures to prevent and treat hypertension are summarized in Table 15 (62). The nonpharmacological interventions presented in Table 15 may be sufficient to prevent hypertension and meet goal BP in managing patients with stage 1 hypertension, and they are an integral part of the management of persons with stage 2 hypertension. To a lesser extent, the Mediterranean diet (49, 63) (which incorporates the basics of healthy eating but emphasizes consumption of legumes and monounsaturated fat, avoidance of red meats, and moderate intake of wine) has been effective in reducing BP, as well as improving lipid profile. Table 15 is a summary of best proven nonpharmacological interventions for prevention and treatment of hypertension. Recommendation-Specific Supportive Text 1. Weight loss is a core recommendation and should be achieved through a combination of reduced calorie intake and increased physical activity (1). The BP-lowering effect of weight loss in patients with elevated BP is consistent with the corresponding effect in patients with established hypertension, with an apparent dose– response relationship of about 1 mm Hg per kilogram of weight loss. Achievement and maintenance of weight loss through behavior change are challenging (64-66) but feasible over prolonged periods of follow-up (64). For those who do not meet their weight loss goals with nonpharmacological interventions, pharmacotherapy or minimally invasive and bariatric surgical procedures can be considered (67, 68). Surgical procedures tend to be more effective but are usually reserved for those with more severe and intractable obesity because of the frequency of complications. (69) 2. The DASH eating plan is the diet best demonstrated to be effective for lowering BP. Because the DASH diet is high in fruits, vegetables, and low-fat dairy products, it provides a means to enhance intake of potassium, calcium, magnesium, and fiber. In hypertensive and nonhypertensive adults, the DASH diet has produced overall reductions in SBP of approximately 11 mm Hg and 3 mm Hg, respectively (7), and the diet was especially effective in blacks (70). When combined with weight loss (6) or a reduction in sodium intake (5, 30), the effect size was substantially increased. Most of the clinical trial experience comes from short-term feeding studies (7), but lifestyle change with the DASH diet has been successful in at least 2 trials that used a behavioral intervention over a 4-month (30) or 6-month (6) period of follow-up. Websites and books provide advice on implementation of the DASH diet. (13, 71-74) Counseling by a knowledgeable nutritionist can be helpful. Several other diets, including diets that are low in calories from carbohydrates (46), high-protein diets (75), vegetarian diets (48), and a Mediterranean dietary pattern (49 , 63), have been shown to lower BP. 3. Sodium reduction interventions prevent hypertension and lower BP in adults with hypertension, especially in those with higher levels of BP, blacks, older persons, and others who are particularly susceptible to the

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effects of sodium on BP (8-11). Sodium reduction interventions may prevent CVD (76, 77). Lifestyle change (behavioral) interventions usually reduce sodium intake by about 25% (approximately 1,000 mg per day) and result in an average of about a 2–mm Hg to 3–mm Hg reduction in SBP in nonhypertensive individuals, though the reduction can be more than double this in more susceptible individuals, those with hypertension, and those concurrently on the DASH diet (5) or following a weight loss intervention (12). Sodium reduction in adults with hypertension who are already being treated with BP-lowering medications further reduces SBP by about 3 mm Hg and can facilitate discontinuation of medication, although this requires maintenance of the lifestyle change and warrants careful monitoring (12). When combined with weight loss, the reduction in BP is almost doubled. A reduction in sodium intake may also lower SBP significantly in individuals with resistant hypertension who are taking multiple antihypertensive medications (78) (see Section 11.1). Reduced dietary sodium has been reported to augment the BP-lowering effects of RAS blocker therapy (79). Maintenance of the lifestyle changes necessary to reduce sodium intake is challenging (2-4, 12), but even a small decrement in sodium consumption is likely to be safe (2, 4, 9, 12, 80) and beneficial (8, 81), especially in those whose BP is salt sensitive (82). In the United States, most dietary sodium comes from additions during food processing or during commercial food preparation at sit-down and fast-food restaurants (83, 84). Person-specific and policy approaches can be used to reduce dietary sodium intake (85, 86). Individuals can take action to reduce their dietary intake of sodium by choice of fresh foods, use of food labels to choose foods that are lower in sodium content, choice of foods with a “no added sodium” label, judicious use of condiments and sodiuminfused foods, use of spices and low-sodium flavorings, careful ordering when eating out, control of food portion size, and avoiding or minimizing use of salt at the table. Dietary counseling by a nutritionist with expertise in behavior modification can be helpful. A reduction in the amount of sodium added during food processing, as well as fast food and restaurant food preparation, has the potential to substantially reduce sodium intake without the need for a conscious change in lifestyle (81, 85, 87). 4. Dietary potassium is inversely related to BP and hypertension in migrant studies (88), cross-sectional reports (89-91), and prospective cohort studies (92). Likewise, dietary potassium (93-96) and a high intake of fruits and vegetables are associated with a lower incidence of stroke (97). Potassium interventions have been effective in lowering BP (13, 14, 16, 81), especially in adult patients consuming an excess of sodium (13, 74, 98) and in blacks (13). The typical BP-lowering effect of a 60-mmol (1380-mg) administration of potassium chloride has been about 2 mm Hg and 4 to 5 mm Hg in adults with normotension and hypertension, respectively, although the response is up to twice as much in persons consuming a high-sodium diet. A reduction in the sodium/potassium index may be more important than the corresponding changes in either electrolyte alone (99). Some but not all studies suggest that the intervention effect may be restricted to adult patients with a low (1500-mg to 2000-mg) daily intake of potassium (92, 100). Most of the intervention experience comes from trials of relatively short duration (median of 5 to 6 weeks) (13, 14), but the BP-lowering effect of potassium in adult patients consuming a high-sodium diet has been reproduced after an interval of 4.4 years (98). In most trials, potassium supplementation was achieved by administration of potassium chloride pills, but the BP response pattern was similar when dietary modification was used (13). Because potassium-rich diets tend to be heart healthy, they are preferred over use of pills for potassium supplementation. The 2015 Dietary Guidelines for Americans (101) encourage a diet rich in potassium and identify the adequate intake level for adult patients as 4700 mg/day (102). The World Health Organization recommends a potassium intake of at least 90 mmol (3510 mg) per day from food for adult patients (15). Good sources of dietary potassium include fruits and vegetables, as well as low-fat dairy products, selected fish and meats, nuts, and soy products. Four to five servings of fruits and vegetables will usually provide 1500 to >3000 mg of potassium. This can be achieved by a diet, such as the DASH diet, that is high in potassium content (6). 5. A BP-lowering effect of increased physical activity has been repeatedly demonstrated in clinical trials, especially during dynamic aerobic exercise (18, 20, 22), but also during dynamic resistance training (18, 21) and static isometric exercise (18, 19, 31). The average reductions in SBP with aerobic exercise are

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline approximately 2 to 4 mm Hg and 5 to 8 mm Hg in adult patients with normotension and hypertension, respectively (18). Most trials have been of relatively short duration, but increased physical activity has been an intrinsic component of longer-term weight reduction interventions used to reduce BP and prevent hypertension (3, 4, 12). BP-lowering effects have been reported with lower- and higher-intensity exercise and with continuous and interval exercise training (18, 103). Meta-analyses suggest isometric exercise results in substantial lowering of BP (18, 19, 31).

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6. In observational studies, there is a strong, predictable direct relationship between alcohol consumption and BP, especially above an intake of 3 standard drinks per day (approximately 36 ounces of regular beer, 15 ounces of wine, or 4.5 ounces of distilled spirits) (29, 104, 105). Meta-analyses of RCTs that have studied the effect of reduced alcohol consumption on BP in adults have identified a significant reduction in SBP and DBP (23, 24). The benefit has seemed to be consistent across trials, but confined to those consuming ≥3 drinks/day, as well as dose dependent, with those consuming ≥6 drinks/day at baseline reducing their alcohol intake by about 50% and experiencing an average reduction in SBP/DBP of approximately 5.5/4.0 mm Hg (23, 24). Only limited information is available on the effect of alcohol reduction on BP in blacks (23, 106). In contrast to its effect on BP, alcohol seems to have a beneficial effect on several biomarkers for CVD risk, including highdensity lipoprotein cholesterol (107, 108). Observational studies have shown a relatively consistent finding of an inverse relationship between alcohol intake and CHD (109, 110), within a moderate range (approximately 12–14 and ≤9 standard drinks/week for men and women, respectively). On balance, it seems reasonable for those who are consuming moderate quantities of alcohol (≤2 drinks/day) to continue their moderate consumption of alcohol.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 15. Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* Nonpharmacological Intervention

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Weight loss

Weight/body fat

Healthy diet

DASH dietary pattern

Reduced intake of dietary sodium

Dietary sodium

Enhanced intake of dietary potassium Physical activity

Dietary potassium

Aerobic Dynamic resistance

Isometric resistance

Moderation in alcohol intake

Alcohol consumption

Dose

Best goal is ideal body weight, but aim for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight. Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. Optimal goal is <1500 mg/d, but aim for at least a 1000-mg/d reduction in most adults. Aim for 3500–5000 mg/d, preferably by consumption of a diet rich in potassium. ● 90–150 min/wk ● 65%–75% heart rate reserve ● 90–150 min/wk ● 50%–80% 1 rep maximum ● 6 exercises, 3 sets/exercise, 10 repetitions/set ● 4 × 2 min (hand grip), 1 min rest between exercises, 30%–40% maximum voluntary contraction, 3 sessions/wk ● 8–10 wk In individuals who drink alcohol, reduce alcohol† to: ● Men: ≤2 drinks daily

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Approximate Impact on SBP Hypertension Normotension Reference -5 mm Hg -2/3 mm Hg (1)

-11 mm Hg

-3 mm Hg

(6, 7)

-5/6 mm Hg

-2/3 mm Hg

(9, 10)

-4/5 mm Hg

-2 mm Hg

(13)

-5/8 mm Hg

-2/4 mm Hg

(18, 22)

-4 mm Hg

-2 mm Hg

(18)

-5 mm Hg

-4 mm Hg

(19, 31)

-4 mm Hg

-3 mm Hg

(22-24)

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline ● Women: ≤1 drink daily *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure. Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH? Available at: http://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to. Accessed September 15, 2017. (72) Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp. Accessed September 15, 2017. (73) †In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol) (29).

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43. Cormick G, Ciapponi A, Cafferata ML, et al. Calcium supplementation for prevention of primary hypertension. Cochrane Database Syst Rev. 2015;6:CD010037. 44. Kass L, Weekes J, Carpenter L. Effect of magnesium supplementation on blood pressure: a meta-analysis. Eur J Clin Nutr. 2012;66:411-8. 45. Zhang X, Li Y, Del Gobbo LC, et al. Effects of magnesium supplementation on blood pressure: a meta-analysis of randomized double-blind placebo-controlled trials. Hypertension. 2016;68:324-33. 46. Bazzano LA, Hu T, Reynolds K, et al. Effects of low-carbohydrate and low-fat diets: a randomized trial. Ann Intern Med. 2014;161:309-18. 47. Nordmann AJ, Nordmann A, Briel M, et al. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med. 2006;166:285-93. 48. Yokoyama Y, Nishimura K, Barnard ND, et al. Vegetarian diets and blood pressure: a meta-analysis. JAMA Intern Med. 2014;174:577-87. 49. Nordmann AJ, Suter-Zimmermann K, Bucher HC, et al. Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. Am J Med. 2011;124:841-51. 50. Rossi GP, Seccia TM, Maniero C, et al. Drug-related hypertension and resistance to antihypertensive treatment: a call for action. J Hypertens. 2011;29:2295-309. 51. Nagele E, Jeitler K, Horvath K, et al. Clinical effectiveness of stress-reduction techniques in patients with hypertension: systematic review and meta-analysis. J Hypertens. 2014;32:1936-44. 52. Rohner A, Ried K, Sobenin IA, et al. A systematic review and metaanalysis on the effects of garlic preparations on blood pressure in individuals with hypertension. Am J Hypertens. 2015;28:414-23. 53. Egan BM, Laken MA, Donovan JL, et al. Does dark chocolate have a role in the prevention and management of hypertension? Commentary on the evidence. Hypertension. 2010;55:1289-95. 54. Ried K, Sullivan T, Fakler P, et al. Does chocolate reduce blood pressure? A meta-analysis. BMC Med. 2010;8:39. 55. Liu G, Mi X-N, Zheng X-X, et al. Effects of tea intake on blood pressure: a meta-analysis of randomised controlled trials. Br J Nutr. 2014;112:1043-54. 56. Steffen M, Kuhle C, Hensrud D, et al. The effect of coffee consumption on blood pressure and the development of hypertension: a systematic review and meta-analysis. J Hypertens. 2012;30:2245-54. 57. Wang J, Xiong X, Liu W. Yoga for essential hypertension: a systematic review. PLoS ONE. 2013;8:e76357. 58. Dickinson H, Campbell F, Beyer F, et al. Relaxation therapies for the management of primary hypertension in adults: a Cochrane review. J Hum Hypertens. 2008;22:809-20. 59. Lee MS, Pittler MH, Guo R, et al. Qigong for hypertension: a systematic review of randomized clinical trials. J Hypertens. 2007;25:1525-32. 60. Yeh GY, Wang C, Wayne PM, et al. The effect of tai chi exercise on blood pressure: a systematic review. Prev Cardiol. 2008;11:82-9. 61. Canter PH, Ernst E. Insufficient evidence to conclude whether or not transcendental meditation decreases blood pressure: results of a systematic review of randomized clinical trials. J Hypertens. 2004;22:2049-54. 62. Whelton PK, He J, Appel LJ, et al. Primary prevention of hypertension: clinical and public health advisory from the National High Blood Pressure Education Program. JAMA. 2002;288:1882-8. 63. Estruch R, Ros E, Martinez-Gonzalez MA. Mediterranean diet for primary prevention of cardiovascular disease. N Engl J Med. 2013;369:676-7. 64. Look AHEAD Research Group, Wing RR, Bolin P, et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369:145-54. 65. Aucott L, Rothnie H, McIntyre L, et al. Long-term weight loss from lifestyle intervention benefits blood pressure? A systematic review. Hypertension 2009;54:756-62. 66. Straznicky N, Grassi G, Esler M, et al. European Society of Hypertension Working Group on Obesity Antihypertensive effects of weight loss: myth or reality? J Hypertens. 2010;28:637-43. 67. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014;129(suppl 2):S102-38. 68. Ryan DH. The pharmacological and surgical management of adults with obesity. J Fam Pract. 2014;63:S21-6. 69. Chang S-H, Stoll CRT, Song J, et al. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012. JAMA Surg. 2014;149:275-87.

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70. Svetkey LP, Simons-Morton D, Vollmer WM, et al. Effects of dietary patterns on blood pressure: subgroup analysis of the Dietary Approaches to Stop Hypertension (DASH) randomized clinical trial. Arch Intern Med. 1999;159:28593. 71. Filippini T, Violi F, D'Amico R, et al. The effect of potassium supplementation on blood pressure in hypertensive subjects: a systematic review and meta-analysis. Int J Cardiol. 2017;230:127-35. 72. National Heart, Lung, and Blood Institute. Your Guide to Lowering Your Blood Pressure With DASH--How Do I Make the DASH? Available at: http://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to. Accessed September 18, 2017. 73. Top 10 DASH Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp. Accessed September 18, 2017. 74. van Bommel E, Cleophas T. Potassium treatment for hypertension in patients with high salt intake: a meta-analysis. Int J Clin Pharmacol Ther. 2012;50:478-82. 75. He J, Wofford MR, Reynolds K, et al. Effect of dietary protein supplementation on blood pressure. Circulation. 2011;124:589-95. 76. Cook NR, Appel LJ, Whelton PK. Lower levels of sodium intake and reduced cardiovascular risk. Circulation. 2014;129:981-9. 77. Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the Trials of Hypertension Orevention (TOHP). BMJ. 2007;334:885-8. 78. Pimenta E, Gaddam KK, Oparil S, et al. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: results from a randomized trial. Hypertension 2009;54:475-81. 79. Huggins CE, Margerison C, Worsley A, et al. Influence of dietary modifications on the blood pressure response to antihypertensive medication. Br J Nutr. 2011;105:248-55. 80. He FJ, Fan S, Macgregor GA, et al. Plasma sodium and blood pressure in individuals on haemodialysis. J Hum Hypertens. 2013;27:85-9. 81. Whelton PK. Sodium, potassium, blood pressure, and cardiovascular disease in humans. Curr Hypertens Rep. 2014;16:465. 82. Weinberger MH, Miller JZ, Luft FC, et al. Definitions and characteristics of sodium sensitivity and blood pressure resistance. Hypertension. 1986;8:II127-34. 83. Mattes RD, Donnelly D. Relative contributions of dietary sodium sources. J Am Coll Nutr. 1991;10:383-93. 84. Anderson CAM, Appel LJ, Okuda N, et al. Dietary sources of sodium in China, Japan, the United Kingdom, and the United States, women and men aged 40 to 59 years: the INTERMAP study. J Am Diet Assoc. 2010;110:736-45. 85. Whelton PK, Appel LJ, Sacco RL, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation. 2012;126:2880-9. 86. Cobb LK, Appel LJ, Anderson CAM. Strategies to reduce dietary sodium intake. Curr Treat Options Cardiovasc Med. 2012;14:425-34. 87. McGuire S. Institute of Medicine. 2010. Strategies to Reduce Sodium Intake in the United States. Washington, DC: The National Academies Press. Adv Nutr. 2010;1:49-50. 88. He J, Tell GS, Tang YC, et al. Effect of migration on blood pressure: the Yi People Study. Epidemiology. 1991;2:8897. 89. Stamler J. The INTERSALT Study: background, methods, findings, and implications. Am J Clin Nutr. 1997;65:626S42S. 90. Zhang Z, Cogswell ME, Gillespie C, et al. Association between usual sodium and potassium intake and blood pressure and hypertension among U.S. adults: NHANES 2005-2010. PLoS ONE. 2013;8:e75289. 91. Mente A, O'Donnell MJ, Rangarajan S, et al. Association of urinary sodium and potassium excretion with blood pressure. N Engl J Med. 2014;371:601-11. 92. Kieneker LM, Gansevoort RT, Mukamal KJ, et al. Urinary potassium excretion and risk of developing hypertension: the prevention of renal and vascular end-stage disease study. Hypertension. 2014;64:769-76. 93. Bazzano LA, He J, Ogden LG, et al. Dietary potassium intake and risk of stroke in US men and women: National Health and Nutrition Examination Survey I epidemiologic follow-up study. Stroke. 2001;32:1473-80. 94. Ascherio A, Rimm EB, Hernan MA, et al. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation. 1998;98:1198-204. 95. Seth A, Mossavar-Rahmani Y, Kamensky V, et al. Potassium intake and risk of stroke in women with hypertension and nonhypertension in the Women's Health Initiative. Stroke. 2014;45:2874-80.

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96. D'Elia L, Barba G, Cappuccio FP, et al. Potassium intake, stroke, and cardiovascular disease a meta-analysis of prospective studies. J Am Coll Cardiol. 2011;57:1210-9. 97. Bazzano LA, He J, Ogden LG, et al. Fruit and vegetable intake and risk of cardiovascular disease in US adults: the first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Am J Clin Nutr. 2002;76:939. 98. Gu D, Zhao Q, Chen J, et al. Reproducibility of blood pressure responses to dietary sodium and potassium interventions: the GenSalt study. Hypertension. 2013;62:499-505. 99. Cook NR, Obarzanek E, Cutler JA, et al. Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the Trials of Hypertension Prevention follow-up study. Arch Intern Med. 2009;169:32-40. 100. Whelton PK, Buring J, Borhani NO, et al. The effect of potassium supplementation in persons with a high-normal blood pressure. Results from phase I of the Trials of Hypertension Prevention (TOHP). Trials of Hypertension Prevention (TOHP) Collaborative Research Group. Ann Epidemiol. 1995;5:85-95. 101. Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans, 2015-2020. Washington, DC: Department of Health and Human Services (U.S.), Department of Agriculture (U.S); 2015. 102. Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: The National Academies Press; 2005. 103. Cornelissen VA, Arnout J, Holvoet P, et al. Influence of exercise at lower and higher intensity on blood pressure and cardiovascular risk factors at older age. J Hypertens. 2009;27:753-62. 104. Klatsky AL, Gunderson E. Alcohol and hypertension: a review. J Am Soc Hypertens 2008;2:307-17. 105. National Institute on Alcohol Abuse and Alcoholism (NIAAA). A Pocket Guide for Alcohol Screening and Brief Intervention. Rockville, MD: NIAAA; 2005. Available at: http://pubs.niaaa.nih.gov/publications/practitioner/pocketguide/pocket_guide.htm. Accessed September 18, 2017. 106. Cushman WC, Cutler JA, Hanna E, et al. Prevention and Treatment of Hypertension Study (PATHS): effects of an alcohol treatment program on blood pressure. Arch Intern Med. 1998;158:1197-207. 107. Rimm EB, Williams P, Fosher K, et al. Moderate alcohol intake and lower risk of coronary heart disease: metaanalysis of effects on lipids and haemostatic factors. BMJ. 1999;319:1523-8. 108. Mukamal KJ. Understanding the mechanisms that link alcohol and lower risk of coronary heart disease. Clin Chem. 2012;58:664-6. 109. Klatsky AL. Alcohol and cardiovascular mortality: common sense and scientific truth. J Am Coll Cardiol. 2010;55:1336-8. 110. Mukamal KJ, Chen CM, Rao SR, et al. Alcohol consumption and cardiovascular mortality among U.S. adults, 1987 to 2002. J Am Coll Cardiol. 2010;55:1328-35.

7. Patient Evaluation The patient evaluation is designed to identify target organ damage and possible secondary causes of hypertension and to assist in planning an effective treatment regimen. Historical features are relevant to the evaluation of the patient (Table 16). The pattern of BP measurements and changes over time may differentiate primary from secondary causes of hypertension. A rise in BP associated with weight gain, lifestyle factors (such as a job change requiring travel and meals away from home), reduced frequency or intensity of physical activity, or advancing age in a patient with a strong family history of hypertension would suggest the diagnosis of primary hypertension. An evaluation of the patient’s dietary habits, physical activity, alcohol consumption, and tobacco use should be performed, with recommendation of the nonpharmacological interventions detailed in Section 6.2 where appropriate. The history should also include inquiry into possible occurrence of symptoms to indicate a secondary cause (Tables 13 and 16). The patient's treatment goals and risk tolerance should also be elicited. This is especially true for older persons, for whom an assessment of multiple chronic conditions, frailty, and prognosis should be performed, including consideration of the time required to see benefit from intervention, which may not be realized for some individuals.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline The physical examination should include accurate measurement of BP (Table 8). Automated oscillometric devices provide an opportunity to obtain repeated measurements without a provider present, thereby minimizing the potential for a white coat effect. Change in BP from seated to standing position should be measured to detect orthostatic hypotension (a decline >20 mm Hg in SBP or >10 mm Hg in DBP after 1 minute is abnormal). For adults ≤30 years of age with elevated brachial BP, a thigh BP measurement is indicated; if the thigh measurement is lower than arm pressures, a diagnosis of coarctation of the aorta should be considered. The physical examination should include assessment of hypertension-related target organ damage. Attention should be paid to physical features that suggest secondary hypertension (Table 13). Table 16. Historical Features Favoring Hypertension Cause

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Primary Hypertension • Gradual increase in BP, with slow rate of rise in BP • Lifestyle factors that favor higher BP (e.g., weight gain, high-sodium diet, decreased physical activity, job change entailing increased travel, excessive consumption of alcohol) • Family history of hypertension

Secondary Hypertension • BP lability, episodic pallor and dizziness (pheochromocytoma) • Snoring, hypersomnolence (obstructive sleep apnea) • Prostatism (chronic kidney disease due to post-renal urinary tract obstruction) • Muscle cramps, weakness (hypokalemia from primary aldosteronism or secondary aldosteronism due to renovascular disease) • Weight loss, palpitations, heat intolerance (hyperthyroidism) • Edema, fatigue, frequent urination (kidney disease or failure) • History of coarctation repair (residual hypertension associated with coarctation) • Central obesity, facial rounding, easy bruisability (Cushing's syndrome) • Medication or substance use (e.g., alcohol, NSAIDS, cocaine, amphetamines) • Absence of family history of hypertension BP indicates blood pressure; and NSAIDs, nonsteroidal anti-inflammatory drugs.

7.1. Laboratory Tests and Other Diagnostic Procedures Laboratory measurements should be obtained for all patients with a new diagnosis of hypertension to facilitate CVD risk factor profiling, establish a baseline for medication use, and screen for secondary causes of hypertension (Table 17). Optional tests may provide information on target organ damage. Monitoring of serum sodium and potassium levels is helpful during diuretic or RAS blocker titration, as are serum creatinine and urinary albumin as markers of CKD progression (1). Measurement of thyroid-stimulating hormone is a simple test to easily detect hypothyroidism and hyperthyroidism, 2 remediable causes of hypertension. A decision to conduct additional laboratory testing would be appropriate in the context of increased hypertension severity, poor response to standard treatment approaches, a disproportionate severity of target organ damage for the level of BP, or historical or clinical clues that support a secondary cause. Table 17. Basic and Optional Laboratory Tests for Primary Hypertension Basic testing

Fasting blood glucose* Complete blood count Lipid profile Serum creatinine with eGFR* Serum sodium, potassium, calcium* Thyroid-stimulating hormone

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Urinalysis Electrocardiogram Optional testing Echocardiogram Uric acid Urinary albumin to creatinine ratio *May be included in a comprehensive metabolic panel. eGFR indicates estimated glomerular filtration rate. Reference 1. Chang AR, Sang Y, Leddy J, et al. Antihypertensive medications and the prevalence of hyperkalemia in a large health system. Hypertension. 2016; 67:1181-8.

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Pulse-wave velocity, carotid intima-media thickness, and coronary artery calcium score provide noninvasive estimates of vascular target organ injury and atherosclerosis (1). High BP readings, especially when obtained several years before a noninvasive measurement, are associated with an increase in subclinical CVD risk (2-4). Although carotid intima-media thickness values and coronary artery calcium scores are associated with cardiovascular events, inadequate or absent information on the effect of improvement in these markers on cardiovascular events prevents their routine use as surrogate markers in the treatment of hypertension. LVH is a secondary manifestation of hypertension and independently predicts future CVD events. LVH is commonly measured by electrocardiography, echocardiography, or MRI (5, 6). Left ventricular (LV) mass is associated with body size (particularly lean body mass), tobacco use, heart rate (inverse), and long-standing DM (7-9). BP lowering leads to a reduction in LV mass. In TOMHS (Treatment of Mild Hypertension Study), the long-acting diuretic chlorthalidone was slightly more effective in reducing LVH than were a calcium channel blocker (CCB) (amlodipine), ACE inhibitor (enalapril), alpha-receptor blocker (doxazosin), or beta-receptor blocker (acebutolol) (10). Beta blockers are inferior to angiotensin receptor blockers (ARBs), angiotensinconverting enzyme (ACE) inhibitors, and CCBs in reducing LVH (11). Hypertension adversely impacts other echocardiographic markers of cardiac structure and function, including left atrial size (both diameter and area; left atrial size is also a precursor of AF); diastolic function (many parameters; a precursor of HF with preserved ejection fraction [HFpEF]); cardiac structure; and subclinical markers of LV systolic function, such as myocardial strain assessment with echocardiography and MRI. Assessment of LVH by means of echocardiography or MRI is not universally recommended during evaluation and management of hypertension in adults because there are limited data on the cost and value of these measures for CVD risk reclassification and changes in type or intensity of treatment. Assessment of LVH is most useful in adults who are young (≤18 years of age) or have evidence of secondary hypertension, chronic uncontrolled hypertension, or history of symptoms of HF. Electrocardiographic criteria for LVH correlate weakly with echocardiographic or MRI definitions of LVH and are less strongly related to CVD outcomes (12-15). Imprecision in lead placement accounts, in part, for the poor correlation of electrocardiographic measurements with direct imaging results. However, electrocardiographic LVH has been valuable in predicting CVD risk in some reports (16, 17). Electrocardiography may also be useful in the assessment of comorbidities, such as rhythm disturbances and prior MI. LVH, as assessed by electrocardiography, echocardiography, or MRI, is an independent predictor of CVD complications (18, 19). Reduction in LVH can predict a reduction in CVD risk, independent of change in BP (20). When used in CVD risk predictor models, echocardiographic LVH has a small but significant independent effect on CVD risk in younger patients. At older ages, LVH measured by electrocardiography or MRI provides no independent contribution to prediction of CVD risk (21-23). Patients can be classified into 4

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline groups on the basis of the presence or absence of LVH and a determination of whether the LVH has an eccentric (normal relative wall thickness) or concentric geometry (6, 22).

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References 1. Persu A, De Plaen J-F. Recent insights in the development of organ damage caused by hypertension. Acta Cardiol. 2004;59:369-81. 2. Allen NB, Siddique J, Wilkins JT, et al. Blood pressure trajectories in early adulthood and subclinical atherosclerosis in middle age. JAMA. 2014;311:490-7. 3. Pletcher MJ, Bibbins-Domingo K, Lewis CE, et al. Prehypertension during young adulthood and coronary calcium later in life. Ann Intern Med. 2008;149:91-9. 4. Juhola J, Magnussen CG, Berenson GS, et al. Combined effects of child and adult elevated blood pressure on subclinical atherosclerosis: the International Childhood Cardiovascular Cohort Consortium. Circulation. 2013;128:217-24. 5. Santos M, Shah AM. Alterations in cardiac structure and function in hypertension. Curr Hypertens Rep. 2014;16:428. 6. Devereux RB, Roman MJ. Left ventricular hypertrophy in hypertension: stimuli, patterns, and consequences. Hypertens Res. 1999;22:1-9. 7. Gidding SS, Liu K, Colangelo LA, et al. Longitudinal determinants of left ventricular mass and geometry: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Circ Cardiovasc Imaging. 2013;6:769-75. 8. Fox ER, Musani SK, Samdarshi TE, et al. Clinical correlates and prognostic significance of change in standardized left ventricular mass in a community-based cohort of African Americans. J Am Heart Assoc. 2015;4:e001224. 9. Lieb W, Xanthakis V, Sullivan LM, et al. Longitudinal tracking of left ventricular mass over the adult life course: clinical correlates of short- and long-term change in the framingham offspring study. Circulation. 2009;119:308592. 10. Liebson PR, Grandits GA, Dianzumba S, et al. Comparison of five antihypertensive monotherapies and placebo for change in left ventricular mass in patients receiving nutritional-hygienic therapy in the Treatment of Mild Hypertension Study (TOMHS). Circulation. 1995;91:698-706. 11. Fagard RH, Celis H, Thijs L, et al. Regression of left ventricular mass by antihypertensive treatment: a meta-analysis of randomized comparative studies. Hypertension. 2009;54:1084-91. 12. Norman JE Jr, Levy D. Improved electrocardiographic detection of echocardiographic left ventricular hypertrophy: results of a correlated data base approach. J Am Coll Cardiol. 1995;26:1022-9. 13. da Costa W, Riera ARP, Costa F de A, et al. Correlation of electrocardiographic left ventricular hypertrophy criteria with left ventricular mass by echocardiogram in obese hypertensive patients. J Electrocardiol. 2008;41:724-9. 14. Bacharova L, Schocken D, Estes EH, et al. The role of ECG in the diagnosis of left ventricular hypertrophy. Curr Cardiol Rev. 2014;10:257-61. 15. Bang CN, Devereux RB, Okin PM. Regression of electrocardiographic left ventricular hypertrophy or strain is associated with lower incidence of cardiovascular morbidity and mortality in hypertensive patients independent of blood pressure reduction--a LIFE review. J Electrocardiol. 2014;47:630-5. 16. Pewsner D, Juni P, Egger M, et al. Accuracy of electrocardiography in diagnosis of left ventricular hypertrophy in arterial hypertension: systematic review. BMJ. 2007;335:711. 17. Rautaharju PM, Soliman EZ. Electrocardiographic left ventricular hypertrophy and the risk of adverse cardiovascular events: a critical appraisal. J Electrocardiol. 2014;47:649-54. 18. Armstrong AC, Gidding S, Gjesdal O, et al. LV mass assessed by echocardiography and CMR, cardiovascular outcomes, and medical practice. JACC Cardiovasc Imaging. 2012;5:837-48. 19. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010;122:e584-636. 20. Devereux RB, Wachtell K, Gerdts E, et al. Prognostic significance of left ventricular mass change during treatment of hypertension. JAMA. 2004;292:2350-6. 21. Armstrong AC, Jacobs DR Jr, Gidding SS, et al. Framingham score and LV mass predict events in young adults: CARDIA study. Int J Cardiol. 2014;172:350-5. 22. Okwuosa TM, Soliman EZ, Lopez F, et al. Left ventricular hypertrophy and cardiovascular disease risk prediction and reclassification in blacks and whites: the Atherosclerosis Risk in Communities Study. Am Heart J. 2015;169:155-61.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 23. Zalawadiya SK, Gunasekaran PC, Bavishi CP, et al. Left ventricular hypertrophy and risk reclassification for coronary events in multi-ethnic adults. Eur J Prev Cardiol. 2015;22:673-9.

8. Treatment of High BP Clinicians managing adults with high BP should focus on overall patient health, with a particular emphasis on reducing the risk of future adverse CVD outcomes. All patient risk factors need to be managed in an integrated fashion with a comprehensive set of nonpharmacological (see Section 6) and pharmacological strategies. As patient BP and risk of future CVD events increase, BP management should be intensified.

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For any specific difference in BP, the relative risk of CVD is constant across groups that differ in absolute risk of atherosclerotic CVD (1-4), albeit with some evidence of lesser relative risk but greater excess risk in older than in younger adults (5-8). Thus, there are more potentially preventable CVD events attributable to elevated BP in individuals with higher than with lower risk of CVD and in older than in younger adults. The relative risk reduction for CVD prevention with use of BP-lowering medications is fairly constant for groups that differ in CVD risk across a wide range of estimated absolute risk (9, 10) and across groups defined by sex, age, body mass index, and the presence or absence of DM, AF, and CKD (5, 11-21). As a consequence, the absolute CVD risk reduction attributable to BP lowering is greater at greater absolute levels of CVD risk (9, 10, 12, 15-19, 22, 23). Put another way, for a given magnitude of BP reduction due to antihypertensive medications, fewer individuals at high CVD risk would need to be treated to prevent a CVD event (i.e., lower number needed to treat) than those at low CVD risk. References 1. Lloyd-Jones DM, Evans JC, Levy D. Hypertension in adults across the age spectrum: current outcomes and control in the community. JAMA. 2005;294:466-72. 2. Ozyilmaz A, Bakker SJL, de Zeeuw D, et al. Screening for albuminuria with subsequent screening for hypertension and hypercholesterolaemia identifies subjects in whom treatment is warranted to prevent cardiovascular events. Nephrol Dial Transplant. 2013;28:2805-15. 3. Peters SAE, Huxley RR, Woodward M. Comparison of the sex-specific associations between systolic blood pressure and the risk of cardiovascular disease: a systematic review and meta-analysis of 124 cohort studies, including 1.2 million individuals. Stroke. 2013;44:2394-401. 4. Schoenfeld SR, Kasturi S, Costenbader KH. The epidemiology of atherosclerotic cardiovascular disease among patients with SLE: a systematic review. Semin Arthritis Rheum. 2013;43:77-95. 5. Lawes CMM, Bennett DA, Lewington S, et al. Blood pressure and coronary heart disease: a review of the evidence. Semin Vasc Med. 2002;2:355-68. 6. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-13. 7. Takashima N, Ohkubo T, Miura K, et al. Long-term risk of BP values above normal for cardiovascular mortality: a 24year observation of Japanese aged 30 to 92 years. J Hypertens. 2012;30:2299-306. 8. Murakami Y. Meta-analyses using individual participant data from cardiovascular cohort studies in Japan: current status and future directions. J Epidemiol. 2014;24:96-101. 9. van Dieren S, Kengne AP, Chalmers J, et al. Effects of blood pressure lowering on cardiovascular outcomes in different cardiovascular risk groups among participants with type 2 diabetes. Diabetes Res Clin Pract. 2012;98:8390. 10. Sundstrom J, Arima H, Woodward M, et al. Blood Pressure Lowering Treatment Trialists' Collaboration. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384:591-8.

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11. Turnbull F, Neal B, Algert C, et al. Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials. Arch Intern Med. 2005;165:1410-9. 12. Wang J-G, Staessen JA, Franklin SS, et al. Systolic and diastolic blood pressure lowering as determinants of cardiovascular outcome. Hypertension. 2005;45:907-13. 13. Turnbull F, Woodward M, Neal B, et al. Do men and women respond differently to blood pressure-lowering treatment? Results of prospectively designed overviews of randomized trials. Eur Heart J. 2008;29:2669-80. 14. Turnbull F, Neal B, Ninomiya T, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ. 2008;336:1121-3. 15. Du X, Ninomiya T, de Galan B, et al. Risks of cardiovascular events and effects of routine blood pressure lowering among patients with type 2 diabetes and atrial fibrillation: results of the ADVANCE study. Eur Heart J. 2009;30:1128-35. 16. Czernichow S, Ninomiya T, Huxley R, et al. Impact of blood pressure lowering on cardiovascular outcomes in normal weight, overweight, and obese individuals: the Perindopril Protection Against Recurrent Stroke Study trial. Hypertension. 2010;55:1193-8. 17. Heerspink HJL, Ninomiya T, Perkovic V, et al. Effects of a fixed combination of perindopril and indapamide in patients with type 2 diabetes and chronic kidney disease. Eur Heart J. 2010;31:2888-96. 18. Ninomiya T, Zoungas S, Neal B, et al. Efficacy and safety of routine blood pressure lowering in older patients with diabetes: results from the ADVANCE trial. J Hypertens. 2010;28:1141-9. 19. Collier DJ, Poulter NR, Dahlof B, et al. Impact of amlodipine-based therapy among older and younger patients in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA). J Hypertens. 2011;29:583-91. 20. Ninomiya T, Perkovic V, Turnbull F, et al. Blood pressure lowering and major cardiovascular events in people with and without chronic kidney disease: meta-analysis of randomised controlled trials. Blood Pressure Lowering Treatment Trialists' Collaboration. BMJ. 2013;347:f5680. 21. Redon J, Mancia G, Sleight P, et al. Safety and efficacy of low blood pressures among patients with diabetes: subgroup analyses from the ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial). J Am Coll Cardiol. 2012;59:74-83. 22. Ogden LG, He J, Lydick E, et al. Long-term absolute benefit of lowering blood pressure in hypertensive patients according to the JNC VI risk stratification. Hypertension. 2000;35:539-43. 23. van der Leeuw J, Visseren FLJ, Woodward M, et al. Predicting the effects of blood pressure-lowering treatment on major cardiovascular events for individual patients with type 2 diabetes mellitus: results from Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation. Hypertension. 2015;65:115-21.

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8.1.2. BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension Recommendations for BP Treatment Threshold and Use of Risk Estimation* to Guide Drug Treatment of Hypertension

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References that support recommendations are summarized in Online Data Supplement 23. COR LOE Recommendations 1. Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP of SBP: 130 mm Hg or higher or an average DBP of 80 mm Hg or higher, and for A I primary prevention in adults with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average SBP 130 DBP: mm Hg or higher or an average DBP 80 mm Hg or higher (1-9). C-EO I

C-LD

2. Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher (3, 10-13).

*ACC/AHA Pooled Cohort Equations (http://tools.acc.org/ASCVD-Risk-Estimator/) (13a) to estimate 10-year risk of atherosclerotic CVD. ASCVD was defined as a first CHD death, non-fatal MI or fatal or non-fatal stroke.

Synopsis Whereas treatment of high BP with BP-lowering medications on the basis of BP level alone is considered cost effective (14), use of a combination of absolute CVD risk and BP level to guide such treatment is more efficient and cost effective at reducing risk of CVD than is use of BP level alone (15-24). Practical approaches have been developed to translate evidence from RCTs into individual patient treatment recommendations that are based on absolute net benefit for CVD risk (25), and several national and international guidelines recommend basing use of BP-lowering medications on a combination of absolute risk of CVD and level of BP instead of relying solely on level of BP (26-31). Attempts to use absolute risk to guide implementation of pharmacological treatment to prevent CVD have had mixed results, with many reports of improvements in provider prescribing behaviors, patient adherence, and reductions in risk (32-38), but with others showing no impact on provider behaviors (39, 40). Use of global CVD risk assessment is infrequent in routine clinical practice (41-46), which suggests that intensive efforts would be required to achieve universal implementation. The choice of specific risk calculators for estimation of risk and risk threshold has been an important source of variability, ambiguity, and controversy (47-54). In addition, implementation of a standard (worldwide) absolute CVD risk threshold for initiating use of BP-lowering medications would result in large variations in medication use at a given level of BP across countries (48, 54, 55). Future research in this area should focus on issues related to implementation of a risk-based approach to CVD prevention, including the use of BP-lowering medications. Although several CVD risk assessment tools are available, on the basis of current knowledge, we recommend use of the ACC/AHA Pooled Cohort Equations (http://tools.acc.org/ASCVD-Risk-Estimator/) to estimate 10-year risk of atherosclerotic CVD (ASCVD) to establish the BP threshold for treatment (56, 57). It should be kept in mind that the ACC/AHA Pooled Cohort Equations are validated for U.S. adults ages 45 to 79 years in the absence of concurrent statin therapy (56). For those older than age 79, the 10-year ASCVD risk is generally >10%, and thus the SBP threshold for antihypertensive drug treatment for patients >79 years old is 130 mm Hg. Two recent reviews have highlighted the importance of using predicted CVD risk together with BP to guide antihypertensive drug therapy (22, 23). Figure 4 is an algorithm on BP thresholds and recommendations for treatment and follow-up. Page 71

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Recommendation-Specific Supportive Text

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1. For the purposes of secondary prevention, clinical CVD is defined as CHD, congestive HF, and stroke. Several meta-analyses of RCTs support the value of using BP-lowering medications, in addition to nonpharmacological treatment, in patients with established CVD in the absence of hypertension, defined previously by an SBP ≥140 mm Hg or a DBP ≥90 mm Hg (1, 6, 7, 9). Many RCTs of BP lowering in adults without CVD have used inclusion criteria designed to increase the level of CVD risk in the study populations to increase trial efficiency by facilitating shorter duration and a smaller sample size. As a consequence, few relatively low-risk adults with hypertension have been included in the trials. Trial results provide evidence of CVD prevention from use of BP-lowering medications in adults with an average SBP ≥130 mm Hg or an average DBP ≥80 mm Hg and clinical CVD; 5-year risk of CVD (defined as stroke, CHD, HF, or other CVD death) of approximately 6% to 7% (3, 5); an estimated 10-year CVD death rate of approximately 4.5% (4); or an annual rate of major CVD events of approximately 0.9% per year (7). In the absence of clinical CVD, these risk estimates are roughly equivalent to a 10-year risk of ASCVD exceeding 10% as per the ACC/AHA Pooled Cohort Equations (56). SPRINT (Systolic Blood Pressure Intervention Trial) provides additional support for the use of BP-lowering medications in patients without CVD at SBP levels ≥130 mm Hg; however, it is important to note that few SPRINT participants had untreated SBP between 130 mm Hg and 139 mm Hg at baseline. Furthermore, SPRINT used a Framingham 10-year risk of general CVD exceeding 15% to identify increased CVD risk (8). Although this level of risk is lower than the levels described previously, being roughly equivalent to a 6% to 7% 10-year ASCVD risk per the ACC/AHA Pooled Cohort Equations, most of the participants in SPRINT had a much higher level of CVD risk. This recommendation differs from JNC 7 in its use of CVD risk, rather than diabetes or CKD, to recognize patients, including older adults, with a SBP/DBP <140/90 mm Hg who are likely to benefit from BP lowering drug therapy in addition to nonpharmacological antihypertensive treatment. In JNC 7, the BP threshold for initiation of antihypertensive drug therapy was ≥ 140/90 mm Hg for the general adult population and ≥ 130/80 mm Hg for adults with diabetes or CKD. Since the publication of JNC 7 in 2003, we have gained additional experience with risk assessment and new data from randomized trials, observational studies and simulation analyses have demonstrated that antihypertensive drug treatment based on overall ASCVD risk assessment combined with BP levels may prevent more CVD events than treatment based on BP levels alone (15-24). According to an analysis of NHANES 2011-2014, the new definition results in only a small increase in the percentage of U.S. adults for whom antihypertensive medication is recommended in conjunction with lifestyle modification. The previously cited meta-analyses are consistent with the conclusion that lowering of BP results in benefit in higher-risk individuals, regardless of their baseline treated or untreated BP ≥130/80 mm Hg and irrespective of the specific cause of their elevated risk. These analyses indicate that the benefit of treatment outweighs the potential harm at threshold BP ≥130/80 mm Hg. 2. This recommendation is consistent with prior guidelines, such as JNC 7. In addition, for those for whom nonpharmacological therapy has been ineffective, antihypertensive drug treatment should be added in patients with an SBP ≥140 mm Hg or a DBP ≥90 mm Hg, even in adults who are at lower risk than those included in RCTs. The rationale for drug treatment in patients with an SBP ≥140 mm Hg or a DBP ≥90 mm Hg and an estimated 10-year risk of CVD <10% is based on several lines of evidence. First, the relationship of SBP with risk of CVD is known to be continuous across levels of SBP and similar across groups that differ in level of absolute risk (10). Second, the relative risk reduction attributable to BP-lowering medication therapy is consistent across the range of absolute risk observed in trials (3, 11, 58), supporting the contention that the relative risk reduction may be similar at lower levels of absolute risk. This is the case even in a meta-analysis of trials in adults without clinical CVD and an average SBP/DBP of 146/84 mm Hg (5). Finally, modeling studies support the effectiveness and cost-effectiveness of treatment of younger, lower-risk patients over the course of their life spans (12, 13). Although the numbers needed to treat with BP-lowering medications to prevent a CVD event in the short term are greater in younger, lower-risk individuals with hypertension than in older, higher-risk adults with hypertension, the estimated gains in life expectancy attributable to long-term use of

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline BP-lowering medications are correspondingly greater in younger, lower-risk individuals than in older adults with a higher risk of CVD (12, 13). Indirect support is also provided by evidence from trials using BP-lowering medications to reduce the risk of developing higher levels of BP (59-61) and, in one case, to achieve a reduction in LV mass (62). In the HOPE-3 (Heart Outcomes Prevention Evaluation-3) BP Trial, there was no evidence of short-term benefit during treatment of adults (average age 66 years) with a relatively low risk of CVD (3.8% CVD event rate during 5.6 years of follow-up). However, subgroup analysis suggested benefit in those with an average SBP approximately >140 mm Hg (and a CVD risk of 6.5% during the 5.6 years of follow-up) (63). We acknowledge the importance of excluding white coat hypertension before initiating pharmacological therapy in hypertensive patients with low ASCVD risk. This may be accomplished (as described in Section 4) by HBPM or ABPM as appropriate. Figure 4. Blood Pressure (BP) Thresholds and Recommendations for Treatment and Follow-Up BP thresholds and recommendations for treatment and follow-up

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Normal BP (BP <120/80 mm Hg)

Elevated BP (BP 120–129/<80 mm Hg)

Promote optimal lifestyle habits

Nonpharmacological therapy (Class I)

Stage 1 hypertension (BP 130-139/80-89 mm Hg)

Clinical ASCVD or estimated 10-y CVD risk ≥10%* No

Reassess in 1y (Class IIa)

Reassess in 3–6 mo (Class I)

Stage 2 hypertension (BP ≥140/90 mm Hg)

Yes

Nonpharmacological therapy (Class I)

Nonpharmacological therapy and BP-lowering medication (Class I)

Reassess in 3–6 mo (Class I)

Reassess in 1 mo (Class I)

Nonpharmacological therapy and BP-lowering medication† (Class I)

BP goal met No Assess and optimize adherence to therapy

Yes Reassess in 3–6 mo (Class I)

Consider intensification of therapy

Colors correspond to Class of Recommendation in Table 1. *Using the ACC/AHA Pooled Cohort Equations (57). Note that patients with DM or CKD are automatically placed in the high-risk category. For initiation of RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and renal function 2 to 4 weeks after initiating therapy. †Consider initiation of pharmacological therapy for stage 2 hypertension with 2 antihypertensive agents of different classes. Patients with stage 2 hypertension and BP ≥160/100 mm Hg should be promptly treated, carefully monitored, and subject to upward medication dose adjustment as necessary to control BP. Reassessment includes BP measurement, detection of orthostatic hypotension in selected patients (e.g., older or with postural symptoms), identification of white coat hypertension or a white coat effect, documentation of adherence, monitoring of the

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline response to therapy, reinforcement of the importance of adherence, reinforcement of the importance of treatment, and assistance with treatment to achieve BP target. ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CKD, chronic kidney disease; DM, diabetes mellitus; and RAS, renin-angiotensin system.

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References 1. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. 2. Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016; 387:957-67. 3. Sundstrom J, Arima H, Woodward M, et al. Blood Pressure Lowering Treatment Trialists' Collaboration. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384:591-8. 4. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 2. Effects at different baseline and achieved blood pressure levels--overview and meta-analyses of randomized trials. J Hypertens. 2014;32:2296-304. 5. Sundstrom J, Arima H, Jackson R, et al. Effects of blood pressure reduction in mild hypertension: a systematic review and meta-analysis. Ann Intern Med. 2015;162:184-91. 6. Thompson AM, Hu T, Eshelbrenner CL, et al. Antihypertensive treatment and secondary prevention of cardiovascular disease events among persons without hypertension: a meta-analysis. JAMA. 2011;305:913-22. 7. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387:435-43. 8. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. SPRINT Research Group. N Engl J Med. 2015;373:2103-16. 9. Czernichow S, Zanchetti A, Turnbull F, et al. The effects of blood pressure reduction and of different blood pressure-lowering regimens on major cardiovascular events according to baseline blood pressure: meta-analysis of randomized trials. J Hypertens. 2011;29:4-16. 10. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-13. 11. van Dieren S, Kengne AP, Chalmers J, et al. Effects of blood pressure lowering on cardiovascular outcomes in different cardiovascular risk groups among participants with type 2 diabetes. Diabetes Res Clin Pract. 2012;98:8390. 12. Montgomery AA, Fahey T, Ben-Shlomo Y, et al. The influence of absolute cardiovascular risk, patient utilities, and costs on the decision to treat hypertension: a Markov decision analysis. J Hypertens. 2003;21:1753-9. 13. Kassai B, Boissel J-P, Cucherat M, et al. Treatment of high blood pressure and gain in event-free life expectancy. Vasc Health Risk Manag. 2005;1:163-9. 13a. ACC/AHA Pooled Cohort Equations. Available at: http://tools.acc.org/ASCVD-Risk-Estimator/. Accessed November 3, 2017. 14. Rubinstein A, Colantonio L, Bardach A, et al. Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina. BMC Public Health. 2010;10:627. 15. Baker S, Priest P, Jackson R. Using thresholds based on risk of cardiovascular disease to target treatment for hypertension: modelling events averted and number treated. BMJ. 2000;320:680-5. 16. Gaziano TA, Steyn K, Cohen DJ, et al. Cost-effectiveness analysis of hypertension guidelines in South Africa: absolute risk versus blood pressure level. Circulation. 2005;112:3569-76. 17. Eddy DM, Adler J, Patterson B, et al. Individualized guidelines: the potential for increasing quality and reducing costs. Ann Intern Med. 2011;154:627-34. 18. Marchant I, Nony P, Cucherat M, et al. The global risk approach should be better applied in French hypertensive patients: a comparison between simulation and observation studies. PLoS ONE. 2011;6:e17508. 19. Cadilhac DA, Carter R, Thrift AG, et al. Organized blood pressure control programs to prevent stroke in Australia: would they be cost-effective? Stroke. 2012;43:1370-5.

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20. Cobiac LJ, Magnus A, Barendregt JJ, et al. Improving the cost-effectiveness of cardiovascular disease prevention in Australia: a modelling study. BMC Public Health. 2012;12:398. 21. Cobiac LJ, Magnus A, Lim S, et al. Which interventions offer best value for money in primary prevention of cardiovascular disease? PLoS ONE. 2012;7:e41842. 22. Karmali KN, Lloyd-Jones DM. Global risk assessment to guide blood pressure management in cardiovascular disease prevention. Hypertension. 2017;69:e2-9. 23. Muntner P, Whelton PK. Using predicted cardiovascular disease risk in conjunction with blood pressure to guide antihypertensive medication treatment. J Am Coll Cardiol. 2017;69:2446-56. 24. Sussman J, Vijan S, Hayward R. Using benefit-based tailored treatment to improve the use of antihypertensive medications. Circulation. 2013;128:2309-17. 25. van der Leeuw J, Ridker PM, van der Graaf Y, et al. Personalized cardiovascular disease prevention by applying individualized prediction of treatment effects. Eur Heart J. 2014;35:837-43. 26. Mendis S, Lindholm LH, Mancia G, et al. World Health Organization (WHO) and International Society of Hypertension (ISH) risk prediction charts: assessment of cardiovascular risk for prevention and control of cardiovascular disease in low and middle-income countries. J Hypertens. 2007;25:1578-82. 27. van Dis I, Geleijnse JM, Verschuren WMM, et al. Cardiovascular risk management of hypertension and hypercholesterolaemia in the Netherlands: from unifactorial to multifactorial approach. Neth Heart J. 2012;20:3205. 28. Nelson MR, Doust JA. Primary prevention of cardiovascular disease: new guidelines, technologies and therapies. Med J Aust. 2013;198:606-10. 29. JBS3 Board. Joint British Societies' consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart. 2014;100(suppl 2):ii1-67. 30. World Health Organization. Prevention of Cardiovascular Disease. Guidelines for Assessment and Management of Cardiovascular Risk. Geneva, Switzerland: World Health Organization; 2007. 31. 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. 32. Sheridan SL, Crespo E. Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature. BMC Health Serv Res. 2008;8:60. 33. Sheridan SL, Viera AJ, Krantz MJ, et al. The effect of giving global coronary risk information to adults: a systematic review. Arch Intern Med. 2010;170:230-9. 34. Viera AJ, Sheridan SL. Global risk of coronary heart disease: assessment and application. Am Fam Physician. 2010;82:265-74. 35. Sheridan SL, Draeger LB, Pignone MP, et al. A randomized trial of an intervention to improve use and adherence to effective coronary heart disease prevention strategies. BMC Health Serv Res. 2011;11:331. 36. Brett T, Arnold-Reed D, Phan C, et al. The Fremantle Primary Prevention Study: a multicentre randomised trial of absolute cardiovascular risk reduction. Br J Gen Pract. 2012;62:e22-8. 37. Sekaran NK, Sussman JB, Xu A, et al. Providing clinicians with a patient's 10-year cardiovascular risk improves their statin prescribing: a true experiment using clinical vignettes. BMC Cardiovasc Disord. 2013;13:90. 38. Sheridan SL, Draeger LB, Pignone MP, et al. The effect of a decision aid intervention on decision making about coronary heart disease risk reduction: secondary analyses of a randomized trial. BMC Med Inform Decis Mak. 2014;14:14. 39. Jansen J, Bonner C, McKinn S, et al. General practitioners' use of absolute risk versus individual risk factors in cardiovascular disease prevention: an experimental study. BMJ Open. 2014;4:e004812. 40. Vagholkar S, Zwar N, Jayasinghe UW, et al. Influence of cardiovascular absolute risk assessment on prescribing of antihypertensive and lipid-lowering medications: a cluster randomized controlled trial. Am Heart J. 2014;167:2835. 41. Rafter N, Connor J, Hall J, et al. Cardiovascular medications in primary care: treatment gaps and targeting by absolute risk. N Z Med J. 2005;118:U1676. 42. Yong TY, Phillipov G, Phillips PJ. Management outcomes of patients with type 2 diabetes: targeting the 10-year absolute risk of coronary heart disease. Med J Aust. 2007;186:622-4. 43. Webster RJ, Heeley EL, Peiris DP, et al. Gaps in cardiovascular disease risk management in Australian general practice. Med J Aust. 2009;191:324-9.

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44. Frikke-Schmidt R, Tybjærg-Hansen A, Schnohr P, et al. Common clinical practice versus new PRIM score in predicting coronary heart disease risk. Atherosclerosis. 2010;213:532-8. 45. Heeley EL, Peiris DP, Patel AA, et al. Cardiovascular risk perception and evidence--practice gaps in Australian general practice (the AusHEART study). Med J Aust. 2010;192:254-9. 46. Shillinglaw B, Viera AJ, Edwards T, et al. Use of global coronary heart disease risk assessment in practice: a crosssectional survey of a sample of U.S. physicians. BMC Health Serv Res. 2012;12:20. 47. Game FL, Bartlett WA, Bayly GR, et al. Comparative accuracy of cardiovascular risk prediction methods in patients with diabetes mellitus. Diabetes Obes Metab. 2001;3:279-86. 48. Bastuji-Garin S, Deverly A, Moyse D, et al. The Framingham prediction rule is not valid in a European population of treated hypertensive patients. J Hypertens. 2002;20:1973-80. 49. Menotti A, Puddu PE, Lanti M. The estimate of cardiovascular risk. Theory, tools and problems. Ann Ital Med Int. 2002;17:81-94. 50. de Visser CL, Bilo HJG, Thomsen TF, et al. Prediction of coronary heart disease: a comparison between the Copenhagen risk score and the Framingham risk score applied to a Dutch population. J Intern Med. 2003;253:55362. 51. Persson M, Carlberg B, Weinehall L, et al. Risk stratification by guidelines compared with risk assessment by risk equations applied to a MONICA sample. J Hypertens. 2003;21:1089-95. 52. Doust J, Sanders S, Shaw J, et al. Prioritising CVD prevention therapy--absolute risk versus individual risk factors. Aust Fam Physician. 2012;41:805-9. 53. Allan GM, Nouri F, Korownyk C, et al. Agreement among cardiovascular disease risk calculators. Circulation. 2013;127:1948-56. 54. Diverse Populations Collaborative Group. Prediction of mortality from coronary heart disease among diverse populations: is there a common predictive function? Heart. 2002;88:222-8. 55. van den Hoogen PC, Feskens EJ, Nagelkerke NJ, et al. The relation between blood pressure and mortality due to coronary heart disease among men in different parts of the world. Seven Countries Study Research Group. N Engl J Med. 2000;342:1-8. 56. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S49-73. 57. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S1-45. 58. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 3. Effects in patients at different levels of cardiovascular risk--overview and meta-analyses of randomized trials. J Hypertens. 2014;32:2305-14. 59. Julius S, Nesbitt SD, Egan BM, et al. Feasibility of treating prehypertension with an angiotensin-receptor blocker. N Engl J Med. 2006;354:1685-97. 60. Julius S, Kaciroti N, Egan BM, et al. TROPHY study: outcomes based on the Seventh Report of the Joint National Committee on Hypertension definition of hypertension. J Am Soc Hypertens. 2008;2:39-43. 61. Luders S, Schrader J, Berger J, et al. The PHARAO study: prevention of hypertension with the angiotensinconverting enzyme inhibitor ramipril in patients with high-normal blood pressure: a prospective, randomized, controlled prevention trial of the German Hypertension League. J Hypertens. 2008;26:1487-96. 62. Fuchs SC, Poli-de-Figueiredo CE, Figueiredo Neto JA, et al. Effectiveness of chlorthalidone plus amiloride for the prevention of hypertension: the PREVER Prevention Randomized Clinical Trial. J Am Heart Assoc. 2016;5:e004248. 63. Lonn EM, Bosch J, Lopez-Jaramillo P, et al. Blood-pressure lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med. 2016;374:2009-20.

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8.1.3. Follow-Up After Initial BP Evaluation Recommendations for Follow-Up After Initial BP Elevation

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References that support recommendations are summarized in Online Data Supplement 24. COR LOE Recommendations 1. Adults with an elevated BP or stage 1 hypertension who have an estimated 10-year ASCVD risk less than 10% should be managed with I B-R nonpharmacological therapy and have a repeat BP evaluation within 3 to 6 months (1, 2). 2. Adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of 10% or higher should be managed initially with a combination of I B-R nonpharmacological and antihypertensive drug therapy and have a repeat BP evaluation in 1 month (1, 2). 3. Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a I B-R combination of nonpharmacological and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation in 1 month (1, 2). 4. For adults with a very high average BP (e.g., SBP ≥180 mm Hg or DBP ≥110 I B-R mm Hg), evaluation followed by prompt antihypertensive drug treatment is recommended (1, 2). IIa C-EO 5. For adults with a normal BP, repeat evaluation every year is reasonable. Synopsis An important component of BP management in hypertensive patients is follow-up. Different periods of time for follow-up are recommended depending on the stage of hypertension, the presence or absence of target organ damage, treatment with antihypertensive medications, and the level of BP control. Recommendations for follow-up are summarized in Figure 4. Recommendation-Specific Supportive Text 1. Nonpharmacological therapy (see Section 6.2) is the preferred therapy for adults with elevated BP and an appropriate first-line therapy for adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of <10%. Adherence to and impact of nonpharmacological therapy should be assessed within 3 to 6 months. 2. Nonpharmacological therapy can help reduce BP in patients with stage 1 hypertension with an estimated 10-year ASCVD risk of ≥10% and should be used in addition to pharmacological therapy as first-line therapy in such patients (see Section 6.2). 3. Prompt evaluation and treatment of patients with stage 2 hypertension with a combination of drug and nonpharmacological therapy are important because of the elevated risk of CVD events in this subgroup, especially those with multiple ASCVD risk factors or target organ damage (1, 2). 4. Prompt management of very high BP is important to reduce the risk of target organ damage (see Section 11.2). The rapidity of the treatment needed is dependent on the patient’s clinical presentation (presence of new or worsening target organ damage) and presence or absence of CVD complications, but treatment should be initiated within at least 1 week. 5. Given that the lifetime risk of hypertension exceeds 80% in U.S. adults (3), it is likely that individuals with a normal BP will develop elevated BP in the future. BP may change over time because of changes in BP-related lifestyle factors, such as degree of sedentary lifestyle, dietary sodium intake, body weight, and alcohol intake. Page 77

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Less commonly, secondary causes of hypertension can occur over time and lead to an increase in BP. Periodic BP screening can identify individuals who develop elevated BP over time. More frequent BP screening may be particularly important for individuals with elevated ASCVD risk. References 1. 2. 3.

Ambrosius WT, Sink KM, Foy CG, et al. The design and rationale of a multicenter clinical trial comparing two strategies for control of systolic blood pressure: the Systolic Blood Pressure Intervention Trial (SPRINT). Clin Trials. 2014;11:532-46. Cushman WC, Grimm RH Jr, Cutler JA, et al. Rationale and design for the blood pressure intervention of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Am J Cardiol. 2007;99:44i-55i. Carson AP, Howard G, Burke GL, et al. Ethnic differences in hypertension incidence among middle-aged and older adults: the Multi-Ethnic study of Atherosclerosis. Hypertension. 2011;57:1101-7.

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Recommendation for General Principle of Drug Therapy

References that support recommendations are summarized in Online Data Supplement 25. COR LOE Recommendation 1. Simultaneous use of an ACE inhibitor, ARB, and/or renin inhibitor is III: A potentially harmful and is not recommended to treat adults with Harm hypertension (1-3). Synopsis Pharmacological agents, in addition to lifestyle modification (see Section 6.2), provide the primary basis for treatment of high BP. A large number of clinical trials have demonstrated that antihypertensive pharmacotherapy not only lowers BP but reduces the risk of CVD, cerebrovascular events, and death (4-7). Numerous classes of antihypertensive agents are available to treat high BP (Table 18). Agents that have been shown to reduce clinical events should be used preferentially. Therefore, the primary agents used in the treatment of hypertension include thiazide diuretics, ACE inhibitors, ARBs, and CCBs (8-11) (see Section 8.1.6). Although many other drugs and drug classes are available, either confirmation that these agents decrease clinical outcomes to an extent similar to that of the primary agents is lacking, or safety and tolerability may relegate their role to use as secondary agents. In particular, there is inadequate evidence to support the initial use of beta blockers for hypertension in the absence of specific cardiovascular comorbidities (see Section 9). When the initial drug treatment of high BP is being considered, several different strategies may be contemplated. Many patients can be started on a single agent, but consideration should be given to starting with 2 drugs of different classes for those with stage 2 hypertension (see Section 8.1.6.1). In addition, other patient-specific factors, such as age, concurrent medications, drug adherence, drug interactions, the overall treatment regimen, out-of-pocket costs, and comorbidities, should be considered. From a societal perspective, total costs must be taken into account. Shared decision making, with the patient influenced by clinician judgment, should drive the ultimate choice of antihypertensive agent(s). Many patients started on a single agent will subsequently require ≥2 drugs from different pharmacological classes to reach their BP goals (12 , 13, 14). Knowledge of the pharmacological mechanisms of action of each agent is important. Drug regimens with complementary activity, where a second antihypertensive agent is used to block compensatory responses to the initial agent or affect a different pressor mechanism, can result in additive lowering of BP. For example, thiazide diuretics may stimulate the renin-angiotensin-aldosterone system. By adding an ACE inhibitor or ARB to the thiazide, an additive BPlowering effect may be obtained (13). Use of combination therapy may also improve adherence. Several 2and 3-fixed-dose drug combinations of antihypertensive drug therapy are available, with complementary

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline mechanisms of action among the components (Online Data Supplement D). However, it should be noted that many triple-dose combinations may contain a lower-than-optimal dose of thiazide diuretic. Table 18 is a summary of oral antihypertensive drugs. Recommendation-Specific Supportive Text 1. Drug combinations that have similar mechanisms of action or clinical effects should be avoided. For example, 2 drugs from the same class should not be administered together (e.g., 2 different beta blockers, ACE inhibitors, or nondihydropyridine CCBs). Likewise, 2 drugs from classes that target the same BP control system are less effective and potentially harmful when used together (e.g., ACE inhibitors, ARBs). Exceptions to this rule include concomitant use of a thiazide diuretic, K-sparing diuretic, and/or loop diuretic in various combinations. Also, dihydropyridine and nondihydropyridine CCBs can be combined. High-quality RCT data demonstrate that simultaneous administration of RAS blockers (i.e., ACE inhibitor with ARB; ACE inhibitor or ARB with renin inhibitor aliskiren) increases cardiovascular and renal risk (1-3). Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 18. Oral Antihypertensive Drugs Class Primary agents Thiazide or thiazide-type diuretics

Drug

Chlorthalidone Hydrochlorothiazide Indapamide Metolazone

Usual Dose, Range (mg/d)* 12.5–25 25–50 1.25–2.5 2.5–10

Daily Frequency 1 1 1 1

Comments

• • •

ACE inhibitors

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ARBs

CCB— dihydropyridin es

CCB— nondihydropyri dines

Benazepril Captopril Enalapril Fosinopril Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril Azilsartan Candesartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan

10–40 12.5–150 5–40 10–40 10–40 7.5–30 4–16 10–80 2.5–10 1–4 40–80 8–32 600–800 150–300 50–100 20–40 20–80 80–320

1 or 2 2 or 3 1 or 2 1 1 1 or 2 1 1 or 2 1 or 2 1 1 1 1 or 2 1 1 or 2 1 1 1

Amlodipine Felodipine Isradipine Nicardipine SR Nifedipine LA Nisoldipine Diltiazem SR Diltiazem ER Verapamil IR Verapamil SR Verapamil-delayed onset ER (various forms)

2.5–10 5–10 5–10 5–20 60–120 30–90 180–360 120–480 40-80 120–480 100–480

1 1 2 1 1 1 2 1 3 1 or 2 1 (in the evening)

0.5–4 20–80 5–10

2 2 1

5–10 50–100

1 or 2 1 or 2

Secondary agents Diuretics— Bumetanide loop Furosemide Torsemide Diuretics— potassium sparing

Amiloride Triamterene

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• • • • •

Chlorthalidone is preferred on the basis of prolonged half-life and proven trial reduction of CVD. Monitor for hyponatremia and hypokalemia, uric acid and calcium levels. Use with caution in patients with history of acute gout unless patient is on uric acid–lowering therapy. Do not use in combination with ARBs or direct renin inhibitor. There is an increased risk of hyperkalemia, especially in patients with CKD or in those on K+ supplements or K+-sparing drugs. There is a risk of acute renal failure in patients with severe bilateral renal artery stenosis. Do not use if patient has history of angioedema with ACE inhibitors. Avoid in pregnancy.

• Do not use in combination with ACE inhibitors or direct renin inhibitor. • There is an increased risk of hyperkalemia in CKD or in those on K+ supplements or K+-sparing drugs. • There is a risk of acute renal failure in patients with severe bilateral renal artery stenosis. • Do not use if patient has history of angioedema with ARBs. Patients with a history of angioedema with an ACE inhibitor can receive an ARB beginning 6 weeks after ACE inhibitor is discontinued. • Avoid in pregnancy. • Avoid use in patients with HFrEF; amlodipine or felodipine may be used if required. • They are associated with dose-related pedal edema, which is more common in women than men.

• Avoid routine use with beta blockers because of increased risk of bradycardia and heart block. • Do not use in patients with HFrEF. • There are drug interactions with diltiazem and verapamil (CYP3A4 major substrate and moderate inhibitor).

• These are preferred diuretics in patients with symptomatic HF. They are preferred over thiazides in patients with moderate-to-severe CKD (e.g., GFR <30 mL/min). • These are monotherapy agents and minimally effective antihypertensive agents. • Combination therapy of potassium-sparing diuretic with a thiazide can be considered in patients with hypokalemia on thiazide monotherapy.

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline

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• Avoid in patients with significant CKD (e.g., GFR <45 mL/min). • These are preferred agents in primary aldosteronism and resistant hypertension. • Spironolactone is associated with greater risk of gynecomastia and impotence as compared with eplerenone. • This is common add-on therapy in resistant hypertension. • Avoid use with K+ supplements, other K+-sparing diuretics, or significant renal dysfunction. • Eplerenone often requires twice-daily dosing for adequate BP lowering. • Beta blockers are not recommended as first-line agents unless the patient has IHD or HF. • These are preferred in patients with bronchospastic airway disease requiring a beta blocker. • Bisoprolol and metoprolol succinate are preferred in patients with HFrEF. • Avoid abrupt cessation. • Nebivolol induces nitric oxide–induced vasodilation. • Avoid abrupt cessation.

Diuretics— aldosterone antagonists

Eplerenone Spironolactone

50–100 25–100

12 1

Beta blockers— cardioselective

Atenolol Betaxolol Bisoprolol Metoprolol tartrate

25–100 5–20 2.5–10 100–400

12 1 1 2

Metoprolol succinate

50–200

1

Beta blockers— cardioselective and vasodilatory Beta blockers— noncardioselec tive Beta blockers— intrinsic sympathomim etic activity Beta blockers— combined alpha- and beta-receptor Direct renin inhibitor

Nebivolol

5–40

1

Nadolol Propranolol IR Propranolol LA

40–120 160–480 80–320

1 2 1

• Avoid in patients with reactive airways disease. • Avoid abrupt cessation.

Acebutolol Carteolol Penbutolol Pindolol

200–800 2.5–10 10–40 10–60

2 1 1 2

• Generally avoid, especially in patients with IHD or HF. • Avoid abrupt cessation.

Carvedilol Carvedilol phosphate Labetalol

12.5–50 20–80 200–800

2 1 2

• Carvedilol is preferred in patients with HFrEF. • Avoid abrupt cessation.

Aliskiren

150–300

1

Alpha-1 blockers

Doxazosin Prazosin Terazosin

1–8 2–20 1–20

1 2 or 3 1 or 2

Central alpha1agonist and other centrally acting drugs

Clonidine oral Clonidine patch Methyldopa Guanfacine

0.1–0.8 0.1–0.3 250–1000 0.5–2

2 1 weekly 2 1

• Do not use in combination with ACE inhibitors or ARBs. • Aliskiren is very long acting. • There is an increased risk of hyperkalemia in CKD or in those on K+ supplements or K+-sparing drugs. • Aliskiren may cause acute renal failure in patients with severe bilateral renal artery stenosis. • Avoid in pregnancy. • These are associated with orthostatic hypotension, especially in older adults. • They may be considered as second-line agent in patients with concomitant BPH. • These are generally reserved as last-line because of significant CNS adverse effects, especially in older adults. • Avoid abrupt discontinuation of clonidine, which may induce hypertensive crisis; clonidine must be tapered to avoid rebound hypertension.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Direct vasodilators

Hydralazine Minoxidil

250-200 5–100

2 or 3 1 -3

• These are associated with sodium and water retention and reflex tachycardia; use with a diuretic and beta blocker. • Hydralazine is associated with drug-induced lupuslike syndrome at higher doses. • Minoxidil is associated with hirsutism and requires a loop diuretic. Minoxidil can induce pericardial effusion. *Dosages may vary from those listed in the FDA approved labeling (available at http://dailymed.nlm.nih.gov/dailymed/). ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; BPH, benign prostatic hyperplasia; CCB, calcium channel blocker; CKD, chronic kidney disease; CNS, central nervous system; CVD, cardiovascular disease; ER, extended release; GFR, glomerular filtration rate; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; IHD, ischemic heart disease; IR, immediate release; LA, long-acting; and SR, sustained release. From Chobanian et al. JNC 7. (15)

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References 1. Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. ONTARGET Investigators. N Engl J Med. 2008;358:1547-59. 2. Parving H-H, Brenner BM, McMurray JJV, et al. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. N Engl J Med. 2012;367:2204-13. 3. Fried LF, Emanuele N, Zhang JH, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013;369:1892-903. 4. Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA. 1967;202:1028-34. 5. Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Hypertension Detection and Follow-up Program Cooperative Group. JAMA. 1979;242:2562-71. 6. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA. 1991;265:3255-64. 7. Kostis JB, Cabrera J, Cheng JQ, et al. Association between chlorthalidone treatment of systolic hypertension and long-term survival. JAMA. 2011;306:2588-93. 8. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. 9. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 2. Effects at different baseline and achieved blood pressure levels--overview and meta-analyses of randomized trials. J Hypertens. 2014;32:2296-304. 10. Czernichow S, Zanchetti A, Turnbull F, et al. The effects of blood pressure reduction and of different blood pressure-lowering regimens on major cardiovascular events according to baseline blood pressure: meta-analysis of randomized trials. J Hypertens. 2011;29:4-16. 11. Fretheim A, Odgaard-Jensen J, Brors O, et al. Comparative effectiveness of antihypertensive medication for primary prevention of cardiovascular disease: systematic review and multiple treatments meta-analysis. BMC Med. 2012;10:33. 12. Cushman WC, Ford CE, Cutler JA, et al. Success and predictors of blood pressure control in diverse North American settings: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). J Clin Hypertens (Greenwich). 2002;4:393-404. 13. Gradman AH, Basile JN, Carter BL, et al. Combination therapy in hypertension. J Clin Hypertens (Greenwich). 2011;13:146-54. 14. Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. ACCORD Study Group. N Engl J Med. 2010;362:1575-85. 15. Chobanian AV, Bakris GL, Black HR, et al; the National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52.

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8.1.5. BP Goal for Patients With Hypertension Recommendations for BP Goal for Patients With Hypertension

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References that support recommendations are summarized in Online Data Supplement 26 and Systematic Review Report. COR LOE Recommendations 1. For adults with confirmed hypertension and known CVD or 10-year ASCVD SBP: SR event risk of 10% or higher (see Section 8.1.2), a BP target of less than 130/80 B-R I mm Hg is recommended (1-5). DBP: C-EO SBP: 2. For adults with confirmed hypertension, without additional markers of B-NR increased CVD risk, a BP target of less than 130/80 mm Hg may be IIb reasonable (6-9). DBP: C-EO SR indicates systematic review.

Synopsis Refer to the “Systematic Review for the 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” for the complete systematic evidence review for additional data and analyses (10). Several trials have tested whether more intensive BP control improves major CVD outcomes. Meta-analyses and systematic reviews of these trials provide strong support for the more intensive approach, but the data are less clear in identification of a specific optimal BP target (1-5, 7, 11-13). Recent trials that address optimal BP targets include SPRINT and ACCORD (Action to Control Cardiovascular Risk in Diabetes), with targets for more intensive (SBP <120 mm Hg) and standard (SBP <140 mm Hg) treatment (14, 15), and SPS-3, with a more intensive target of <130/80 mm Hg (16). These trials yielded mixed results in achieving their primary endpoints. SPRINT was stopped early, after a median follow-up of 3.26 years, when more intensive treatment resulted in a significant reduction in the primary outcome (a CVD composite) and in all-cause mortality rate. In ACCORD, more intensive BP treatment failed to demonstrate a significant reduction in the primary outcome (a CVD composite). However, the incidence of stroke, a component of the primary outcome, was significantly reduced. The standard glycemia subgroup did show significant benefit in ACCORD, and a meta-analysis of the only 2 trials (ACCORD and SPRINT) testing an SBP goal of <120 mm Hg showed significant reduction in CVD events (17). SPS-3 failed to demonstrate benefit for the primary endpoint of recurrent stoke (p=0.08) but found a significant reduction in a subgroup with hemorrhagic stroke. Pooling of the experience from 19 trials (excluding SPRINT) that randomly assigned participants to different BP treatment targets identified a significant reduction in CVD events, MI, and stroke in those assigned to a lower (average achieved SBP/DBP was 133/76 mm Hg) versus a higher BP treatment target (2). Similar patterns of benefit were reported in 3 other meta-analyses of trials in which participants were randomly assigned to different BP targets (3-5) and in larger meta-analyses that additionally included trials that compared different intensities of treatment (12). Data from the most recent meta-analysis (42 trials and 144,220 patients) (5) demonstrate a linear association between mean achieved SBP and risk of CVD mortality with the lowest risk at 120 to 124 mm Hg. The totality of the available information provides evidence that a lower BP target is generally better than a higher BP target and that some patients will benefit from an SBP treatment goal <120 mm Hg, especially those at high risk of CVD (15). The specific inclusion and exclusion criteria of any RCT may limit extrapolation to a more general population with hypertension. In addition, all of the relevant trials have been efficacy studies in which BP measurements were more consistent with guideline recommendations than is common in clinical practice, resulting in lower

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline absolute values for SBP. For both of these reasons, the SBP target recommended during BP lowering (<130 mm Hg) is higher than that which was used in SPRINT. Recommendation-Specific Supportive Text 1. Meta-analysis and systematic review of trials that compare more intensive BP reduction to standard BP reduction report that more intense BP lowering significantly reduces the risk of stroke, coronary events, major cardiovascular events, and cardiovascular mortality (1). In a stratified analysis of these data, achieving an additional 10–mm Hg reduction in SBP reduced CVD risk when compared with an average SBP of 158/82 to 143/76 mm Hg, 144/85 to 137/81 mm Hg, and 134/79 to 125/76 mm Hg. Patients with DM and CKD were included in the analysis (1, 2, 11-13, 18). (Specific management details are in Section 9.3 for CKD and Section 9.6 for DM.)

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2. The treatment of patients with hypertension without elevated risk has been systematically understudied because lower-risk groups would require prolonged follow-up to have a sufficient number of clinical events to provide useful information. Although there is clinical trial evidence that both drug and nondrug therapy will interrupt the progressive course of hypertension (6), there is no trial evidence that this treatment decreases CVD morbidity and mortality. The clinical trial evidence is strongest for a target BP of 140/90 mm Hg in this population. However, observational studies suggest that these individuals often have a high lifetime risk and would benefit from BP control earlier in life (19, 20). References 1. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels--updated overview and meta-analyses of randomized trials. J Hypertens. 2016; 34:613-22. 2. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387:435-43. 3. Verdecchia P, Angeli F, Gentile G, et al. More versus less intensive blood pressure-lowering strategy: cumulative evidence and trial sequential analysis. Hypertension. 2016;68:642-53. 4. Bangalore S, Toklu B, Gianos E, et al. Optimal systolic blood pressure target after SPRINT: insights from a network meta-analysis of randomized trials. Am J Med. 2017;30:707-19.e8. 5. Bundy JD, Li C, Stuchlik P, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol. 2017;2:775-81. 6. Julius S, Nesbitt SD, Egan BM, et al. Feasibility of treating prehypertension with an angiotensin-receptor blocker. N Engl J Med. 2006;354:1685-97. 7. Lawes CMM, Bennett DA, Lewington S, et al. Blood pressure and coronary heart disease: a review of the evidence. Semin Vasc Med. 2002;2:355-68. 8. Lonn EM, Bosch J, Lopez-Jaramillo P, et al. Blood-pressure lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med. 2016;374:2009-20. 9. Neaton JD, Grimm RH Jr, Prineas RJ, et al. Treatment of Mild Hypertension Study. Final results. Treatment of Mild Hypertension Study Research Group. JAMA. 1993;270:713-24. 10. Reboussin DM, Allen NB, Griswold ME, et al. Systematic review for the 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. Circulation. 2017. In press. 11. Brunstrom M, Carlberg B. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses. BMJ. 2016;352:i717. 12. Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957-67. 13. Lv J, Ehteshami P, Sarnak MJ, et al. Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta-analysis. CMAJ. 2013;185:949-57. 14. Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. ACCORD Study. N Engl J Med. 2010;362:1575-85.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 15. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. SPRINT Research Group. N Engl J Med. 2015;373:2103-16. 16. Taler SJ, Textor SC, Canzanello VJ, et al. Role of steroid dose in hypertension early after liver transplantation with tacrolimus (FK506) and cyclosporine. Transplantation. 1996;62:1588-92. 17. Perkovic V, Rodgers A. Redefining blood-pressure targets--SPRINT starts the marathon. N Engl J Med. 2015;373:2175-8. 18. Lawes CMM, Rodgers A, Bennett DA, et al. Blood pressure and cardiovascular disease in the Asia Pacific region. J Hypertens. 2003;21:707-16. 19. Allen NB, Siddique J, Wilkins JT, et al. Blood pressure trajectories in early adulthood and subclinical atherosclerosis in middle age. JAMA. 2014;311:490-7. 20. Ference BA, Julius S, Mahajan N, et al. Clinical effect of naturally random allocation to lower systolic blood pressure beginning before the development of hypertension. Hypertension. 2014;63:1182-8.

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Recommendation for Choice of Initial Medication

References that support the recommendation are summarized in Online Data Supplement 27 and Systematic Review Report. COR LOE Recommendation 1. For initiation of antihypertensive drug therapy, first-line agents include I ASR thiazide diuretics, CCBs, and ACE inhibitors or ARBs. (1, 2) SR indicates systematic review.

Synopsis The overwhelming majority of persons with BP sufficiently elevated to warrant pharmacological therapy may be best treated initially with 2 agents (see Section 8.1.6.1). When initiation of pharmacological therapy with a single medication is appropriate, primary consideration should be given to comorbid conditions (e.g., HF, CKD) for which specific classes of BP-lowering medication are indicated (see Section 9) (1, 3). In the largest headto-head comparison of first-step drug therapy for hypertension (4, 5), the thiazide-type diuretic chlorthalidone was superior to the CCB amlodipine and the ACE inhibitor lisinopril in preventing HF, a BP-related outcome of increasing importance in the growing population of older persons with hypertension (6-9). Additionally, ACE inhibitors were less effective than thiazide diuretics and CCBs in lowering BP and in prevention of stroke. For black patients, ACE inhibitors were also notably less effective than CCBs in preventing HF (5, 10) and in the prevention of stroke (11, 12) (see Section 10.1). ARBs may be better tolerated than ACE inhibitors in black patients, with less cough and angioedema, but according to the limited available experience they offer no proven advantage over ACE inhibitors in preventing stroke or CVD in this population, making thiazide diuretics (especially chlorthalidone) or CCBs the best initial choice for single-drug therapy. For stroke, in the general population, beta blockers were less effective than CCBs (36% lower risk) and thiazide diuretics (30% lower risk). CCBs have been shown to be as effective as diuretics for reducing all CVD events other than HF, and CCBs are a good alternative choice for initial therapy when thiazide diuretics are not tolerated. Alpha blockers are not used as first-line therapy for hypertension because they are less effective for prevention of CVD than other first-step agents, such as thiazide diuretics (4, 13). Recommendation-Specific Supportive Text 1. The overall goal of treatment should be reduction in BP, in the context of underlying CVD risk. Five drug classes have been shown, in high-quality RCTs, to prevent CVD as compared with placebo (diuretics, ACE inhibitors, ARBs, CCBs, and beta blockers) (14, 15). In head-to-head comparisons of first-step therapy, different drug classes have been reported to provide somewhat divergent capacity to prevent specific CVD events. Interpretation of meta-analyses comparing agents from different drug classes is challenging because the

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relevant RCTs were conducted in different time periods, during which concurrent antihypertensive therapy was less or more common, and the efficacy of agents from certain drug classes may have changed. In recognition of this, some (2) but not all (14, 15) meta-analyses, as well as the largest individual RCT that compared first-step agents (4), have suggested that diuretics, especially the long-acting thiazide-type agent chlorthalidone, may provide an optimal choice for first-step drug therapy of hypertension. In contrast, some meta-analyses have suggested that beta blockers may be less effective, especially for stroke prevention in older adults, but interpretation is hampered by inclusion of RCTs that used beta blockers that are now considered to be inferior for prevention of CVD (16, 17 ). In a systematic review and network meta-analysis conducted for the present guideline, beta blockers were significantly less effective than diuretics for prevention of stroke and cardiovascular events (1). Diuretics were also significantly better than CCBs for prevention of HF. There were some other nonsignificant differences between diuretics, ACE inhibitors, ARBs, and CCBs, but the general pattern was for similarity in effect. As indicated in Section 8.1.6.1, most adults with hypertension require more than one drug to control their BP. As recommended in Section 10.1, for black adults with hypertension (without HF or CKD), initial antihypertensive treatment should include a thiazide diuretic or CCB. References 1. Reboussin DM, Allen NB, Griswold ME, et al. Systematic review for the 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. Circulation. 2017. In press. 2. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA. 2003;289:2534-44. 3. Peart S. Results of MRC (UK) trial of drug therapy for mild hypertension. Clin Invest Med. 1987;10:616-20. 4. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-97. 5. Julius S, Weber MA, Kjeldsen SE, et al. The Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) trial: outcomes in patients receiving monotherapy. Hypertension. 2006;48:385-91. 6. Ferrucci L, Guralnik JM, Pahor M, et al. Hospital diagnoses, Medicare charges, and nursing home admissions in the year when older persons become severely disabled. JAMA. 1997;277:728-34. 7. Curtis LH, Whellan DJ, Hammill BG, et al. Incidence and prevalence of heart failure in elderly persons, 1994-2003. Arch Intern Med. 2008;168:418-24. 8. Bleumink GS, Knetsch AM, Sturkenboom MCJM, et al. Quantifying the heart failure epidemic: prevalence, incidence rate, lifetime risk and prognosis of heart failure The Rotterdam Study. Eur Heart J. 2004;25:1614-9. 9. Bertoni AG, Hundley WG, Massing MW, et al. Heart failure prevalence, incidence, and mortality in the elderly with diabetes. Diabetes Care. 2004;27:699-703. 10. Ogedegbe G, Shah NR, Phillips C, et al. Comparative effectiveness of angiotensin-converting enzyme inhibitorbased treatment on cardiovascular outcomes in hypertensive blacks versus whites. J Am Coll Cardiol. 2015;66:1224-33. 11. Leenen FHH, Nwachuku CE, Black HR, et al. Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the Antihypertensive and LipidLowering Treatment to Prevent Heart Attack Trial. Hypertension 2006;48:374-84. 12. Zanchetti A, Julius S, Kjeldsen S, et al. Outcomes in subgroups of hypertensive patients treated with regimens based on valsartan and amlodipine: an analysis of findings from the VALUE trial. J Hypertens. 2006;24:2163-8. 13. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Collaborative Research Group. Diuretic versus alpha-blocker as first-step antihypertensive therapy: final results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertension. 2003;42:239-46. 14. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 15. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure-lowering on outcome incidence in hypertension: 5. Head-to-head comparisons of various classes of antihypertensive drugs--overview and meta-analyses. J Hypertens. 2015;33:1321-41. 16. Zhang Y, Sun N, Jiang X, et al. Comparative efficacy of β-blockers on mortality and cardiovascular outcomes in patients with hypertension: a systematic review and network meta-analysis. J Am Soc. Hypertens. 2017;11:394401. 17. Larochelle P, Tobe SW, Lacourciere Y. β-Blockers in hypertension: studies and meta-analyses over the years. Can J Cardiol. 2014;30:S16-22.

8.1.6.1. Choice of Initial Monotherapy Versus Initial Combination Drug Therapy Recommendations for Choice of Initial Monotherapy Versus Initial Combination Drug Therapy*

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COR

LOE

I

C-EO

IIa

C-EO

Recommendation 1. Initiation of antihypertensive drug therapy with 2 first-line agents of different classes, either as separate agents or in a fixed-dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mm Hg above their BP target. 2. Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target.

*Fixed-dose combination antihypertensive medications are listed in Online Data Supplement D.

Synopsis Systematic review of the evidence comparing the initiation of antihypertensive treatment with monotherapy and sequential (stepped-care) titration of additional agents versus initiation of treatment with combination therapy (including fixed-dose combinations) did not identify any RCTs meeting the systematic review questions posed in the PICOTS format (P=population, I=intervention, C=comparator, O=outcome, T=timing, S=setting). However, in both ACCORD and SPRINT, 2-drug therapy was recommended for most participants in the intensive- but not standard-therapy groups. Recommendation-Specific Supportive Text 1. Because most patients with hypertension require multiple agents for control of their BP and those with higher BPs are at greater risk, more rapid titration of antihypertensive medications began to be recommended in patients with BP >20/10 mm Hg above their target, beginning with the JNC 7 report (1). In these patients, initiation of antihypertensive therapy with 2 agents is recommended. Evidence favoring this approach comes mostly from studies using fixed-dose combination products showing greater BP lowering with fixed-dose combination agents than with single agents, as well as better adherence to therapy (2, 3). The safety and efficacy of this strategy have been demonstrated in adults to reduce BPs to <140/90 mm Hg though not compared with other strategies (4-6). In general, this approach is reasonable in the very elderly, those at high CVD risk, or those who have a history of hypotension or drug-associated side effects. However, caution is advised in initiating antihypertensive pharmacotherapy with 2 drugs in older patients because hypotension or orthostatic hypotension may develop in some patients; BP should be carefully monitored. 2. The stepped-care approach defined by the initiation of antihypertensive drug therapy with a single agent followed by the sequential titration of the dose and addition of other agents has been the recommended treatment strategy since the first report of the National High Blood Pressure Education Program (7). This approach is also reasonable in the very elderly or those at risk or who have a history of hypotension or drug-

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline associated side effects. This strategy has been used successfully in nearly all hypertension treatment trials but has not been formally tested against other antihypertensive drug treatment strategies for effectiveness in achieving BP control or in preventing adverse outcomes.

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References 1. Chobanian AV, Bakris GL, Black HR, et al; the National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52. 2. Law MR, Wald NJ, Morris JK, et al. Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ. 2003;326:1427. 3. Bangalore S, Kamalakkannan G, Parkar S, et al. Fixed-dose combinations improve medication compliance: a metaanalysis. Am J Med.. 2007;120:713-9. 4. Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008;359:2417-28. 5. Sundstrom J, Arima H, Jackson R, et al. Effects of blood pressure reduction in mild hypertension: a systematic review and meta-analysis. Ann Intern Med. 2015;162:184-91. 6. Luders S, Schrader J, Berger J, et al. The PHARAO study: prevention of hypertension with the angiotensinconverting enzyme inhibitor ramipril in patients with high-normal blood pressure: a prospective, randomized, controlled prevention trial of the German Hypertension League. J Hypertens. 2008;26:1487-96. 7. Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. A cooperative study. JAMA. 1977;237:255-61.

8.2. Achieving BP Control in Individual Patients Recommendations for lifestyle modifications and drug selection are specified in Sections 6.2, 8.1.4, and 8.1.6. Initial drug selections should be based on trial evidence of treatment efficacy, combined with recognition of compelling indications for use of an agent from a specific drug class, as well as the individual patient’s lifestyle preferences and traits. For a subset of patients (25% to 50%) (1), the initial drug therapy will be well tolerated and effective in achieving the desired level of BP, with only the need for subsequent monitoring (see Section 8.3 for an appropriate follow-up schedule). For others, the initial drug will not be tolerated or will not be effective, requiring either a change in medication or addition of another medication, followed by BP monitoring (2). Approximately 25% of patients will require additional treatment adjustments. In a minority of this group, achievement of goal BP can be challenging. In patients who do not respond to or do not tolerate treatment with 2 to 3 medications or medication combinations, additional trials of treatment tend to be ineffective or poorly tolerated. Some patients may become disillusioned and lost to follow-up, whereas others will identify an alternative healthcare provider, including nontraditional healers, or will try popular home remedies. Working with this more demanding subset requires provider expertise, patience, and a mechanism to respond efficiently and sensitively to concerns as they arise. In this setting, team-based care (see Section 12) may be effective, encouraging coupling of nonpharmacological and pharmacological treatments, while improving access to and communication with care providers. In the setting of medication intolerance, consider allowing a defined period of time to evaluate the effects of lifestyle modification in patients with a relatively low CVD risk (10-year risk of ASCVD <10%, based on the ASCVD Risk Estimator [http://tools.acc.org/ASCVD-Risk-Estimator]), with scheduled follow-up visits for assessment of BP levels, including a review of HBPM data, and an appraisal of lifestyle change goal achievements. For patients with a higher level of CVD risk or with significant elevations in BP (SBP or DBP >20 or >10 mm Hg above target, respectively), medication is usually started even while the patient is pursuing lifestyle change (see Section 8.1.2). Consideration of patient comorbidities, lifestyle, and preferences may suggest better tolerance or greater effect from one class of medication versus other classes. For example, if hyponatremia is present, it would be important to avoid or stop thiazide diuretic therapy. In this case, a loop diuretic should be used if a

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline diuretic is required. If hypokalemia is present, primary or secondary aldosteronism should be excluded, after which one should consider a potassium-sparing agent, such as spironolactone, eplerenone, triamterene, or amiloride. In addition, reducing dietary sodium intake will diminish urinary potassium losses. If the patient has chronic cough or a history of ACE inhibitor–induced cough or develops a cough or bronchial responsiveness while on an ACE inhibitor, one should use an ARB in place of an ACE inhibitor. For patients with bronchospastic lung disease, a beta-1-selective blocker (e.g., bisoprolol, metoprolol) should be considered if beta-blocker therapy is required. A patient who is already adherent to lifestyle change recommendations, including diligent reduction in sodium intake, may show a greater response to a RAS blocker. Prior patient experience should be considered, as in the case of cough associated with prior use of an ACE inhibitor, which is likely to reoccur if an agent from the same class is prescribed. References 1. Neaton JD, Grimm RH Jr, Prineas RJ, et al. Treatment of Mild Hypertension Study. Final results. Treatment of Mild Hypertension Study Research Group. JAMA. 1993;270:713-24. 2. Senn S. Individual response to treatment: is it a valid assumption? BMJ. 2004;329:966-8. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

8.3. Follow-Up of BP During Antihypertensive Drug Therapy Appropriate follow-up and monitoring enable assessment of adherence (see Section 12.1) and response to therapy, help identify adverse responses to therapy and target organ damage, and allow assessment of progress toward treatment goals. High-quality RCTs have successfully and safely developed strategies for follow-up, monitoring, and reassessment from which recommendations can be made (Figure 4) (1, 2). A systematic approach to out-of-office BP assessment is an essential part of follow-up and monitoring of BP, to assess response to therapy; check for evidence of white coat hypertension, white coat effect, masked hypertension, or masked uncontrolled hypertension; and help achieve BP targets (see Sections 4 and 12). References 1. Ambrosius WT, Sink KM, Foy CG, et al. The design and rationale of a multicenter clinical trial comparing two strategies for control of systolic blood pressure: the Systolic Blood Pressure Intervention Trial (SPRINT). Clin Trials. 2014;11:532-46. 2. Cushman WC, Grimm RH Jr, Cutler JA, et al. Rationale and design for the blood pressure intervention of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Am J Cardiol. 2007;99:44i-55i.

8.3.1. Follow-Up After Initiating Antihypertensive Drug Therapy Recommendation for Follow-Up After Initiating Antihypertensive Drug Therapy

References that support the recommendation are summarized in Online Data Supplement 28. COR LOE Recommendation 1. Adults initiating a new or adjusted drug regimen for hypertension should have a follow-up evaluation of adherence and response to treatment at I B-R monthly intervals until control is achieved (1-3). Recommendation-Specific Supportive Text 1. Components of the follow-up evaluation should include assessment of BP control, as well as evaluation for orthostatic hypotension, adverse effects from medication therapy, adherence to medication and lifestyle therapy, need for adjustment of medication dosage, laboratory testing (including electrolyte and renal function status), and other assessments of target organ damage (1-3).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline References 1. Ambrosius WT, Sink KM, Foy CG, et al. The design and rationale of a multicenter clinical trial comparing two strategies for control of systolic blood pressure: the Systolic Blood Pressure Intervention Trial (SPRINT). Clin Trials. 2014;11:532-46. 2. Cushman WC, Grimm RH Jr, Cutler JA, et al. Rationale and design for the blood pressure intervention of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Am J Cardiol. 2007;99:44i-55i. 3. Xu W, Goldberg SI, Shubina M, et al. Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study. BMJ. 2015;350:h158.

8.3.2. Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP Recommendation for Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

References that support the recommendation are summarized in Online Data Supplement 29. COR LOE Recommendation 1. Follow-up and monitoring after initiation of drug therapy for hypertension control should include systematic strategies to help improve BP, including I A use of HBPM, team-based care, and telehealth strategies (1-6).

Recommendation-Specific Supportive Text 1. Systematic approaches to follow-up have been shown to improve hypertension control and can be adapted and incorporated into clinical practices according to local needs and resource availability (see Section 8.3.1 for time intervals for treatment follow-up and monitoring and Sections 12.2 and 12.3.2 on systematic strategies to improve BP control). References 1. Brennan T, Spettell C, Villagra V, et al. Disease management to promote blood pressure control among African Americans. Popul Health Manag. 2010;13:65-72. 2. Bosworth HB, Olsen MK, Grubber JM, et al. Two self-management interventions to improve hypertension control: a randomized trial. Ann Intern Med. 2009;151:687-95. 3. Bosworth HB, Powers BJ, Olsen MK, et al. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Arch Intern Med. 2011;171:1173-80. 4. Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA. 2008;299:2857-67. 5. Heisler M, Hofer TP, Schmittdiel JA, et al. Improving blood pressure control through a clinical pharmacist outreach program in patients with diabetes mellitus in 2 high-performing health systems: the adherence and intensification of medications cluster randomized, controlled pragmatic trial. Circulation. 2012;125:2863-72. 6. Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA. 2013;310:46-56.

9. Hypertension in Patients With Comorbidities Certain comorbidities may affect clinical decision-making in hypertension. These include ischemic heart disease, HF with reduced ejection fraction (HFrEF), HFpEF, CKD (including renal transplantation), cerebrovascular disease, AF, PAD, DM, and metabolic syndrome (1). As noted in Section 8.1.2, this guideline generally recommends use of BP-lowering medications for secondary prevention of CVD in patients with clinical CVD (CHD, HF, and stroke) and an average BP ≥130/80 mm Hg and for primary prevention of CVD in adults with an estimated 10-year ASCVD risk of ≥10% and an average SBP ≥130 mm Hg or an average DBP ≥80 mm Hg. Although we recommend use of the ACC/AHA Pooled Cohort Equations (http://tools.acc.org/ASCVDPage 90

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Risk-Estimator/) to estimate 10-year risk of ASCVD to establish the BP threshold for treatment, the vast majority of adults with a co-morbidity are likely to have a 10-year risk of ASCVD that exceeds 10%. In some instances, clinical trial confirmation of treatment in patients with comorbidities is limited to a target BP of 140/90 mm Hg. In addition, the selection of medications for use in treating high BP in patients with CVD is guided by their use for other compelling indications (e.g., beta blockers after MI, ACE inhibitors for HFrEF), as discussed in specific guidelines for the clinical condition (2-4). The present guideline does not address the recommendations for treatment of hypertension occurring with acute coronary syndromes.

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References 1. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. Circulation. 2011;123:2434-506. 2. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240-327. 3. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014;130:1749-67. 4. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e726-79.

9.1. Stable Ischemic Heart Disease Recommendations for Treatment of Hypertension in Patients With Stable Ischemic Heart Disease (SIHD)

References that support recommendations are summarized in Online Data Supplements 30-32. COR LOE Recommendations SBP: 1. In adults with SIHD and hypertension, a BP target of less than 130/80 mm B-R Hg is recommended (1-5). I DBP: C-EO 2. Adults with SIHD and hypertension (BP ≥130/80 mm Hg) should be treated SBP: with medications (e.g., GDMT (6) beta blockers, ACE inhibitors, or ARBs) for B-R compelling indications (e.g., previous MI, stable angina) as first-line therapy, I with the addition of other drugs (e.g., dihydropyridine CCBs, thiazide DBP: diuretics, and/or mineralocorticoid receptor antagonists) as needed to C-EO further control hypertension (7-10). 3. In adults with SIHD with angina and persistent uncontrolled hypertension, I B-NR the addition of dihydropyridine CCBs to GDMT (6) beta blockers is recommended (8, 11, 12). 4. In adults who have had a MI or acute coronary syndrome, it is reasonable to continue GDMT (6) beta blockers beyond 3 years as long-term therapy for IIa B-NR hypertension (13, 14).

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C-EO

5. Beta blockers and/or CCBs might be considered to control hypertension in patients with CAD (without HFrEF) who had an MI more than 3 years ago and have angina.

Synopsis Hypertension is a major risk factor for ischemic heart disease. Numerous RCTs have demonstrated the benefits of antihypertensive drug therapy in reducing the risk of ischemic heart disease. The following recommendations apply only to management of hypertension in patients with SIHD without HF. See Section 9.2 for recommendations for the treatment of patients with SIHD and HF. Figure 5 is an algorithm on management of hypertension in patients with SIHD. Recommendation-Specific Supportive Text 1. In patients with increased cardiovascular risk, reduction of SBP to <130/80 mm Hg has been shown to reduce CVD complications by 25% and all-cause mortality by 27% (1). Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

2. After 5 years of randomized therapy in high-CVD-risk patients, ramipril produced a 22% reduction in MI, stroke, or CVD compared with placebo (10). No added benefit on CVD outcomes was seen when compared with CCBs and diuretics (15, 16). After 4.2 years of randomized therapy in patients with SIHD, perindopril reduced CVD death, MI, or cardiac arrest by 20% compared with placebo (7). Beta blockers are effective drugs for preventing angina pectoris, improving exercise time until the onset of angina pectoris, reducing exerciseinduced ischemic ST-segment depression, and preventing coronary events (8, 17-22). Because of their compelling indications for treatment of SIHD, these drugs are recommended as a first-line therapy in the treatment of hypertension when it occurs in patients with SIHD. GDMT beta blockers for SIHD that are also effective in lowering BP include carvedilol, metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, and timolol. Atenolol is not as effective as other antihypertensive drugs in the treatment of hypertension (23). 3. Dihydropyridine CCBs are effective antianginal drugs that can lower BP and relieve angina pectoris when added to beta blockers in patients in whom hypertension is present and angina pectoris persists despite betablocker therapy (8, 17, 19-22, 24, 25). GDMT beta blockers for SIHD that are also effective in lowering BP include carvedilol, metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, and timolol. 4. In randomized long-term trials, use of beta blockers after MI reduced all-cause mortality by 23% (13). Given the established efficacy of beta blockers for treating hypertension and SIHD, their use for treatment continuing beyond 3 years after MI is reasonable (6, 25). 5. GDMT beta blockers and CCBs are effective antihypertensive and antianginal agents. CCBs include dihydropyridine and nondihydropyridine agents. CCBs can be used separately or together with beta blockers beginning 3 years after MI in patients with CAD who have both hypertension and angina.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 5. Management of Hypertension in Patients With SIHD

Hypertension With SIHD

Reduce BP to <130/80 mm Hg with GDMT beta blockers*, ACE inhibitor, or ARBs† (Class I) BP goal not met Angina pectoris Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Yes Add dihydropyridine CCBs if needed (Class I)

No Add dihydropyridine CCBs, thiazide-type diuretics, and/or MRAs as needed (Class I)

Colors correspond to Class of Recommendation in Table 1. *GDMT beta blockers for BP control or relief of angina include carvedilol, metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, and timolol. Avoid beta blockers with intrinsic sympathomimetic activity. The beta blocker atenolol should not be used because it is less effective than placebo in reducing cardiovascular events. †If needed for BP control. ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; GDMT, guideline-directed management and therapy; and SIHD, stable ischemic heart disease. References 1. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. SPRINT Research Group. N Engl J Med. 2015;373:2103-16. 2. Bundy JD, Li C, Stuchlik P, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol. 2017;2:775-81. 3. Leenen FHH, Nwachuku CE, Black HR, et al. Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Hypertension 2006;48:374-84. 4. Zanchetti A, Julius S, Kjeldsen S, et al. Outcomes in subgroups of hypertensive patients treated with regimens based on valsartan and amlodipine: an analysis of findings from the VALUE trial. J Hypertens. 2006;24:2163-8. 5. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Collaborative Research Group. Diuretic versus alpha-blocker as first-step antihypertensive therapy: final results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertension. 2003;42:239-46. 6. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014;130:1749-67.

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8. 9. 10. 11. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

12. 13. 14. 15. 16. 17. 18. 19. 20.

21. 22. 23. 24. 25.

Fox KM, EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet. 2003;362:782-8. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. Pfeffer MA, Braunwald E, Moye LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med. 1992;327:669-77. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000;342:145-53. Leon MB, Rosing DR, Bonow RO, et al. Clinical efficacy of verapamil alone and combined with propranolol in treating patients with chronic stable angina pectoris. Am J Cardiol. 1981;48:131-9. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350:757-64. Freemantle N, Cleland J, Young P, et al. Beta Blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318:1730-7. de Peuter OR, Lussana F, Peters RJG, et al. A systematic review of selective and non-selective beta blockers for prevention of vascular events in patients with acute coronary syndrome or heart failure. Neth J Med. 2009;67:28494. Bavry AA, Anderson RD, Gong Y, et al. Outcomes among hypertensive patients with concomitant peripheral and coronary artery disease: findings from the INternational VErapamil-SR/Trandolapril STudy. Hypertension 2010;55:48-53. Piller LB, Simpson LM, Baraniuk S, et al. Characteristics and long-term follow-up of participants with peripheral arterial disease during ALLHAT. J Gen Intern Med. 2014;29:1475-83. Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Circulation. 2015;131:e435-70. Ekelund LG, Olsson AG, Oro L, et al. Effects of the cardioselective beta-adrenergic receptor blocking agent metoprolol in angina pectoris. Subacute study with exercise tests. Br Heart J. 1976; 38:155-61. Aronow WS, Turbow M, Van Camp S, et al. The effect of timolol vs placebo on angina pectoris. Circulation. 1980;61:66-9. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. Circulation. 2011;123:2434-506. Aronow WS, Frishman WH. Angina pectoris in the elderly. In: Aronow WS, Fleg JL, Rich MW, eds. Tresch and Aronow's Cardiovascular Disease in the Elderly. Boca Raton, FL: CRC Press, Taylor & Francis Group; 2013:215-37. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458-73. Carlberg B, Samuelsson O, Lindholm LH. Atenolol in hypertension: is it a wise choice? Lancet. 2004;364:1684-9. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians,

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9.2. Heart Failure Recommendation for Prevention of HF in Adults With Hypertension

References that support the recommendation are summarized in Online Data Supplement 33. COR LOE Recommendation SBP: 1. In adults at increased risk of HF, the optimal BP in those with hypertension B-R should be less than 130/80 mm Hg (1-3). I DBP: C-EO Synopsis Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Antecedent hypertension is present in 75% of patients with chronic HF (4). In the Cardiovascular Health Study (5) and the Health, Aging and Body Composition Study (6), 11.2% of 4408 persons (53.1% women, with a mean age of 72.8 years, living in the community, and not receiving antihypertensive drugs at baseline) developed HF over 10 years (7). Compared with those with an average SBP <120 mm Hg, the adjusted incidence of HF was increased 1.6, 2.2, and 2.6 times in those with average SBPs between 120 and 139 mm Hg, between 140 and 159 mm Hg, and ≥160 mm Hg, respectively (7). No RCTs are available that compare one BP-lowering agent to another for the management of patients with HF. The following recommendations for treatment of hypertension in HF are based on use of drugs that lower BP and also have compelling indications for management of HF (with HFrEF or HFpEF) as recommended in current ACC/AHA guidelines (4, 8). Recommendation-Specific Supportive Text 1. In adults with hypertension (SBP ≥130 mm Hg or DBP ≥80 mm Hg) and a high risk of CVD, a strong body of evidence supports treatment with antihypertensive medications (see Section 8.1.2) and more-intensive rather than less-intensive intervention (see Section 8.1.5). In SPRINT, a more intensive intervention that targeted an SBP <120 mm Hg significantly reduced the primary outcome (CVD composite) by about 25% (9). The incidence of HF, a component of the primary outcome, was also substantially decreased (hazard ratio: 0.62; 95% confidence interval: 0.45–0.84). Meta-analyses of clinical trials have identified a similar beneficial effect of more-intensive BP reduction on the incidence of HF (2, 10), but the body of information from studies confined to trials that randomly assigned participants to different BP targets is more limited and less compelling (3). In addition, the available trials were efficacy studies in which BP measurements were more consistent with guideline recommendations than is common in clinical practice, resulting in lower absolute values for SBP. For both of these reasons, the SBP target recommended during BP lowering (<130 mm Hg) is higher than that used in SPRINT. References 1. Lv J, Ehteshami P, Sarnak MJ, et al. Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta-analysis. CMAJ. 2013;185:949-57. 2. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels--updated overview and meta-analyses of randomized trials. J Hypertens. 2016; 34:613-22. 3. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387:435-43. 4. Yancy CW, Jessup M, Bozkurt B, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the

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American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016;134:e282-93. 5. Visser M, Langlois J, Guralnik JM, et al. High body fatness, but not low fat-free mass, predicts disability in older men and women: the Cardiovascular Health Study. Am J Clin Nutr. 1998;68:584-90. 6. Goodpaster BH, Park SW, Harris TB, et al. The loss of skeletal muscle strength, mass, and quality in older adults: the health, aging and body composition study. J Gerontol A Biol Sci Med Sci. 2006;61:1059-64. 7. Butler J, Kalogeropoulos AP, Georgiopoulou VV, et al. Systolic blood pressure and incident heart failure in the elderly. The Cardiovascular Health Study and the Health, Ageing and Body Composition Study. Heart. 2011;97:1304-11. 8. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240-327. 9. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. SPRINT Research Group. N Engl J Med. 2015;373:2103-16. 10. Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957-67.

9.2.1. Heart Failure With Reduced Ejection Fraction Recommendations for Treatment of Hypertension in Patients With HFrEF

References that support recommendations are summarized in Online Data Supplement 34. COR LOE Recommendation 1. Adults with HFrEF and hypertension should be prescribed GDMT (2) titrated I C-EO to attain a BP of less than 130/80 mm Hg.

III: No Benefit

B-R

2. Nondihydropyridine CCBs are not recommended in the treatment of hypertension in adults with HFrEF (1).

Synopsis Approximately 50% of patients with HF have HFrEF (2-6). Numerous RCTs have shown that treatment of HFrEF with GDMT reduces mortality and HF hospitalizations (7). Large-scale RCTs have shown that antihypertensive drug therapy reduces the incidence of HF in patients with hypertension (8-11). In ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), chlorthalidone reduced the risk of HFrEF more than amlodipine and doxazosin but similarly to lisinopril (12, 13). Recommendation-Specific Supportive Text 1. This recommendation is based on guidance in the 2017 ACC/AHA/HFSA guideline focused update on heart failure (14) (see figure from the HF focused update that is reproduced in Online Data Supplement A). Lifestyle modification, such as weight loss and sodium reduction, may serve as adjunctive measures to help these agents work better. No RCT evidence is available to support the superiority of one BP-lowering medication with compelling indications for treatment of HFrEF over another. Medications with compelling indications for HF that may be used as first-line therapy to treat high BP include ACE inhibitors or ARBs, angiotensin receptor– neprilysin inhibitors, mineralocorticoid receptor antagonists, diuretics, and GDMT beta blockers (carvedilol, metoprolol succinate, or bisoprolol). Clinical trials evaluating goal BP reduction and optimal BP-lowering agents in the setting of HFrEF and concomitant hypertension have not been performed. However, in patients at higher CVD risk, BP lowering is associated with fewer adverse cardiovascular events (7). GDMT for HFrEF with agents known to lower BP should consider a goal BP reduction consistent with a threshold now associated with improved clinical outcomes but not yet proven by RCTs in an HF population.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 2. Nondihydropyridine CCBs (verapamil, diltiazem) have myocardial depressant activity. Several clinical trials have demonstrated either no clinical benefit or even worse outcomes in patients with HF treated with these drugs (1). Therefore, nondihydropyridine CCBs are not recommended in patients with hypertension and HFrEF.

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References 1. Goldstein RE, Boccuzzi SJ, Cruess D, et al. Diltiazem increases late-onset congestive heart failure in postinfarction patients with early reduction in ejection fraction. The Adverse Experience Committee; and the Multicenter Diltiazem Postinfarction Research Group. Circulation. 1991;83:52-60. 2. Aronow WS, Ahn C, Kronzon I. Normal left ventricular ejection fraction in older persons with congestive heart failure. Chest. 1998;113:867-9. 3. Aronow WS, Ahn C, Kronzon I. Comparison of incidences of congestive heart failure in older African-Americans, Hispanics, and whites. Am J Cardiol. 1999;84:611-2, A9. 4. Gottdiener JS, McClelland RL, Marshall R, et al. Outcome of congestive heart failure in elderly persons: influence of left ventricular systolic function. The Cardiovascular Health Study. Ann Intern Med. 2002;137:631-9. 5. Owan TE, Hodge DO, Herges RM, et al. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355:251-9. 6. Vasan RS, Larson MG, Benjamin EJ, et al. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol. 1999;33:1948-55. 7. Yancy CW, Jessup M, Bozkurt B, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016;134:e282-93. 8. Amery A, Birkenhager W, Brixko P, et al. Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet. 1985;1:1349-54. 9. Kostis JB, Davis BR, Cutler J, et al. Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group. JAMA. 1997;278:212-6. 10. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-98. 11. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. 12. Davis BR, Kostis JB, Simpson LM, et al. Heart failure with preserved and reduced left ventricular ejection fraction in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Circulation. 2008;118:2259-67. 13. Piller LB, Baraniuk S, Simpson LM, et al. Long-term follow-up of participants with heart failure in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Circulation. 2011;124:1811-8. 14. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136:e137-61.

9.2.2. Heart Failure With Preserved Ejection Fraction Recommendations for Treatment of Hypertension in Patients With HFpEF

References that support recommendations are summarized in Online Data Supplements 35 and 36. COR LOE Recommendations 1. In adults with HFpEF who present with symptoms of volume overload, I C-EO diuretics should be prescribed to control hypertension. 2. Adults with HFpEF and persistent hypertension after management of I C-LD volume overload should be prescribed ACE inhibitors or ARBs and beta blockers titrated to attain SBP of less than 130 mm Hg (1-6).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Synopsis Approximately 50% of patients with HF have HFpEF (2, 7-11). The ejection fraction in these studies has varied from >40% to ≥55% (2). Patients with HFpEF are usually older women with a history of hypertension. Obesity, CHD, DM, AF, and hyperlipidemia are also highly prevalent in patients with HFpEF (2, 11, 12). Hypertension is the most important cause of HFpEF, with a prevalence of 60% to 89% in large RCTs, epidemiological studies, and HF registries (2, 13). Patients with HFpEF also have an exaggerated hypertensive response to exercise (14). Hypertensive acute pulmonary edema is an expression of HFpEF (15). BP control is important for prevention of HFpEF in patients with hypertension (2, 16-19). ALLHAT showed that treatment of hypertension with chlorthalidone reduced the risk of HF compared with amlodipine, doxazosin, and lisinopril (19, 20). Improved BP control also reduces hospitalization, CVD events, and mortality (2, 16-19). Recommendation-Specific Supportive Text Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

1. Diuretics are the only drugs used for the treatment of hypertension and HF that can adequately control the fluid retention of HF. Appropriate use of diuretics is also crucial to the success of other drugs used for the treatment of hypertension in the presence of HF. The use of inappropriately low doses of diuretics can result in fluid retention. Conversely, the use of inappropriately high doses of diuretics can lead to volume contraction, which can increase the risk of hypotension and renal insufficiency. Diuretics should be prescribed to all patients with hypertension and HFpEF who have evidence of, and to most patients with a prior history of, fluid retention. 2. In a trial of patients with HFpEF and MI, patients randomized to propranolol had at 32-month follow-up a 35% reduction in mortality rate (3). After 21 months of treatment in patients with HFrEF and HFpEF, compared with placebo, those randomized to nebivolol had a 14% reduction in mortality or CVD hospitalization if they had HFrEF and a 19% reduction if they had HFpEF (4). In patients with HFpEF, the primary outcome (a composite of CVD death or HF hospitalization) was observed in 22% for candesartan and 24% for placebo (11% reduction), but fewer patients receiving candesartan were hospitalized for HF (5). The use of nitrates in the setting of HFpEF is associated with a signal of harm and in most situations should be avoided. For many other common antihypertensive agents, including alpha blockers, beta blockers, and calcium channel blockers, limited data exist to guide the choice of antihypertensive therapy in the setting of HFpEF (21). Reninangiotensin-aldosterone system inhibition, however, with ACE inhibitor or ARB and especially MRA would represent the preferred choice. A shared decision-making discussion, with the patient influenced by clinician judgment, should drive the ultimate choice of antihypertensive agents. References 1. Pfeffer MA, Claggett B, Assmann SF, et al. Regional variation in patients and outcomes in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) trial. Circulation. 2015;131:3442. 2. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240-327. 3. Aronow WS, Ahn C, Kronzon I. Effect of propranolol versus no propranolol on total mortality plus nonfatal myocardial infarction in older patients with prior myocardial infarction, congestive heart failure, and left ventricular ejection fraction > or = 40% treated with diuretics plus angiotensin-converting enzyme inhibitors. Am J Cardiol. 1997;80:207-9. 4. van Veldhuisen DJ, Cohen-Solal A, Bohm M, et al. Beta-blockade with nebivolol in elderly heart failure patients with impaired and preserved left ventricular ejection fraction: Data From SENIORS (Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors With Heart Failure). J Am Coll Cardiol. 2009;53:2150-8. 5. Yusuf S, Pfeffer MA, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet. 2003;362:777-81.

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13. 14. 15. 16.

17. 18. 19. 20. 21.

Massie BM, Carson PE, McMurray JJ, et al. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med. 2008;359:2456-67. Aronow WS, Ahn C, Kronzon I. Normal left ventricular ejection fraction in older persons with congestive heart failure. Chest. 1998;113:867-9. Aronow WS, Ahn C, Kronzon I. Comparison of incidences of congestive heart failure in older African-Americans, Hispanics, and whites. Am J Cardiol. 1999;84:611-2, A9. Vasan RS, Larson MG, Benjamin EJ, et al. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol. 1999;33:1948-55. Gottdiener JS, McClelland RL, Marshall R, et al. Outcome of congestive heart failure in elderly persons: influence of left ventricular systolic function. The Cardiovascular Health Study. Ann Intern Med. 2002;137:631-9. Owan TE, Hodge DO, Herges RM, et al. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355:251-9. Lee DS, Gona P, Vasan RS, et al. Relation of disease pathogenesis and risk factors to heart failure with preserved or reduced ejection fraction: insights from the Framingham Heart Study of the National Heart, Lung, and Blood Institute. Circulation. 2009;119:3070-7. Bhuiyan T, Maurer MS. Heart failure with preserved ejection fraction: persistent diagnosis, therapeutic enigma. Curr Cardiovasc Risk Rep. 2011;5:440-9. Kato S, Onishi K, Yamanaka T, et al. Exaggerated hypertensive response to exercise in patients with diastolic heart failure. Hypertens Res. 2008;31:679-84. St Gyalai-Korpos I, Tomescu M, Pogorevici A. Hypertensive acute pulmonary oedema as expression of diastolic heart failure. Rom J Intern Med. 2008;46:153-7. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. Circulation. 2011;123:2434-506. Kostis JB, Davis BR, Cutler J, et al. Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group. JAMA. 1997;278:212-6. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-98. Piller LB, Baraniuk S, Simpson LM, et al. Long-term follow-up of participants with heart failure in the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). Circulation. 2011;124:1811-8. Davis BR, Kostis JB, Simpson LM, et al. Heart failure with preserved and reduced left ventricular ejection fraction in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Circulation. 2008;118:2259-67. Redfield MM, Chen HH, Borlaug BA, et al. Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction: a randomized clinical trial. JAMA. 2013;309:1268-77.

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9.3. Chronic Kidney Disease Recommendations for Treatment of Hypertension in Patients With CKD

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References that support recommendations are summarized in Online Data Supplements 37 and 38 and Systematic Review Report. COR LOE Recommendations SBP: 1. Adults with hypertension and CKD should be treated to a BP goal of less than B-RSR 130/80 mm Hg (1-6). I DBP: C-EO 2. In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-creatinine ratio or the IIa B-R equivalent in the first morning void]), treatment with an ACE inhibitor is reasonable to slow kidney disease progression (3, 7-12). 3. In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-creatinine ratio in the IIb C-EO first morning void]) (7, 8), treatment with an ARB may be reasonable if an ACE inhibitor is not tolerated. SR indicates systematic review.

Synopsis Refer to the “Systematic Review for the 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” for the complete systematic evidence review for additional data and analyses (13). Hypertension is the most common comorbidity affecting patients with CKD. Hypertension has been reported in 67% to 92% of patients with CKD, with increasing prevalence as kidney function declines (14). Hypertension may occur as a result of kidney disease, yet the presence of hypertension may also accelerate further kidney injury; therefore, treatment is an important means to prevent further kidney functional decline. This tight interaction has led to extensive debate about the optimal BP target for patients with CKD (15-18). Masked hypertension may occur in up to 30% of patients with CKD and portends higher risk of CKD progression (19-23). CKD is an important risk factor for CVD (24), and the coexistence of hypertension and CKD further increases the risk of adverse CVD and cerebrovascular events, particularly when proteinuria is present (25). Even as the importance of hypertension treatment is widely accepted, data supporting BP targets in CKD are limited, as patients with CKD were historically excluded from clinical trials. Furthermore, CKD is not included in the CVD risk calculations used to determine suitability for most clinical trials (26-28). Until publication of the SPRINT results, most guidelines for BP targets in patients with CKD favored treatment to a BP <140/90 mm Hg (15), with consideration of the lower target of <130/80 mm Hg for those with more severe proteinuria (≥300 mg albuminuria in 24 hours or the equivalent), if tolerated (16-18). Patients with stage 3 to 4 CKD (eGFR of 20 to <60 mL/minute/1.73 m2) comprised 28% of the SPRINT study population, and in this group intensive BP management seemed to provide the same benefits for reduction in the CVD composite primary outcome and all-cause mortality as were seen in the full study cohort. Given that most patients with CKD die from CVD complications, this RCT evidence supports a lower target of <130/80 mm Hg for all patients with CKD (Figure 6). It is appropriate to acknowledge that many patients with CKD have additional comorbidities and evidence of frailty that caused them to be excluded from past clinical trials. Observational studies of CKD cohorts indicate a higher risk of mortality at lower systolic pressures and a flat relationship of SBP to event risk in elderly patients with CKD (29, 30), which supports concerns that these complex patients may be at greater risk of complications from intensive BP treatment and may fail to achieve benefits from lower BP targets. In contrast, in the prespecified subgroup analysis of the elderly cohort in

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline SPRINT, frail elderly patients did sustain benefit from the lower BP target, which supports a lower goal for all patients, including those with CKD (31). In this setting, incremental BP reduction may be appropriate, with careful monitoring of physical and kidney function. An ACE inhibitor (or an ARB, in case of ACE inhibitor intolerance) is a preferred drug for treatment of hypertension if albuminuria (≥300 mg/day or ≥300 mg/g creatinine by first morning void) is present, although the evidence is mixed (10, 11) (Figure 6). In the course of reducing intraglomerular pressure and thereby reducing albuminuria, serum creatinine may increase up to 30% because of concurrent reduction in GFR (32). Further GFR decline should be investigated and may be related to other factors, including volume contraction, use of nephrotoxic agents, or renovascular disease (33). The combination of an ACE inhibitor and an ARB should be avoided because of reported harms demonstrated in several large cardiology trials (34, 35) and in 1 diabetic nephropathy trial (36). Because of the greater risk of hyperkalemia and hypotension and lack of demonstrated benefit, the combination of an ARB (or ACE inhibitor) and a direct renin inhibitor is also contraindicated during management of patients with CKD (37). Figure 6 is an algorithm on management of hypertension in patients with CKD. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Recommendation-Specific Supportive Text 1. We recommend ASCVD risk assessment in all adults with hypertension, including those with CKD. As a matter of convenience, however, it can be assumed that the vast majority of patients with CKD have a 10-year ASCVD risk ≥10%, placing them in the high risk category that requires initiation of antihypertensive drug therapy at BP ≥130/80 mm Hg (see Section 8.1.2, Figure 4 and Table 23 for BP thresholds for initiating antihypertensive drug treatment). In SPRINT, the participants with CKD who were randomized to intensive antihypertensive therapy (SBP target <120 mm Hg) appeared to derive the same beneficial reduction in CVD events and all-cause mortality that was seen in their counterparts without CKD at baseline. Likewise, intensive therapy was beneficial even in those ≥75 years of age with frailty or the slowest gait speed. There was no difference in the principal kidney outcome (≥50% decline in eGFR or ESRD) between the intensive-and standard-therapy (SBP target <140 mm Hg) groups (26). Three other RCTs (1-3) have evaluated the effect of differing BP goals of <140/90 mm Hg versus 125–130/75–80 mm Hg on CKD progression in patients with CKD. None of these trials demonstrated a benefit for more intensive BP reduction, although post hoc follow-up analyses favored the lower targets in patients with more severe proteinuria (38, 39), and these trials were underpowered to detect differences in CVD event rates. Recent meta-analyses and systematic reviews that included patients with CKD from SPRINT support more intensive BP treatment (40-42) to reduce cardiovascular events but do not demonstrate a reduction in the rate of progression of kidney disease (doubling of serum creatinine or reaching ESRD). More intensive BP treatment may result in a modest reduction in GFR, which is thought to be primarily due to a hemodynamic effect and may be reversible. Electrolyte abnormalities are also more likely during intensive BP treatment. More intensive BP lowering in patients with CKD is also supported by a BP Lowering Treatment Trialists’ Collaboration meta-analysis of RCTs in patients with CKD (43). 2. Evidence comes from AASK (The African American Study of Kidney Disease and Hypertension), 2 small trials (1 positive, 1 negative), and a meta-analysis (3, 6, 10, 11). Albuminuria is quantified by 24-hour urine collection. A 10% to 25% increase in serum creatinine may occur in some patients with CKD as a result of ACE inhibitor therapy. 3. ARBs were shown to be noninferior to ACE inhibitors in clinical trials in the non-CKD population (35). A 10% to 25% increase in serum creatinine may occur in some patients with CKD as a result of ARB therapy.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 6. Management of Hypertension in Patients With CKD

Treatment of hypertension in patients with CKD

BP goal <130/80 mm Hg (Class I)

Albuminuria (≥300 mg/d or ≥300 mg/g creatinine) Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

No

Yes

ACE inhibitor (Class IIa)

Usual “first-line” medication choices

ACE inhibitor intolerant Yes

ARB* (Class IIb)

No

ACE inhibitor* (Class IIa)

Colors correspond to Class of Recommendation in Table 1. *CKD stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d or ≥300 mg/g creatinine. ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP blood pressure; and CKD, chronic kidney disease. References 1. Klahr S, Levey AS, Beck GJ, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994;330:877-84. 2. Ruggenenti P, Perna A, Loriga G, et al. Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. Lancet. 2005;365:939-46. 3. Wright JT Jr, Bakris G, Greene T, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288:2421-31. 4. Upadhyay A, Earley A, Haynes SM, et al. Systematic review: blood pressure target in chronic kidney disease and proteinuria as an effect modifier. Ann Intern Med. 2011;154:541-8. 5. Lv J, Ehteshami P, Sarnak MJ, et al. Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta-analysis. CMAJ. 2013;185:949-57.

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12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Jafar TH, Stark PC, Schmid CH, et al. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med. 2003;139:244-52. Lambers Heerspink HJ, Brantsma AH, de Zeeuw D, et al. Albuminuria assessed from first-morning-void urine samples versus 24-hour urine collections as a predictor of cardiovascular morbidity and mortality. Am J Epidemiol. 2008;168:897-905. Lambers Heerspink HJ, Gansevoort RT, Brenner BM, et al. Comparison of different measures of urinary protein excretion for prediction of renal events. J Am Soc Nephrol. 2010;21:1355-60. Contreras G, Greene T, Agodoa LY, et al. Blood pressure control, drug therapy, and kidney disease. Hypertension. 2005;46:44-50. Esnault VLM, Brown EA, Apetrei E, et al. The effects of amlodipine and enalapril on renal function in adults with hypertension and nondiabetic nephropathies: a 3-year, randomized, multicenter, double-blind, placebo-controlled study. Clin Ther. 2008;30:482-98. Marin R, Ruilope LM, Aljama P, et al. A random comparison of fosinopril and nifedipine GITS in patients with primary renal disease. J Hypertens. 2001;19:1871-6. Giatras I, Lau J, Levey AS. Effect of angiotensin-converting enzyme inhibitors on the progression of nondiabetic renal disease: a meta-analysis of randomized trials. Angiotensin-Converting-Enzyme Inhibition and Progressive Renal Disease Study Group. Ann Intern Med. 1997;127:337-45. Reboussin DM, Allen NB, Griswold ME, et al. Systematic review for the 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. Circulation. 2017. In press. Muntner P, Anderson A, Charleston J, et al. Hypertension awareness, treatment, and control in adults with CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis. 2010;55:441-51. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507-20. National Clinical Guideline Centre (UK). Chronic Kidney Disease (Partial Update): Early Identification and Management of Chronic Kidney Disease in Adults in Primary and Secondary Care. London, UK: National Institute for Health and Care Excellence (UK); 2014. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. KDIGO clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int Suppl (2011). 2012;2(5):337-414. Kanno A, Metoki H, Kikuya M, et al. Usefulness of assessing masked and white-coat hypertension by ambulatory blood pressure monitoring for determining prevalent risk of chronic kidney disease: the Ohasama study. Hypertens Res. 2010;33:1192-8. Terawaki H, Metoki H, Nakayama M, et al. Masked hypertension determined by self-measured blood pressure at home and chronic kidney disease in the Japanese general population: the Ohasama study. Hypertens Res. 2008;31:2129-35. Minutolo R, Gabbai FB, Agarwal R, et al. Assessment of achieved clinic and ambulatory blood pressure recordings and outcomes during treatment in hypertensive patients with CKD: a multicenter prospective cohort study. Am J Kidney Dis. 2014;64:744-52. Drawz PE, Alper AB, Anderson AH, et al. Masked hypertension and elevated nighttime blood pressure in CKD: prevalence and association with target organ damage. Clin J Am Soc Nephrol. 2016;11:642-52. Agarwal R, Andersen MJ. Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease. Kidney Int. 2006;69:1175-80. Navaneethan SD, Schold JD, Arrigain S, et al. Cause-specific deaths in non-dialysis-dependent CKD. J Am Soc Nephrol. 2015;26:2512-20. Matsushita K, van der Velde M, Astor BC, et al. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Chronic Kidney Disease Prognosis Consortium. Lancet. 2010;375:2073-81.

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26. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. SPRINT Research Group. N Engl J Med. 2015;373:2103-16. 27. Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. ACCORD Study Group. N Engl J Med. 2010;362:1575-85. 28. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S49-73. 29. Kovesdy CP, Alrifai A, Gosmanova EO, et al. Age and outcomes associated with BP in patients with incident CKD. Clin J Am Soc Nephrol. 2016;11:821-31. 30. Weiss JW, Peters D, Yang X, et al. Systolic BP and mortality in older adults with CKD. Clin J Am Soc Nephrol. 2015;10:1553-9. 31. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA. 2016;315:2673-82. 32. Holtkamp FA, de Zeeuw D, Thomas MC, et al. An acute fall in estimated glomerular filtration rate during treatment with losartan predicts a slower decrease in long-term renal function. Kidney Int. 2011;80:282-7. 33. Hricik DE, Browning PJ, Kopelman R, et al. Captopril-induced functional renal insufficiency in patients with bilateral renal-artery stenoses or renal-artery stenosis in a solitary kidney. N Engl J Med. 1983;308:373-6. 34. Pfeffer MA, McMurray JJV, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med. 2003;349:1893-906. 35. Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. ONTARGET Investigators. N Engl J Med. 2008;358:1547-59. 36. Fried LF, Emanuele N, Zhang JH, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013;369:1892-903. 37. Parving H-H, Brenner BM, McMurray JJV, et al. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. N Engl J Med. 2012;367:2204-13. 38. Peterson JC, Adler S, Burkart JM, et al. Blood pressure control, proteinuria, and the progression of renal disease. The Modification of Diet in Renal Disease Study. Ann Intern Med. 1995;123:754-62. 39. Appel LJ, Wright JT Jr, Greene T, et al. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med. 2010;363:918-29. 40. Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957-67. 41. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels--updated overview and meta-analyses of randomized trials. J Hypertens. 2016;34:613-22. 42. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387:435-43. 43. Ninomiya T, Perkovic V, Turnbull F, et al. Blood pressure lowering and major cardiovascular events in people with and without chronic kidney disease: meta-analysis of randomised controlled trials. BMJ. 2013;347:f5680.

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9.3.1. Hypertension After Renal Transplantation Recommendations for Treatment of Hypertension After Renal Transplantation

References that support recommendations are summarized in Online Data Supplements 39 and 40. COR LOE Recommendations SBP: 1. After kidney transplantation, it is reasonable to treat patients with B-NR hypertension to a BP goal of less than 130/80 mm Hg (1). IIa DBP: C-EO 2. After kidney transplantation, it is reasonable to treat patients with IIa B-R hypertension with a calcium antagonist on the basis of improved GFR and kidney survival (2). Synopsis Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

After kidney transplantation, hypertension is common because of preexisting kidney disease, the effects of immunosuppressive medications, and the presence of allograft pathology (3). Transplant recipients frequently harbor multiple CVD risk factors and are at high risk of CVD events. Hypertension may accelerate target organ damage and kidney function decline, particularly when proteinuria is present (4-6). Use of calcineurin inhibitor–based immunosuppression regimens after transplantation is associated with a high (70% to 90%) prevalence of hypertension (7). Hypertension is less common when calcineurin inhibitors have been used without corticosteroids in liver transplantation patients (8), although prevalence rates have not differed in steroid minimization trials after kidney transplantation (9, 10). Reports from longterm belatacept-based immunosuppression studies indicate higher GFR and preservation of kidney function. However, hypertension was still present in the majority of patients, although fewer agents were needed to achieve BP goals (11). Severity of hypertension and intensity of treatment may differ somewhat depending on the type of organ transplanted; however, most concepts relevant to kidney transplant recipients will apply to the other solid organ recipients as well. BP targets change over time after transplantation. Initially, it is important to maintain ample organ perfusion with less stringent BP targets (<160/90 mm Hg) to avoid hypotension and risk of graft thrombosis. Beyond the first month, BP should be controlled to prevent target organ damage as in the nontransplantation setting (12, 13). Hypertension after transplantation is often associated with altered circadian BP rhythm with loss of the normal nocturnal BP fall (14, 15) and, in some, a nocturnal BP rise. These changes may return to normal after a longer period of follow-up (16). Recommendation-Specific Supportive Text 1. Although treatment targets for hypertension after transplantation should probably be similar to those for other patients with CKD, there are no trials in post-transplantation patients comparing different BP targets. As kidney transplant recipients generally have a single functioning kidney and CKD, BP targets should be similar to those for the general CKD population. 2. Limited studies have compared drug choice for initial antihypertensive therapy in patients after kidney transplantation. On the basis of a Cochrane analysis (2), most studies favor CCBs to reduce graft loss and maintain higher GFR, with some evidence suggesting potential harm from ACE inhibitors because of anemia, hyperkalemia, and lower GFR. In recognition of this concern, RAS inhibitors may be reserved for the subset of patients with hypertension and additional comorbidities that support the need for ACE inhibitor therapy (i.e., proteinuria or HF after transplantation). With appropriate potassium and creatinine monitoring, this has been demonstrated to be safe (17).

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References 1. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. SPRINT Research Group. N Engl J Med. 2015;373:2103-16. 2. Cross NB, Webster AC, Masson P, et al. Antihypertensive treatment for kidney transplant recipients. Cochrane Database Syst Rev. 2009;CD003598. 3. Cosio FG, Pelletier RP, Pesavento TE, et al. Elevated blood pressure predicts the risk of acute rejection in renal allograft recipients. Kidney Int. 2001;59:1158-64. 4. Peschke B, Scheuermann EH, Geiger H, et al. Hypertension is associated with hyperlipidemia, coronary heart disease and chronic graft failure in kidney transplant recipients. Clin Nephrol. 1999;51:290-5. 5. Mange KC, Cizman B, Joffe M, et al. Arterial hypertension and renal allograft survival. JAMA. 2000;283:633-8. 6. Mange KC, Feldman HI, Joffe MM, et al. Blood pressure and the survival of renal allografts from living donors. J Am Soc Nephrol. 2004;15:187-93. 7. Taler SJ, Textor SC, Canzanello VJ, et al. Cyclosporin-induced hypertension: incidence, pathogenesis and management. Drug Saf. 1999;20:437-49. 8. Taler SJ, Textor SC, Canzanello VJ, et al. Role of steroid dose in hypertension early after liver transplantation with tacrolimus (FK506) and cyclosporine. Transplantation. 1996;62:1588-92. 9. Woodle ES, First MR, Pirsch J, et al. A prospective, randomized, double-blind, placebo-controlled multicenter trial comparing early (7 day) corticosteroid cessation versus long-term, low-dose corticosteroid therapy. Ann Surg. 2008;248:564-77. 10. Vincenti F, Schena FP, Paraskevas S, et al. A randomized, multicenter study of steroid avoidance, early steroid withdrawal or standard steroid therapy in kidney transplant recipients. Am J Transplant. 2008;8:307-16. 11. Rostaing L, Vincenti F, Grinyo J, et al. Long-term belatacept exposure maintains efficacy and safety at 5 years: results from the long-term extension of the BENEFIT study. Am J Transplant. 2013;13:2875-83. 12. Opelz G, Dohler B, Collaborative Transplant Study. Improved long-term outcomes after renal transplantation associated with blood pressure control. Am J Transplant. 2005;5:2725-31. 13. Hillebrand U, Suwelack BM, Loley K, et al. Blood pressure, antihypertensive treatment, and graft survival in kidney transplant patients. Transpl Int. 2009;22:1073-80. 14. Wadei HM, Amer H, Taler SJ, et al. Diurnal blood pressure changes one year after kidney transplantation: relationship to allograft function, histology, and resistive index. J Am Soc Nephrol.. 2007;18:1607-15. 15. Ambrosi P, Kreitmann B, Habib G. Home blood pressure monitoring in heart transplant recipients: comparison with ambulatory blood pressure monitoring. Transplantation. 2014;97:363-7. 16. Haydar AA, Covic A, Jayawardene S, et al. Insights from ambulatory blood pressure monitoring: diagnosis of hypertension and diurnal blood pressure in renal transplant recipients. Transplantation. 2004;77:849-53. 17. Jennings DL, Taber DJ. Use of renin-angiotensin-aldosterone system inhibitors within the first eight to twelve weeks after renal transplantation. Ann Pharmacother. 2008;42:116-20.

9.4. Cerebrovascular Disease Stroke is a leading cause of death, disability, and dementia (1). Because of its heterogeneous causes and hemodynamic consequences, the management of BP in adults with stroke is complex and challenging (2). To accommodate the variety of important issues pertaining to BP management in the stroke patient, treatment recommendations require recognition of stroke acuity, stroke type, and therapeutic objectives. Future studies should target more narrowly defined questions, such as optimal BP-reduction timing and target, as well as ideal antihypertensive agent therapeutic class by patient type and event type. References 1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics--2017 update: a report from the American Heart Association. Circulation. 2017;135:e146-603. 2. Boan AD, Lackland DT, Ovbiagele B. Lowering of blood pressure for recurrent stroke prevention. Stroke. 2014;45:2506-13.

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9.4.1. Acute Intracerebral Hemorrhage Recommendations for Management of Hypertension in Patients With Acute Intracerebral Hemorrhage (ICH)

References that support recommendations are summarized in Online Data Supplement 41. COR LOE Recommendations 1. In adults with ICH who present with SBP greater than 220 mm Hg, it is IIa C-EO reasonable to use continuous intravenous drug infusion (Table 19) and close BP monitoring to lower SBP. 2. Immediate lowering of SBP (Table 19) to less than 140 mm Hg in adults with III: spontaneous ICH who present within 6 hours of the acute event and have A Harm an SBP between 150 mm Hg and 220 mm Hg is not of benefit to reduce death or severe disability and can be potentially harmful (1, 2).

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Synopsis Spontaneous, nontraumatic ICH is a significant global cause of morbidity and mortality (3). Elevated BP is highly prevalent in the setting of acute ICH and is linked to greater hematoma expansion, neurological worsening, and death and dependency after ICH. Figure 7 is an algorithm on management of hypertension in patients with acute ICH. Recommendation-Specific Supportive Text 1. Information about the safety and effectiveness of early intensive BP-lowering treatment is least well established for patients with markedly elevated BP (sustained SBP >220 mm Hg) on presentation, patients with large and severe ICH, or patients requiring surgical decompression. However, given the consistent nature of the data linking high BP with poor clinical outcomes (4-6) and some suggestive data for treatment in patients with modestly high initial SBP levels (1, 7), early lowering of SBP in ICH patients with markedly high SBP levels (>220 mm Hg) might be sensible. A secondary endpoint in 1 RCT and an overview of data from 4 RCTs indicate that intensive BP reduction, versus BP-lowering guideline treatment, is associated with greater functional recovery at 3 months (1, 7). 2. RCT data have suggested that immediate BP lowering (to <140/90 mm Hg) within 6 hours of an acute ICH was feasible and safe (1, 8, 9), may be linked to greater attenuation of absolute hematoma growth at 24 hours (7), and might be associated with modestly better functional recovery in survivors (1, 7). However, a recent RCT (2) that examined immediate BP lowering within 4.5 hours of an acute ICH found that treatment to achieve a target SBP of 110 to 139 mm Hg did not lead to a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg. Moreover, there were significantly more renal adverse events within 7 days after randomization in the intensive-treatment group than in the standard-treatment group (2). Put together, neither of the 2 key trials (1, 2) evaluating the effect of lowering SBP in the acute period after spontaneous ICH met their primary outcomes of reducing death and severe disability at 3 months.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 7. Management of Hypertension in Patients With Acute ICH Acute (<6 h from symptom onset) spontaneous ICH

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SBP 150–220 mm Hg

SBP >220 mm Hg

SBP lowering to <140 mm Hg (Class III:Harm)

SBP lowering with continuous IV infusion and close BP monitoring (Class IIa)

Colors correspond to Class of Recommendation in Table 1. BP indicates blood pressure; ICH, intracerebral hemorrhage; IV, intravenous; and SBP, systolic blood pressure. References 1. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355-65. 2. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375:1033-43. 3. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics--2017 update: a report from the American Heart Association. Circulation. 2017;135:e146-603. 4. Zhang Y, Reilly KH, Tong W, et al. Blood pressure and clinical outcome among patients with acute stroke in Inner Mongolia, China J Hypertens. 2008;26:1446-52. 5. Rodriguez-Luna D, Pineiro S, Rubiera M, et al. Impact of blood pressure changes and course on hematoma growth in acute intracerebral hemorrhage. Eur J Neurol. 2013;20:1277-83. 6. Sakamoto Y, Koga M, Yamagami H, et al. Systolic blood pressure after intravenous antihypertensive treatment and clinical outcomes in hyperacute intracerebral hemorrhage: the Stroke Acute Management With Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage Study. Stroke. 2013;44:1846-51. 7. Tsivgoulis G, Katsanos AH, Butcher KS, et al. Intensive blood pressure reduction in acute intracerebral hemorrhage: a meta-analysis. Neurology. 2014;83:1523-9. 8. Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) investigators. Antihypertensive treatment of acute cerebral hemorrhage. Crit Care Med. 2010;38:637-48. 9. Anderson CS, Huang Y, Wang JG, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 2008;7:391-9.

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9.4.2. Acute Ischemic Stroke Recommendations for Management of Hypertension in Patients With Acute Ischemic Stroke

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References that support recommendations are summarized in Online Data Supplement 42. COR LOE Recommendations 1. Adults with acute ischemic stroke and elevated BP who are eligible for treatment with intravenous tissue plasminogen activator should have their I B-NR BP slowly lowered to less than 185/110 mm Hg before thrombolytic therapy is initiated (1, 2). 2. In adults with an acute ischemic stroke, BP should be less than 185/110 mm Hg before administration of intravenous tissue plasminogen activator and I B-NR should be maintained below 180/105 mm Hg for at least the first 24 hours after initiating drug therapy (3). 3. Starting or restarting antihypertensive therapy during hospitalization in patients with BP greater than 140/90 mm Hg who are neurologically stable IIa B-NR is safe and reasonable to improve long-term BP control, unless contraindicated (4, 5). 4. In patients with BP of 220/120 mm Hg or higher who did not receive intravenous alteplase or endovascular treatment and have no comorbid conditions requiring acute antihypertensive treatment, the benefit of IIb C-EO initiating or reinitiating treatment of hypertension within the first 48 to 72 hours is uncertain. It might be reasonable to lower BP by 15% during the first 24 hours after onset of stroke. 5. In patients with BP less than 220/120 mm Hg who did not receive intravenous thrombolysis or endovascular treatment and do not have a III: No comorbid condition requiring acute antihypertensive treatment, initiating A Benefit or reinitiating treatment of hypertension within the first 48 to 72 hours after an acute ischemic stroke is not effective to prevent death or dependency (49). Synopsis Elevated BP is common during acute ischemic stroke (occurring in up to 80% of patients), especially among patients with a history of hypertension (10). However, BP often decreases spontaneously during the acute phase of ischemic stroke, as soon as 90 minutes after the onset of symptoms. Countervailing theoretical concerns about arterial hypertension during acute ischemic stroke include aiming to enhance cerebral perfusion of the ischemic tissue while minimizing the exacerbation of brain edema and hemorrhagic transformation of the ischemic tissue (11, 12). Some studies have shown a U-shaped relationship between the admission BP and favorable clinical outcomes, with an optimal SBP and DBP ranging from 121 to 200 mm Hg and 81 to 110 mm Hg, respectively (13). It is conceivable that an optimal arterial BP range exists during acute ischemic stroke on an individual basis, contingent on the ischemic stroke subtype and other patient-specific comorbidities. Early initiation or resumption of antihypertensive treatment after acute ischemic stroke is indicated only in specific situations: 1) patients treated with tissue-type plasminogen activator (1, 2), and 2) patients with SBP >220 mm Hg or DBP >120 mm Hg. For the latter group, it should be kept in mind that cerebral autoregulation in the ischemic penumbra of the stroke is grossly abnormal and that systemic perfusion pressure is needed for blood flow and oxygen delivery. Rapid reduction of BP, even to lower levels within the hypertensive range, can be detrimental. For all other acute ischemic stroke patients, the advantage of lowering BP early to reduce death and dependency is uncertain (4-9), but restarting antihypertensive therapy

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline to improve long-term BP control is reasonable after the first 24 hours for patients who have preexisting hypertension and are neurologically stable (4, 5, 14, ). Figure 8 is an algorithm on management of hypertension in patients with acute ischemic stroke. Recommendation-Specific Supportive Text 1. These BP cutoffs correspond to study inclusion criteria in pivotal clinical trials of intravenous thrombolysis for acute ischemic stroke (1). 2. In a large observational study of patients with acute ischemic stroke who received intravenous tissue-type plasminogen activator, high BP during the initial 24 hours was linked to greater risk of symptomatic ICH (3). 3. For the goal of antihypertensive therapy, see Section 8.1.5.

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4. Extreme arterial hypertension is detrimental because it can lead to encephalopathy, cardiac compromise, and renal damage. However, hypotension, especially when too rapidly achieved, is potentially harmful because it abruptly reduces perfusion to multiple organs, including the brain. 5. Data from 2 RCTs (5, 9), as well as systematic reviews and meta-analyses (6-8), indicate that antihypertensive agents reduce BP during the acute phase of an ischemic stroke but do not confer benefit with regard to short- and long-term dependency and mortality rate. One RCT did not demonstrate a benefit of continuing prestroke antihypertensive drugs during the first few days after an acute stroke, but it was substantially underpowered to answer the question (4).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 8. Management of Hypertension in Patients With Acute Ischemic Stroke Acute (<72 h from symptom onset) ischemic stroke and elevated BP

Patient qualifies for IV thrombolysis therapy

Yes

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Lower SBP to <185 mm Hg and DBP <110 mm Hg before initiation of IV thrombolysis (Class I)

No

BP ≤220/110 mm Hg

BP >220/110 mm Hg

Initiating or reinitiating treatment of hypertension within the first 48-72 hours after an acute ischemic stroke is ineffective to prevent death or dependency (Class III: No Benefit)

Lower BP 15% during first 24 h (Class IIb)

And

Maintain BP <180/105 mm Hg for first 24 h after IV thrombosis (Class I)

For preexisting hypertension, reinitiate antihypertensive drugs after neurological stability (Class IIa)

Colors correspond to Class of Recommendation in Table 1. BP indicates blood pressure; DBP, diastolic blood pressure; IV, intravenous; and SBP, systolic blood pressure. References 1. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-7. 2. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317-29. 3. Ahmed N, Wahlgren N, Brainin M, et al. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Stroke. 2009;40:2442-9. 4. Robinson TG, Potter JF, Ford GA, et al. Effects of antihypertensive treatment after acute stroke in the Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS): a prospective, randomised, open, blindedendpoint trial. Lancet Neurol. 2010;9:767-75. 5. He J, Zhang Y, Xu T, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA. 2014;311:479-89. 6. Wang H, Tang Y, Rong X, et al. Effects of early blood pressure lowering on early and long-term outcomes after acute stroke: an updated meta-analysis. PLoS ONE. 2014;9:e97917.

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14.

Zhao R, Liu F-D, Wang S, et al. Blood pressure reduction in the acute phase of an ischemic stroke does not improve short- or long-term dependency or mortality: a meta-analysis of current literature. Medicine (Baltimore). 2015;94:e896. Bath PM, Krishnan K. Interventions for deliberately altering blood pressure in acute stroke. Cochrane Database Syst Rev. 2014;10:CD000039. Sandset EC, Bath PMW, Boysen G, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet. 2011;377:741-50. Qureshi AI, Ezzeddine MA, Nasar A, et al. Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25:32-8. Leonardi-Bee J, Bath PM, Phillips SJ, et al. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke. 2002;33:1315-20. Castillo J, Leira R, Garcia MM, et al. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004;35:520-6. Vemmos KN, Tsivgoulis G, Spengos K, et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J Intern Med. 2004;255:257-65. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947.

9.4.3. Secondary Stroke Prevention Recommendations for Treatment of Hypertension for Secondary Stroke Prevention

References that support recommendations are summarized in Online Data Supplements 43 and 44. COR LOE Recommendations 1. Adults with previously treated hypertension who experience a stroke or transient ischemic attack (TIA) should be restarted on antihypertensive I A treatment after the first few days of the index event to reduce the risk of recurrent stroke and other vascular events (1-3). 2. For adults who experience a stroke or TIA, treatment with a thiazide I A diuretic, ACE inhibitor, or ARB, or combination treatment consisting of a thiazide diuretic plus ACE inhibitor, is useful (1, 3-5). 3. Adults not previously treated for hypertension who experience a stroke or TIA and have an established BP of 140/90 mm Hg or higher should be I B-R prescribed antihypertensive treatment a few days after the index event to reduce the risk of recurrent stroke and other vascular events (1-3). 4. For adults who experience a stroke or TIA, selection of specific drugs should I B-NR be individualized on the basis of patient comorbidities and agent pharmacological class (6). 5. For adults who experience a stroke or TIA, a BP goal of less than 130/80 mm IIb B-R Hg may be reasonable (6, 7). 6. For adults with a lacunar stroke, a target SBP goal of less than 130 mm Hg IIb B-R may be reasonable (8). 7. In adults previously untreated for hypertension who experience an ischemic stroke or TIA and have a SBP less than 140 mm Hg and a DBP less than 90 IIb C-LD mm Hg, the usefulness of initiating antihypertensive treatment is not well established (9). Synopsis Each year in the United States, >750,000 adult patients experience a stroke, of which up to 25% are recurrent strokes (10). For an individual who experiences an initial stroke or TIA, the annual risk of a subsequent or

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“secondary” stroke is approximately 4% (11), and the case mortality rate is 41% after a recurrent stroke versus 22% after an initial stroke (12). Among patients with a recent stroke or TIA, the prevalence of premorbid hypertension is approximately 70% (13). Risk of recurrent stroke is heightened by presence of elevated BP, and guideline-recommended antihypertensive drug treatment to lower BP has been linked to a reduction in 1-year recurrent stroke risk (14). RCT meta-analyses show an approximately 30% decrease in recurrent stroke risk with BP-lowering therapies (1-3). An issue frequently raised by clinicians is whether the presence of clinically asymptomatic cerebral infarction incidentally noted on brain imaging (computed tomography or MRI scan) in patients without a history of or symptoms of a stroke or TIA warrants implementation of secondary stroke prevention measures. Clinically asymptomatic vascular brain injury is increasingly being considered as an entry point for secondary stroke prevention therapies, because these apparently “silent” brain infarctions are associated with typical stroke risk factors, accumulatively lead to subtle neurological impairments, and bolster risk of future symptomatic stroke events (15). Although the evidence for using antihypertensive treatment to prevent recurrent stroke in stroke patients with elevated BP is compelling (1-3), questions remain about when precisely after an index stroke to initiate it, what specific agent(s) to use (if any), which therapeutic targets to aim for, and whether the treatment approach should vary by index stroke mechanism and baseline level of BP (16). Figure 9 is an algorithm on management of hypertension in patients with a previous history of stroke (secondary stroke prevention). Recommendation-Specific Supportive Text 1. Two overviews of RCTs published through 2009 showed that antihypertensive medications lowered the risk of recurrent vascular events in patients with stroke or TIA (1-3). 2. Specific agents that have shown benefit in either dedicated RCTs or systematic reviews of RCT data include diuretics, ACE inhibitors, and ARBs. 3. Support for this recommendation is based on data from 2 dedicated RCTs, as well as a systematic review and meta-analysis, among patients with a history of stroke or TIA (1-3). 4. Reduction in BP appears to be more important than the choice of specific agents used to achieve this goal. Thus, if diuretic and ACE inhibitor or ARB treatment do not achieve BP target, other agents, such as CCB and/or mineralocorticoid receptor antagonist, may be added. 5. An overview of RCTs showed that larger reductions in SBP tended to be associated with greater reduction in risk of recurrent stroke. However, a separate overview of RCTs in patients who experienced a stroke noted that achieving an SBP level <130 mm Hg was not associated with a lower stroke risk, and several observational studies did not show benefit with achieved SBP levels <120 mm Hg (5). 6. Patients with a lacunar stroke treated to an SBP target of <130 mm Hg versus 130 to 140 mm Hg may be less likely to experience a future ICH. 7. No published RCTs have specifically addressed this question, but a post hoc analysis of an RCT suggests that the effectiveness of antihypertensive treatment for secondary stroke prevention diminishes as initial baseline BP declines (9).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 9. Management of Hypertension in Patients With a Previous History of Stroke (Secondary Stroke Prevention) Stroke ≥72 h from symptom onset and stable neurological status or TIA

Previous diagnosed or treated hypertension

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Restart antihypertensive treatment (Class I) Aim for BP <140/90 mm Hg (Class IIb)

No

Established SBP ≥140 mm Hg or DBP ≥90 mm Hg

Established SBP <140 mm Hg and DBP <90 mm Hg

Initiate antihypertensive treatment (Class I)

Usefulness of starting antihypertensive treatment is not well established (Class IIb)

Aim for BP <130/80 mm Hg (Class IIb)

Colors correspond to Class of Recommendation in Table 1. DBP indicates diastolic blood pressure; SBP, systolic blood pressure; and TIA, transient ischemic attack. References 1. Liu L, Wang Z, Gong L, et al. Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature. Hypertens Res. 2009;32:1032-40. 2. Lakhan SE, Sapko MT. Blood pressure lowering treatment for preventing stroke recurrence: a systematic review and meta-analysis. Int Arch Med. 2009;2:30. 3. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033-41. 4. PATS Collaborating Group. Post-stroke antihypertensive treatment study. A preliminary result. Chin Med J. 1995;108:710-7. 5. Lee M, Saver JL, Hong K-S, et al. Renin-angiotensin system modulators modestly reduce vascular risk in persons with prior stroke. Stroke. 2012;43:113-9. 6. Wang W-T, You L-K, Chiang C-E, et al. Comparative effectiveness of blood pressure-lowering drugs in patients who have already suffered from stroke: traditional and Bayesian network meta-analysis of randomized trials. Medicine (Baltimore). 2016;95:e3302. 7. Katsanos AH, Filippatou A, Manios E, et al. Blood pressure reduction and secondary stroke prevention: a systematic review and metaregression analysis of randomized clinical trials. Hypertension. 2017;69:171-9.

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16.

Benavente OR, Coffey CS, Conwit R, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. SPS3 Study Group. Lancet. 2013;382:507-15. Arima H, Chalmers J, Woodward M, et al. Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial. J Hypertens. 2006;24:1201-8. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics--2017 update: a report from the American Heart Association. Circulation. 2017;135:e146-603. Dhamoon MS, Sciacca RR, Rundek T, et al. Recurrent stroke and cardiac risks after first ischemic stroke: the Northern Manhattan Study. Neurology. 2006;66:641-6. Hardie K, Hankey GJ, Jamrozik K, et al. Ten-year risk of first recurrent stroke and disability after first-ever stroke in the Perth Community Stroke Study. Stroke. 2004;35:731-5. Lovett JK, Coull AJ, Rothwell PM. Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Neurology. 2004;62:569-73. Toschke AM, Gulliford MC, Wolfe CDA, et al. Antihypertensive treatment after first stroke in primary care: results from the General Practitioner Research Database. J Hypertens. 2011;29:154-60. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:2160-236. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care. 2007;30:162-72.

9.5. Peripheral Arterial Disease Recommendation for Treatment of Hypertension in Patients With PAD

References that support the recommendation are summarized in Online Data Supplement 45. COR LOE Recommendation 1. Adults with hypertension and PAD should be treated similarly to patients I B-NR with hypertension without PAD (1-4). Synopsis Patients with PAD are at increased risk of CVD and stroke. Hypertension is a major risk factor for PAD, so these patients are commonly enrolled in trials of antihypertensive drug therapy. However, patients with PAD typically comprise a small fraction of participants, so in the few trials that report results in patients with PAD, subgroup analyses are generally underpowered. Recommendation-Specific Supportive Text 1. There is no major difference in the relative risk reduction in CVD from BP-lowering therapy between patients with hypertension and PAD and patients without PAD (1). There is also no evidence that any one class of antihypertensive medication or strategy is superior (2-4). In the INVEST (International Verapamil-Trandolapril) study, the beta blocker atenolol (with or without hydrochlorothiazide) was compared with the CCB verapamil (with or without perindopril). The study showed no significant difference in CVD outcomes between the 2 drug regimens in patients with and without PAD (3). No trials have reported the effects of a higher versus a lower BP goal in patients with PAD. In the 1 trial (ALLHAT) that reported the effects of different classes of BP medications on PAD as an outcome, there was no significant difference by medication class (5). References 1. Ostergren J, Sleight P, Dagenais G, et al. Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Eur Heart J. 2004;25:17-24. 2. Thompson AM, Hu T, Eshelbrenner CL, et al. Antihypertensive treatment and secondary prevention of cardiovascular disease events among persons without hypertension: a meta-analysis. JAMA. 2011;305:913-22.

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Bavry AA, Anderson RD, Gong Y, et al. Outcomes among hypertensive patients with concomitant peripheral and coronary artery disease: findings from the INternational VErapamil-SR/Trandolapril STudy. Hypertension 2010;55:48-53. Zanchetti A, Julius S, Kjeldsen S, et al. Outcomes in subgroups of hypertensive patients treated with regimens based on valsartan and amlodipine: an analysis of findings from the VALUE trial. J Hypertens. 2006;24:2163-8. Piller LB, Simpson LM, Baraniuk S, et al. Characteristics and long-term follow-up of participants with peripheral arterial disease during ALLHAT. J Gen Intern. Med. 2014;29:1475-83.

9.6. Diabetes Mellitus Recommendations for Treatment of Hypertension in Patients With DM

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References that support recommendations are summarized in Online Data Supplements 46 and 47 and Systematic Review Report. COR LOE Recommendations 1. In adults with DM and hypertension, antihypertensive drug treatment SBP: should be initiated at a BP of 130/80 mm Hg or higher with a treatment goal B-RSR I of less than 130/80 mm Hg (1-8). DBP: C-EO 2. In adults with DM and hypertension, all first-line classes of antihypertensive SR I A agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective (1, 9, 10). 3. In adults with DM and hypertension, ACE inhibitors or ARBs may be IIb B-NR considered in the presence of albuminuria (11, 12). SR indicates systematic review.

Synopsis Refer to the “Systematic Review for the 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” for the complete systematic evidence review for additional data and analyses (13). The prevalence of hypertension among adults with DM is approximately 80%, and hypertension is at least twice as common in persons with type 2 DM than in age-matched individuals without DM (14-16). The coexistence of hypertension and DM markedly increases the risk of developing CVD damage, resulting in a higher incidence of CHD, HF, PAD, stroke, and CVD mortality (17), and may increase risk of microvascular disease, such as nephropathy or retinopathy (16, 18). There is limited quality evidence to determine a precise BP target in adults with DM. No RCTs have explicitly 1) documented whether treatment to an SBP goal <140 mm Hg versus a higher goal improves clinical outcomes in adults with hypertension and DM or 2) directly evaluated clinical outcomes associated with SBP <130 mm Hg (2). However, 2 high-quality systematic reviews of RCTs support an SBP target of <140 mm Hg (4, 7). There is little or no available RCT evidence supporting a specific DBP threshold for initiation of pharmacological therapy. Several RCTs, including the HOT (Hypertension Optimal Treatment) trial, UKPDS (United Kingdom Prospective Diabetes Study), and ABCD (Appropriate Blood Pressure Control in Diabetes) trial (19-22), are often cited to support a lower DBP target (e.g., ≤85 or 80 mm Hg) for adults with hypertension and DM. However, these trials were conducted when the diagnostic criteria for DM were more conservative than they are currently (2 fasting glucose levels >140 mg/dL as opposed to 126 mm/dL today).

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1. We recommend ASCVD risk assessment in all adults with hypertension, including adults with DM. As a matter of convenience, however, it can be assumed that the vast majority of adults with DM have a 10-year ASCVD risk ≥ 10%, placing them in the high risk category that requires initiation of antihypertensive drug therapy at BP ≥ 130/80 mm Hg (see Section 8.1.2, Figure 4 and Table 23 for BP thresholds for initiating antihypertensive drug treatment). The ACCORD trial (5), which compared CVD outcomes in adults with DM and hypertension who were randomized to an SBP target of <140 mm Hg (standard therapy) or <120 mm Hg (intensive therapy), did not document a significant reduction in the primary outcome (CVD composite) with the lower BP goal, but the trial was underpowered to detect a statistically significant difference between the 2 treatment arms. The ACCORD trial demonstrated a small reduction in absolute risk (1.1%) for stroke, but there were few such events. More adverse events (2% increase in absolute risk) were identified in the lower BP group, especially self-reported hypotension and a reduction in estimated GFR, but these did not result in an excess of stroke or ESRD. The ACCORD trial was a factorial study; secondary analysis demonstrated a significant outcome benefit in the intensive BP/standard glycemic group (3), but benefit in the intensive BP/intensive glycemic control group was no better than in the intensive BP/standard glycemic control group, which suggests a floor benefit beyond which the combined intensive interventions were ineffective (5). An ACCORD secondary analysis suggested that an SBP <120 mm Hg is superior to standard BP control in reducing LVH (6). A meta-analysis of 73,913 patients with DM reported that an SBP <130 mm Hg reduced stroke by 39%. However, there was no significant risk reduction for MI (23). Two meta-analyses addressing target BP in adults with DM restricted the analysis to RCTs that randomized patients to different BP levels (4, 7). Target BP of 133/76 mm Hg provided significant benefit compared with that of 140/81 mm Hg for major cardiovascular events, MI, stroke, albuminuria, and retinopathy progression (4). Several meta-analyses of RCTs included all trials with a difference in BP (24, 25), but 2 restricted their analyses to trials in which participants were randomized to different BP target levels (4, 7). SPRINT demonstrated cardiovascular benefit from intensive treatment of BP to a goal of <120 mm Hg as compared with <140 mm Hg but did not include patients with DM. However, the results of ACCORD and SPRINT were generally consistent (26). In addition, a SPRINT substudy demonstrated that patients with prediabetes derived a benefit similar to that of patients with normoglycemia (8). Previous trials have shown similar quantitative benefits from lowering BP in persons with and without DM (9). 2. BP control is more difficult to achieve in patients with DM than in those without DM, necessitating use of combination therapy in the majority of patients (27). All major antihypertensive drug classes (i.e., ACE inhibitors, ARBs, CCBs, and diuretics) are useful in the treatment of hypertension in DM (1, 9). However, in ALLHAT, doxazosin was clearly inferior to chlorthalidone, which also reduced some events more than amlodipine or lisinopril (28). 3. ACE inhibitors and ARBs have the best efficacy among the drug classes on urinary albumin excretion (12) (see Section 9.3). Therefore, an ACE inhibitor or ARB may be considered as part of the combination. A metaanalysis of RCTs of primary prevention of albuminuria in patients with DM demonstrated a significant reduction in progression of moderately to severely increased albuminuria with the use of ACE inhibitors or ARBs (11). References 1. Emdin CA, Rahimi K, Neal B, et al. Blood pressure lowering in type 2 diabetes: a systematic review and metaanalysis. JAMA. 2015;313:603-15. 2. Arguedas JA, Leiva V, Wright JM. Blood pressure targets for hypertension in people with diabetes mellitus. Cochrane Database Syst Rev. 2013;10:CD008277. 3. Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. ACCORD Study. N Engl J Med. 2010;362:1575-85.

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Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387:435-43. 5. Margolis KL, O'Connor PJ, Morgan TM, et al. Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial. Diabetes Care. 2014;37:1721-8. 6. Soliman EZ, Byington RP, Bigger JT, et al. Effect of intensive blood pressure lowering on left ventricular hypertrophy in patients with diabetes mellitus: Action to Control Cardiovascular Risk in Diabetes Blood Pressure Trial. Hypertension. 2015;66:1123-9. 7. Lv J, Ehteshami P, Sarnak MJ, et al. Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta-analysis. CMAJ. 2013;185:949-57. 8. Bress AP, King JB, Kreider KE, et al. Effect of intensive versus standard blood pressure treatment according to baseline prediabetes status: a post hoc analysis of a randomized trial. Diabetes Care. 2017;40:1401-8. 9. Turnbull F, Neal B, Algert C, et al. Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials. Arch Intern Med. 2005;165:1410-9. 10. Whelton PK, Barzilay J, Cushman WC, et al. Clinical outcomes in antihypertensive treatment of type 2 diabetes, impaired fasting glucose concentration, and normoglycemia: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2005;165:1401-9. 11. Palmer SC, Mavridis D, Navarese E, et al. Comparative efficacy and safety of blood pressure-lowering agents in adults with diabetes and kidney disease: a network meta-analysis. Lancet. 2015;385:2047-56. 12. Schmieder RE, Hilgers KF, Schlaich MP, et al. Renin-angiotensin system and cardiovascular risk. Lancet. 2007;369:1208-19. 13. Reboussin DM, Allen NB, Griswold ME, et al. Systematic review for the 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. Circulation. 2017. In press. 14. Kannel WB, Wilson PW, Zhang TJ. The epidemiology of impaired glucose tolerance and hypertension. Am Heart J. 1991;121:1268-73. 15. Tarnow L, Rossing P, Gall MA, et al. Prevalence of arterial hypertension in diabetic patients before and after the JNC-V. Diabetes Care. 1994;17:1247-51. 16. Adler AI, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ. 2000;321:412-9. 17. Stamler J, Vaccaro O, Neaton JD, et al. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993;16:434-44. 18. Do DV, Wang X, Vedula SS, et al. Blood pressure control for diabetic retinopathy. Cochrane Database Syst Rev. 2015;1:CD006127. 19. Estacio RO, Jeffers BW, Gifford N, et al. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care. 2000;23(suppl 2):B54-64. 20. Estacio RO, Jeffers BW, Hiatt WR, et al. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. N Engl J Med. 1998;338:645-52. 21. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-13. 22. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351:1755-62. 23. Reboldi G, Gentile G, Angeli F, et al. Effects of intensive blood pressure reduction on myocardial infarction and stroke in diabetes: a meta-analysis in 73,913 patients. J Hypertens. 2011;29:1253-69. 24. Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957-67. 25. Brunstrom M, Carlberg B. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses. BMJ. 2016;352:i717. 26. Perkovic V, Rodgers A. Redefining blood-pressure targets--SPRINT starts the marathon. N Engl J Med. 2015;373:2175-8.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 27. Mancia G, Schumacher H, Redon J, et al. Blood pressure targets recommended by guidelines and incidence of cardiovascular and renal events in the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET). Circulation. 2011;124:1727-36. 28. Wright JT Jr, Probstfield JL, Cushman WC, et al. ALLHAT findings revisited in the context of subsequent analyses, other trials, and meta-analyses. Arch Intern Med. 2009;169:832-42.

9.7. Metabolic Syndrome

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Metabolic syndrome is a state of metabolic dysregulation characterized by visceral fat accumulation, insulin resistance, hyperinsulinemia, and hyperlipidemia, as well as predisposition to type 2 DM, hypertension, and atherosclerotic CVD (1-3). According to data from the NHANES III and NHANES 1999–2006 (1, 4), the prevalence of metabolic syndrome in the United States was 34.2% in 2006 and has likely increased substantially since that time. The metabolic syndrome is linked to several other disorders, including nonalcoholic steatohepatitis, polycystic ovary syndrome, certain cancers, CKD, Alzheimer’s disease, Cushing’s syndrome, lipodystrophy, and hyperalimentation (5, 6). Lifestyle modification, with an emphasis on improving insulin sensitivity by means of dietary modification, weight reduction, and exercise, is the foundation of treatment of the metabolic syndrome. The optimal antihypertensive drug therapy for patients with hypertension in the setting of the metabolic syndrome has not been clearly defined (1). Although caution exists with regard to the use of thiazide diuretics in this population because of their ability to increase insulin resistance, dyslipidemia, and hyperuricemia and to accelerate conversion to overt DM, no data are currently available demonstrating deterioration in cardiovascular or renal outcomes in patients treated with these agents (1). Indeed, as shown in follow-up of ALLHAT, chlorthalidone use was associated with only a small increase in fasting glucose levels (1.5–4.0 mg/dL), and this increase did not translate into increased CVD risk at a later date (7-10). In addition, in post hoc analysis of the nearly two thirds of participants in ALLHAT that met criteria for the metabolic syndrome, chlorthalidone was unsurpassed in reducing CVD and renal outcomes compared with lisinopril, amlodipine, or doxazosin (9, 11). Similarly, high-dose ARB therapy reduces arterial stiffness in patients with hypertension with the metabolic syndrome, but no outcomes data are available from patients in which this form of treatment was used (12). Use of traditional beta blockers may lead to dyslipidemia or deterioration of glucose tolerance, and ability to lose weight (2). In several large clinical trials, the risk of developing DM as a result of traditional betablocker therapy was 15% to 29% (2). However, the newer vasodilating beta blockers (e.g., labetalol, carvedilol, nebivolol) have shown neutral or favorable effects on metabolic profiles compared with the traditional beta blockers (13). Trials using vasodilator beta blockers have not been performed to demonstrate effects on CVD outcomes. References 1. Lim S, Eckel RH. Pharmacological treatment and therapeutic perspectives of metabolic syndrome. Rev Endocr Metab Disord. 2014;15:329-41. 2. Owen JG, Reisin E. Anti-hypertensive drug treatment of patients with and the metabolic syndrome and obesity: a review of evidence, meta-analysis, post hoc and guidelines publications. Curr Hypertens Rep. 2015;17:558. 3. Ruderman NB, Shulman GI. Metabolic syndrome. In: Jameson JL, ed. Endocrinology: Adult & Pediatric. Philadelphia, PA: Elsevier Saunders; 2015:752-9. 4. Mozumdar A, Liguori G. Persistent increase of prevalence of metabolic syndrome among U.S. adults: NHANES III to NHANES 1999-2006. Diabetes Care. 2011;34:216-9. 5. Chen J, Muntner P, Hamm LL, et al. The metabolic syndrome and chronic kidney disease in U.S. adults. Ann Intern Med. 2004;140:167-74. 6. Chen J, Gu D, Chen C-S, et al. Association between the metabolic syndrome and chronic kidney disease in Chinese adults. Nephrol Dial Transplant. 2007;22:1100-6. 7. Barzilay JI, Davis BR, Whelton PK. The glycemic effects of antihypertensive medications. Curr Hypertens Rep. 2014;16:410.

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12. 13.

Kostis JB, Wilson AC, Freudenberger RS, et al. Long-term effect of diuretic-based therapy on fatal outcomes in subjects with isolated systolic hypertension with and without diabetes. Am J Cardiol. 2005;95:29-35. Wright JT Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2008;168:207-17. Wright JT Jr, Probstfield JL, Cushman WC, et al. ALLHAT findings revisited in the context of subsequent analyses, other trials, and meta-analyses. Arch Intern Med. 2009;169:832-42. Black HR, Davis B, Barzilay J, et al. Metabolic and clinical outcomes in nondiabetic individuals with the metabolic syndrome assigned to chlorthalidone, amlodipine, or lisinopril as initial treatment for hypertension: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Diabetes Care. 2008;31:353-60. Laurent S, Boutouyrie P, Vascular Mechanism Collaboration. Dose-dependent arterial destiffening and inward remodeling after olmesartan in hypertensives with metabolic syndrome. Hypertension. 2014;64:709-16. Reisin E, Owen J. Treatment: special conditions. Metabolic syndrome: obesity and the hypertension connection. J Am Soc Hypertens. 2015;9:156-9; quiz 160.

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9.8. Atrial Fibrillation Recommendation for Treatment of Hypertension in Patients With AF

References that support the recommendation are summarized in Online Data Supplement 48. COR LOE Recommendation 1. Treatment of hypertension with an ARB can be useful for prevention of IIa B-R recurrence of AF (1, 2). Synopsis AF and hypertension are common and often coexistent conditions, both of which increase in frequency with age. AF occurs in 3% to 4% of the population >65 years of age (3). Hypertension is present in more than 80% of patients with AF and is by far the most common comorbid condition, regardless of age (4). AF is associated with systemic thromboembolism, as recognized in the CHADS2 and CHA2DS2-VASc scoring systems for stroke risk (5). It is also associated with gradual worsening of ventricular function, the subsequent development of HF, and increased mortality. Hypertension has long been recognized as a risk factor for AF because it is associated with LVH, decreased diastolic function with impaired LV filling, rising left atrial pressures with left atrial hypertrophy and enlargement, increased atrial fibrosis, and slowing of intra-atrial and interatrial electrical conduction velocities. Such a distortion of atrial anatomy and physiology increases the incidence of AF (6). Left atrial pressure also increases with ischemic or valvular heart disease and myopathies that are often associated with systemic hypertension, potentially leading to AF. Although management of AF will continue to revolve around restoration of sinus rhythm when appropriate, rate control when it is not, and anticoagulation, control of hypertension is a key component of therapy (1, 2). Treatment of hypertension may prevent new-onset AF, especially in patients with LVH or LV dysfunction (1). Five RCTs have compared the value of antihypertensive agents for reduction of new-onset AF (7-11). One study suggested superiority of RAS blockade over a CCB (8), and another reported superiority of RAS blockade over a beta blocker that is no longer recommended for treatment of hypertension (9). In the largest trial, there was no difference in incident AF among adults with hypertension assigned to first-step therapy with a diuretic, ACE inhibitor, or CCB (10). In ALLHAT, the incidence of AF was 23% higher during firststep antihypertensive therapy with the alpha-receptor blocker doxazosin than with chlorthalidone. Furthermore, the occurrence of AF or atrial flutter during the study, either new onset or recurrent, was associated with an increase in mortality of nearly 2.5-fold (10).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Recommendation-Specific Supportive Text 1. Although RAS blockade in theory is the treatment of choice for hypertension in patients with prior AF, relative to other classes of agents, all of the trials that have shown clinical superiority of ARBs over other agents were comparisons with CCBs or beta blockers that are no longer recommended as first-line agents for treatment of hypertension (2). There are no available trials comparing ACE inhibitors with other drugs or any RAS-blocking agents with diuretics.

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References 1. Healey JS, Baranchuk A, Crystal E, et al. Prevention of atrial fibrillation with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: a meta-analysis. J Am Coll Cardiol. 2005;45:1832-9. 2. Zhao D, Wang Z-M, Wang L-S. Prevention of atrial fibrillation with renin-angiotensin system inhibitors on essential hypertensive patients: a meta-analysis of randomized controlled trials. J Biomed Res. 2015;29:475-85. 3. Kistler PM, Sanders P, Fynn SP, et al. Electrophysiologic and electroanatomic changes in the human atrium associated with age. J Am Coll Cardiol. 2004;44:109-16. 4. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014;130:e199-267. 5. Olesen JB, Torp-Pedersen C, Hansen ML, et al. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;107:1172-9. 6. Healey JS, Connolly SJ. Atrial fibrillation: hypertension as a causative agent, risk factor for complications, and potential therapeutic target. Am J Cardiol. 2003;91:9G-14G. 7. Hansson L, Lindholm LH, Ekbom T, et al. Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity. The Swedish Trial in Old Patients with Hypertension-2 study. Lancet. 1999;354:1751-6. 8. Julius S, Kjeldsen SE, Weber M, et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial. Lancet. 2004;363:2022-31. 9. Wachtell K, Lehto M, Gerdts E, et al. Angiotensin II receptor blockade reduces new-onset atrial fibrillation and subsequent stroke compared to atenolol: the Losartan Intervention For End Point Reduction in Hypertension (LIFE) study. J Am Coll Cardiol. 2005;45:712-9. 10. Haywood LJ, Ford CE, Crow RS, et al. Atrial fibrillation at baseline and during follow-up in ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). J Am Coll Cardiol. 2009;54:2023-31. 11. Hansson L, Lindholm LH, Niskanen L, et al. Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPPP) randomised trial. Lancet. 1999;353:611-6.

9.9. Valvular Heart Disease Recommendations for Treatment of Hypertension in Patients With Valvular Heart Disease

References that support recommendations are summarized in Online Data Supplements 49 and 50. COR LOE Recommendation 1. In adults with asymptomatic aortic stenosis, hypertension should be treated I B-NR with pharmacotherapy, starting at a low dose and gradually titrating upward as needed (1-4). 2. In patients with chronic aortic insufficiency, treatment of systolic IIa C-LD hypertension with agents that do not slow the heart rate (i.e., avoid beta blockers) is reasonable (5, 6).

Recommendation-Specific Supportive Text 1. Hypertension is a risk factor for the development of aortic stenosis (stage A [e.g., aortic sclerosis or bicuspid aortic valve]) and asymptomatic aortic stenosis (stage B [progressive asymptomatic aortic stenosis]). The

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline combination of hypertension and aortic stenosis, “2 resistors in series,” increases the rate of complications. In patients with asymptomatic mild-to-moderate aortic stenosis, hypertension has been associated with more abnormal LV structure and increased cardiovascular morbidity and mortality (1). There is no evidence that antihypertensive medications will produce an inordinate degree of hypotension in patients with aortic stenosis. Nitroprusside infusion in hypertensive patients with severe aortic stenosis lowers pulmonary and systemic resistance, with improvements in stroke volume and LV end-diastolic pressure (2). Thus, careful use of antihypertensive agents to achieve BP control in patients with hypertension and aortic stenosis is beneficial. Although there are no specific trials comparing various classes of antihypertensive agents, RAS blockade may be advantageous because of the potentially beneficial effects on LV fibrosis (3), control of hypertension, reduction of dyspnea, and improved effort tolerance (4). Diuretics should be used sparingly in patients with small LV chamber dimensions. Beta blockers may be appropriate for patients with aortic stenosis who have reduced ejection fraction, prior MI, arrhythmias, or angina pectoris. In patients with moderate or severe aortic stenosis, consultation or co-management with a cardiologist is preferred for hypertension management. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

2. Vasodilator therapy can reduce the LV volume and mass and improve LV performance in patients with aortic regurgitation (5), but improvement of long-term clinical outcomes, such as time to valve replacement, have been variable (5, 6). Beta blockers may result in increased diastolic filling period because of bradycardia, potentially causing increased aortic insufficiency. Marked reduction in DBP may lower coronary perfusion pressure in patients with chronic severe aortic regurgitation (stage B [progressive asymptomatic aortic regurgitation] and stage C [asymptomatic severe AR]). However, there are no outcomes data to support these theoretical concerns. References 1. Rieck ÅE, Cramariuc D, Boman K, et al. Hypertension in aortic stenosis: implications for left ventricular structure and cardiovascular events. Hypertension. 2012;60:90-7. 2. Eleid MF, Nishimura RA, Sorajja P, et al. Systemic hypertension in low-gradient severe aortic stenosis with preserved ejection fraction. Circulation. 2013;128:1349-53. 3. Bull S, Loudon M, Francis JM, et al. A prospective, double-blind, randomized controlled trial of the angiotensinconverting enzyme inhibitor Ramipril In Aortic Stenosis (RIAS trial). Eur Heart J Cardiovasc Imaging. 2015;16:83441. 4. Chockalingam A, Venkatesan S, Subramaniam T, et al. Safety and efficacy of angiotensin-converting enzyme inhibitors in symptomatic severe aortic stenosis: Symptomatic Cardiac Obstruction-Pilot Study of Enalapril in Aortic Stenosis (SCOPE-AS). Am Heart J. 2004;147:E19. 5. Scognamiglio R, Rahimtoola SH, Fasoli G, et al. Nifedipine in asymptomatic patients with severe aortic regurgitation and normal left ventricular function. N Engl J Med. 1994;331:689-94. 6. Evangelista A, Tornos P, Sambola A, et al. Long-term vasodilator therapy in patients with severe aortic regurgitation. N Engl J Med. 2005;353:1342-9.

9.10. Aortic Disease Recommendation for Management of Hypertension in Patients With Aortic Disease

COR

LOE

I

C-EO

Recommendation 1. Beta blockers are recommended as the preferred antihypertensive agents in patients with hypertension and thoracic aortic disease (1, 2).

Synopsis Thoracic aortic aneurysms are generally asymptomatic until a person presents with a sudden catastrophic event, such as an aortic dissection or rupture, which is rapidly fatal in the majority of patients (3, 4). The rationale for antihypertensive therapy is based largely on animal and observational studies associating hypertension with aortic dissection (5, 6). RCTs specifically addressing hypertension and aortic disease are not available, and trials in patients with primary hypertension do not provide insight on either the optimal BP Page 122

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline target or choice of antihypertensive drug therapy in patients with thoracic aortic aneurysm, aortic dissection, or aortic disease (7, 8). A study in 20 humans with hypertension suggested that hypertension is associated with significant changes in the mechanical properties of the aortic wall, with more strain-induced stiffening in hypertension than in normotension, which may reflect destruction of elastin and predisposition to aortic dissection in the presence of hypertension (9). In a retrospective observational study, high BP variability was an independent risk factor for the prognosis of aortic dissection (10). Recommendations for treatment of acute aortic dissection are provided in Section 11.2. Recommendation-Specific Supportive Text 1. In patients with chronic aortic dissection, observational studies suggest lower risk for operative repair with beta-blocker therapy (1). In a series of patients with type A and type B aortic dissections, beta blockers were associated with improved survival in both groups, whereas ACE inhibitors did not improve survival (2).

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References 1. Genoni M, Paul M, Jenni R, et al. Chronic beta-blocker therapy improves outcome and reduces treatment costs in chronic type B aortic dissection. Eur J Cardiothorac Surg. 2001;19:606-10. 2. Suzuki T, Isselbacher EM, Nienaber CA, et al. Type-selective benefits of medications in treatment of acute aortic dissection (from the International Registry of Acute Aortic Dissection [IRAD]). Am J Cardiol. 2012;109:122-7. 3. Masuda Y, Yamada Z, Morooka N, et al. Prognosis of patients with medically treated aortic dissections. Circulation. 1991;84:III7-13. 4. Rampoldi V, Trimarchi S, Eagle KA, et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Ann Thorac Surg. 2007;83:55-61. 5. Suzuki T, Mehta RH, Ince H, et al. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD). Circulation. 2003;108(suppl 1):II312-7. 6. Mehta RH, O'Gara PT, Bossone E, et al. Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol. 2002;40:685-92. 7. Chan KK, Lai P, Wright JM. First-line beta-blockers versus other antihypertensive medications for chronic type B aortic dissection. Cochrane Database Syst Rev. 2014;2:CD010426. 8. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266-369. 9. Gaddum NR, Keehn L, Guilcher A, et al. Altered dependence of aortic pulse wave velocity on transmural pressure in hypertension revealing structural change in the aortic wall. Hypertension. 2015;65:362-9. 10. Zhang L, Tian W, Feng R, et al. Prognostic impact of blood pressure variability on aortic dissection patients after endovascular therapy. Medicine (Baltimore). 2015;94:e1591.

10. Special Patient Groups Special attention is needed for specific patient subgroups.

10.1. Race and Ethnicity In the United States, at any decade of life, blacks have a higher prevalence of hypertension than that of Hispanic Americans, whites, Native Americans, and other subgroups defined by race and ethnicity (see Section 3.3). Hypertension control rates are lower for blacks, Hispanic Americans, and Asian Americans than for whites (1). Among men with hypertension, non-Hispanic white (53.8%) adults had a higher prevalence of controlled high blood pressure than did non-Hispanic black (43.8%), non-Hispanic Asian (39.9%), and Hispanic (43.5%) adults. For women with hypertension, the percentage of non-Hispanic white (59.1%) adults with controlled

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high blood pressure was higher than among non-Hispanic black (52.3%) and non-Hispanic Asian (46.8%) adults (1). In Hispanic Americans, the lower control rates result primarily from lack of awareness and treatment (2, 3), whereas in blacks, awareness and treatment are at least as high as in whites, but hypertension is more severe and some agents are less effective at BP control (4). Morbidity and mortality attributed to hypertension are also more common in blacks and Hispanic Americans than in Whites. Blacks have a 1.3-times greater risk of nonfatal stroke, 1.8-times greater risk of fatal strokes, 1.5-times greater risk of HF, and 4.2-times greater risk of ESRD (4). Hispanic Americans have lower rates of hypertension awareness and treatment than those of whites and blacks, as well as a high prevalence of comorbid CVD risk factors (e.g., obesity, DM). In 2014, ageadjusted hypertension-attributable mortality rates per 1,000 persons for non-Hispanic white, non-Hispanic black, and Hispanic-American men and women were 19.3 and 15.8, 50.1 and 35.6, and 19.1 and 14.6, respectively (5). However, Hispanics in the United States are a heterogeneous subgroup, and rates of both hypertension and its consequences vary according to whether their ancestry is from the Caribbean, Mexico, Central or South America, or Europe (6-8). Hispanics from Mexico and Central America have lower CVD rates than U.S. whites, whereas those of Caribbean origin have higher rates. Thus, pooling of data for Hispanics may not accurately reflect risk in a given patient. Finally, the excess risk of CKD outcomes in at least some blacks with hypertension may be due to the presence of high-risk APOL1 (apolipoprotein L1) genetic variants (9-11). The rate of renal decline associated with this genotype appears to be largely unresponsive to either BP lowering or RAS inhibition (9-12). References 1. Yoon SSS, Carroll MD, Fryar CD. Hypertension prevalence and control among adults: United States, 2011-2014. NCHS Data Brief. 2015;1-8. 2. Margolis KL, Piller LB, Ford CE, et al. Blood pressure control in Hispanics in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Hypertension. 2007;50:854-61. 3. Cooper-DeHoff RM, Aranda JM Jr, Gaxiola E, et al. Blood pressure control and cardiovascular outcomes in high-risk Hispanic patients--findings from the International Verapamil SR/Trandolapril Study (INVEST). Am Heart J. 2006;151:1072-9. 4. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics--2017 update: a report from the American Heart Association. Circulation. 2017;135:e146-603. 5. Centers for Disease Control and Prevention. Compressed Mortality File: Underlying Cause-of-Death 1999-2013. 2014. Available at: http://wonder.cdc.gov/mortsql.html. Accessed November 2, 2017. 6. Guzman NJ. Epidemiology and management of hypertension in the Hispanic population: a review of the available literature. Am J Cardiovasc Drugs. Am J Cardiovasc Drugs. 2012;12:165-78. 7. Sorlie PD, Allison MA, Aviles-Santa ML, et al. Prevalence of hypertension, awareness, treatment, and control in the Hispanic Community Health Study/Study of Latinos. Am J Hypertens. 2014;27:793-800. 8. Rodriguez CJ, Allison M, Daviglus ML, et al. Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association. Circulation. 2014;130:593-625. 9. Parsa A, Kao WHL, Xie D, et al. APOL1 risk variants, race, and progression of chronic kidney disease. N Engl J Med. 2013;369:2183-96. 10. Lipkowitz MS, Freedman BI, Langefeld CD, et al. Apolipoprotein L1 gene variants associate with hypertensionattributed nephropathy and the rate of kidney function decline in African Americans. Kidney Int. 2013;83:114-20. 11. Langefeld CD, Divers J, Pajewski NM, et al. Apolipoprotein L1 gene variants associate with prevalent kidney but not prevalent cardiovascular disease in the Systolic Blood Pressure Intervention Trial. Kidney Int. 2015;87:169-75. 12. Grams ME, Rebholz CM, Chen Y, et al. Race, APOL1 risk, and eGFR decline in the general population. J Am Soc Nephrol. 2016;27:2842-50.

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10.1.1 Racial and Ethnic Differences in Treatment Recommendations for Race and Ethnicity

References that support recommendations are summarized in Online Data Supplement 51. COR LOE Recommendations 1. In black adults with hypertension but without HF or CKD, including those I B-R with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB (1-4). 2. Two or more antihypertensive medications are recommended to achieve a I C-LD BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension (5-7). Synopsis Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Lifestyle modification (i.e., weight reduction, dietary modification, and increased physical activity) is particularly important in blacks and Hispanic Americans for prevention and first-line or adjunctive therapy of hypertension (see Sections 12.1.2 and 12.1.3). However, the adoption of lifestyle recommendations is often challenging in ethnic minority patients because of poor social support, limited access to exercise opportunities and healthy foods, and financial considerations. The greater prevalence of lower socioeconomic status may impede access to basic living necessities (8), including medical care and medications. Consideration must also be given to learning styles and preference, personal beliefs, values, and culture (9, 10). The principles of antihypertensive drug selection discussed in Sections 8.1.4 through 8.1.6 apply to ethnic minorities with a few caveats. In Blacks, thiazide-type diuretics and CCBs are more effective in lowering BP when given as monotherapy or as initial agents in multidrug regimens (11-13). In addition, thiazide-type agents are superior to drugs that inhibit the RAS (i.e., ACE inhibitors, ARBs, renin inhibitors, and beta blockers) for prevention of selected clinical outcomes in blacks (2, 14-16). For optimum endpoint protection, the thiazide chlorthalidone should be administered at a dose of 12.5 to 25 mg/day (or 25–50 mg/d for hydrochlorothiazide) because lower doses are either unproven or less effective in clinical outcome trials (2, 16). The CCB amlodipine is as effective as chlorthalidone and more effective than the ACE inhibitor lisinopril in reducing BP, CVD, and stroke events but less effective in preventing HF. Blacks have a greater risk of angioedema with ACE inhibitors (2, 3), and Asian Americans have a higher incidence of ACE inhibitor–induced cough (17). ACE inhibitors and ARBs are recommended more generally as components of multidrug antihypertensive regimens in blacks with CKD (see Section 9.3), with the addition of beta blockers in those with HF (see Section 9.2). Beta blockers are recommended for treatment of patients with CHD who have had a MI. Most patients with hypertension, especially blacks, require ≥2 antihypertensive medications to achieve adequate BP control. A single-tablet combination that includes either a diuretic or a CCB may be particularly effective in achieving BP control in blacks. Racial and ethnic differences should not be the basis for excluding any class of antihypertensive agent in combination therapy. Recommendation-Specific Supportive Text 1. In blacks, thiazide diuretics or CCBs are more effective in lowering BP than are RAS inhibitors or beta blockers and more effective in reducing CVD events than are RAS inhibitors or alpha blockers. RAS inhibitors are recommended in black patients with hypertension, DM, and nephropathy, but they offer no advantage over diuretics or CCBs in hypertensive patients with DM without nephropathy or HF. 2. Four drug classes (thiazide diuretic, CCB, ACE inhibitor, or ARB) lower BP and reduce cardiovascular or renal outcomes (18-21). Thus, except for the combination of ACE inhibitors and ARBs, regimens containing a combination of these classes are reasonable to achieve the BP target (16, 21). Furthermore, the combination of an ACE inhibitor or ARB with a CCB or thiazide diuretic produces similar BP lowering in blacks as in other

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References 1. Leenen FHH, Nwachuku CE, Black HR, et al. Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Hypertension 2006;48:374-84. 2. Wright JT Jr, Probstfield JL, Cushman WC, et al. ALLHAT findings revisited in the context of subsequent analyses, other trials, and meta-analyses. Arch Intern Med. 2009;169:832-42. 3. Wright JT Jr, Dunn JK, Cutler JA, et al. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005;293:1595-608. 4. Wright JT Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2008;168:207-17. 5. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-97. 6. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. SPRINT Research Group. N Engl J Med. 2015;373:2103-16. 7. Wright JT Jr, Bakris G, Greene T, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288:2421-31. 8. Odedosu T, Schoenthaler A, Vieira DL, et al. Overcoming barriers to hypertension control in African Americans. Cleve Clin J Med. 2012;79:46-56. 9. Ferdinand KC. Management of high blood pressure in African Americans and the 2010 ISHIB consensus statement: meeting an unmet need. J Clin Hypertens (Greenwich). 2010;12:237-9. 10. Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension. 2010;56:780-800. 11. Jamerson K, DeQuattro V. The impact of ethnicity on response to antihypertensive therapy. Am J Med. 1996;101:22S-32S. 12. Saunders E, Weir MR, Kong BW, et al. A comparison of the efficacy and safety of a beta-blocker, a calcium channel blocker, and a converting enzyme inhibitor in hypertensive blacks. Arch Intern Med. 1990;150:1707-13. 13. Cushman WC, Reda DJ, Perry HM, et al. Regional and racial differences in response to antihypertensive medication use in a randomized controlled trial of men with hypertension in the United States. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Arch Intern Med. 2000;160:825-31. 14. Brewster LM, van Montfrans GA, Kleijnen J. Systematic review: antihypertensive drug therapy in black patients. Ann Intern Med. 2004;141:614-27. 15. Zanchetti A, Julius S, Kjeldsen S, et al. Outcomes in subgroups of hypertensive patients treated with regimens based on valsartan and amlodipine: an analysis of findings from the VALUE trial. J Hypertens. 2006;24:2163-8. 16. Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008;359:2417-28. 17. Woo KS, Nicholls MG. High prevalence of persistent cough with angiotensin converting enzyme inhibitors in Chinese. Br J Clin Pharmacol. 1995;40:141-4. 18. Czernichow S, Zanchetti A, Turnbull F, et al. The effects of blood pressure reduction and of different blood pressure-lowering regimens on major cardiovascular events according to baseline blood pressure: meta-analysis of randomized trials. J Hypertens. 2011;29:4-16. 19. Fretheim A, Odgaard-Jensen J, Brors O, et al. Comparative effectiveness of antihypertensive medication for primary prevention of cardiovascular disease: systematic review and multiple treatments meta-analysis. BMC Med. 2012;10:33. 20. Jafar TH, Stark PC, Schmid CH, et al. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med. 2003;139:244-52.

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10.2. Sex-Related Issues The prevalence of hypertension is lower in women than in men until about the fifth decade but is higher later in life (1). Other than special recommendations for management of hypertension during pregnancy, there is no evidence that the BP threshold for initiating drug treatment, the treatment target, the choice of initial antihypertensive medication, or the combination of medications for lowering BP differs for women versus men (2, 3).

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References 1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics--2017 update: a report from the American Heart Association. Circulation. 2017;135:e146-603. 2. Gueyffier F, Boutitie F, Boissel JP, et al. Effect of antihypertensive drug treatment on cardiovascular outcomes in women and men. A meta-analysis of individual patient data from randomized, controlled trials. The INDANA Investigators. Ann Intern Med. 1997;126:761-7. 3. Turnbull F, Woodward M, Neal B, et al. Do men and women respond differently to blood pressure-lowering treatment? Results of prospectively designed overviews of randomized trials. Eur Heart J. 2008;29:2669-80.

10.2.1. Women A potential limitation of RCTs, including SPRINT, is that they are not specifically powered to determine the value of intensive SBP reduction in subgroups, including women in the case of SPRINT. However, in prespecified analyses, there was no evidence of an interaction between sex and treatment effect. Furthermore, no significant differences in CVD outcomes were observed between men and women in a large meta-analysis that included 31 RCTs with about 100,000 men and 90,000 women with hypertension (1). Some have called for a SPRINT-like trial with sufficient power to assess the effects of intensive SBP reduction in women (2). In meta-analyses, there was no convincing evidence that different antihypertensive drug classes exerted sex-related differences in BP lowering or provided distinct CVD protection (1). Calcium antagonists offered slightly greater benefits for stroke prevention than did ACE inhibitors for women than for men, whereas calcium antagonists reduced all-cause deaths compared with placebo in men but not in women. However, these sex-related differences might have been due to chance because of the large number of statistical comparisons that were performed. The Heart Attack Trial and Hypertension Care Computing Project reported that beta blockers were associated with reduced mortality in men but not in women, but this finding was likely due to the low event rates in women (3). Similarly, in the open-label Second Australian National BP study, a significant reduction in CVD events was demonstrated in men but not in women with ACE inhibitors versus diuretics (4). Adverse effects of antihypertensive therapy were noted twice as often in women as in men in the TOMHS study (5). A higher incidence of ACE inhibitor–induced cough and of edema with calcium antagonists was observed in women than in men (6). Women were more likely to experience hypokalemia and hyponatremia and less likely to experience gout with diuretics (7). Hypertension in pregnancy has special requirements (see Section 10.2.2). References 1. Turnbull F, Woodward M, Neal B, et al. Do men and women respond differently to blood pressure-lowering treatment? Results of prospectively designed overviews of randomized trials. Eur Heart J. 2008;29:2669-80. 2. Wenger NK, Ferdinand KC, Bairey Merz CN, et al. Women, hypertension, and the Systolic Blood Pressure Intervention Trial. Am J Med. 2016;129:1030-6.

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Fletcher A, Beevers DG, Bulpitt C, et al. Beta adrenoceptor blockade is associated with increased survival in male but not female hypertensive patients: a report from the DHSS Hypertension Care Computing Project (DHCCP). J Hum Hypertens. 1988;2:219-27. Jansen J, Bonner C, McKinn S, et al. General practitioners' use of absolute risk versus individual risk factors in cardiovascular disease prevention: an experimental study. BMJ OPEN. 2014;4:e004812. Lewis CE, Grandits A, Flack J, et al. Efficacy and tolerance of antihypertensive treatment in men and women with stage 1 diastolic hypertension. Results of the Treatment of Mild Hypertension Study. Arch Intern Med. 1996;156:377-85. Kloner RA, Sowers JR, DiBona GF, et al. Sex- and age-related antihypertensive effects of amlodipine. The Amlodipine Cardiovascular Community Trial Study Group. Am J Cardiol. 1996;77:713-22. Igho Pemu P, Ofili E. Hypertension in women: part I. J Clin Hypertens (Greenwich). 2008;10:406-10.

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Recommendations for Treatment of Hypertension in Pregnancy References that support recommendations are summarized in Online Data Supplement 53. COR

LOE

I

C-LD

III: Harm

C-LD

Recommendations 1. Women with hypertension who become pregnant, or are planning to become pregnant, should be transitioned to methyldopa, nifedipine, and/or labetalol (1) during pregnancy (2-6). 2. Women with hypertension who become pregnant should not be treated with ACE inhibitors, ARBs, or direct renin inhibitors (4-6).

Synopsis BP usually declines during the first trimester of pregnancy and then slowly rises. Hypertension management during pregnancy includes 4 general areas: 1) the newly pregnant mother with existing hypertension; 2) incident hypertension; 3) preeclampsia (a dangerous form of hypertension with proteinuria that has the potential to result in serious adverse consequences for the mother [stroke, HF] and fetus [small for gestational age, premature birth]); and 4) severe hypertension, often in the setting of preeclampsia, requiring urgent treatment to prevent HF, stroke, and adverse fetal outcomes. Hypertension during pregnancy and preeclampsia are recognized as risk factors for future hypertension and CVD (7-9). BP management during pregnancy is complicated by the fact that many commonly used antihypertensive agents, including ACE inhibitors and ARBs, are contraindicated during pregnancy because of potential harm to the fetus (2, 3). The goal of antihypertensive treatment during pregnancy includes prevention of severe hypertension and the possibility of prolonging gestation to allow the fetus more time to mature before delivery. There are 3 Cochrane database reviews of treatment for mild-to-moderate hypertension during pregnancy (10-12). With regard to the treatment of mild-to-moderate hypertension (SBP of 140–169 or DBP of 90–109 mm Hg), antihypertensive treatment reduces the risk of progression to severe hypertension by 50% compared with placebo but has not been shown to prevent preeclampsia, preterm birth, small for gestational age, or infant mortality. Beta blockers and CCBs appear superior to alpha-methyldopa in preventing preeclampsia (10). An earlier review of 2 small trials did not show improved outcomes with more comprehensive treatment of BP to a target of <130/80 mm Hg (11). Consistent with the results of the Cochrane reviews, a large multinational RCT of treatment in pregnant women with mild-to-moderate hypertension also reported that treatment prevented progression to severe hypertension, but other maternal and infant outcomes were unaffected by the intensity of treatment (13). An earlier review confined to assessing the effect of beta blockers found them generally safe and effective but of no benefit for newborn outcomes, either in placebo-controlled studies or when compared with other antihypertensive agents. There was a suggestion that beta-blocker therapy might be associated with small for gestational age and neonatal bradycardia (12). The largest experience for beta blockers is with labetalol; the largest experience for CCBs is with nifedipine.

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Methyldopa and hydralazine may also be used. A review of treatment for pregnancy-associated severe hypertension found insufficient evidence to recommend specific agents; rather, clinician experience was recommended in this setting (14). Preeclampsia is a potentially dangerous condition for the pregnant woman and fetus, occurring in 3.8% of pregnancies, and preeclampsia and eclampsia account for 9% of maternal deaths in the United States (15). Preeclampsia is associated with an increased risk of preterm delivery, intrauterine growth restriction, placental abruption, and perinatal mortality and is twice as likely to occur in the first pregnancy. The U.S. Preventive Services Task Force has recommended screening all pregnant women for preeclampsia by measuring BP at every prenatal visit (16). It is beyond the scope of the present guideline to address the management of hypertension during pregnancy in detail. Several international guidelines provide guidance on management of hypertension during pregnancy (2, 3, 17). The American College of Obstetricians and Gynecologists has issued a task force report that includes recommendations for prevention (aspirin in selected cases) and treatment (magnesium for severe hypertension) of hypertension in pregnancy (2). A report detailing treatment of hypertensive emergencies during pregnancy and postpartum has also been released (2, 17, 18). Recommendation-Specific Supportive Text 1. ACE inhibitors and ARBs are not approved for use during pregnancy; they are fetotoxic. Among the agents recommended, no specific agent is first choice because there are no data supporting one over another. Therapeutic classes are not recommended because potential toxicity differs among agents within classes. 2. ACE inhibitors and ARBs are fetotoxic in the second and third trimesters of pregnancy. Adverse effects in the first trimester of pregnancy may be secondary to hypertension or the medication (4, 5). Adverse events in the later trimesters have been suggested by observational data and meta-analyses (6). For ARBs, case reports with effects similar to ACE inhibitors have been published (19). References 1. James PR, Nelson-Piercy C. Management of hypertension before, during, and after pregnancy. Heart. 2004;90:1499-504. 2. American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122:1122-31. 3. National Clinical Guideline Centre (UK). Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34. London, UK: Royal College of Physicians (UK); 2011. 4. Pucci M, Sarween N, Knox E, et al. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in women of childbearing age: risks versus benefits. Expert Rev Clin Pharmacol. 2015;8:221-31. 5. Moretti ME, Caprara D, Drehuta I, et al. The fetal safety of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. Obstet Gynecol Int. 2012;2012:658310. 6. Ferrer RL, Sibai BM, Mulrow CD, et al. Management of mild chronic hypertension during pregnancy: a review. Obstet Gynecol. 2000;96:849-60. 7. Garovic VD, August P. Preeclampsia and the future risk of hypertension: the pregnant evidence. Curr Hypertens Rep. 2013;15:114-21. 8. Kessous R, Shoham-Vardi I, Pariente G, et al. Long-term maternal atherosclerotic morbidity in women with preeclampsia. Heart. 2015;101:442-6. 9. Veerbeek JHW, Hermes W, Breimer AY, et al. Cardiovascular disease risk factors after early-onset preeclampsia, late-onset preeclampsia, and pregnancy-induced hypertension. Hypertension. 2015;65:600-6. 10. Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2014;2:CD002252. 11. Nabhan AF, Elsedawy MM. Tight control of mild-moderate pre-existing or non-proteinuric gestational hypertension. Cochrane Database Syst Rev. 2011:CD006907.

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12. Magee LA, Duley L. Oral beta-blockers for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2003;CD002863. 13. Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372:407-17. 14. Duley L, Meher S, Jones L. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2013;7:CD001449. 15. Gulati M. Early identification of pregnant women at risk for preeclampsia: USPSTF recommendations on screening for preeclampsia. JAMA Cardiol. 2017;2:593-5. 16. Henderson JT, Thompson JH, Burda BU, et al. Preeclampsia screening: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2017;317:1668-83. 17. Regitz-Zagrosek V, Blomstrom LC, Borghi C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147-97. 18. Committee on Obstetric Practice. Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015;125:521-5. 19. Shimada C, Akaishi R, Cho K, et al. Outcomes of 83 fetuses exposed to angiotensin receptor blockers during the second or third trimesters: a literature review. Hypertens Res. 2015;38:308-13.

10.3. Age-Related Issues 10.3.1. Older Persons Recommendations for Treatment of Hypertension in Older Persons

References that support recommendations are summarized in Online Data Supplement 54. COR LOE Recommendations 1. Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory communityI A dwelling adults (≥65 years of age) with an average SBP of 130 mm Hg or higher (1). 2. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable IIa C-EO for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. Synopsis Because of its extremely high prevalence in older adults, hypertension is not only a leading cause of preventable morbidity and mortality but, perhaps more importantly, is under-recognized as a major contributor to premature disability and institutionalization (2-5). Both SBP and DBP increase linearly up to the fifth or sixth decade of life, after which DBP gradually decreases while SBP continues to rise (6). Thus, isolated systolic hypertension is the predominant form of hypertension in older persons (7, 8). RCTs have clearly demonstrated that BP lowering in isolated systolic hypertension (defined as SBP ≥160 mm Hg with variable DBP ≤90, ≤95, or ≤110 mm Hg) is effective in reducing the risk of fatal and nonfatal stroke (primary outcome), cardiovascular events, and death (9-12). Cross-sectional and longitudinal epidemiologic studies in older adults have raised questions about the benefits of more intensive antihypertensive treatment and the relationship between BP lowering and risk of falls (13). Treatment of elevated BP in older persons is challenging because of a high degree of heterogeneity in comorbidity, as well as poly-pharmacy, frailty, cognitive impairment, and variable life expectancy. However, over the past 3 decades, RCTs of antihypertensive therapy have included large numbers of older persons, and in every instance, including when the SBP treatment goal was <120 mm Hg, more intensive treatment has

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safely reduced the risk of CVD for persons over the ages of 65, 75, and 80 years (1, 14). Both HYVET (Hypertension in the Very Elderly Trial) and SPRINT included those who were frail but still living independently in the community (1, 14), and both were stopped early for benefit (HYVET after 1.8 years and SPRINT after 3.26 years). In fact, BP-lowering therapy is one of the few interventions shown to reduce mortality risk in frail older individuals. RCTs in noninstitutionalized community-dwelling older persons have also demonstrated that improved BP control does not exacerbate orthostatic hypotension and has no adverse impact on risk of injurious falls (1, 15, 16). It should be noted, however, that SPRINT excluded those with low (<110 mm Hg) standing BP on study entry. Older persons need to be carefully monitored for orthostatic hypotension during treatment. Intensive BP control increases the risk of acute kidney injury, but this is no different from the risk seen in younger adults (1). In summary, despite the complexity of management in caring for older persons with hypertension, RCTs have demonstrated that in many community-dwelling older adults, even adults >80 years of age, BP-lowering goals during antihypertensive treatment need not differ from those selected for persons <65 years of age (17). Importantly, no randomized trial of BP lowering in persons >65 years of age has ever shown harm or less benefit for older versus younger adults. However, clinicians should implement careful titration of BP lowering and monitoring in persons with high comorbidity burden; large RCTs have excluded older persons at any age who live in nursing homes, as well as those with prevalent dementia and advanced HF. Recommendation-Specific Supportive Text 1. We recommend ASCVD risk assessment in all adults with hypertension, including older persons. As a matter of convenience, however, it can be assumed that the vast majority of older adults have a 10-year ASCVD risk ≥ 10%, placing them in the high risk category that requires initiation of antihypertensive drug therapy at BP ≥ 130/80 mm Hg (see Section 8.1.2, Figure 4 and Table 23 for BP thresholds for initiating antihypertensive drug treatment). Large RCTs using medications to reduce hypertension-related CVD risk with a mean follow-up of ≥2 years have now included a large number of adults ≥65 years of age. These trials have enrolled a broad range of ages ≥65 years, including persons in their 90s and even 100s, as well as those with mild-to-moderate frailty but who were ambulatory and able to travel to a treatment clinic. In these patients, RCTs have shown that BP lowering decreased CVD morbidity and mortality but did not increase the risk of orthostatic hypotension or falls (1, 15, 16). Analysis of the NHANES (2011–2014) data set indicates that 88% of U.S. adults (98% men and 80% women) ≥65 years old have a 10-year predicted ASCVD risk ≥10% or have a history of CVD (CHD, stroke, or HF). For persons ≥75 years of age, 100% have an ASCVD risk score ≥10% or a history of CVD. Therefore, the BP target of ≤130/80 mm Hg would be appropriate (see Section 8.1.2). Initiation of antihypertensive therapy with 2 agents should be undertaken cautiously in older persons, and they need to be monitored carefully for orthostatic hypotension and history of falls. In SPRINT, the benefit was for an SBP goal of <120 mm Hg. Older persons may present with neurogenic orthostatic hypotension associated with supine hypertension. This is particularly common in Parkinson’s disease and other neurodegenerative disorders. For management of this problem, the reader is referred to the recommendations of a 2017 consensus panel (18). 2. Patients with prevalent and frequent falls, advanced cognitive impairment, and multiple comorbidities may be at risk of adverse outcomes with intensive BP lowering, especially when they require multiple BP-lowering medications. Older persons in this category typically reside in nursing homes and assisting living facilities, are unable to live independently in the community, and have not been represented in RCTs. References 1. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA. 2016;315:2673-82. 2. Ettinger WH Jr, Fried LP, Harris T, et al. Self-reported causes of physical disability in older people: the Cardiovascular Health Study. CHS Collaborative Research Group. J Am Geriatr Soc. 1994;42:1035-44. 3. Ferrucci L, Guralnik JM, Pahor M, et al. Hospital diagnoses, Medicare charges, and nursing home admissions in the year when older persons become severely disabled. JAMA. 1997;277:728-34.

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11. 12. 13. 14.

15. 16. 17. 18.

den Ouden MEM, Schuurmans MJ, Mueller-Schotte S, et al. Do subclinical vascular abnormalities precede impaired physical ability and ADL disability? Exp Gerontol. 2014;58:1-7. Ezzati M, Lopez AD, Rodgers A, et al. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360:1347-60. Duprez DA. Systolic hypertension in the elderly: addressing an unmet need. Am J Med. 2008;121:179-84.e3. Egan BM, Li J, Hutchison FN, et al. Hypertension in the United States, 1999 to 2012: progress toward Healthy People 2020 goals. Circulation. 2014;130:1692-9. Liu X, Rodriguez CJ, Wang K. Prevalence and trends of isolated systolic hypertension among untreated adults in the United States. J Am Soc Hypertens. 2015;9:197-205. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA. 1991;265:3255-64. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350:757-64. Liu L, Wang JG, Gong L, et al. Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Systolic Hypertension in China (Syst-China) Collaborative Group. J Hypertens. 1998;16:18239. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-98. Tinetti ME, Han L, Lee DSH, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014;174:588-95. Warwick J, Falaschetti E, Rockwood K, et al. No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: an investigation of the impact of frailty upon treatment effect in the HYpertension in the Very Elderly Trial (HYVET) study, a double-blind, placebo-controlled study of antihypertensives in people with hypertension aged 80 and over. BMC Med. 2015;13:78. Gangavati A, Hajjar I, Quach L, et al. Hypertension, orthostatic hypotension, and the risk of falls in a communitydwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011;59:383-9. Margolis KL, Palermo L, Vittinghoff E, et al. Intensive blood pressure control, falls, and fractures in patients with type 2 diabetes: the ACCORD trial. J Gen Intern Med. 2014;29:1599-606. Bavishi C, Bangalore S, Messerli FH. Outcomes of intensive blood pressure lowering in older hypertensive patients. J Am Coll Cardiol. 2017;69:486-93. Gibbons CH, Schmidt P, Biaggioni I, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol. 2017;264:1567-82.

10.3.2. Children and Adolescents Pediatric guidelines are available from other organizations (1, 2). The 2011 report updates the 2004 report for publications through 2008 (antihypertensive medication trials, normative data on pediatric BP) but is otherwise unchanged. In the 2011 guideline (3), BP was stratified into normal, prehypertension (90th percentile to 95th percentile), stage 1 hypertension (95th percentile to >99th percentile), and stage 2 hypertension (above stage 1) by using age-, sex-, and height-based tables beginning at 1 year of age, which were based on the distribution of BP in more than 60,000 healthy children in various population-based studies (1). These definitions were designed to be analogous to definitions in the extant JNC 7 report; for older adolescents (≥14 years), the JNC 7 thresholds generally apply (4). Treatment recommendations are based on hypertension severity, published short-term clinical trials of antihypertensive treatment, age, coexisting CVD risk factors, and risk stratification by presence of LVH on echocardiogram. The treatment goal is to achieve BP <90th percentile. New tables for ambulatory BP distribution in children have been developed. A classification of BP that is based on these ambulatory BP results has been proposed (5, 6). Publication of new evidencebased pediatric guidelines is anticipated in late 2017.

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References 1. Moser M, Roccella EJ. The treatment of hypertension: a remarkable success story. J Clin Hypertens (Greenwich). 2013;15:88-91. 2. Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Bethesda, MD: National Heart, Lung, and Blood Institute, U.S. Department of Health and Human Services; 2012:S144. NIH Publication No. 12-7486. 3. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, National Heart, Lung, and Blood Institute. Integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(suppl 5):S213-56. 4. Chobanian AV, Bakris GL, Black HR, et al; the National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52. 5. Flynn JT, Daniels SR, Hayman LL, et al. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63:1116-35. 6. O'Brien E, Parati G, Stergiou G, et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31:1731-68.

11. Other Considerations 11.1. Resistant Hypertension The diagnosis of resistant hypertension is made when a patient takes 3 antihypertensive medications with complementary mechanisms of action (a diuretic should be 1 component) but does not achieve control or when BP control is achieved but requires ≥4 medications (1). On the basis of the previous cutoff of 140/90 mm Hg, the prevalence of resistant hypertension is approximately 13% in the adult population (2, 3). Multiple single-cohort studies have indicated that common risk factors for resistant hypertension include older age, obesity, CKD, black race, and DM. Estimates suggest the prevalence would be about 4% higher with the newly recommended control target of <130/80 mm Hg (subject to validation in future study). The prognosis of resistant hypertension (by the previous definition) (1), compared with the prognosis of those who more readily achieve control, has not been fully ascertained; however, risk of MI, stroke, ESRD, and death in adults with resistant hypertension and CHD may be 2- to 6-fold higher than in hypertensive adults without resistant hypertension (4-6). The evaluation of resistant hypertension involves consideration of many patient characteristics, pseudoresistance (BP technique, white coat hypertension, and medication compliance), and screening for secondary causes of hypertension (Figure 10; Section 5.4; Table 13). The term “refractory hypertension” has been used to refer to an extreme phenotype of antihypertensive treatment failure, defined as failure to control BP despite use of at least 5 antihypertensive agents of different classes, including a longacting thiazide-type diuretic, such as chlorthalidone, and a mineralocorticoid receptor antagonist, such as spironolactone (7). The prevalence of refractory hypertension is low; patients with refractory hypertension experience high rates of CVD complications, including LVH, HF, and stroke. Treatment of resistant hypertension involves improving medication adherence, improving detection and correction of secondary hypertension, and addressing other patient characteristics (8-10). Pharmacological therapy with combinations of medications with complementary mechanisms of action provides an empirical approach that enhances BP control while mitigating untoward effects of potent vasodilators (e.g., fluid retention and reflex tachycardia). CCBs, inhibitors of RAS, and chlorthalidone comprise a common 3-drug regimen (11). Considerable evidence indicates that the addition of spironolactone to multidrug regimens provides substantial BP reduction (12) when compared with placebo. Substantial data also demonstrate the advantage of spironolactone as compared with other active drugs (8, 13-15). In particular, the recent PATHWAY-2 (Optimum Treatment for Drug-Resistant Hypertension) RCT demonstrated the superiority of spironolactone over alpha and beta blockers (13). There is also clinical trial evidence that the addition of hydralazine or minoxidil is effective in achieving BP control in patients resistant to usual

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline combination therapy (8, 12-16). The dosing of multidrug regimens, occasionally including nighttime dosing, may be best optimized by hypertension specialists. Several studies have investigated devices that interrupt sympathetic nerve activity (carotid baroreceptor pacing and catheter ablation of renal sympathetic nerves); however, these studies have not provided sufficient evidence to recommend the use of these device in managing resistant hypertension (810). In particular, 2 RCTS of renal sympathetic nerve ablation have been negative (8, 9).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 10. Resistant Hypertension: Diagnosis, Evaluation, and Treatment

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Confirm treatment resistance Office SBP/DBP ≥130/80 mm Hg and Patient prescribed ≥3 antihypertensive medications at optimal doses, including a diuretic, if possible or Office SBP/DBP <130/80 mm Hg but patient requires ≥4 antihypertensive medications ↓ Exclude pseudoresistance Ensure accurate office BP measurements Assess for nonadherence with prescribed regimen Obtain home, work, or ambulatory BP readings to exclude white coat effect ↓ Identify and reverse contributing lifestyle factors* Obesity Physical inactivity Excessive alcohol ingestion High-salt, low-fiber diet ↓ Discontinue or minimize interfering substances† NSAIDs Sympathomimetic (e.g., amphetamines, decongestants) Stimulants Oral contraceptives Licorice Ephedra ↓ Screen for secondary causes of hypertension‡ Primary aldosteronism (elevated aldosterone/renin ratio) CKD (eGFR <60 mL/min/1.73 m2) Renal artery stenosis (young female, known atherosclerotic disease, worsening kidney function) Pheochromocytoma (episodic hypertension, palpitations, diaphoresis, headache) Obstructive sleep apnea (snoring, witnessed apnea, excessive daytime sleepiness) ↓ Pharmacological treatment Maximize diuretic therapy Add a mineralocorticoid receptor antagonist Add other agents with different mechanisms of actions Use loop diuretics in patients with CKD and/or patients receiving potent vasodilators (e.g., minoxidil) ↓ Refer to specialist Refer to appropriate specialist for known or suspected secondary cause(s) of hypertension Refer to hypertension specialist if BP remains uncontrolled after 6 mo of treatment *See additional details in Section 6, Nonpharmacological Intervention. †See Section 5.4.1 and Table 14 for complete list of drugs that elevate BP. ‡See Section 5.4 and Table 13 for secondary hypertension. BP indicates blood pressure; CKD, chronic kidney disease; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; NSAIDs, nonsteroidal anti-inflammatory drugs; and SBP, systolic blood pressure. Adapted with permission from Calhoun et al. (1) (American Heart Association, Inc.).

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References 1. Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008;51:1403-19. 2. Persell SD. Prevalence of resistant hypertension in the United States, 2003-2008. Hypertension. 2011;57:1076-80. 3. Achelrod D, Wenzel U, Frey S. Systematic review and meta-analysis of the prevalence of resistant hypertension in treated hypertensive populations. Am J Hypertens. 2015;28:355-61. 4. Smith SM, Huo T, Delia Johnson B, et al. Cardiovascular and mortality risk of apparent resistant hypertension in women with suspected myocardial ischemia: a report from the NHLBI-sponsored WISE Study. J Am Heart Assoc. 2014;3:e000660. 5. Tanner RM, Calhoun DA, Bell EK, et al. Incident ESRD and treatment-resistant hypertension: the reasons for geographic and racial differences in stroke (REGARDS) study. Am J Kidney Dis. 2014;63:781-8. 6. Bangalore S, Fayyad R, Laskey R, et al. Prevalence, predictors, and outcomes in treatment-resistant hypertension in patients with coronary disease. Am J Med. 2014;127:71-81.e1. 7. Calhoun DA, Booth JN 3rd, Oparil S, et al. Refractory hypertension: determination of prevalence, risk factors, and comorbidities in a large, population-based cohort. Hypertension. 2014;63:451-8. 8. Rosa J, Widimsky P, Waldauf P, et al. Role of adding spironolactone and renal denervation in true resistant hypertension: one-year outcomes of randomized PRAGUE-15 Study. Hypertension. 2016;67:397-403. 9. Bhatt DL, Kandzari DE, O'Neill WW, et al. A controlled trial of renal denervation for resistant hypertension. N Engl J Med. 2014;370:1393-401. 10. Bisognano JD, Bakris G, Nadim MK, et al. Baroreflex activation therapy lowers blood pressure in patients with resistant hypertension: results from the double-blind, randomized, placebo-controlled rheos pivotal trial. J Am Coll Cardiol. 2011;58:765-73. 11. Stergiou GS, Makris T, Papavasiliou M, et al. Comparison of antihypertensive effects of an angiotensin-converting enzyme inhibitor, a calcium antagonist and a diuretic in patients with hypertension not controlled by angiotensin receptor blocker monotherapy. J Hypertens. 2005;23:883-9. 12. Liu G, Zheng XX, Xu YL, et al. Effect of aldosterone antagonists on blood pressure in patients with resistant hypertension: a meta-analysis. J Hum Hypertens. 2015;29:159-66. 13. Williams B, MacDonald TM, Morant S, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015;386:2059-68. 14. Rodilla E, Costa JA, Perez-Lahiguera F, et al. Spironolactone and doxazosin treatment in patients with resistant hypertension. Rev Esp Cardiol. 2009;62:158-66. 15. Dahal K, Kunwar S, Rijal J, et al. The effects of aldosterone antagonists in patients with resistant hypertension: a meta-analysis of randomized and nonrandomized studies. Am J Hypertens. 2015;28:1376-85. 16. Agodoa LY, Appel L, Bakris GL, et al. Effect of ramipril vs amlodipine on renal outcomes in hypertensive nephrosclerosis: a randomized controlled trial. JAMA. 2001;285:2719-28.

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11.2. Hypertensive Crises—Emergencies and Urgencies Recommendations for Hypertensive Crises and Emergencies

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References that support recommendations are summarized in Online Data Supplement 55. COR LOE Recommendations 1. In adults with a hypertensive emergency, admission to an intensive care unit is recommended for continuous monitoring of BP and target organ damage I B-NR and for parenteral administration of an appropriate agent (Tables 19 and 20) (1, 2). 2. For adults with a compelling condition (i.e., aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma crisis), SBP should be I C-EO reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection. 3. For adults without a compelling condition, SBP should be reduced by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg I C-EO within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours. Synopsis Hypertensive emergencies are defined as severe elevations in BP (>180/120 mm Hg) associated with evidence of new or worsening target organ damage (3-6). The 1-year death rate associated with hypertensive emergencies is >79%, and the median survival is 10.4 months if the emergency is left untreated (7). The actual BP level may not be as important as the rate of BP rise; patients with chronic hypertension can often tolerate higher BP levels than previously normotensive individuals. Hypertensive emergencies demand immediate reduction of BP (not necessarily to normal) to prevent or limit further target organ damage. Examples of target organ damage include hypertensive encephalopathy, ICH, acute ischemic stroke, acute MI, acute LV failure with pulmonary edema, unstable angina pectoris, dissecting aortic aneurysm, acute renal failure, and eclampsia. In general, use of oral therapy is discouraged for hypertensive emergencies. Hypertensive emergencies in patients with acute ICH and acute ischemic stroke are discussed in Section 9.4. In contrast, hypertensive urgencies are situations associated with severe BP elevation in otherwise stable patients without acute or impending change in target organ damage or dysfunction. Many of these patients have withdrawn from or are noncompliant with antihypertensive therapy and do not have clinical or laboratory evidence of acute target organ damage. These patients should not be considered as having a hypertensive emergency and instead are treated by reinstitution or intensification of antihypertensive drug therapy and treatment of anxiety as applicable. There is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for such patients. Figure 11 is an algorithm on diagnosis and management of a hypertensive crisis. Tables 19 and 20 summarize intravenous antihypertensive drugs for treatment of hypertensive emergencies. Recommendation-Specific Supportive Text 1. There is no RCT evidence that antihypertensive drugs reduce morbidity or mortality in patients with hypertensive emergencies (8). However, from clinical experience, it is highly likely that antihypertensive therapy is an overall benefit in a hypertensive emergency (9). There is also no high-quality RCT evidence to inform clinicians as to which first-line antihypertensive drug class provides more benefit than harm in hypertensive emergencies (8). This lack of evidence is related to the small size of trials, the lack of long-term follow-up, and failure to report outcomes. However, 2 trials have demonstrated that nicardipine may be better than labetalol in achieving the short-term BP target (1, 10-12). Several antihypertensive agents in various pharmacological classes are available for the treatment of hypertensive emergencies (Table 19). Because

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline autoregulation of tissue perfusion is disturbed in hypertensive emergencies, continuous infusion of shortacting titratable antihypertensive agents is often preferable to prevent further target organ damage (5, 6). The selection of an antihypertensive agent should be based on the drug’s pharmacology, pathophysiological factors underlying the patient’s hypertension (as well as they can be rapidly determined), degree of progression of target organ damage, the desirable rate of BP decline, and the presence of comorbidities (Table 20). The therapeutic goal is to minimize target organ damage safely by rapid recognition of the problem and early initiation of appropriate antihypertensive treatment. 2. Compelling conditions requiring rapid lowering of SBP, usually to <140 mm Hg, in the first hour of treatment include aortic dissection, severe preeclampsia or eclampsia, and pheochromocytoma with hypertensive crisis.

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3. There is no RCT evidence comparing different strategies to reduce BP, except in patients with ICH (9, 13). Neither is there RCT evidence to suggest how rapidly or how much BP should be lowered in a hypertensive emergency (9). However, clinical experience indicates that excessive reduction of BP may cause or contribute to renal, cerebral, or coronary ischemia and should be avoided. Thus, comprehensive dosing of intravenous or even oral antihypertensive agents to rapidly lower BP is not without risk. Oral loading doses of antihypertensive agents can engender cumulative effects, causing hypotension after discharge from the emergency department or clinic.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Figure 11. Diagnosis and Management of a Hypertensive Crisis SBP >180 mm Hg and/or DBP >120 mm Hg

Target organ damage new/ progressive/worsening

Yes Hypertensive emergency

No

Markedly elevated BP

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Admit to ICU (Class I)

Reinstitute/intensify oral antihypertensive drug therapy and arrange follow-up

Conditions: • Aortic dissection • Severe preeclampsia or eclampsia • Pheochromocytoma crisis

Yes

Reduce SBP to <140 mm Hg during first h* and to <120 mm Hg in aortic dissection† (Class I)

No

Reduce BP by max 25% over first h†, then to 160/100–110 mm Hg over next 2–6 h, then to normal over next 24–48 h (Class I)

Colors correspond to Class of Recommendation in Table 1. *Use drug(s) specified in Table 19. †If other comorbidities are present, select a drug specified in Table 20. BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care unit; and SBP, systolic blood pressure.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 19. Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies Class CCB— dihydropyridines

Drug(s) Nicardipine

Clevidipine

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Vasodilators— Nitric-oxide dependent

Sodium nitroprusside

Nitroglycerin

Usual Dose Range Initial 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h. Initial 1–2 mg/h, doubling every 90 s until BP approaches target, then increasing by less than double every 5–10 min; maximum dose 32 mg/h; maximum duration 72 h. Initial 0.3–0.5 mcg/kg/min; increase in increments of 0.5 mcg/kg/min to achieve BP target; maximum dose 10 mcg/kg/min; duration of treatment as short as possible. For infusion rates ≥4–10 mcg/kg/min or duration >30 min, thiosulfate can be coadministered to prevent cyanide toxicity. Initial 5 mcg/min; increase in increments of 5 mcg/min every 3–5 min to a maximum of 20 mcg/min.

Vasodilators— direct

Hydralazine

Initial 10 mg via slow IV infusion (maximum initial dose 20 mg); repeat every 4–6 h as needed.

Adrenergic blockers—beta1 receptor selective antagonist

Esmolol

Adrenergic blockers— combined alpha1 and nonselective

Labetalol

Loading dose 500–1000 mcg/kg/min over 1 min followed by a 50mcg/kg/min infusion. For additional dosing, the bolus dose is repeated and the infusion increased in 50mcg/kg/min increments as needed to a maximum of 200 mcg/kg/min. Initial 0.3–1.0-mg/kg dose (maximum 20 mg) slow IV injection every 10 min or 0.4–1.0-mg/kg/h IV infusion up to 3 mg/kg/h. Adjust

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Comments Contraindicated in advanced aortic stenosis; no dose adjustment needed for elderly. Contraindicated in patients with soybean, soy product, egg, and egg product allergy and in patients with defective lipid metabolism (e.g., pathological hyperlipidemia, lipoid nephrosis or acute pancreatitis). Use low-end dose range for elderly patients. Intra-arterial BP monitoring recommended to prevent “overshoot.” Lower dosing adjustment required for elderly. Tachyphylaxis common with extended use. Cyanide toxicity with prolonged use can result in irreversible neurological changes and cardiac arrest.

Use only in patients with acute coronary syndrome and/or acute pulmonary edema. Do not use in volume-depleted patients. BP begins to decrease within 10–30 min, and the fall lasts 2–4 h. Unpredictability of response and prolonged duration of action do not make hydralazine a desirable first-line agent for acute treatment in most patients. Contraindicated in patients with concurrent beta-blocker therapy, bradycardia, or decompensated HF. Monitor for bradycardia. May worsen HF. Higher doses may block beta2 receptors and impact lung function in reactive airway disease. Contraindicated in reactive airways disease or chronic obstructive pulmonary disease. Especially useful in hyperadrenergic syndromes. May worsen HF and should not be given in

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline beta receptor antagonist

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Adrenergic blockers— nonselective alpha receptor antagonist

Phentolamine

Dopamine1receptor selective agonist

Fenoldopam

ACE inhibitor

Enalaprilat

rate up to total cumulative dose of 300 mg. This dose can be repeated every 4–6 h. IV bolus dose 5 mg. Additional bolus doses every 10 min as needed to lower BP to target.

Initial 0.1–0.3 mcg/kg/min; may be increased in increments of 0.05–0.1 mcg/kg/min every 15 min until target BP is reached. Maximum infusion rate 1.6 mcg/kg/min. Initial 1.25 mg over a 5-min period. Doses can be increased up to 5 mg every 6 h as needed to achieve BP target.

patients with second- or third-degree heart block or bradycardia. Used in hypertensive emergencies induced by catecholamine excess (pheochromocytoma, interactions between monamine oxidase inhibitors and other drugs or food, cocaine toxicity, amphetamine overdose, or clonidine withdrawal). Contraindicated in patients at risk of increased intraocular pressure (glaucoma) or intracranial pressure and those with sulfite allergy.

Contraindicated in pregnancy and should not be used in acute MI or bilateral renal artery stenosis. Mainly useful in hypertensive emergencies associated with high plasma renin activity. Dose not easily adjusted. Relatively slow onset of action (15 min) and unpredictability of BP response. BP indicates blood pressure; CCB, calcium channel blocker; HF, heart failure; IV, intravenous; and MI, myocardial infarction.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 20. Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies in Patients With Selected Comorbidities Comorbidity Acute aortic dissection

Acute pulmonary edema Acute coronary syndromes Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Acute renal failure Eclampsia or preeclampsia

Preferred Drug(s)* Esmolol labetalol

Clevidipine, nitroglycerin nitroprusside Esmolol† labetalol nicardipine nitroglycerin† Clevidipine fenoldopam nicardipine Hydralazine labetalol nicardipine Clevidipine esmolol nicardipine, nitroglycerin

Comments Requires rapid lowering of SBP to ≤120 mm Hg. Beta blockade should precede vasodilator (e.g., nicardipine or nitroprusside) administration, if needed for BP control or to prevent reflex tachycardia or inotropic effect; SBP ≤120 mm Hg should be achieved within 20 min. Βeta blockers contraindicated. Nitrates given in the presence of PDE-5 inhibitors may induce profound hypotension. Contraindications to beta blockers include moderate-to-severe LV failure with pulmonary edema, bradycardia (<60 bpm), hypotension (SBP <100 mm Hg), poor peripheral perfusion, second- or third-degree heart block, and reactive airways disease. N/A Requires rapid BP lowering. ACE inhibitors, ARBs, renin inhibitors, and nitroprusside contraindicated. Intraoperative hypertension is most frequently seen during anesthesia induction and airway manipulation.

Perioperative hypertension (BP ≥160/90 mm Hg or SBP elevation ≥20% of the preoperative value that persists for >15 min) Acute sympathetic discharge Clevidipine Requires rapid lowering of BP. or catecholamine excess nicardipine states (e.g., phentolamine pheochromocytoma, postcarotid endarterectomy status) Acute ICH Section 9.4.1 Section 9.4.1 Acute ischemic stroke Section 9.4.2 Section 9.4.2 *Agents are listed in alphabetical order, not in order of preference. †Agent of choice for acute coronary syndromes. ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; bpm, beats per minute; ICH, intracerebral hemorrhage; LV, left ventricular; PDE-5, phosphodiesterase type-5; and SBP, systolic blood pressure. References 1. Farias S, Peacock WF, Gonzalez M, et al. Impact of initial blood pressure on antihypertensive response in patients with acute hypertension. Am J Emerg Med. 2014;32:833-6. 2. Peacock WF, Chandra A, Char D, et al. Clevidipine in acute heart failure: results of the A Study of Blood Pressure Control in Acute Heart Failure--A Pilot Study (PRONTO). Am Heart J. 2014;167:529-36. 3. Papadopoulos DP, Sanidas EA, Viniou NA, et al. Cardiovascular hypertensive emergencies. Curr Hypertens Rep. 2015;17:5. 4. Manning L, Robinson TG, Anderson CS. Control of blood pressure in hypertensive neurological emergencies. Curr. Hypertens Rep. 2014;16:436.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 5. 6. 7. 8. 9. 10. 11.

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12. 13.

Rhoney D, Peacock WF. Intravenous therapy for hypertensive emergencies, part 1. Am J Health Syst Pharm. 2009;66:1343-52. Rhoney D, Peacock WF. Intravenous therapy for hypertensive emergencies, part 2. Am J Health Syst Pharm. 2009;66:1448-57. Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: their course and prognosis. Am J Med Sci. 1974;268:336-45. Perez MI, Musini VM. Pharmacological interventions for hypertensive emergencies: a Cochrane systematic review. J Hum Hypertens. 2008;22:596-607. Gifford RW Jr. Current practices in general medicine. 7. Treatment of hypertensive emergencies including use of sodium nitroprusside. Proc Staff Meet Mayo Clin. 1959;34:387-94. Peacock WF, Varon J, Baumann BM, et al. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Crit Care. 2011;15:R157. Cannon CM, Levy P, Baumann BM, et al. Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial. BMJ OPEN. 2013;3:e002338. Varon J, Soto-Ruiz KM, Baumann BM, et al. The management of acute hypertension in patients with renal dysfunction: labetalol or nicardipine? Postgrad Med. 2014;126:124-30. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355-65.

11.3. Cognitive Decline and Dementia Recommendation for Prevention of Cognitive Decline and Dementia

References that support the recommendation are summarized in Online Data Supplement 56. COR LOE Recommendation 1. In adults with hypertension, BP lowering is reasonable to prevent cognitive IIa B-R decline and dementia (1-6). Synopsis Dementia is a leading cause of mortality and placement into nursing homes and assisted living facilities, affecting >46 million individuals globally and 5 million persons in the United States, a number that is expected to double by 2050 (7). A 5-year delay in onset of dementia would likely decrease the number of cases of incident dementia by about 50% after several decades (8). Vascular disease and its risk factors are implicated in a large proportion of patients with dementia, including those with Alzheimer’s dementia (9-11). Hypertension is also the primary risk factor for small-vessel ischemic disease and cortical white matter abnormalities (12-15). Most observational studies have suggested that better control of SBP may reduce Alzheimer’s disease and other dementias, and the evidence is stronger for BP lowering in middle age than in the elderly (9, 16). Clinical trials with dementia assessment have evaluated all-cause dementia but not Alzheimer’s disease specifically. However, all of these trials have methodological issues, such as low power, insufficient follow-up length, and inadequately designed dementia assessment batteries. Recommendation-Specific Supportive Text 1. Five clinical trials of BP lowering have included assessment for incident dementia. Of these 5 trials, 4 demonstrated a reduction in dementia incidence, with 2 of these 4 demonstrating statistical significance (746751). SYST-EUR (Systolic Hypertension in Europe) (17) and PROGRESS (Perindopril Protection Against Recurrent Stroke) (18) both showed statistically significant reductions in incident dementia. SYST-EUR achieved an SBP of 152 mm Hg in the treatment arm (8.3 mm Hg lower than placebo arm) during its blinded phase and an SBP of 149 mm Hg (7.0 mm Hg lower than comparison group) during its open-label follow-up phase (2, 3). PROGRESS achieved an SBP of 138 mm Hg in the treatment group (9 mm Hg lower than the placebo group) and demonstrated dementia prevention in patients with a recent stroke (5). The trial showing

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline no benefit in the direction of dementia reduction achieved an SBP reduction of only 3.2 mm Hg, whereas the other 4 trials achieved SBP reductions of 7 to 15 mm Hg (746-751). When the rate of cognitive decline (not dementia) has been a trial outcome, 7 clinical trials of BP-lowering therapy have been completed, and 2 of these have shown benefit (4-6, 19-22). No randomized trial of BP lowering has demonstrated an adverse impact on dementia incidence or cognitive function. However, the anticipated results from SPRINT, the first adequately powered RCT to test whether intensive BP control reduces dementia, may help clarify this issue in the near future.

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References 1. Applegate WB, Pressel S, Wittes J, et al. Impact of the treatment of isolated systolic hypertension on behavioral variables. Results from the systolic hypertension in the elderly program. Arch Intern Med. 1994;154:2154-60. 2. Forette F, Seux ML, Staessen JA, et al. Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet. 1998;352:1347-51. 3. Forette F, Seux M-L, Staessen JA, et al. The prevention of dementia with antihypertensive treatment: new evidence from the Systolic Hypertension in Europe (Syst-Eur) study. Arch Intern Med. 2002;162:2046-52. 4. Lithell H, Hansson L, Skoog I, et al. The Study on Cognition and Prognosis in the Elderly (SCOPE): principal results of a randomized double-blind intervention trial. J Hypertens. 2003;21:875-86. 5. Tzourio C, Anderson C, Chapman N, et al. Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Arch Intern Med. 2003;163:1069-75. 6. Peters R, Beckett N, Forette F, et al. Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial. Lancet Neurol. 2008;7:683-9. 7. Prince M, Wimo A, Guerchet M, et al. World Alzheimer Report 2015: The Global Impact of Dementia: An Analysis of Prevalence, Incidence, Cost and Trends. London, UK: Alzheimer's Disease International; 2015:10-27. 8. Brookmeyer R, Corrada MM, Curriero FC, et al. Survival following a diagnosis of Alzheimer disease. Arch Neurol. 2002;59:1764-7. 9. Qiu C, Winblad B, Fratiglioni L. The age-dependent relation of blood pressure to cognitive function and dementia. Lancet Neurol. 2005;4:487-99. 10. Kivipelto M, Helkala EL, Hanninen T, et al. Midlife vascular risk factors and late-life mild cognitive impairment: a population-based study. Neurology. 2001;56:1683-9. 11. Kuller LH, Lopez OL, Jagust WJ, et al. Determinants of vascular dementia in the Cardiovascular Health Cognition Study. Neurology. 2005;64:1548-52. 12. Liao D, Cooper L, Cai J, et al. Presence and severity of cerebral white matter lesions and hypertension, its treatment, and its control. The ARIC Study. Atherosclerosis Risk in Communities Study. Stroke. 1996;27:2262-70. 13. Longstreth WT Jr, Manolio TA, Arnold A, et al. Clinical correlates of white matter findings on cranial magnetic resonance imaging of 3301 elderly people. The Cardiovascular Health Study. Stroke. 1996;27:1274-82. 14. O'Rourke MF, Safar ME. Relationship between aortic stiffening and microvascular disease in brain and kidney: cause and logic of therapy. Hypertension. 2005;46:200-4. 15. Skoog I. A review on blood pressure and ischaemic white matter lesions. Dement Geriatr Cogn Disord. 1998;9(suppl 1):13-9. 16. Hughes TM, Sink KM. Hypertension and its role in cognitive function: current evidence and challenges for the future. Am J Hypertens. 2016;29:149-57. 17. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350:757-64. 18. Czernichow S, Ninomiya T, Huxley R, et al. Impact of blood pressure lowering on cardiovascular outcomes in normal weight, overweight, and obese individuals: the Perindopril Protection Against Recurrent Stroke Study trial. Hypertension. 2010;55:1193-8. 19. Bosch J, Yusuf S, Pogue J, et al. Use of ramipril in preventing stroke: double blind randomised trial. BMJ. 2002;324:699-702.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 20. Williamson JD, Launer LJ, Bryan RN, et al. Cognitive function and brain structure in persons with type 2 diabetes mellitus after intensive lowering of blood pressure and lipid levels: a randomized clinical trial. JAMA Intern Med. 2014;174:324-33. 21. Anderson C, Teo K, Gao P, et al. Renin-angiotensin system blockade and cognitive function in patients at high risk of cardiovascular disease: analysis of data from the ONTARGET and TRANSCEND studies. Lancet Neurol. 2011;10:43-53. 22. Diener H-C, Sacco RL, Yusuf S, et al. Effects of aspirin plus extended-release dipyridamole versus clopidogrel and telmisartan on disability and cognitive function after recurrent stroke in patients with ischaemic stroke in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial: a double-blind, active and placebocontrolled study. Lancet Neurol. 2008;7:875-84.

11.4. Sexual Dysfunction and Hypertension

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An association among sexual dysfunction, atherosclerosis, and hypertension can be constructed from several epidemiology surveys, clinical trials, and cohort studies. Although these data converge to suggest that endothelial dysfunction is a common denominator, the story is complete. Sexual dysfunction represents several domains in desire or interest, as well as physical limitations such as erectile dysfunction. In addition, beta blockers, mineralocorticoid receptor antagonists, and other antihypertensive drugs can have negative effects on libido and erectile function. There are emerging data on the association between erectile dysfunction and CVD compared with other domains of sexual dysfunction. Experimental and clinical studies describe a role for angiotensin II, endothelin, and hydrogen sulfide on cavernous tissue function (1). Many of the signaling pathways for the increased production of oxidative stress and the subsequent deleterious effects of oxidative stress on vascular tissue have been described. Accordingly, it is reasonable to suggest that hypertension might lead to vascular changes that cause erectile dysfunction but, conversely, erectile dysfunction may be part of the causal pathway to CVD (1). Although there is insufficient evidence to recommend screening for CVD risk factors in all men with erectile dysfunction, it has been reported as a sole precursor for CVD in men (2-6). With the introduction of the phosphodiesterase-5 inhibitors, which can be coadministered with antihypertensive medications, there is now effective therapy for erectile dysfunction that has implications for systemic vascular disease (7). These drugs have additive effects on lowering BP and are recommended as a primary therapy for pulmonary hypertension (8). Although data are available to suggest that some antihypertensive medications affect erectile dysfunction more than others, the use of phosphodiesterase-5 inhibitors make drug class distinctions for erectile dysfunction less relevant (9). The long-term safety and efficacy of chronic administration of phosphodiesterase-5 inhibitors for the mitigation of CVD has yet to be determined and represents an important knowledge gap. References 1. Nunes KP, Labazi H, Webb RC. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens. 2012;21:163-70. 2. Johannes CB, Araujo AB, Feldman HA, et al. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study. J Urol. 2000;163:460-3. 3. Ayta IA, McKinlay JB, Krane RJ. The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU Int. 1999;84:50-6. 4. Thompson IM, Tangen CM, Goodman PJ, et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA. 2005;294:2996-3002. 5. Shin D, Pregenzer G Jr, Gardin JM. Erectile dysfunction: a disease marker for cardiovascular disease. Cardiol Rev. 2011;19:5-11. 6. Martin SA, Atlantis E, Lange K, et al. Predictors of sexual dysfunction incidence and remission in men. J Sex Med. 2014;11:1136-47. 7. Vasquez EC, Gava AL, Graceli JB, et al. Novel therapeutic targets for phosphodiesterase 5 inhibitors: current stateof-the-art on systemic arterial hypertension and atherosclerosis. Curr Pharm Biotechnol. 2016;17:347-64.

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Ghiadoni L, Versari D, Taddei S. Phosphodiesterase 5 inhibition in essential hypertension. Curr Hypertens Rep. 2008;10:52-7. Al Khaja KAJ, Sequeira RP, Alkhaja AK, et al. Antihypertensive drugs and male sexual dysfunction: a review of adult hypertension guideline recommendations. J Cardiovasc Pharmacol Ther. 2016;21:233-44.

11.5. Patients Undergoing Surgical Procedures Recommendations for Treatment of Hypertension in Patients Undergoing Surgical Procedures

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References that support recommendations are summarized in Online Data Supplements 57 and 58. COR LOE Recommendations Preoperative 1. In patients with hypertension undergoing major surgery who have been on I B-NR beta blockers chronically, beta blockers should be continued (1-7). 2. In patients with hypertension undergoing planned elective major surgery, it IIa C-EO is reasonable to continue medical therapy for hypertension until surgery. 3. In patients with hypertension undergoing major surgery, discontinuation of IIb B-NR ACE inhibitors or ARBs perioperatively may be considered (8-10). 4. In patients with planned elective major surgery and SBP of 180 mm Hg or IIb C-LD higher or DBP of 110 mm Hg or higher, deferring surgery may be considered (11, 12). III: 5. For patients undergoing surgery, abrupt preoperative discontinuation of B-NR Harm beta blockers or clonidine is potentially harmful (2, 13). III: 6. Beta blockers should not be started on the day of surgery in beta blocker– B-NR Harm naïve patients (14). Intraoperative 7. Patients with intraoperative hypertension should be managed with I C-EO intravenous medications (Table 19) until such time as oral medications can be resumed. Synopsis Hypertension in the perioperative period increases the risk of CVD, cerebrovascular events, and bleeding (15, 16). As many as 25% of patients who undergo major noncardiac surgery (17) and 80% of patients who have cardiac surgery experience perioperative hypertension (16, 18). In general, the level of risk is related to the severity of the hypertension. No high-quality RCTs were identified relating to the treatment of hypertension in patients undergoing major surgical procedures. One analysis evaluated data from 3 prospective, randomized, open-label, parallelcomparison studies in patients undergoing cardiac surgery and concluded that clevidipine is a safe and effective treatment for acute hypertension in patients undergoing cardiac surgery (19). Another systematic review and meta-analysis, including 4 studies, concluded that clevidipine is more effective than other antihypertensive drugs in the management of perioperative hypertension without adverse events (20). Several general strategies and principles based on experience and observation are recommended for this section. In the management of patients with perioperative hypertension, it is important to assess other potential contributing factors, such as volume status, pain control, oxygenation, and bladder distention, when the use of pharmacological therapy to control BP is under consideration. Uncontrolled hypertension is associated with increased perioperative and postoperative complications. Certain medications (e.g., beta blockers, clonidine) may be associated with rebound hypertension if discontinued abruptly (13). Therefore,

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline several general strategies and principles based on experience and observation are recommended for this section. These recommendations for beta blockers, ACE inhibitors, and ARBs are generally consistent with the “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery” and are provided to assist in the management of patients undergoing major noncardiac surgical procedures (21). Recommendation-Specific Supportive Text 1. If well tolerated, beta blockers should be continued in patients who are currently receiving them for longitudinal reasons, particularly when longitudinal treatment is provided according to GDMT, such as for MI (22). Multiple observational studies support the benefits of continuing beta blockers in patients who are undergoing surgery and who are on these agents for longitudinal indications (1-7).

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2. In the absence of conclusive RCTs, the expert opinion of this writing committee is that control of BP to levels recommended by the present guideline (BP <130/80 mm Hg) or other target levels specified for a particular individual is reasonable before undertaking major elective procedures in either the inpatient or outpatient setting. If the patient is unable to take oral medications, it is reasonable to use intravenous medications (Table 19) as necessary to control BP. Special consideration of placement on parenteral therapy usually occurs for patients taking clonidine or beta blockers because of the risk of stopping these medications acutely. Withdrawal syndromes, accompanied by sympathetic discharge and acute hypertension, can occur on cessation of these agents (13). 3. Data on the potential risk and benefit of ACE inhibitors in the perioperative setting are limited to observational analyses, and this area is controversial. Recent evidence from a large cohort study demonstrates that patients who stopped their ACE inhibitors or ARBs 24 hours before noncardiac surgery were less likely to suffer the primary composite outcome (all-cause death, stroke, or myocardial injury) and intraoperative hypotension than were those continuing these medications until surgery (10). 4. JNC 6 (23) noted conflicting evidence for patients with DBP >110 mm Hg and recommended delay of surgery for gradual reduction in DBP before proceeding with surgery. In a systematic review and meta-analysis of 30 observational studies, preoperative hypertension was associated with a 35% increase in cardiovascular complications (12). An increase in complications, including dysrhythmias, myocardial ischemia or infarction, neurological complications, and renal failure, has been reported in patients with DBP ≥110 mm Hg immediately before surgery (24). In contrast, patients with DBP <110 mm Hg do not appear to be at significantly increased risk (25). The relationship of systolic hypertension to surgical risk is less certain. Among patients undergoing carotid endarterectomy, increased risk of postoperative hypertension and neurological defects were observed (26), and an increased risk of CVD morbidity after coronary artery bypass graft surgery has been observed in patients with isolated systolic hypertension (27). During induction of anesthesia for surgery, sympathetic action can result in a 20– to 30–mm Hg increase in BP and a 15- to 20-bpm increase in heart rate among patients with normal BP (24). Exaggerated responses may occur in patients with poorly treated or untreated hypertension by as much as 90 mm Hg and 40 bpm (24). With further anesthesia, the accompanying inhibition of the sympathetic nervous system and loss of baroreceptor control may result in intraoperative hypotension. Lability in BP appears more likely in patients with poorly controlled hypertension (25), whereas studies have observed that patients with controlled hypertension respond similarly to those who are normotensive (28). Early work indicated that patients with severe hypertension (SBP >210 mm Hg and DBP >105 mm Hg) had exaggerated responses in BP during the induction of anesthesia (28). 5. Although few studies describe risks of withdrawing beta blockers in the perioperative time period (2, 5), longstanding evidence from other settings suggests that abrupt withdrawal of long-term beta blockers is

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline harmful (29-31). There are fewer data to describe whether short-term (1 to 2 days) perioperative use of beta blockers, followed by rapid discontinuation, is harmful (5, 14, 21, 30). 6. The 2014 ACC/AHA perioperative guideline specifically recommends against starting beta blockers on the day of surgery in beta-blocker–naive patients (5, 21, 30), particularly at high initial doses, in long-acting form, and if there are no plans for dose titration or monitoring for adverse events. Data from the POISE (Perioperative Ischemic Evaluation) study demonstrate the risk of initiating long-acting beta blockers on the day of surgery (14). 7. Several antihypertensive agents in a variety of pharmacological classes are available for the treatment of hypertensive emergencies (Table 19).

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References 1. Lindenauer PK, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349-61. 2. Shammash JB, Trost JC, Gold JM, et al. Perioperative beta-blocker withdrawal and mortality in vascular surgical patients. Am Heart J. 2001;141:148-53. 3. Wallace AW, Au S, Cason BA. Association of the pattern of use of perioperative β-blockade and postoperative mortality. Anesthesiology. 2010;113:794-805. 4. Andersson C, Merie C, Jorgensen M, et al. Association of β-blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing noncardiac surgery: a Danish nationwide cohort study. JAMA Intern Med. 2014;174:336-44. 5. Hoeks SE, Scholte Op Reimer WJM, van Urk H, et al. Increase of 1-year mortality after perioperative beta-blocker withdrawal in endovascular and vascular surgery patients. Eur J Vasc Endovasc Surg. 2007;33:13-9. 6. Barrett TW, Mori M, De Boer D. Association of ambulatory use of statins and beta-blockers with long-term mortality after vascular surgery. J Hosp Med. 2007;2:241-52. 7. London MJ, Hur K, Schwartz GG, et al. Association of perioperative β-blockade with mortality and cardiovascular morbidity following major noncardiac surgery. JAMA. 2013;309:1704-13. 8. Turan A, You J, Shiba A, et al. Angiotensin converting enzyme inhibitors are not associated with respiratory complications or mortality after noncardiac surgery. Anesth Analg. 2012;114:552-60. 9. Rosenman DJ, McDonald FS, Ebbert JO, et al. Clinical consequences of withholding versus administering reninangiotensin-aldosterone system antagonists in the preoperative period. J Hosp Med. 2008;3:319-25. 10. Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before noncardiac surgery: an analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort. Anesthesiology. 2017;126:16-27. 11. Fleisher LA. Preoperative evaluation of the patient with hypertension. JAMA. 2002;287:2043-6. 12. Howell SJ, Sear JW, Foex P. Hypertension, hypertensive heart disease and perioperative cardiac risk. Br J Anaesth. 2004;92:570-83. 13. Hart GR, Anderson RJ. Withdrawal syndromes and the cessation of antihypertensive therapy. Arch Intern Med. 1981;141:1125-7. 14. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing noncardiac surgery (POISE trial): a randomised controlled trial. POISE Study Group. Lancet. 2008;371:1839-47. 15. Charlson ME, MacKenzie CR, Gold JP, et al. The preoperative and intraoperative hemodynamic predictors of postoperative myocardial infarction or ischemia in patients undergoing noncardiac surgery. Ann Surg. 1989;210:637-48. 16. Cheung AT. Exploring an optimum intra/postoperative management strategy for acute hypertension in the cardiac surgery patient. J Card Surg. 2006;21(suppl 1):S8-14. 17. Dix P, Howell S. Survey of cancellation rate of hypertensive patients undergoing anaesthesia and elective surgery. Br J Anaesth. 2001;86:789-93. 18. Haas CE, LeBlanc JM. Acute postoperative hypertension: a review of therapeutic options. Am J Health Syst Pharm. 2004;61:1661-73.

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19. Aronson S, Dyke CM, Stierer KA, et al. The ECLIPSE trials: comparative studies of clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine for acute hypertension treatment in cardiac surgery patients. Anesth Analg. 2008;107:1110-21. 20. Espinosa A, Ripolles-Melchor J, Casans-Frances R, et al. Perioperative use of clevidipine: a systematic review and meta-analysis. PLoS ONE. 2016;11:e0150625. 21. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215-45. 22. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458-73. 23. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med. 1997;157:2413-46. 24. Wolfsthal SD. Is blood pressure control necessary before surgery? Med Clin North Am. 1993;77:349-63. 25. Goldman L, Caldera DL. Risks of general anesthesia and elective operation in the hypertensive patient. Anesthesiology. 1979;50:285-92. 26. Towne JB, Bernhard VM. The relationship of postoperative hypertension to complications following carotid endarterectomy. Surgery. 1980;88:575-80. 27. Aronson S, Boisvert D, Lapp W. Isolated systolic hypertension is associated with adverse outcomes from coronary artery bypass grafting surgery. Anesth Analg. 2002;94:1079-84. 28. Foex P, Meloche R, Prys-Roberts C. Studies of anaesthesia in relation to hypertension. 3. Pulmonary gas exchange during spontaneous ventilation. Br J Anaesth. 1971;43:644-61. 29. Gerber JG, Nies AS. Abrupt withdrawal of cardiovascular drugs. N Engl J Med. 1979;301:1234-5. 30. Rangno RE, Langlois S. Comparison of withdrawal phenomena after propranolol, metoprolol, and pindolol. Am Heart J. 1982;104:473-8. 31. Walker PR, Marshall AJ, Farr S, et al. Abrupt withdrawal of atenolol in patients with severe angina. Comparison with the effects of treatment. Br Heart J. 1985;53:276-82.

12. Strategies to Improve Hypertension Treatment and Control In addition to promoting pharmacological and nonpharmacological treatment adherence in individual patients with hypertension, several population-based systems approaches can play an important role in treatment goals.

12.1. Adherence Strategies for Treatment of Hypertension Therapeutic nonadherence (not following recommended medical or health advice, including failure to “persist” with medications and recommended lifestyle modifications) is a major contributor to poor control of hypertension and a key barrier to reducing CVD deaths. Adherence rates vary substantially in different populations and, in general, are lower for lifestyle change and more behaviorally demanding regimens.

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12.1.1. Antihypertensive Medication Adherence Strategies Recommendations for Antihypertensive Medication Adherence Strategies

References that support recommendations are summarized in Online Data Supplements 59 and 60. COR LOE Recommendations 1. In adults with hypertension, dosing of antihypertensive medication once I B-R daily rather than multiple times daily is beneficial to improve adherence (13). 2. Use of combination pills rather than free individual components can be IIa B-NR useful to improve adherence to antihypertensive therapy (4-7). Synopsis

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Up to 25% of patients do not fill their initial prescription for antihypertensive therapy (8-10). During the first year of treatment, the average patient has possession of antihypertensive medications only 50% of the time, and only 1 in 5 patients has sufficiently high adherence to achieve the benefits observed in clinical trials (11, 12). Factors contributing to poor adherence are myriad, complex, and multilevel (11, 13, 14). Therefore, solutions to improve adherence may be introduced at patient, provider, and healthcare system levels (13, 15, 16). Several systematic reviews and meta-analyses have assessed the impact of interventions on adherence to antihypertensive medications, including modification of antihypertensive therapy (1-7, 11, 15, 16). No single intervention is uniquely effective, and a sustained, coordinated effort that targets all barriers to adherence in an individual is likely to be the most effective approach. See Online Data Supplement F for barriers to medication adherence and the most successful interventions. The creation of an encouraging, blame-free environment in which patients are recognized for achieving treatment goals and given “permission” to answer questions related to their treatment honestly is essential to identify and address nonadherence. Patient medication adherence assessment tools (17) are presented in Online Data Supplement A. Members of the hypertension care team may use these self-report tools in a nonthreatening fashion to identify barriers and facilitate behaviors associated with improved adherence to antihypertensive medications. Use of more objective methods (e.g., pill counts, data on medication refills) to assess adherence along with self-report methods is optimal. Recommendation-Specific Supportive Text 1. Remembering to take medication is often challenging, particularly for regimens that must be dosed several times daily. Taking medications several times throughout the day requires greater attention to scheduling, as well as additional issues such as transportation or storage, which can be challenging for some patients. The impact of once-daily dosing of antihypertensive drugs versus dosing multiple times daily has been evaluated in several meta-analyses (1-3). Medication adherence was greatest with once-daily dosing (range 71% to 94%) and declined as dosing frequency increased (1, 2). 2. Assessment and possible modification of drug therapy regimens can improve suboptimal adherence. Simplifying medication regimens, either by less frequent dosing (i.e., once daily versus multiple times daily) or use of combination drug therapy, improves adherence. Available fixed-dose combination drug therapy is listed in Online Data Supplement D. References 1. Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001;23:1296-310. 2. Iskedjian M, Einarson TR, MacKeigan LD, et al. Relationship between daily dose frequency and adherence to antihypertensive pharmacotherapy: evidence from a meta-analysis. Clin Ther. 2002;24:302-16.

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10. 11. 12. 13. 14. 15. 16. 17.

Schroeder K, Fahey T, Ebrahim S. How can we improve adherence to blood pressure-lowering medication in ambulatory care? Systematic review of randomized controlled trials. Arch Intern Med. 2004;164:722-32. Bangalore S, Kamalakkannan G, Parkar S, et al. Fixed-dose combinations improve medication compliance: a metaanalysis. Am J Med. 2007;120:713-9. Gupta AK, Arshad S, Poulter NR. Compliance, safety, and effectiveness of fixed-dose combinations of antihypertensive agents: a meta-analysis. Hypertension. 2010;55:399-407. Sherrill B, Halpern M, Khan S, et al. Single-pill vs free-equivalent combination therapies for hypertension: a metaanalysis of health care costs and adherence. J Clin Hypertens (Greenwich). 2011;13:898-909. Yang W, Chang J, Kahler KH, et al. Evaluation of compliance and health care utilization in patients treated with single pill vs. free combination antihypertensives. Curr Med Res Opin. 2010;26:2065-76. Franklin SS, Thijs L, Hansen TW, et al. Significance of white-coat hypertension in older persons with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population. Hypertension. 2012;59:564-71. Holland N, Segraves D, Nnadi VO, et al. Identifying barriers to hypertension care: implications for quality improvement initiatives. Dis Manag. 2008;11:71-7. Berra E, Azizi M, Capron A, et al. Evaluation of adherence should become an integral part of assessment of patients with apparently treatment-resistant hypertension. Hypertension. 2016;68:297-306. Gwadry-Sridhar FH, Manias E, Lal L, et al. Impact of interventions on medication adherence and blood pressure control in patients with essential hypertension: a systematic review by the ISPOR medication adherence and persistence special interest group. Value Health. 2013;16:863-71. Petrilla AA, Benner JS, Battleman DS, et al. Evidence-based interventions to improve patient compliance with antihypertensive and lipid-lowering medications. Int J Clin Pract. 2005;59:1441-51. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011;86:304-14. Krousel-Wood MA, Muntner P, Islam T, et al. Barriers to and determinants of medication adherence in hypertension management: perspective of the cohort study of medication adherence among older adults. Med Clin North Am. 2009;93:753-69. Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2014;11:CD000011. Viswanathan M, Golin CE, Jones CD, et al. Closing the quality gap: revisiting the state of the science (vol. 4: medication adherence interventions: comparative effectiveness). Evid RepTechnol Assess (Full Rep). 2012;1-685. Kim MT, Hill MN, Bone LR, et al. Development and testing of the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Prog Cardiovasc Nurs. 2000;15:90-6.

12.1.2. Strategies to Promote Lifestyle Modification Recommendation for Strategies to Promote Lifestyle Modification

References that support the recommendation are summarized in Online Data Supplement 61. COR LOE Recommendations 1. Effective behavioral and motivational strategies to achieve a healthy lifestyle (i.e., tobacco cessation, weight loss, moderation in alcohol intake, I C-EO increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension (1, 2). Synopsis The primary lifestyle modification interventions that can help reduce high BP are outlined in Section 6 (healthy diet, weight loss, exercise and moderate alcohol intake). In addition, tobacco cessation is crucial for CVD risk reduction. These modifications are central to good health and require specific motivational and cognitive intervention strategies designed to promote adherence to these healthy behaviors. High-quality evidence supporting some of these strategies is provided in Online Data Supplement G. Additionally, interventions such as goal setting, provision of feedback, self-monitoring, follow-up, motivational interviewing, and promotion of self-sufficiency are most effective when combined. Most individuals have clear expectations about what a

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline new lifestyle will provide; if their experiences do not match these expectations, they will be dissatisfied and less motivated to maintain a lifestyle change, particularly in environments that do not support healthy choices. Other factors that may influence adoption and maintenance of new physical activity or dietary behaviors include age, sex, baseline health status, and body mass index, as well as the presence of comorbid conditions and depression, which negatively affect adherence to most lifestyle change regimens (1). Primary strategies include cognitive-behavioral strategies for promoting behavior change, intervention processes and delivery strategies, and addressing cultural and social context variables that influence behavioral change. Recommendation-Specific Supportive Text

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1. It is crucial to translate and implement into practice the most effective evidence-based strategies for adherence to nonpharmacological treatment for hypertension. Both adoption and maintenance of new CVD risk-reducing behaviors pose challenges for many individuals. Success requires consideration of race, ethnicity, and socioeconomic status, as well as individual, provider, and environmental factors that may influence the design of such interventions (1). High-quality evidence has shown that even modest sustained lifestyle changes can substantially reduce CVD morbidity and mortality (1). Because many beneficial effects of lifestyle changes accrue over time, long-term adherence maximizes individual and population benefits. Interventions targeting sodium restriction, other dietary patterns, weight reduction, and new physical activity habits often result in impressive rates of initial behavior changes but frequently are not translated into long-term behavioral maintenance. References 1. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 2010;122:406-41. 2. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S76-99.

12.1.3. Improving Quality of Care for Resource-Constrained Populations The availability of financial, informational, and instrumental support resources can be important though not sole determinants of hypertension control (1, 2). The management of hypertension in resource-constrained populations poses a challenge that will require the implementation of all recommendations discussed in Section 13 (Table 21), with specific sensitivity to challenges posed by limited financial resources, including those related to health literacy, alignment of and potential need to realign healthcare priorities by patients, the convenience and complexity of the management strategy, accessibility to health care, and health-related costs (including medications). Resource-constrained populations are also populations with high representation of groups most likely to manifest health disparities, including racial and ethnic minorities (see Section 10.1), residents located in rural areas, and older adults. The more comprehensive BP targets proposed in the present guideline will present added challenges in these populations. It is crucial to invest in measures to enhance health literacy and reinforce the importance of adhering to treatment strategies, while paying attention to cultural sensitivities. These measures may include identification of and partnering with community resources and organizations devoted to hypertension control and cardiovascular health. Although comparative-effectiveness data documenting efficacy of various interventions are limited, multidisciplinary team–based approaches and the use of community health workers (see Sections 12.1.1 and 12.2) have shown some utility, as has the use of out-of-office BP monitoring (or nocost BP control visits), particularly among resource-constrained populations (3-5). Long-acting once-daily medications (e.g., chlorthalidone, amlodipine) that are now available generically and often on discount formularies can often be used to reduce complexity of the regimen and promote adherence by decreasing the effect of missed medication dosages. When possible, prescriptions requiring longer than 30-day refills should Page 152

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline be considered, especially once a stable regimen is achieved. Where appropriate, using scored tablets and pill cutters can decrease the cost of medication for patients. References 1. Havranek EP, Mujahid MS, Barr DA, et al. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132:873-98. 2. Institute of Medicine (U.S.) Committee on Public Health Priorities to Reduce and Control Hypertension. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: National Academies Press; 2010. 3. Margolius D, Bodenheimer T, Bennett H, et al. Health coaching to improve hypertension treatment in a lowincome, minority population. Ann Fam Med. 2012;10:199-205. 4. Polgreen LA, Han J, Carter BL, et al. Cost-effectiveness of a physician-pharmacist collaboration intervention to improve blood pressure control. Hypertension. 2015;66:1145-51. 5. Brownstein JN, Chowdhury FM, Norris SL, et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. 2007;32:435-47. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

12.2. Structured, Team-Based Care Interventions for Hypertension Control Recommendation for Structured, Team-Based Care Interventions for Hypertension Control

References that support the recommendation are summarized in Online Data Supplement 62. COR LOE Recommendations 1. A team-based care approach is recommended for adults with hypertension I A (1-7).

Synopsis Team-based care to improve BP control is a health systems–level, organizational intervention that incorporates a multidisciplinary team to improve the quality of hypertension care for patients (8-10). Various team-based hypertension care models have been demonstrated to increase the proportion of individuals with controlled BP and to reduce both SBP and DBP (1-7, 11, 12). A team-based care approach is patient centered and is frequently implemented as part of a multifaceted approach, with systems support for clinical decision making (i.e., treatment algorithms), collaboration, adherence to prescribed regimen, BP monitoring, and patient self-management. Team-based care for hypertension includes the patient, the patient’s primary care provider, and other professionals, such as cardiologists, nurses, pharmacists, physician assistants, dietitians, social workers, and community health workers. These professionals complement the activities of the primary care provider by providing process support and sharing the responsibilities of hypertension care. Section 13 contains a comprehensive, patient-centered plan of care that should be the basis of all team-based care for hypertension. Team-based care aims to achieve effective control of hypertension by application of the strategies outlined in Online Data Supplement H (3). Delineation of individual team member roles on the basis of knowledge, skill set, and availability, as well as the patient’s needs, allows the primary care provider to delegate routine matters to the team, thereby permitting more time to manage complex and critical patientcare issues. Important implementation aspects, such as type of team member added, role of team members related to medication management, and number of team members, influence BP outcomes (3, 13). Team member roles should be clear to all team members and to patients and families. Team-based care often requires organizational change and reallocation of resources (14, 15). Systemslevel support, such as use of electronic health records (EHR) (see Section 12.3.1), clinical decision support (i.e., treatment algorithms), technology-based remote monitoring (see Section 12.3.2), self-management support tools, and monitoring of performance, are likely to augment and intensify team-based care efforts to reduce high BP.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Recommendation-Specific Supportive Text 1. RCTs and meta-analyses of RCTs of team-based hypertension care involving nurse or pharmacist intervention demonstrated reductions in SBP and DBP and/or greater achievement of BP goals when compared with usual care (1, 2, 4, 5). Similarly, systematic reviews of team-based care, including a review of studies that included community health workers, for patients with primary hypertension showed reductions in SBP and DBP and improvements in BP control, appointment keeping, and hypertension medication adherence as compared with usual care (3, 12).

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References 1. Carter BL, Rogers M, Daly J, et al. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med. 2009;169:1748-55. 2. Clark CE, Smith LFP, Taylor RS, et al. Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis. BMJ. 2010;341:c3995. 3. Proia KK, Thota AB, Njie GJ, et al. Team-based care and improved blood pressure control: a community guide systematic review. Am J Prev Med. 2014;47:86-99. 4. Santschi V, Chiolero A, Colosimo AL, et al. Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 2014;3:e000718. 5. Shaw RJ, McDuffie JR, Hendrix CC, et al. Effects of nurse-managed protocols in the outpatient management of adults with chronic conditions: a systematic review and meta-analysis. Ann Intern Med. 2014;161:113-21. 6. Thomas KL, Shah BR, Elliot-Bynum S, et al. Check it, change it: a community-based, multifaceted intervention to improve blood pressure control. Circ Cardiovasc Qual Outcomes. 2014;7:828-34. 7. Carter BL, Coffey CS, Ardery G, et al. Cluster-randomized trial of a physician/pharmacist collaborative model to improve blood pressure control. Circ Cardiovasc Qual Outcomes. 2015;8:235-43. 8. Himmelfarb CRD, Commodore-Mensah Y, Hill MN. Expanding the role of nurses to improve hypertension care and control globally. Ann Glob Health. 2016;82:243-53. 9. The Guide to Community Preventive Services (The Community Guide). Cardiovascular Disease: Team-Based Care to Improve Blood Pressure Control. 2012. Available at: http://www.thecommunityguide.org/findings/cardiovasculardisease-team-based-care-improve-blood-pressure-control. Accessed June 1, 2017. 10. Centers for Disease Control and Prevention. Task Force recommends team-based care for improving blood pressure control. Press Release. May 15, 2012. Available at: http://www.cdc.gov/media/releases/2012/p0515_bp_control.html. Accessed September 17, 2017. 11. Tsuyuki RT, Al Hamarneh YN, Jones CA, et al. The effectiveness of pharmacist interventions on cardiovascular risk: The Multicenter Randomized Controlled RxEACH Trial. J Am Coll Cardiol. 2016;67:2846-54. 12. Brownstein JN, Chowdhury FM, Norris SL, et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. 2007;32:435-47. 13. Brush JE Jr, Handberg EM, Biga C, et al. 2015 ACC health policy statement on cardiovascular team-based care and the role of advanced practice providers. J Am Coll Cardiol. 2015;65:2118-36. 14. Patient-Centered Primary Care Collaborative. The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes: Resource Guide. 2010. Available at: : http://www.pcpcc.org/sites/default/files/media/medmanagement.pdf. Accessed June 15, 2017. 15. Dunn SP, Birtcher KK, Beavers CJ, et al. The role of the clinical pharmacist in the care of patients with cardiovascular disease. J Am Coll Cardiol. 2015;66:2129-39.

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12.3. Health Information Technology–Based Strategies to Promote Hypertension Control 12.3.1. EHR and Patient Registries Recommendations for EHR and Patient Registries

References that support recommendations are summarized in Online Data Supplement 63. COR LOE Recommendations 1. Use of the EHR and patient registries is beneficial for identification of I B-NR patients with undiagnosed or undertreated hypertension (1-3). 2. Use of the EHR and patient registries is beneficial for guiding quality I B-NR improvement efforts designed to improve hypertension control (1-3). Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Synopsis A growing number of health systems are developing or using registries and EHR that permit large-scale queries to support population health management strategies to identify undiagnosed or undertreated hypertension. Such innovations are implemented as ongoing quality improvement initiatives in clinical practice. To reduce undiagnosed hypertension and improve hypertension management, a multipronged approach may include 1) application of hypertension screening algorithms to EHR databases to identify at-risk patients, 2) contacting at-risk patients to schedule BP measurements, 3) monthly written feedback to clinicians about at-risk patients who have yet to complete a BP measurement, and 4) electronic prompts for BP measurements whenever atrisk patients visit the clinic (1, 2). Recommendation-Specific Supportive Text 1. A growing number of health systems have implemented secure EHR and are developing databases that permit large-scale queries to support population health management strategies for more effective and accurate identification of patients with hypertension (1-3). 2. A growing number of health systems have implemented secure EHR and are developing databases that permit large-scale quality improvement initiative–designed queries to support population health management strategies for more effective management and control of hypertension (1-3). References 1. Rakotz MK, Ewigman BG, Sarav M, et al. A technology-based quality innovation to identify undiagnosed hypertension among active primary care patients. Ann Fam Med. 2014;12:352-8. 2. Borden WB, Maddox TM, Tang F, et al. Impact of the 2014 expert panel recommendations for management of high blood pressure on contemporary cardiovascular practice: insights from the NCDR PINNACLE registry. J Am Coll Cardiol. 2014;64:2196-203. 3. Jaffe MG, Lee GA, Young JD, et al. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310:699-705.

12.3.2. Telehealth Interventions to Improve Hypertension Control Recommendation for Telehealth Interventions to Improve Hypertension Control

References that support the recommendation are summarized in Online Data Supplement 64. COR LOE Recommendations 1. Telehealth strategies can be useful adjuncts to interventions shown to IIa A reduce BP for adults with hypertension (1-5).

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Telehealth strategies, such as telemedicine, digital health (“eHealth”), and use of mobile computing and communication technologies (“mHealth”), are new and innovative tools to facilitate improvements in managing patients with hypertension. mHealth interventions show promise in reducing SBP in patients with hypertension but with large variability in behavioral targets, intervention components, delivery modalities, and patient engagement (5). In addition, there are important implications for the role of social networks, social media, and electronic technology as viable components of weight management and other lifestyle modification and disease management programs (6). Commonly used telehealth interventions for hypertension management are listed in Online Data Supplement I. Wireless technologies (Online Data Supplement I) allow linking BP devices and other measurement devices to telephone- or Internet-based transmission systems or to Wi-Fi access points available in users’ homes and in communities. Some systems require patients to manually enter data, which is then forwarded to a remote computer or the mobile device of the telehealth provider through a telephone line or the Internet (7). When data are received, they are stored and analyzed, and reports are generated, including variations and averages in BP and other parameters over the recording period. Recommendation-Specific Supportive Text 1. Meta-analyses of RCTs of different telehealth interventions have demonstrated greater SBP and DBP reductions (1, 2, 4) and a larger proportion of patients achieving BP control (2) than those achieved with usual care without telehealth. The effect of various telehealth interventions on BP lowering was significantly greater than that of BP self-monitoring without transmission of BP data, which suggests a possible added value of the teletransmission approach (1, 3). Although mHealth interventions in general showed promise in reducing SBP in patients with hypertension, results were inconsistent (5). It is unclear which combination of telehealth intervention features is most effective, and telehealth has not been demonstrated to be effective as a standalone strategy for improving hypertension control. References 1. Omboni S, Gazzola T, Carabelli G, et al. Clinical usefulness and cost effectiveness of home blood pressure telemonitoring: meta-analysis of randomized controlled studies. J Hypertens. 2013;31:455-67; discussion 467-8. 2. Verberk WJ, Kessels AGH, Thien T. Telecare is a valuable tool for hypertension management, a systematic review and meta-analysis. Blood Press Monit. 2011;16:149-55. 3. Agarwal R, Bills JE, Hecht TJW, et al. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension. 2011;57:29-38. 4. Liu S, Dunford SD, Leung YW, et al. Reducing blood pressure with Internet-based interventions: a meta-analysis. Can J Cardiol. 2013;29:613-21. 5. Burke LE, Ma J, Azar KMJ, et al. Current science on consumer use of mobile health for cardiovascular disease prevention: a scientific statement from the American Heart Association. Circulation. 2015;132:1157-213. 6. Li JS, Barnett TA, Goodman E, et al. Approaches to the prevention and management of childhood obesity: the role of social networks and the use of social media and related electronic technologies: a scientific statement from the American Heart Association. Circulation. 2013;127:260-7. 7. Omboni S, Ferrari R. The role of telemedicine in hypertension management: focus on blood pressure telemonitoring. Curr Hypertens Rep. 2015;17:535.

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12.4. Improving Quality of Care for Patients With Hypertension 12.4.1. Performance Measures Recommendation for Performance Measures

References that support the recommendation are summarized in Online Data Supplement 65. COR LOE Recommendations 1. Use of performance measures in combination with other quality IIa B-NR improvement strategies at patient-, provider-, and system-based levels is reasonable to facilitate optimal hypertension control (1-3). Synopsis

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Efforts to improve suboptimal medical care include the use of performance measures, which are defined as standardized, validated approaches to assess whether correct healthcare processes are being performed and that desired patient outcomes are being achieved (4). Performance measures are often combined with other quality improvement strategies, such as certification or financial incentives tied to higher-quality care (5). Guidelines help define clinical care standards that can be used to develop performance measures. As guidelines evolve over time to incorporate new evidence, related performance measures may also evolve. Because identification, treatment, and control of hypertension are suboptimal, performance measures for hypertension control have been developed and recommended for use in quality improvement projects aimed at improving hypertension control and related outcomes in clinical practice (6-8). Because the specific methods used in performance measures can have an impact on their accuracy and ultimate impact (e.g., the method of BP measurement used in the assessment), they should be developed, tested, and implemented according to published standards (9). See Online Data Supplement J for publicly available performance measures to assess the quality of hypertension care (generally using JNC 7 criteria). Recommendation-Specific Supportive Text 1. RCTs on the impact of performance measures on hypertension control are lacking; RCTs of quality improvement protocols have shown improvements in hypertension control (1, 2). Furthermore, a large observational study showed that a systematic approach to hypertension control, including the use of performance measures, was associated with significant improvement in hypertension control compared with historical control groups (3). References 1. Svetkey LP, Pollak KI, Yancy WS Jr, et al. Hypertension improvement project: randomized trial of quality improvement for physicians and lifestyle modification for patients. Hypertension. 2009;54:1226-33. 2. de Lusignan S, Gallagher H, Jones S, et al. Audit-based education lowers systolic blood pressure in chronic kidney disease: the Quality Improvement in CKD (QICKD) trial results. Kidney Int. 2013;84:609-20. 3. Jaffe MG, Lee GA, Young JD, et al. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310:699-705. 4. Performance Management and Measurement. U.S. Department of Health and Human Services, Health Resources and Services Administration; 2011. Available at: http://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/performancemanagementandmeasurement.pdf . Accessed October 30, 2017. 5. Bardach NS, Wang JJ, De Leon SF, et al. Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial. JAMA. 2013;310:1051-9. 6. Navar-Boggan AM, Shah BR, Boggan JC, et al. Variability in performance measures for assessment of hypertension control. Am Heart J. 2013;165:823-7. 7. Drozda J Jr, Messer JV, Spertus J, et al. ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart

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8. 9.

Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement. Circulation. 2011;124:248-70. Powers BJ, Olsen MK, Smith VA, et al. Measuring blood pressure for decision making and quality reporting: where and how many measures? Ann Intern Med. 2011;154:781-8, W-289-90. Bonow RO, Douglas PS, Buxton AE, et al. ACCF/AHA methodology for the development of quality measures for cardiovascular technology: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures. Circulation. 2011;124:1483-502.

12.4.2. Quality Improvement Strategies Recommendation for Quality Improvement Strategies

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References that support the recommendation are summarized in Online Data Supplements 66 and 67. COR LOE Recommendations 1. Use of quality improvement strategies at the health system, provider, and IIa B-R patient levels to improve identification and control of hypertension can be effective (1-8). Synopsis High-quality BP management is multifactorial and requires the engagement of patients, families, providers, and healthcare delivery systems (9). The difference between patient outcomes achieved with current hypertension treatment methods and patient outcomes thought to be possible with best-practice treatment methods is known as a quality gap, and such gaps are at least partly responsible for the loss of thousands of lives each year (10). This includes expanding patient and healthcare provider awareness, appropriate lifestyle modifications, access to care, evidence-based treatment, a high level of medication adherence, and adequate follow-up (9). Quality improvement strategies or interventions aimed at reducing the quality gap for a group of patients who are representative of those encountered in routine practice have been effective in improving the hypertension care and outcomes across a wide variety of clinic and community settings (1-4, 6, 8, 10). Hypertension quality improvement strategies, with examples of substrategies that have been demonstrated to reduce BP and improve BP, are provided in Online Data Supplement E. Because the effects of the different quality improvement strategies varied across trials, and most trials included >1 quality improvement strategy, it is not possible to discern which specific quality improvement strategies have the greatest effects. Team-based care (see Section 12.4) and an organized system of regular review, with antihypertensive drug therapy implemented via a stepped-care protocol, had a clinically significant effect on reducing SBP and DBP and improving BP control. The assessed strategies in Online Data Supplement E may be beneficial under some circumstances and in varying combinations (1-5). National initiatives such as Million Hearts Make Control Your Goal Blood Pressure Toolkit and Team Up Pressure Down provide quality improvement tools to support hypertension care in communities and clinical settings (11). For other national and regional initiatives to improve hypertension, see Online Data Supplement G. Recommendation-Specific Supportive Text 1. Systematic review and meta-analyses of trials of quality improvement interventions at health system, provider, and patient levels have demonstrated greater SBP and DBP reductions and a larger proportion of patients achieving BP control than those observed with no intervention or usual care. Multicomponent and multilevel strategies at the local community and healthcare delivery system levels have been shown to improve BP control (6, 7). References 1. Walsh JME, McDonald KM, Shojania KG, et al. Quality improvement strategies for hypertension management: a systematic review. Med Care. 2006;44:646-57.

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Carter BL, Rogers M, Daly J, et al. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med. 2009;169:1748-55. 3. Glynn LG, Murphy AW, Smith SM, et al. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2010;CD005182. 4. Proia KK, Thota AB, Njie GJ, et al. Team-based care and improved blood pressure control: a community guide systematic review. Am J Prev Med. 2014;47:86-99. 5. Anchala R, Pinto MP, Shroufi A, et al. The role of Decision Support System (DSS) in prevention of cardiovascular disease: a systematic review and meta-analysis. PLoS ONE. 2012;7:e47064. 6. Thomas KL, Shah BR, Elliot-Bynum S, et al. Check it, change it: a community-based, multifaceted intervention to improve blood pressure control. Circ Cardiovasc Qual Outcomes. 2014;7:828-34. 7. Jaffe MG, Lee GA, Young JD, et al. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310:699-705. 8. Agarwal R, Bills JE, Hecht TJW, et al. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension. 2011;57:29-38. 9. Go AS, Bauman MA, Coleman King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension. 2014;63:878-85. 10. Walsh J, McDonald KM, Shojania KG, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 3: Hypertension Care). Rockville, MD: Agency for Healthcare Research and Quality (U.S.), 2005. 11. Center for Medicare and Medicaid Services. Million Hearts: Cardiovascular Disease Risk Reduction Model. 2016. Available at: http://innovation.cms.gov/initiatives/Million-Hearts-CVDRRM/. Accessed October 30, 2017.

12.5. Financial Incentives Recommendations for Financial Incentives

References that support recommendations are summarized in Online Data Supplement 68. COR LOE Recommendations 1. Financial incentives paid to providers can be useful in achieving IIa B-R improvements in treatment and management of patient populations with hypertension (1-3). 2. Health system financing strategies (e.g., insurance coverage and copayment IIa B-NR benefit design) can be useful in facilitating improved medication adherence and BP control in patients with hypertension (4). Synopsis With the evolution of the U.S. health system to reward “value over volume,” payment systems have focused on financial incentives to improve quality of care. Use of performance measures promulgated by national organizations, governmental payers, and commercial payers have fostered greater attention to control of high BP among healthcare providers and their patients. These performance measures have formed the basis for determining financial incentives for pay for performance initiatives, commercial insurer “pay-for-value” contracts, and the Medicare Shared Savings Programs developed by the Centers for Medicare & Medicaid Services Innovation for Accountable Care Organizations. In addition, the Centers for Medicare and Medicaid Services has developed The Million Hearts: Cardiovascular Disease Risk Reduction Model, which is an RCT designed to identify and test scalable models of care delivery that reduce CVD risk (5). Greater attention is being paid to the influence of health insurance coverage and benefit designs focused on reducing patient copayments for antihypertensive medications. Recommendation-Specific Supportive Text 1. Moderate-quality evidence with mixed results suggests that population-based payment incentive programs can play an important role in achieving better BP control (1-3).

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline 2. Reduced copayments for health care, including for medications, and improved outcomes of hypertension care have been identified in several U.S. studies and in single studies in Finland, Israel, and Brazil (4). This is consistent with other evidence on how copayments reduce uptake of care and has implications for policy makers, particularly because the balance of evidence does not suggest that reducing medication copayments leads to an increase in overall healthcare expenditure.

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References 1. Hysong SJ, Simpson K, Pietz K, et al. Financial incentives and physician commitment to guideline-recommended hypertension management. Am J Manag Care. 2012;18:e378-91. 2. Petersen LA, Simpson K, Pietz K, et al. Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial. JAMA. 2013;310:1042-50. 3. Karunaratne K, Stevens P, Irving J, et al. The impact of pay for performance on the control of blood pressure in people with chronic kidney disease stage 3-5. Nephrol Dial Transplant. 2013;28:2107-16. 4. Maimaris W, Paty J, Perel P, et al. The influence of health systems on hypertension awareness, treatment, and control: a systematic literature review. PLoS Med. 2013;10:e1001490. 5. Center for Medicare and Medicaid Services. Million Hearts: Cardiovascular Disease Risk Reduction Model. 2016. Available at: http://innovation.cms.gov/initiatives/Million-Hearts-CVDRRM/. Accessed October 30, 2017.

13. The Plan of Care for Hypertension COR

LOE

I

C-EO

Recommendation for the Plan of Care for Hypertension Recommendation 1. Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals, encourages effective management of comorbid conditions, prompts timely follow-up with the healthcare team, and adheres to CVD GDMT (Table 22).

Synopsis A specific plan of care for hypertension is essential and should reflect understanding of the modifiable and nonmodifiable determinants of health behaviors, including the social determinants of risk and outcomes. A clinician’s sequential flow chart for management of hypertension is presented in Table 21. Detailed evidencebased elements of the plan of care are listed in Table 22. The determinants will vary among demographic subgroups (see Section 10 for additional information). Recommendation-Specific Supportive Text 1. Studies demonstrate that implementation of a plan of care for hypertension can lead to sustained reduction of BP and attainment of BP targets over several years (1). Meta-analysis of RCTs shows reductions in BP of patients with hypertension and achievement of BP goals at 6 months and 1 year when compared with usual care.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 21. Clinician’s Sequential Flow Chart for the Management of Hypertension

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Clinician’s Sequential Flow Chart for the Management of Hypertension Measure office BP accurately Section 4 Detect white coat hypertension or masked Section 4 hypertension by using ABPM and HBPM Evaluate for secondary hypertension Section 5 Identify target organ damage Sections 5 and 7 Introduce lifestyle interventions Section 6 Identify and discuss treatment goals Sections 7 and 8 Use ASCVD risk estimation to guide BP threshold for Section 8.1.2 drug therapy Align treatment options with comorbidities Section 9 Account for age, race, ethnicity, sex, and special Sections 10 and 11 circumstances in antihypertensive treatment Initiate antihypertensive pharmacological therapy Section 8 Insure appropriate follow-up Section 8 Use team-based care Section 12 Connect patient to clinician via telehealth Section 12 Detect and reverse nonadherence Section 12 Detect white coat effect or masked uncontrolled Section 4 hypertension Use health information technology for remote Section 12 monitoring and self-monitoring of BP ABPM indicates ambulatory blood pressure monitoring; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; and HBPM, home blood pressure monitoring.

13.1. Health Literacy Communicating alternative behaviors that support self-management of healthy BP in addition to medication adherence is important. This should be done both verbally and in writing. Today, mobile phones have a recording option. For patients with mobile phones, the phone can be used to inform patients and family members of medical instructions after the doctor’s visit as an additional level of communication. Inclusion of a family member or friend that can help interpret and encourage self-management treatment goals is suggested when appropriate. Examples of needed communication for alternative behaviors include a specific regimen relating to physical activity; a specific sodium-reduced meal plan indicating selections for breakfast, lunch, and dinner; lifestyle recommendations relating to sleep, rest, and relaxation; and finally, suggestions and alternatives to environmental barriers, such as barriers that prevent healthy food shopping or limit reliable transportation to and from appointments with health providers and pharmacy visits.

13.2. Access to Health Insurance and Medication Assistance Plans Health insurance and medication plan assistance for patients is especially important to improving access to and affordability of medical care and BP medications. Learning how the patient financially supports and budgets for his or her medical care and medications offers the opportunity to share additional insight relating to cost reductions, including restructured payment plans. Ideally, this would improve the patient’s compliance with medication adherence and treatment goals.

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13.3. Social and Community Services Health care can be strengthened through local partnerships. Hypertensive patients, particularly patients with lower incomes, have more opportunity to achieve treatment goals with the assistance of strong local partnerships. In patients with low socioeconomic status or patients who are challenged by social situations, integration of social and community services offers complementary reinforcement of clinically identified treatment goals. Social and community services are helpful when explicitly related to medical care. However, additional financial support and financial services are incredibly beneficial to patients, some of whom may choose to skip a doctor’s appointment to pay a residential utility bill.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 22. Evidence-Based Elements of the Plan of Care for Patients With Hypertension Plan of Care

Associated Section(s) of Guideline and Other Reference(s)

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Pharmacological and nonpharmacological treatments Medication selection (initial and ongoing) Monitoring for adverse effects and adherence Nonpharmacological interventions • Diet • Exercise • Weight loss if overweight • Moderate alcohol consumption Management of common comorbidities and conditions Ischemic heart disease Heart failure • Reduced ejection fraction • Preserved ejection fraction Diabetes mellitus Chronic kidney disease Cerebrovascular disease Peripheral arterial disease Atrial fibrillation Valvular heart disease Left ventricular hypertrophy Thoracic aortic disease Patient and family education Achieving BP control and self-monitoring Risk assessment and prognosis Sexual activity and dysfunction Special patient groups Pregnancy Older persons Children and adolescents Metabolic syndrome Possible secondary causes of hypertension Resistant hypertension Patients with hypertension undergoing surgery Renal transplantation Psychosocial factors Sex-specific issues Culturally sensitive issues (race and ethnicity) Resource constraints Clinician follow-up, monitoring, and care coordination Follow-up visits Team-based care Electronic health record Health information technology tools for remote and self-monitoring Socioeconomic and cultural factors Health literacy Access to health insurance and medication assistance plans Social services

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Section 8.1 Sections 8.3.1, 8.3.2, 12.1.1 Sections 6, 12.1.2 (2)

Section 9.1 (3, 4) Section 9.2 (5)

Section 9.6 (6) Section 9.3 Section 9.4 Section 9.5 Section 9.8 Section 9.9 Section 7.3 Section 9.10 Sections 4.2, 8.2 Section 8.1.2 Section 11.4 Section 10.2.2 Section 10.3.1 Section 10.3.2 Section 9.7 Section 5.4 Section 11.1 Section 11.5 Section 9.3.1 Section 10.2 Section 10.1 Section 12.5 Sections 8.1.3, 8.3.1, 8.3.2 Section 12.2 Section 12.3.1 Section 12.3.2 Section 13.1.3 Section 13.1.3 Section 13.1.3

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Community services BP indicates blood pressure.

Section 13.1.3

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References 1. Jaffe MG, Young JD. The Kaiser Permanente Northern California story: improving hypertension control from 44% to 90% in 13 years (2000 to 2013). J Clin Hypertens (Greenwich). 2016;18:260-1. 2. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458-73. 3. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014;130:1749-67. 4. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126:e354-471. 5. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240-327. 6. Standards of Medical Care in Diabetes--2016: Summary of Revisions. Diabetes Care. 2016;39(suppl 1):S4-5.

14. Summary of BP Thresholds and Goals for Pharmacological Therapy Several different BP thresholds and goals for the long-term treatment of hypertension with pharmacological therapy are recommended in this guideline. To provide a quick reference for practicing clinicians, these are summarized for hypertensive patients in general and for those with specific comorbidities in Table 23.

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Table 23. BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions Clinical Condition(s)

BP Threshold, mm Hg

BP Goal, mm Hg

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General Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80 No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80 Older persons (≥65 years of age; noninstitutionalized, ≥130 (SBP) <130 (SBP) ambulatory, community-living adults) Specific comorbidities Diabetes mellitus ≥130/80 <130/80 Chronic kidney disease ≥130/80 <130/80 Chronic kidney disease after renal transplantation ≥130/80 <130/80 Heart failure ≥130/80 <130/80 Stable ischemic heart disease ≥130/80 <130/80 Secondary stroke prevention ≥140/90 <130/80 Secondary stroke prevention (lacunar) ≥130/80 <130/80 Peripheral arterial disease ≥130/80 <130/80 ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

15. Evidence Gaps and Future Directions In the present guideline, the writing committee was able to call on the large body of literature on BP and hypertension to make strong recommendations across a broad range of medical conditions. Nonetheless, significant gaps in knowledge exist. Importantly, there are areas where epidemiological and natural history studies suggest that hypertension prevention or earlier treatment of hypertension might substantially improve outcomes, but clinical trials are lacking to provide guidance. The combination of epidemiological data showing a graded relationship between BP and outcomes, particularly above a BP of 120/80 mm Hg, and the results of the SPRINT trial showing benefit of more comprehensive treatment to a target BP of <120/80 mm Hg, suggests that a lifelong BP below that level will substantially lower CVD and CKD incidence. This is especially the case for younger individuals, those with DM, and those with high lifetime CVD risk based on the presence of multiple risk factors, including high BP. If hard, cardiovascular outcome clinical trials remain the sole driver of evidence-based guidelines, then determining the full benefit of earlier intervention may not be possible because of the cost and length of time needed for intervention. Outcomes may be different if antihypertensive treatment is initiated earlier in the natural history of CVD. DM may provide a population in whom to test this hypothesis. Composite outcomes that include both prevention of events and surrogates, such as prevention of decline in renal function or amelioration of measures of subclinical atherosclerosis, vascular stiffness, or LV structure and function, should be considered. Otherwise, these younger individuals may be undertreated and experience mortality or CVD events before being old enough to enter hard outcome–driven trials such as SPRINT. Replication of SPRINT, especially in younger patients with DM and in countries where nonischemic stroke is the predominant cause of CVD, is highly desirable. Likewise, implementation studies that demonstrate the practicality of SPRINT-like interventions in resource-constrained practice settings are needed. More information is urgently needed relating hypertensive target organ damage to CVD risk and outcomes. Should the identification of target organ damage and hypertensive heart disease prompt more aggressive BP management (i.e., increase the rationale for instituting pharmacological therapy earlier or more intensively? Should all patients with hypertension be screened with echocardiogram for LVH? Should

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echocardiography be repeated once LVH is noted? Is it important to document LVH regression? At present, there are no RCT data to inform guideline recommendations. ABPM and HBPM provide enhanced ability to both diagnose hypertension and monitor treatment. Although evidence is sufficient to recommend incorporating these tools into clinical practice, more knowledge about them is required. Areas of inquiry include closer mapping of the relationship of outcomes to ambulatory and home BP measurements, so that definitions of hypertension and hypertension severity based on these measures can be developed, including the importance of masked hypertension, white coat hypertension, and nocturnal hypertension. Reproducibility of ambulatory and home BPs must be studied, and cohorts should include a broader range of ethnicities. Trials with entry criteria and treatment goals based on ambulatory or home BP measures should be conducted, including studies of masked and white coat hypertension. The practicality and cost of incorporating ABPM into EHR and routine care should be assessed. The existence of these techniques should not hamper efforts to investigate ways to improve accuracy in the measurement of clinic BP. Further research on improving accuracy of office BP measurements, including number of measurements, training of personnel measuring BP, and device comparisons, will help standardize care and thus improve outcomes. Technology for measurement of BP continues to evolve with the emergence of cuffless devices and other strategies that provide the opportunity for continuous noninvasive assessment of BP. The accuracy, cost, and usefulness of these new technologies will need to be assessed. The contemporary healthcare environment is dramatically different from the era in which awareness of hypertension as a risk factor and benefits of treatment were discovered. With the advent of the EHR, complex calculations of CVD risk and renal function can be incorporated into routine reports, and many new avenues to support intervention strategies are available to clinicians. Optimizing these approaches will require continued focused research. Recognition that simply applying what we know about BP control would have a large impact on population health, observations on inefficiencies and excessive cost in the U.S. healthcare system, and the growth of information technology have led to promising studies of ways to improve and monitor hypertension care. Results of this research are reflected in this guideline, but further work is required. Examples for study include the effectiveness of multidisciplinary healthcare teams to achieve BP treatment goals at lower cost, social media to maintain contact with patients, information technology to monitor outcomes and decrease practice variability, and incentives to providers to achieve better outcomes for patients. A key goal of these efforts should be to demonstrate reduction in healthcare disparities across ethnicity, sex, social and economic class, and age barriers. More research on the prevention of the development of hypertension and the benefit of lifetime low BP should be conducted. In this regard, elucidation of genetic expression, epigenetic effects, transcriptomics, and proteomics that link genotypes with longitudinal databases may add considerable knowledge about beneficial outcomes of lifelong lower BP, determinants of rise in BP over time, and identification of new treatment targets through understanding the underlying pathophysiological mechanisms. Research should be directed toward the development of therapies that directly counteract the mechanisms accounting for the development of hypertension and disease progression. Additional research aimed at development of practical approaches to implementation of clinical and population-based strategies to prevent obesity, increase physical fitness, and control excess salt and sugar intake could have significant public health impact. In addition, there are minimal, if any, data on whether treatment of hypertension during pregnancy mitigates risk; thus, there is a need for further research in this area, considering both proximate (during the pregnancy and postpartum period) and distant (CVD prevention) outcomes (1). In the very old, frailty and higher risk of medication side effects complicate treatment. Additional knowledge of the effects of antihypertensive treatment for patients with dementia and patients who reside in long-term-care facility settings is needed. The best approach to older persons who have supine hypertension but postural hypotension needs to be clarified. Further research related to shared decision-making with patients and their families is needed. Examples include areas where evidence does not clearly identify one treatment or goal as substantially better

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline than another, where improved patient knowledge (or improved provider knowledge of the patient’s circumstances) might improve compliance, where reliance on patient collaboration improves achievement of outcomes (e.g., HBPM, use of social media), and where there are competing health concerns (e.g., older individuals with frailty). Finally, clinical guidelines are increasingly required to manage the large body of accumulated knowledge related to diagnosis and management of high BP. However, guidelines often cause controversy and confusion when competing recommendations are made by different “expert” groups or when changes in definitions, treatments, or treatment goals are introduced. Now may be the time to begin the investigation of the impact of guidelines on clinical practice, costs, and patient outcomes, as well as ways to facilitate communication and collaboration between different guideline-developing organizations. This document is, as its name implies, a guide. In managing patients, the responsible clinician’s judgment remains paramount. Reference 1. Moser M, Brown CM, Rose CH, et al. Hypertension in pregnancy: is it time for a new approach to treatment? J Hypertens. 2012;30:1092-100. Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Presidents and Staff American College of Cardiology Mary Norine Walsh, MD, MACC, President Shalom Jacobovitz, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publishing MaryAnne Elma, MPH, Senior Director, Science, Education, Quality, and Publishing Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/American Heart Association Katherine A. Sheehan, PhD, Director, Guideline Strategy and Operations Abdul R. Abdullah, MD, Science and Medicine Advisor Naira Tahir, MPH, Associate Guideline Advisor American Heart Association John J. Warner, MD, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Jody Hundley, Production Manager, Scientific Publications, Office of Science Operations Key Words: ACC/AHA Clinical Practice Guidelines; blood pressure; hypertension; ambulatory care; antihypertensive agents; behavior modification; risk reduction; treatment adherence; treatment outcomes; Systems of care, hypertension emergency, secondary hypertension, blood pressure, measurement, diabetes, chronic kidney disease, resistant hypertension, nonpharmacologic treatment, lifestyle measures

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Appendix 1. Author Relationships With Industry and Other Entities (Relevant)—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 (October 2017)

Committee Member Paul K. Whelton (Chair)

Robert M. Carey (Vice Chair)

Wilbert S. Aronow

Donald E. Casey, Jr

Employment Tulane University School of Hygiene and Tropical Medicine—Show Chwan Professor of Global Public Health University of Virginia—Dean Emeritus and University Professor, Department of Medicine Westchester Medical Center and New York Medical College— Professor of Medicine Thomas Jefferson College of Population Health—Adjunct Faculty; Alvarez & Marsal Ipo4health— Principal and Founder

Consultant None

Speakers Bureau None

Ownership/ Partnership /Principal None

Personal Research None

Institutional, Organizational, or Other Financial Benefit None

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Expert Witness None

Salary None

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Cheryl Dennison Himmelfarb

Sondra M. DePalma

Samuel Gidding

David C. Goff, Jr*

Collins Collaboration— President John Hopkins University— Professor of Nursing and Medicine, Institute for Clinical and Translational Research PinnacleHealth CardioVascular Institute— Physician Assistant; American Academy of PAs—Director, Regulatory and Professional Practice Alfred I. Dupont Hospital for Children—Chief, Division of Pediatric Cardiology, Nemours Cardiac Center Colorado School of Public Health— Professor and Dean, Department of Epidemiology

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Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline Kenneth A. Jamerson Downloaded from http://hyper.ahajournals.org/ by guest on February 27, 2018

Danie W. l Jones

Eric J. MacLaughlin

University of Michigan Health System— Professor of Internal Medicine and Frederick G.L. Huetwell Collegiate Professor of Cardiovascular Medicine University of Mississippi Medical Center— Professor of Medicine and Physiology; Metabolic Diseases and Nutrition— University Sanderson Chair in Obesity Mississippi Center for Obesity Research— Director, Clinical and Population Science Texas Tech University Health Sciences Center— Professor and Chair, Department of Pharmacy Practice, School of Pharmacy

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Bruce Ovbiagele

Sidney C. Smith, Jr

Crystal C. Spencer Randall S. Stafford

Sandra J. Taler

University of Alabama at Birmingham— Professor, Department of Epidemiology Medical University of South Carolina— Pihl Professor and Chairman of Neurology University of North Carolina at Chapel Hill— Professor of Medicine; Center for Cardiovascular Science and Medicine— Director Spencer Law, PA—Attorney at Law Stanford Prevention Research Center— Professor of Medicine; Program on Prevention Outcomes— Director Mayo Clinic— Professor of Medicine, College of Medicine

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Mayo Clinic— None None None None None None None Medical Director, Cardiac Rehabilitation Program Kim A. Williams, Sr Rush University None None None None None None None Medical Center— James B. Herrick Professor; Division of Cardiology— Chief Jeff D. Williamson Wake Forest None None None None None None None Baptist Medical Center— Professor of Internal Medicine; Section on Gerontology and Geriatric Medicine—Chief Jackson T. Wright, Jr Case Western None None None None None None None Reserve University— Professor of Medicine; William T. Dahms MD Clinical Research Unit— Program Director; University Hospitals Case Medical Center— Director, Clinical Hypertension Program This table represents the relationships of committee members with industry and other entities (RWI) that are considered relevant to this document. Although most ACC/AHA guideline writing committees are constituted such that no more than half the members may have relevant RWI for 1 year before and during development of the guideline, rules for the prevention guidelines require that no members have relevant RWI from 1 year before appointment until 1 year after publication of the guideline. Members’ RWI were

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reviewed and updated at all meetings and conference calls of the writing committee during the document development period. The complete ACC/AHA policy on RWI is available at http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy. We gratefully acknowledge the contributions of Dr. Lawrence Appel, who served as a member of the Writing Committee from November 2014 to September 2015. *Dr. David C. Goff resigned from the writing committee in December 2016 because of a change in employment before the recommendations were balloted. The writing committee thanks him for his contributions, which were extremely beneficial to the development of the draft. AAPA indicates American Academy of Physician Assistants; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; ABC, Association of Black Cardiologists; NMA, National Medical Association; and PCNA, Preventive Cardiovascular Nurses Association.

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Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive)—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 (October 2017)

Reviewer

Representati on

Employment

Consultant

Kim K. Birtcher

Official Reviewer— TFPG Lead Reviewer

University of Houston College of Pharmacy— Clinical Professor, Department of Pharmacy Practice and Translational Research

Roger Blumenthal

Official Reviewer— Prevention Subcommitt ee

Johns Hopkins None Hospital— Kenneth Jay Pollin Professor of Cardiology; Ciccarone Center for the Prevention of Heart Disease— Director

• Jones & Bartlett Learning

Speakers Bureau

Ownership/ Partnership/ Principal

Personal Research

Institutional, Organizational, or Other Financial Benefit

Expert Witness

Salary

None

None

None

• Accreditation Council for Clinical Lipidology†

None

• Walgreens*

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None

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Anna Dominiczak

Official Reviewer— AHA

University of Glasgow— Regius Professor of Medicine; Vice-Principal and Head of College of Medical, Veterinary and Life Sciences

None

None

None

None

None

None

None

Carlos M. Ferrario

Official Reviewer— AHA

Wake Forest School of Medicine— Professor, of Physiology and Pharmacology; Hypertension and Vascular Disease Center— Director

None

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None

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None

Eugene Yang

Official Reviewer— ACC-BOG

University of Washington School of Medicine— Associate Clinical Professor of Medicine; UW Medicine Eastside Specialty Center— Medical Director

• RubiconMD* • Regeneron*

None

None

• Amgen Inc.* • Gilead Sciences, Inc. (DSMB)*

None

• Third party, CAD, 2016*

None

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Robert Jay Amrien

Organization al Reviewer— AAPA

Massachusetts General Hospital— Clinical Physician Assistant, Chelsea Health Center; Bryant University— Physician Assistant Program

None

None

None

None

None

• Defendant None , aortic dissection, 2016*

Greg Holzman

Organization Montana al Reviewer Department of —ACPM Public Health and Human Services—State Medical Officer

None

None

None

None

• American Academy of Family Medicine† • American College of Preventive Medicine†

None

None

None

None

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None

• REATA (spouse)*

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None

Martha Gulati Organization al Reviewer— ASPC

University of Arizona College of Medicine— Professor of Medicine; Chief, Division of Cardiology; University Medicine Cardiovascular Institute in Phoenix— Physician Executive Director, Banner

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Wallace Johnson

Organization al Reviewer— NMA

University of Maryland Medical Center— Assistant Professor of Medicine

None

None

None

Amgen†

None

None

None

Nancy Houston Miller

Organization al Reviewer— PCNA

The Lifecare Company— Associate Director

• Moving Analytics*

None

None

None

None

None

None

Aldo J. Peixoto

Organization al Reviewer— ASH

Yale University School of Medicine— Professor of Medicine (Nephrology); Associate Chair for Ambulatory Services Operations and Quality, Department of Internal Medicine; Clinical Chief, Section of Nephrology

• Lundbeck Inc.

None

None

None • Bayer Healthcare • Bayer Pharmaceuticals† Healthcare Pharmaceuticals

None

Carlos Rodriguez

Organization al Reviewer— ABC

Wake Forest University— Professor, Epidemiology and Prevention

• Amgen Inc.

None

None

None

None

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None

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Joseph Saseen

Organization al Reviewer— APhA

University of Colorado Anschutz Medical Campus—ViceChair, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences

None

None

None

None

• National Lipid Association†

• Defendant None , statin use, 2016

Mark Supiano Organization al Reviewer— AGS

University of Utah School of Medicine—D. Keith Barnes, MD, and Dottie Barnes Presidential Endowed Chair in Medicine; Chief, Division of Geriatrics; VA Salt Lake City Geriatric Research— Director, Education, and Clinical Center; University of Utah Center on Aging Executive— Director

None

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None

• American Geriatrics Society† • Division Chief† • McGraw-Hill Medical

None

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Sana M. AlKhatib

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

Duke Clinical Research Institute— Professor of Medicine

None

None

None

• AHRQ* • Elsevier* • FDA* • NIH, NHLBI • PCORI* • VA Health System (DSMB)

George Bakris Content Reviewer

University of Chicago Medicine— Professor of Medicine; Director, Hypertensive Diseases Unit

None

None

None

• AbbVie, Inc. • Janssen, Bayer, Relypsa

None

None

None

Jan Basile

Content Reviewer

Medical University of South Carolina— Professor of Medicine, Seinsheimer Cardiovascular Health Program; Ralph H Johnson VA Medical Center— Internist

None

• Amgen Inc. • Arbor • Janssen Pharmace uticals, Inc

None

• Eli Lilly and Company • NHLBI

None

None

None

Joshua A. Beckman

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

Vanderbilt • AstraZeneca* University • Merck* Medical Center: • SANOFI* Director, Cardiovascular Fellowship Program,

None

• EMX† • JanaCare†

• Bristol Myers Squibb*

• Vascular Interventional Advances *

None

• 2015Defendant; Venous thromboemb olism*

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None • Third party, implantabl e cardiverte r defibrillato rs, 2017

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John Bisognano

Content Reviewer

University of Rochester Medical Center— Cardiologist

None

None

• CVRx* • NIH*

None

None

None

Biykem Bozkurt

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

Baylor College None of Medicine— Medical Care Line Executive, Cardiology Chief, Gordon Cain Chair, Professor of Medicine, Debakey

None

None

• Novartis Corporation

None

None

None

David Calhoun

Content Reviewer

University of Alabama, Birmingham School of Medicine— Professor, Department of Cardiovascular Disease

None • Novartis • Valencia Technologies*

None

• MEDTRONIC* • ReCor Medical*

None

None

None

• CVRx

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Joaquin E. Cigarroa

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

Oregon Health and Science University— Clinical Professor of Medicine

None

None

None

• NIH

• ACC/AHA • Defendant None Taskforce on , CAD, Clinical Practice 2011† Guidelines† • Defendant • AHA, Board of , sudden Directors, death/CAD Western , 2010† Affiliate† • American Stroke Association, Cryptogenic Stroke Initiative Advisory Committee† • Catheterization and Cardiovascular Intervention† • SCAI Quality Interventional Council†

William Cushman

Content Reviewer

Memphis VA Medical Center—Chief, Preventive Medicine Section; University of Tennessee College of Medicine— Professor, Medicine, Preventive Medicine, and Physiology

None

None

None

• Lilly

• Novartis Corporation† • Takeda†

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None

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Anita Deswal

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

Baylor College of Medicine-Associate Professor of Medicine,

None

None

None

• NIH *

• bAurora Health Care Inc. • American Heart Association† • AHA Committee on Heart Failure and Transplantation – Chair† • Heart Failure Society of America†

None

None

Dave Dixon

Content Reviewer— Cardiovascul ar Team

Virginia None Commonwealth University School of Pharmacy— Associate Professor

None

None

None

None

None

None

Winnipeg • GSK* Regional Health • Servier* Authority— • Valeant Medical Pharmaceutic Director, als Cardiac International Sciences * Program; University of Manitoba— Professor of Medicine

None

None

None

None

None

None

Ross Feldman Content Reviewer

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Keith Ferdinand

Content Reviewer

Tulane University School of Medicine— Professor of Clinical Medicine

Stephan Fihn

Content Reviewer

University of None Washington— Professor of Medicine, Heath Services; Division Head, General Internal Medicine; Director, Office of Analytics and Business Intelligence for the Veterans Health Administration; VA Puget Sound Health Care System— General Internist

• Amgen Inc.* • Boehringer Ingelheim* • Eli Lilly* • SanofiAventis* • Novartis • Quantum Genomics • SanofiAventis*

None

None

None

• Novartis

None

None

None

None

None

• University of Washington

None

None

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Lawrence Fine

Content Reviewer

National Heart, None Lung and Blood Institute— Chief, Clinical Applications and Prevention Branch, Division of Prevention and Population Sciences

None

None

None

John Flack

Content Reviewer

Southern Illinois University School of Medicine— Chair and Professor Department of Internal Medicine; Chief, Hypertension Specialty Services

• Regeneron* • NuSirt

None

None

• Bayer Healthcare • American Pharmaceuticals† Journal of Hypertension* • GSK† • CardioRenal Medicine† • International Journal of Hypertension† • Southern Illinois University Department of Medicine*

Joseph Flynn

Content Reviewer

Seattle Children's Hospital—Chief of the Division of Nephrology; University of Washington School of Medicine— Professor of Pediatrics

• Ultragenyx, Inc. (DSMB)

None

None

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• NIH*

• UpToDate, Springer*

None

None

None

None

None

None

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Federico Gentile

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

Centro Cardiologico

None

None

None

None

None

None

None

Joel Handler

Content Reviewer

Kaiser None Permanente— Physician; National Kaiser Permanente Hypertension— Clinical Leader

None

None

None

None

None

None

Hani Jneid

Content Reviewer— ACC/AHA Task Force on Clinical Data Standards

Baylor College of Medicine— Associate Professor of Medicine, MEDVAMC

None

None

None

None

None

None

None

José A. Joglar

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

UT Southwestern Medical Center— Professor of Internal Medicine; Cardiovascular Clinical Research Center— Director

None

None

None

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None

None

None

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Amit Khera

Content Reviewer

University of Texas Southwestern Medical Center— Assistant Professor of Medicine

None

None

None

None

None

Glenn N. Levine

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

Baylor College of Medicine— Professor of Medicine; Director, Cardiac Care Unit

None

None

None

None

None

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None

• Defendant None , catherizati on laboratory procedure, 2016 • Defendant , interpretat ion of ECG of a patient, 2014 • Defendant , interpretat ion of angiogram (non-ACS), 2014 • Defendant , out-ofhospital death, 2016

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Giuseppe Mancia

Content Reviewer

University of MilanBicocca— Professor of Medicine; Chairman, Department of Clinical Medicine, Prevention and Applied Biotechnologies

None • Boehringer Ingelheim* • CVRx • Ferrer • MEDTRONIC • Menarini International* • Recordati • Servier International* • Actavis

None

None

• Novartis*

None

None

Andrew Miller

Content Reviewer— Geriatric Cardiology Section

Cardiovascular Associates— Cardiologist

None

None

None

• Novartis Corporation† • Pfizer Inc†

• Bristol-Myers Squibb Company • Janssen Pharmaceuticals , Inc. • NIH

None

None

Pamela Morris

Content Reviewer— Prevention Council, Chair

Seinsheimer • Amgen Inc. Cardiovascular • AstraZeneca Health • Sanofi Program— Regeneron Director; Women's Heart Care Medical University of South Carolina— CoDirector

None

None

• Amgen Inc.

None

None

None

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Martin Myers Content Reviewer

Sunnybrook • Ideal Life Inc* Health Sciences Centre— Affiliate Scientist; University of Toronto— Professor, Cardiology

None

None

None

None

None

None

Rick Nishimura

Content Reviewer

Mayo Clinic None College of Medicine— Judd and Mary Morris Leighton Professor of Medicine; Mayo Clinic— Division of Cardiovascular Diseases

None

None

None

None

None

None

Patrick T. O’Gara

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

Harvard Medical School— Professor of Medicine; Brigham and Women's Hospital— Director, Strategic Planning, Cardiovascular Division

None

None

None

• MEDTRONIC • NIH*

None

None

None

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Suzanne Oparil

Content Reviewer

University of Alabama at Birmingham— Distinguished Professor of Medicine; Professor of Cell, Developmental and Integrative Biology, Division of Cardiology

None • Actelion • Lundbeck • Novo Nordisk, Inc.

None

• AstraZeneca (Duke University)* • Bayer Healthcare Pharmaceuticals, Inc.* • Novartis* • NIH*

Carl Pepine

Content Reviewer— CV Disease in Women Committee

Shands Hospital None at University of Florida— Professor of Medicine, Chief of Cardiovascular Medicine

None

None

None • Capricor, Inc. • NIH • Cytori Therapeutics, Inc. • Sanofi-Aventis • InVentive Health Clinical. LLC

Mahboob Rahman

Content Reviewer

Case Western Reserve University School of Medicine— Professor of Medicine

None

None

None

None

None

None

None

Vankata Ram

Content Reviewer

UT None Southwestern Medical Center; Apollo Institute for Blood Pressure Clinics

None

None

None

None

None

None

Page 189

• NIH/NHLBI, • Takeda WHF/ESH/EPH

None

None

None

None

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Barbara Riegel

Content Reviewer— ACC/AHA Task Force on Clinical Practice Guidelines

University of Pennsylvania School of NursingProfessor

None

None

None

• Co-Investigatormentor† • Co-investigator NIH • NIH grant • PCORI

• Novartis Corp †

None

None

Edward Roccella

Content Reviewer

National Heart, Lung, and Blood Institute— Coordinator, National High Blood Pressure Education Program

• Medical University of South Carolina

None

None

None

• American Society of Hypertension† • Consortium for Southeast Hypertension Control† • Consortium Southeast Hypertension Control • Inter American Society of Hypertension†

None

None

Ernesto Schiffrin

Content Reviewer

Jewish General Hospital— Physician-inChief, Chief of the Department of Medicine and Director of the Cardiovascular Prevention Centre; McGill University— Professor, Department of Medicine, Division of Experimental Medicine

• Novartis • Servier

• Novartis

None

• Servier* • CME Medical Grand Rounds • Canadian Institutes for Health Research*

None

None

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Raymond Townsend

Content Reviewer

University of • MEDTRONIC Pennsylvania School of Medicine— Professor of Medicine; Director, Hypertension Section, Department of Internal Medicine/Renal ; Institute for Translational Medicine and Therapeutics— Member

None

None

• NIH*

• ASN • UpToDate

None

None

Michael Weber

Content Reviewer

SUNY Downstate College of Medicine— Professor of Medicine

• Menarini* • Merck & Co., Inc.*

None

None

None

None

None

• Ablative Solutions* • Allergan, Inc • Astellas Pharma US* • Boston Scientific* • Eli Lilly and Company • MEDTRONIC* • Novartis • Recor

This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review, including those not deemed to be relevant to this document, at the time this document was under review. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories or additional information about the ACC/AHA Disclosure Policy for Writing Committees. *Significant relationship. †No financial benefit.

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AHRQ indicates Agency for Healthcare Research and Quality; AAPA, American Academy of Physician Assistants; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; ABC, Association of Black Cardiologists; BOG, Board of Governors; CME, continuing medical education; DSMB, Data and Safety Monitoring Board; FDA, U.S. Food and Drug Administration; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; NMA, National Medical Association; PCNA, Preventive Cardiovascular Nurses Association; PCORI, Patient-Centered Outcomes Research Institute; SCAI, Society for Cardiovascular Angiography and Interventions; SUNY, State University of New York; TFPG, Task Force on Practice Guidelines; and UT, University of Texas.

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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 Paul K. Whelton, Robert M. Carey, Wilbert S. Aronow, Donald E. Casey, Jr, Karen J. Collins, Cheryl Dennison Himmelfarb, Sondra M. DePalma, Samuel Gidding, Kenneth A. Jamerson, Daniel W. Jones, Eric J. MacLaughlin, Paul Muntner, Bruce Ovbiagele, Sidney C. Smith, Jr, Crystal C. Spencer, Randall S. Stafford, Sandra J. Taler, Randal J. Thomas, Kim A. Williams, Sr, Jeff D. Williamson and Jackson T. Wright, Jr Hypertension. published online November 13, 2017; Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2017 American Heart Association, Inc. All rights reserved. Print ISSN: 0194-911X. Online ISSN: 1524-4563

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hyper.ahajournals.org/content/early/2017/11/10/HYP.0000000000000065.citation

Data Supplement (unedited) at: http://hyper.ahajournals.org/content/suppl/2017/11/13/HYP.0000000000000065.DC1 http://hyper.ahajournals.org/content/suppl/2017/11/13/HYP.0000000000000065.DC2

Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Hypertension can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Hypertension is online at: http://hyper.ahajournals.org//subscriptions/

Author Relationships With Industry and Other Entities (Comprehensive)—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 (October 2017)

Committee Member Paul K. Whelton (Chair)

Robert M. Carey (Vice Chair)

Wilbert S. Aronow

Donald E. Casey, Jr

Karen J. Collins

Employment Tulane University School of Hygiene and Tropical Medicine—Show Chwan Professor of Global Public Health University of Virginia—Dean Emeritus and University Professor, Department of Medicine Westchester Medical Center and New York Medical College—Professor of Medicine Thomas Jefferson College of Population Health—Adjunct Faculty; Alvarez & Marsal Ipo4health— Principal and Founder Collins Collaboration— President

Institutional, Organizational, or Other Financial Benefit None

Expert Witness None

Salary None

Consultant None

Speakers Bureau None

Ownership/ Partnership/ Principal None

None

None

None

• NIH†

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

• North Carolina A&T State University Alumni Association‡

None

None

© 2017 by the American College of Cardiology Foundation and the American Heart Association, Inc.

Personal Research • NIH–SPRINT trial† (PI)

Cheryl Dennison Himmelfarb

Sondra M. DePalma

Samuel Gidding

David C. Goff, Jr*

Kenneth A. Jamerson

John Hopkins University— Professor of Nursing and Medicine, Institute for Clinical and Translational Research PinnacleHealth CardioVascular Institute—Physician Assistant; American Academy of PAs— Director, Regulatory and Professional Practice Alfred I. Dupont Hospital for Children—Chief, Division of Pediatric Cardiology, Nemours Cardiac Center Colorado School of Public Health— Professor and Dean, Department of Epidemiology University of Michigan Health System—Professor of Internal Medicine and Frederick G.L. Huetwell Collegiate Professor of Cardiovascular Medicine

• MedThink Communicatio ns

None

None

• Helene Fuld Health Trust† • NIH†

• Preventive Cardiovascular Nurses Association‡

None

None

• American Society of Hypertension

None

None

None

• Accreditation Council for Clinical Lipidology‡

None

None

• Familial Hypercholester olemia Foundation‡ • Regenxbio

None

None

• Familial Hypercholesterolemia Foundation‡ • NIH†

• Cardiology Division Head‡

None

None

None

None

None

None

None

None

None

• American Society of Hypertension

None

None

• NIH/NIDDK/NHLBI†

• American Society of Hypertension‡ • International Society of Hypertension In Blacks‡ • Bayer Healthcare Pharmaceuticals

None

None

© 2017 by the American College of Cardiology Foundation and the American Heart Association, Inc.

Daniel W. Jones

Eric J. MacLaughlin

Paul Muntner

Bruce Ovbiagele

Sidney C. Smith, Jr

University of Mississippi Medical Center— Professor of Medicine and Physiology; Metabolic Diseases and Nutrition— University Sanderson Chair in Obesity Mississippi Center for Obesity Research— Director, Clinical and Population Science Texas Tech University Health Sciences Center— Professor and Chair, Department of Pharmacy Practice, School of Pharmacy

None

None

None

None

None

None

None

• American Society of Hypertension

None

None

None

None

None

University of Alabama at Birmingham— Professor, Department of Epidemiology Medical University of South Carolina— Pihl Professor and Chairman of Neurology University of North Carolina at Chapel Hill—Professor of Medicine; Center for Cardiovascular Science and Medicine—Director

• Amgen Inc. • National Center for Health Statistics†

None

None

• AHA† • Amgen Inc.† • NIH†

• AHA‡ • American College of Clinical Pharmacy‡ • American Pharmacists Association‡ • Texas Tech University Health Sciences Center† • NIH None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

© 2017 by the American College of Cardiology Foundation and the American Heart Association, Inc.

None

None

None

• AHA‡ • Dermatologic Surgery Associates† • Hospital Corporation of America† None

None

None

None

None

None

None

None

None

None

None

None

• American Society of Hypertension Clinical Specialist Program† • American Society of Nephrology† None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

Crystal C. Spencer

Spencer Law, PA— Attorney at Law

None

None

None

Randall S. Stafford

Stanford Prevention Research Center— Professor of Medicine; Program on Prevention Outcomes— Director Mayo Clinic— Professor of Medicine, College of Medicine

None

None

None

None

None

Mayo Clinic— Medical Director, Cardiac Rehabilitation Program Rush University Medical Center— James B. Herrick Professor; Division of Cardiology— Chief Wake Forest Baptist Medical Center— Professor of Internal Medicine; Section on Gerontology and Geriatric Medicine—Chief

None

Sandra J. Taler

Randal J. Thomas

Kim A. Williams, Sr

Jeff D. Williamson

© 2017 by the American College of Cardiology Foundation and the American Heart Association, Inc.

None

Jackson T. Wright, Jr

Case Western Reserve University— Professor of Medicine; William T. Dahms MD Clinical Research Unit—Program Director; University Hospitals Case Medical Center— Director, Clinical Hypertension Program

None

None

None

None

• Northeast Ohio Neighborhood Health Centers‡

None

None

This table represents all relationships of committee members with industry and other entities that were reported by authors, including those not deemed to be relevant to this document, at the time this document was under development. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories or additional information about the ACC/AHA Disclosure Policy for Writing Committees. We gratefully acknowledge the contributions of Dr. Lawrence Appel, who served as a member of the Writing Committee from November 2014 to September 2015. *Dr. David C. Goff resigned from the writing committee in December 2016 due to a change in employment before the recommendations were balloted. The writing committee thanks him for his contributions, which were extremely beneficial to the development of the draft. †Significant relationship. ‡No financial benefit. AAPA indicates American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; NMA, National Medical Association; PCNA, Preventive Cardiovascular Nurses Association; and PI, principal investigator.

© 2017 by the American College of Cardiology Foundation and the American Heart Association, Inc.

2017 Hypertension Guideline Data Supplements

2017 Hypertension Guideline Data Supplements (Section numbers correspond to the full-text guideline.)

Table of Contents Data Supplement 1. Coexistence of Hypertension and Related Chronic Conditions (Section 2.4) ................................................................................................................................. 7 Data Supplement 2. Definition of High BP (Section 3.1).................................................................................................................................................................................................. 8 Data Supplement 3. Out-of-Office and Self-Monitoring of BP (Section 4.2) .................................................................................................................................................................. 18 Data Supplement 4. White Coat Hypertension (Section 4.4) ......................................................................................................................................................................................... 21 Data Supplement 5. White Coat Hypertension (Prevalence) (Section 4.4) ................................................................................................................................................................... 23 Data Supplement 6. White Coat Hypertension (Correlation with Clinical Outcomes) (Section 4.4) .............................................................................................................................. 25 Data Supplement 7. Renal Artery Stenosis (Section 5.4.3) ........................................................................................................................................................................................... 27 Data Supplement 8. RCTs Comparing Obstructive Sleep Apnea (Section 5.4.4) ......................................................................................................................................................... 29 Data Supplement 9. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Dietary Fiber Intake) (Section 6.2) .................................................................................. 31 Data Supplement 10. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Fish Oil) (Section 6.2) ................................................................................................... 33 Data Supplement 11. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Potassium Supplementation to Placebo or Usual Diet) (Section 6.2) ........................... 34 Data Supplement 12. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Protein Intake on BP) (Section 6.2)............................................................................... 36 Data Supplement 13. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Sodium Reduction to Placebo or Usual Diet) (Section 6.2) .......................................... 38 Data Supplement 14. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Stress Reduction) (Section 6.2) .................................................................................... 43 Data Supplement 15. RCTs and Meta-analyses Studying the Effect of Nonpharmacologic Interventions on BP (Dietary Patterns) (Section 6.2) ...................................................... 44 Data Supplement 16. RCTs and Meta-analysis RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Alcohol Reduction) (Section 6.2) .......................................... 51 Data Supplement 17. RCTs and Meta-analysis RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Calcium Supplementation) (Section 6.2) .............................. 55 Data Supplement 18. RCTs and Meta-analyses RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Physical Activity) (Section 6.2) ............................................ 56

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Data Supplement 19. RCTs and Meta-analysis RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Magnesium Supplementation) (Section 6.2) ......................... 59 Data Supplement 20. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Weight Loss) (Section 6.2) ............................................................................................ 61 Data Supplement 21. RCTs and Systematic Reviews for RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Section 6.2) ........................................................... 64 Data Supplement 22. Observational Studies of CV Target Organ Damage Including LVH (Section 7.2) ..................................................................................................................... 66 Data Supplement 23. RCTs on Use of Risk Estimation to Guide Treatment of Hypertension (Section 8.1.2) .............................................................................................................. 67 Data Supplement 24. Follow-Up After Initial BP Evaluation (Section 8.1.3) .................................................................................................................................................................. 81 Data Supplement 25. RCTs for General Principles of Drug Therapy (Combination Therapies that Inhibit the RAAS) (Section 8.1.4) ......................................................................... 83 Data Supplement 26. BP Goal for Patients with Hypertension (Section 8.1.5)............................................................................................................................................................. 85 Data Supplement 27. Choice of Initial Medication (Section 8.1.6) ................................................................................................................................................................................. 92 Data Supplement 28. Follow-Up After Initiating Antihypertensive Drug Therapy (Section 8.3.1) .................................................................................................................................. 95 Data Supplement 29. Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP (Section 8.3.2) ................................................................................ 97 Data Supplement 30. RCTs Comparing Stable Ischemic Heart Disease (Section 9.1) ............................................................................................................................................... 100 Data Supplement 31. Meta-analyses of ischemic heart disease (Section 9.1) ............................................................................................................................................................ 110 Data Supplement 32. Nonrandomized Trials, Observational Studies, and/or Registries of Ischemic Heart Disease (Section 9.1) ............................................................................ 111 Data Supplement 33. RCTs Comparing Heart Failure (Section 9.2) ........................................................................................................................................................................... 112 Data Supplement 34. RCTs Comparing HFrEF (Section 9.2.1) .................................................................................................................................................................................. 113 Data Supplement 35. RCTs Comparing HFpEF (Section 9.2.2).................................................................................................................................................................................. 119 Data Supplement 36. Nonrandomized Trials, Observational Studies, and/or Registries of HFpEF (Section 9.2.2) .................................................................................................... 122 Data Supplement 37. RCTs Comparing CKD (Section 9.3) ........................................................................................................................................................................................ 123 Data Supplement 38. Nonrandomized Trials, Observational Studies, and/or Registries of CKD (Section 9.3)........................................................................................................... 133 Data Supplement 39. RCTs Comparing Hypertension after Renal Transplantation (Section 9.3.1) ........................................................................................................................... 137 Data Supplement 40. Nonrandomized Trials, Observational Studies, and/or Registries for Hypertension after Renal Transplantation (Section 9.3.1) ............................................ 140 Data Supplement 41. RCTs Comparing Acute Intracerebral Hemorrhage Outcomes (Section 9.4.1) ....................................................................................................................... 143 Data Supplement 42. RCTs Comparing Acute Ischemic Stroke Outcomes (Section 9.4.2) ........................................................................................................................................ 147 Data Supplement 43. RCTs Comparing Secondary Stroke Prevention (Section 9.4.3) ............................................................................................................................................. 158 Data Supplement 44. Nonrandomized Trials, Observational Studies, and/or Registries of Secondary Stroke Prevention (Section 9.4.3) ................................................................ 161 © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Data Supplement 45. RCTs and Meta-analysis Comparing PAD (Section 9.5) .......................................................................................................................................................... 168 Data Supplement 46. RCTs and Meta-analyses Comparing BP Targets in DM (Section 9.6) .................................................................................................................................... 174 Data Supplement 47. Nonrandomized Trials, Observational Studies, and/or Registries in DM (Section 9.6) ............................................................................................................ 183 Data Supplement 48. Atrial Fibrillation (Section 9.8) ................................................................................................................................................................................................... 190 Data Supplement 49. Valvular Heart Disease (Section 9.9) ........................................................................................................................................................................................ 191 Data Supplement 50. RCTs and Meta-analysis Comparing Valvular Heart Disease (Section 9.9) ............................................................................................................................. 194 Data Supplement 51. RCTs Comparing Race/Ethnicity (Section 10.1) ....................................................................................................................................................................... 197 Data Supplement 52. RCTs Comparing Women With Hypertension (Section 10.2.1) ................................................................................................................................................ 201 Data Supplement 53. RCTs Comparing Pregnancy (Section 10.2.2) .......................................................................................................................................................................... 203 Data Supplement 54. RCT for Older Persons (Section 10.3.1) ................................................................................................................................................................................... 204 Data Supplement 55. RCTs Comparing Hypertensive Crises and Emergencies (Section 11.2) ................................................................................................................................ 204 Data Supplement 56. RCTs Assessing Impact of Hypertension Therapy on Dementia Incidence (Section 11.3) ...................................................................................................... 207 Data Supplement 57. RCTs for Patients Undergoing Surgical Procedures (Section 11.5) ......................................................................................................................................... 210 Data Supplement 58. Observational and Nonrandomized Studies for Patients Undergoing Surgical Procedures (Section 11.5) .............................................................................. 211 Data Supplement 59. RCTs of Adherence and Compliance with Fixed Dose Combinations Regimens (Section 12.1.1) .......................................................................................... 213 Data Supplement 60. Nonrandomized Trials, Observational Studies, and/or Registries of Antihypertensive Medication Adherence Strategies (Section 12.1.1)............................ 214 Data Supplement 61. RCTs and Meta-analysis on Strategies to Promote Lifestyle Modification (Section 12.1.2) ..................................................................................................... 220 Data Supplement 62. RCTs, Meta-analyses, and Systematic Reviews on the Effect of Structured, Team-based Care Interventions for Hypertension Control (Section 12.2)........ 221 Data Supplement 63. Electronic Health Records and Patient Registries (Section 12.3.1) .......................................................................................................................................... 227 Data Supplement 64. RCTs, Meta-analyses, and Systematic Reviews on the Effect of Telehealth Interventions to Improve Hypertension Control (Section 12.3.2)....................... 232 Data Supplement 65. RCTs and Observational Studies that Report on the Effect of Performance Measures and on Hypertension Control (Section 12.4.1) .................................. 236 Data Supplement 66. RCTs, Meta-analyses, and Systematic Reviews on Quality Improvement Strategies on Hypertension Treatment Outcomes (Section 12.4.2) ..................... 238 Data Supplement 67. Nonrandomized Trials, Observational Studies, and/or Registries of Effect of Quality Improvement Strategies on Hypertension Treatment Outcomes (Section 12.4.2) .......................................................................................................................................................................................................................................................................... 244 Data Supplement 68. RCTs Comparing Financial Incentives (Section 12.5) ............................................................................................................................................................. 245 Additional Data Supplement Tables and Figures......................................................................................................................................................................................................... 252 © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Data Supplement A. Treatment of HFrEF Stages C and D ..................................................................................................................................................................................... 252 Data Supplement B. Medication Adherence Assessment Scales ........................................................................................................................................................................... 253 Data Supplement C. Categories Defining Normal BP, Elevated BP, and Stages 1, 2, and 3 Hypertension ........................................................................................................... 253 Data Supplement D. Fixed-Dose Combination Antihypertensive Drugs ................................................................................................................................................................. 255 Data Supplement E. Examples of Hypertension Quality Improvement Strategies .................................................................................................................................................. 256 Data Supplement F. Barriers and Improvement Strategies in Antihypertensive Medication Adherence (350-354) ................................................................................................ 257 Data Supplement G. Examples of Strategies to Promote Lifestyle Modification Interventions in Patients With Hypertension (319,320,356-362)................................................. 258 Data Supplement H. Responsibilities and Roles of the Hypertension Team........................................................................................................................................................... 259 Data Supplement I. Examples of Telehealth Strategies and Technologies to Promote Effective Hypertension Management ............................................................................... 260 Data Supplement J. Publicly Available Performance Measures Used to Assess Hypertension Care Quality Services (364-368) ......................................................................... 261 Data Supplement K. Online Quality Improvement Resources for Treatment and Control of Hypertension ............................................................................................................ 263 References................................................................................................................................................................................................................................................................... 264

Search Terms: 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, devises, 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; intervention; lifestyle: measures, modification; office visits; patient outcome; performance measures; physical activity; potassium intake; protein intake; renin inhibitor; risk reduction: behavior, counseling; screening; sphygmomanometers; spironolactone; therapy; treatment: adherence, compliance, efficacy, outcome, protocol, regimen; weight. Additional relevant studies published through June 2016, during the guideline writing process, were also considered by the writing committee, and added to the evidence tables when appropriate.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Abbreviations: 1°, primary; 2º, secondary; AASK, African American Study of Kidney Disease and Hypertension; ABI, ankle-brachial index; ABCD, Appropriate Blood Pressure Control in Diabetes; ABPM, ambulatory blood pressure monitoring; ACCESS, Acute Candesartan Cilexetil Evaluation in Stroke Survivors; ACCOMPLISH, Avoiding Cardiovascular Events Through Combination Therapy in Patients Living With Systolic Hypertension; ACCORD, Action to Control Cardiovascular Risk in Diabetes; ACE, angiotensin-converting enzyme; ACEI, angiotensin-converting enzyme inhibitor; ACS, acute coronary syndrome; ADVANCE, Action in Diabetes and Vascular Disease; AF, atrial fibrillation; AFL, atrial flutter; AHR, adjusted hazard ratio; AIPRD, Angiotensin-Converting Enzyme Inhibition in Progressive Renal Disease; ALLHAT, Antihypertensive Lipid Lowering Treatment to Prevent Heart Attack Trial; AMI, acute myocardial infarction; ARB, angiotensin-receptor blocker; ARIC, Atherosclerosis Risk in Communities; ASCOT, Anglo-Scandinavian Cardiac Outcomes Trial; BB, beta blocker; BMI, body mass index; BP, blood pressure; BPLTTC, Blood Pressure Lowering Treatment Trialists’ Collaboration; bpm, beats per minute; BUN, blood urea nitrogen; CABG, coronary artery bypass graft; CAD, coronary artery disease; CATIS, China Antihypertensive Trial in Acute Ischemic Stroke; CCB, calcium-channel blocker; CCU, coronary care unit; CHD, coronary heart disease; CHF, congestive heart failure; CHHIPS, Controlling Hypertension and Hypotension Immediately Post-Stroke; CI, confidence interval; CKD, chronic kidney disease; COMFORT, Combination Pill of Losartan Potassium and Hydrochlorothiazide for Improvement of Mediation Compliance Trial; COSSACS, the Continue or Stop Post-Stroke Antihypertensives Collaborative Study; CPAP, continuous positive airway pressure; Cr, creatinine; CrCL, creatinine clearance; CRP, c-reactive protein; CR/XL, metoprolol controlled release/extended release; CT, computed tomography; CV, cardiovascular; CVD, cardiovascular disease; DASH, Dietary Approaches to Stop Hypertension; DBP, diastolic blood pressure; DM, diabetes mellitus; DM-1, diabetes mellitus type-1; DM-2, diabetes mellitus type-2; ECG, electrocardiogram; ED, emergency department; EF, ejection fraction; eGFR, estimated glomerular filtration rate; ESKD, end-stage kidney disease; ESRD, end-stage renal disease; FC, functional class; FDC, fixed dose combination; FEVER, Felodipine EVent Reduction; GITS, gastrointestinal therapeutic system; GFR, glomerular filtration rate; HBPM, home blood pressure monitoring; HCTZ, hydrochlorthiazide; HDL, high-density lipoprotein; HDL-C, high-density lipoprotein cholesterol; HEDIS, Healthcare Effectiveness Data and Information Set; HF, heart failure; HFrEF, reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HIV, human immunodeficiency virus; HR, hazard ratio; HTN, hypertension; ICD, implantable cardioverter-defibrillator; ICH, intracerebral hemorrhage; IDACO, International Database of Ambulatory Blood Pressure in relation to Cardiovascular Outcome; IHD, ischemic heart disease; IMT, intimal media thickness; INDANA, Individual Data Analysis of Antihypertensive drug intervention trials; INTERACT2, the second Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial; INVEST, International Verapamil-Trandolapril Study; INWEST, the Intravenous Nimodipine West European Stroke Trial; IQI, interquartile interval; IQR, interquartile range; IRR, incident rate ratio; ISDN, isosorbide dinitrate; IV, intravenous; JNC-7, 7th Report of the Joint National Committee; KPNC, Kaiser Permanente Northern California; LDL, low-density lipoprotein; LGSAS, low-gradient severe aortic stenosis; LIFE, Losartan Intervention For Endpoint Reduction in Hypertension; LVEF, left ventricular ejection fraction; LVH, left ventricular hypertrophy; LVMI; left ventricular mass index; MACCE, major adverse cardiac and cerebrovascular events; MACE, major adverse cardiac events; MAP, mean arterial pressure; MD, mean difference; MDPIT, Multicenter Dilitiazem Postinfarction Research Group; MDRD, Modification of Diet in Renal Disease; MERIT, Metoprolol CR/XL Randomised Intervention Trial; MESA, Multi-Ethnic Study of Atherosclerosis; MH, masked hypertension; MI, myocardial infarction; MOSES, The Morbidity and Mortality After Stroke, Eprosartan Compared With Nitrendipine for Secondary Prevention; MPR, medication possession ratio; MRFIT, Multiple Risk Factor Intervention Trial; MRI, magnetic resonance imaging; N/A, not available; NCQA, National Committee for Quality Assurance; NEMESIS, North East Melbourne Stroke Incidence Study; NHANES, National Health and Nutrition Examination Surveys; NIH, National Institute of Health; NNT, number needed to treat; NR, not relative; © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements NS, nonsignificant; NSAID, nonsteroidal anti-inflammatory drug; NUTRICODE, Nutrition and Chronic Diseases Expert Group; NYHA, New York Heart Association; ONTARGET, Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial; OR, odds ratio; OSA, obstructive sleep apnea; P4P, pay for performance; PA, pulmonary artery; PAD, peripheral artery disease; PAMELA, Pressione Arteriose Monitorate E Loro Associazioni; PCP, primary care provider; periop, perioperative; PREDIMED, Prevention with a Mediterranean Diet; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PROBE, Prospective, randomized, open, blinded endpoint; PROGRESS, The perindopril protection against recurrent stroke study; PRONTO, Prospective Optical Coherence Tomography Imaging of Patients with endovascular Age-Related Macular Degeneration Treated with Intraocular Ranibizumab; pt, patient; PTCA, percutaneous transluminal coronary angioplasty; PVD, peripheral vascular disease; QI, quality improvement; RAAS, renin angiotensin aldosterone system; RCT, randomized controlled trial; REIN-2, Blood Pressure Control for Renoprotection in Patients with Non-diabetic Renal Disease; RH, relative hazard; ROADMAP, Randomized Olmesartan and Diabetes Microalbuminuria Prevention; RR, relative risk; Rx, medical prescription; SAE, severe adverse event; SBP, systolic blood pressure; SCOPE-AS, Symptomatic Cardiac Obstruction – Pilot Study of Enalapril in Aortic Stenosis; SD, standard deviation; SE, stress echocardiography; SH, sustained hypertension; SHEP, Summer Health Enrichment; SITS-ISTR, Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register; SKIPOGH, Swiss Kidney Project on Genes in Hypertension; SPC, single pill combination; SPRINT, Systolic Blood Pressure Intervention Trial; Syst-Eur, Systolic Hypertension in Europe; t-PA, tissue plasminogen activator; TIA, transient ischemic attack; TOHP, Trials of Hypertension Prevention; TOMHS, Treatment of Mild Hypertension Study; TONE, Trial of Nonpharmacologic Intervention in the Elderly; TOPCAT, Treatment of Preserved Cardiac Function Heart Failure With Aldosterone Antagonist; TR, target range; UA, unstable angina; U.K., United Kingdom; UKPDS, United Kingdom Prospective Diabetes Study; U.S., United States; VA, Veterans Affairs; VA Coop; Veterans Administration Cooperative Study Group on Antihypertensive Agents; VA NEPHRON-D, Veterans Affairs Nephropathy in Diabetes; VALIANT, Valsartan in Acute Myocardial Infarction Trial; VALUE, Valsartan Antihypertensive Long-term Use Evaluation; WCH, white coat hypertension; and WPW; Wolff-Parkinson-White syndrome.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements

Data Supplement 1. Coexistence of Hypertension and Related Chronic Conditions (Section 2.4) Study Acronym; Author; Year Published Wilson PW, et al., 1999 (1) 10335688

Berry JD, et al., 2012 (2) 22276822

Study Type/Design; Study Size (N) Study type: Nonrandomized Size: 2,406 men, 2,569 women (1,759 men, 1,818 women with follow-up)

Study type: Nonrandomized Size: 257,384 black and white men and women, including 67,890 pts (from 17 meta-analysis) and 189,494 pts (from MRFIT)

Patient Population Inclusion criteria: Men and women 18–74 y and free of CHD at baseline, from the Framingham Offspring Study Exclusion criteria: N/A Inclusion criteria: Metaanalysis of 18 cohort studies Exclusion criteria: N/A

Primary Endpoint and Results (include P value; OR RR; & 95% CI)

Summary/Conclusion Comment(s)

1° endpoint: Total CHD (first occurrence of angina, UA, MI, and coronary death), Hard CHD (first MI and coronary death)

• CVD risk factors infrequently occur in isolation (only 28%–30% of the time); presence of ≥3 risk factors occurred 17% of the time in both men and women; presence of ≥3 risk factors associated with high risk of CHD and coronary death (attributable risk of 20% in men and 48% in women)

Results: Presence of ≥3 risk factors was associated with a 2.39 times greater risk of CHD in men (95% CI: 1.56–3.36; p<0.001) and a 5.90 increased risk of CHD in women (95% CI: 2.54–13.73; p<0.001) 1° endpoint: Fatal CHD, nonfatal MI, fatal or nonfatal stroke

• Increased burden of 80 risk factors associated with higher lifetime risk of CVD

Results: Participants with optimal RF profile (total cholesterol <180 mg/dL, untreated BP <120 mm Hg systolic, and <80 mm Hg diastolic, nondiabetic, nonsmoker) compared to participants with ≥2 risk factors had lower risk of CVD through the age of 80 y (4.7% vs. 29.6% for men, 6.4% vs. 20.5% for women), lower lifetime risk of fatal heart disease and nonfatal MI (3.6% vs. 37.5% for men, <1% vs. 18.3% for women), and lower lifetime risk of fatal or nonfatal stroke (2.3% vs. 8.3% for men, 5.3% vs. 10.7% for women)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements

Data Supplement 2. Definition of High BP (Section 3.1) Study Acronym; Author; Year Published Lewington S, et al., 2002 12493255

Rapsomaniki E, et al., 2014 24881994

Wilson PW, et al., 1999 (1) 10335688

Study Type/Design; Study Size (N) Study type: Meta-analysis of 61 observational cohort studies

Study type: Observational cohort study Size: 1.25 million patients, in 225 primary care practices in the UK, followed for a median of 5.2 y using electronic medical records. Study type: Nonrandomized

Patient Population Inclusion criteria: Men and women with no history of previous CVD and record of key study variables. Exclusion criteria: Prior CVD

Inclusion criteria: Men and women ≥30 y, with no previous diagnosis of CVD, who had been registered at their practices for ≥1 year. Exclusion criteria: N/A

Inclusion criteria: Men and women 18– 74 y and free of CHD at baseline, from the Framingham Offspring Study

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Primary Endpoint and Results (include P value; OR or RR; and CI; & 95% CI) 1° endpoint: Cause-specific mortality Results: 958,074 persons followed for a mean of 12 y to death (12.7 million person-y at risk. Number of deaths attributed to: -Stroke: 11960 -IHD: 34,283 -Other vascular:10092 -Non-vascular: 60797 Above a SBP ≥115 mm Hg and DBP ≥75 mm Hg, there was a progressive rise in vascular death with progressively high BP with no evidence of a J-curve (approximately doubling of stroke and IHD mortality for a 20 mm Hg higher level of SBP or 10 mm Hg higher level of DBP, in those 40–69 y). With progressively higher age, the BP-related proportional risk of vascular mortality was somewhat reduced but the corresponding absolute risk was much higher. 1° endpoint: 12 acute and chronic CVD outcomes Results: 83,098 initial CVD events recorded. Within each of 3 age groups (30–59, 60–79, and ≥80 y), the lowest risk for CVD was in those with a SBP 90–114 mm Hg and DBP 60–74 mm Hg. There was a direct relationship between level of BP and most CVD outcomes, with no evidence of J-curve, with the strongest relationship for SBP and stroke and weakest for abdominal aneurysm. 1° endpoint: Total CHD (first occurrence of angina, UA, MI, and coronary death), Hard CHD (first MI and coronary death)

Summary/Conclusion Comment(s) • In adults aged 40–89 y, usual BP is strongly related to vascular (and overall) mortality, without evidence of a threshold down to at least an SBP/DBP of 115/75 mm Hg.

• Despite modern treatments, the lifetime burden of BPrelated CVD was substantial.

• CVD risk factors infrequently occur in isolation (only 28%–30% of the time) 8

2017 Hypertension Guideline Data Supplements

Guo X, et al., 2013 (3) 23634212

Guo X, et al., 2013 (4) 24234576

Size: 2,406 men, 2,569 women (1,759 men, 1,818 women with follow-up)

Exclusion criteria: N/A

Results: Presence of ≥3 risk factors was associated with a 2.39 times greater risk of CHD in men (95% CI: 1.56–3.36; p<0.001) and a 5.90 increased risk of CHD in women (95% CI: 2.54– 13.73; p<0.001)

Study type: Metaanalysis of nonrandomized studies

Inclusion criteria: Studies reporting adjusted risk for CVD or mortality with preHTN

1° endpoint: CVD and all-cause mortality

Size: 870,678 pts

Exclusion criteria: N/A

Study type: Metaanalysis of nonrandomized studies

Inclusion criteria: Studies reporting adjusted risk for fatal and nonfatal stroke, CHD, MI and total CVD events with preHTN, 120–129/80–84 mm Hg or 130– 139/85–89 mm Hg

Size: 1,010,858 pts

Exclusion criteria: N/A

Huang Y, et al., 2013 (5) 23915102

Study type: Metaanalysis of nonrandomized studies Size: 468,561 pts from 18 prospective cohort studies

Inclusion criteria: Studies reporting risk for CVD, CHD and stroke, with 120– 139/80–89 mm Hg, 120–129/80–84 mm Hg or130–139/85–89 mm Hg Adults ≥18 y BP evaluated at baseline

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Results: SBP/DBP 120–129/80–84 mm Hg compared to <120/80 mm Hg: • All-cause mortality: RR: 0.91; 95% CI: 0.81– 1.02) • CVD mortality: RR: 1.10 (95% CI: 0.92, 1.30) SBP/DBP 130–139/85–89 mm Hg compared to <120/80 mm Hg: • All-cause mortality: 1.00; 95% CI: 0.95–1.06 • CVD mortality: RR: 1.26; 95% CI: 1.13–1.41 1° endpoint: Fatal and nonfatal stroke, CHD, MI and total CVD events Results: SBP/DBP 120-129/80-84 mm Hg compared to <120/80 mm Hg: • CVD RR: 1.24; 95% CI: 1.10–1.39 • MI RR: 1.43; 95% CI: 1.10–1.86 • Stroke: RR: 1.35; 95% CI: 1.10–1.66 SBP/DBP 130–139/85–89 mm Hg compared to <120/80 mm Hg: • CVD RR: 1.56; 95% CI: 1.36–1.78 • MI RR: 1.99; 95% CI: 1.59–2.50 • Stroke RR: 1.95; 95% CI: 1.69–2.24 1° endpoint: CVD, CHD, and stroke Results: Comparing SBP/DBP 120–129/80–84 mm Hg to <120/80 mm Hg: • CVD RR: 1.46; 95% CI: 1.32–1.62

• Presence of ≥3 risk factors occurred 17% of the time in both men and women • Presence of ≥3 risk factors associated with high risk of CHD and coronary death (attributable risk of 20% in men and 48% in women) • SBP/DBP of 120–129/80– 84 mm Hg associated with increased risk for all-cause or CVD mortality. • SBP/DBP of 130–139/85– 89 mm Hg associated with an increased risk for CVD mortality.

• Compared to pts with SBP/DBP<120/80 mm Hg, the RR for CVD, MI and stroke were larger for pts with SBP/DBP of 130–139/85–89 mm Hg vs. SBP/DBP of 120– 129/80–84 mm Hg.

• Compared to pts with SBP/DBP <120/80 mm Hg, the RR for CVD was larger for pts with SBP/DBP of 130– 139/85–89 mm Hg vs.

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2017 Hypertension Guideline Data Supplements ≥2 y follow-up for outcomes Results reported with adjustment Exclusion criteria: N/A

Huang Y, et al., 2014 (6) 24074825

Study type: Metaanalysis of nonrandomized studies Size: 1,003,793 pts were derived from 6 prospective cohort studies

Huang Y, et al., 2013 (7) 24623843

Study type: Metaanalysis of nonrandomized studies Size: 762,393 pts from 19 prospective cohort studies

Inclusion criteria: Studies reporting adjusted risk for ESRD with 120–139/80– 89 mm Hg, 120–129/80–84 mm Hg or130–139/85–89 mm Hg Adults ≥18 y BP evaluated at baseline ≥ 1 y follow-up for ESRD Results reported with adjustment Exclusion criteria: 1) enrollment depended on having a condition or risk factor, 2) the study reported only age- and sex-adjusted RRs, and 3) data were derived from the same cohort or from a 2º analysis Inclusion criteria: Studies reporting adjusted risk for stroke with 120–139/80– 89 mm Hg, 120–129/80-84 mm Hg or130– 139/85–89 mm Hg • Adults ≥18 y • BP evaluated at baseline • ≥1 y follow-up for stroke • Results reported with adjustment Exclusion criteria: • Enrollment depended on having a specific risk factor condition (e.g., DM or other baseline chronic diseases) • The RR was unadjusted or only adjusted for age and sex • Data were derived from the same cohort or meta-analysis of other cohort studies.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Comparing SBP/DBP RR: 130–139/85–89 mm Hg to <120/80 mm Hg: • CVD RR: 1.63; 95% CI: 1.47–1.80; p value comparing these risk ratios=0.02 • The RR comparing CHD and stroke by levels of SBP/DBP: 130–139/85–89 mm Hg and SBP/DBP of 120–129/80–84 mm Hg vs. <120/80 mm Hg were not reported. 1° endpoint: ESRD Results: Comparing SBP/DBP 120–129/80–84 mm Hg to <120/80 mm Hg: • ESRD RR: 1.44; 95% CI: 1.19–1.74 Comparing SBP/DBP 130–139/85–89 mm Hg to <120/80 mm Hg: • ESRD RR: 2.02; 95% CI: 1.70–2.40; • p value comparing these risk ratios=0.01

1° endpoint: Stroke Results: Comparing SBP/DBP 120–129/80–84 mm Hg to <120/80 mm Hg: • Stroke: RR: 1.44; 95% CI: 1.27–1.63 Comparing SBP/DBP 130–139/85–89 mm Hg to <120/80 mm Hg: • Stroke: RR: 1.95; 95% CI: 1.73–2.21 • p value comparing these risk ratios ≤0.001

SBP/DBP of 120–129/80–84 mm Hg

• Compared to pts with SBP/DBP <120/80 mm Hg, the RR for ESRD was larger for pts with SBP/DBP of 130– 139/85–89 mm Hg vs. SBP/DBP of 120–129/80–84 mm Hg

• Compared to pts with SBP/DBP <120/80 mm Hg, the RR for stroke was larger for pts with SBP/DBP of 130– 139/85–89 mm Hg vs. SBP/DBP of 120–129/80–84 mm Hg

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2017 Hypertension Guideline Data Supplements Huang Y, et al., 2014 (8) 24439976

Study type: Metaanalysis of nonrandomized studies Size: 1,129,098 pts from 20 prospective cohort studies

Huang Y, et al., 2015 (9) 25699996

Study type: Metaanalysis of nonrandomized studies Size: 591,664 pts from 17 prospective cohort studies

Lee M, et al., 2011 (10) 21956722

Study type: Metaanalysis of nonrandomized studies

Inclusion criteria: • Studies reporting adjusted risk for allcause/CVD mortality with 120–139/80–89 mm Hg, 120-129/80–84 mm Hg or 130– 139/85–89 mm Hg • Adults ≥18 y • BP evaluated at baseline • ≥2 y follow-up for mortality • Results reported with adjustment Exclusion criteria: • Enrollment depended on having a specific risk factor condition (e.g., DM or other baseline chronic diseases) • The RR was unadjusted or only adjusted for age and sex • Data were derived from the same cohort or meta-analysis of other cohort studies. Inclusion criteria: • Studies reporting adjusted risk for CHD with 120–139/80–89 mm Hg, 120–129/80– 84 mm Hg or130–139/85–89 mm Hg • Adults ≥18 y • BP evaluated at baseline • Results reported with adjustment Exclusion criteria: • Enrollment depended on having a specific risk factor condition (e.g., DM or other baseline chronic diseases) • The RR was unadjusted or only adjusted for age and sex • Data were derived from the same cohort or meta-analysis of other cohort studies. Inclusion criteria: • Studies reporting adjusted risk for stroke with 120–139/80–89 mm Hg, 120–129/80– 84 mm Hg or130–139/85–89 mm Hg • Adults ≥18 y

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: All-cause and CVD mortality Results: Comparing SBP/DBP 120–129/80-84 mm Hg to <120/80 mm Hg: • All-cause mortality RR: 0.96; 95% CI: 0.85–1.08 • CVD mortality RR: 1.08; 95% CI: 0.98–1.18 Comparing SBP/DBP 130-139/85-89 mm Hg to <120/80 mm Hg: • All-cause mortality RR: 1.03; 95% CI: 0.95–1.12 • CVD mortality RR: 1.28; 95% CI: 1.16–1.41 • p value comparing these risk ratios: • All-cause mortality p=0.33 • CVD mortality p=0.01

1° endpoint: CHD Results: Comparing SBP/DBP 120–129/80–84 mm Hg to <120/80 mm Hg: • CHD RR: 1.27; 95% CI: 1.07–1.50 Comparing SBP/DBP 130-139/85-89 mm Hg to <120/80 mm Hg: • CHD RR: 1.58; 95% CI: 1.24–2.02 • p value comparing these RR: 0.15

1° endpoint: Incident stroke Results: Comparing SBP/DBP 120–129/80–84 mm Hg to <120/80 mm Hg: • Stroke RR: 1.22; 95% CI: 0.95–1.57

• Compared to pts with SBP/DBP <120/80 mm Hg, the RR for CVD mortality was larger for pts with SBP/DBP of 130–139/85-89 mm Hg vs. SBP/DBP of 120–129/80-84 mm Hg. • The RR for not all-cause mortality was similar for these 2 BP levels.

• Compared to pts with SBP/DBP<120/80 mm Hg, the RR for CHD was larger for pts with SBP/DBP of 130– 139/85–89 mm Hg vs. SBP/DBP of 120-129/80–84 mm Hg. • However, this difference was not statistically significant.

• Compared to pts with SBP/DBP <120/80 mm Hg, the RR for stroke was larger for pts with SBP/DBP of 130– 139/85–89 mm Hg vs. 11

2017 Hypertension Guideline Data Supplements Size: 518,520 pts from 18 prospective cohort studies

Shen L, et al., 2013 (11) 23608614

Study type: Metaanalysis of nonrandomized studies Size: 934,106 pts from 18 prospective cohort studies

Wang S, et al., 2013 (12) 23932039

Study type: Metaanalysis of nonrandomized studies Size: 396,200 pts from 13 prospective cohort studies

• BP evaluated at baseline • Results reported with adjustment Exclusion criteria: • Cross-sectional, case-control or retrospective cohort • The RR was unadjusted or only adjusted for age and sex • 95% CI not reported • Data were derived from the same cohort or meta-analysis of other cohort studies • Results from trial of antihypertensive medication Inclusion criteria: • Studies reporting adjusted risk for CHD with 120–139/80–89 mm Hg, 120–129/80– 84 mm Hg or 130–139/85–89 mm Hg • BP evaluated at baseline • 95% CI was reported Exclusion criteria: N/A Inclusion criteria: • Prospective cohort studies reporting risk for outcomes with 120–139/80–89 mm Hg • Pts free of CVD at baseline, • Follow-up ≥5 y • Adjusted results reported • 95% CI was reported Exclusion criteria: N/A

Cushman WC, et al., 2002 (13) 12461301

Study type: 2º analysis of an RCT

Inclusion criteria: Men and women ≥55 y with HTN and 1 additional CHD risk factor

Size: 33,357 pts in the ALLHAT

Exclusion criteria: Pts randomized to doxazosin.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Comparing SBP/DBP 130–139/85–89 mm Hg to <120/80 mm Hg: • Stroke RR: 1.79; 95% CI: 1.49–2.16

SBP/DBP of 120–129/80–84 mm Hg

1° endpoint: CHD

• Compared to pts with SBP/DBP <120/80 mm Hg, the RR for CHD was larger for pts with SBP/DBP of 130– 139/85–89 mm Hg vs. SBP/DBP of 120–129/80–84 mm Hg

Results: Comparing SBP/DBP 120–129/80–84 mm Hg to <120/80 mm Hg: • CHD RR: 1.16; 95% CI: 0.96–1.42 Comparing SBP/DBP 130–139/85–89 mm Hg to <120/80 mm Hg: • CHD RR: 1.53; 95% CI: 1.19–1.97) 1° endpoint: CVD, CVD mortality, all-cause mortality Results: Comparing SBP/DBP 120-129/80-84 mm Hg to <120/80 mm Hg: • CVD RR: 1.41; 95% CI: 1.25–1.59 • CVD mortality RR: 1.18; 95% CI: 0.98–1.42 • All-cause mortality RR: 0.99; 95% CI: 0.88–1.13 Comparing SBP/DBP 130–139/85–89 mm Hg to <120/80 mm Hg: • CVD RR: 1.74; 95% CI: 1.51–2.01 • CVD mortality RR: 1.33; 95% CI: 1.13–1.58 • All-cause mortality RR: 1.02; 95% CI: 0.97–1.08 1° endpoint: Achieving SBP/DBP<140/90 mm Hg, use of ≥2 drug classes

• Compared to pts with SBP/DBP<120/80 mm Hg, RR for CVD and CVD mortality were larger for pts with SBP/DBP of 130–139/85–89 mm Hg vs. SBP/DBP of 120– 129/80–84 mm Hg. • No difference in all-cause mortality was present across BP levels.

• BP control (<140/90 mm Hg) can be achieved in most pts ≥2 or more drug classes are often required.

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2017 Hypertension Guideline Data Supplements

Dalhof B, et al., 2002 (14) 11937178

Wald DS, et. al., 2009 (15) 19272490

Lewington S, et al., 2002 (16) 12493255

Study type: RCT Size: 9,193 pts 55–80 y in the Losartan Intervention For Endpoint reduction in HTN Study type: Metaanalysis of RCT Size: 10,968 pts in 42 trials of factorial designs comparing monotherapy, combination therapy and placebo.

Aim: To describe the agespecific relevance of BP to cause-specific mortality Study type: Metaanalysis of cohort studies Size: 61 prospective studies with 12.7 million person-y of observation, 56,000 vascular deaths in 40–89 y.

Inclusion criteria: Men and women with ECG signs of LVH. Trough sitting SBP 160–200 mm Hg or DBP 95–115 mm Hg after 1–2 wk of placebo. Exclusion criteria: 2º HTN, MI/stroke within 6 mo, angina, HF or LVEF <40%. Inclusion criteria: Randomized placebocontrolled trials comparing 2 of 4 (thiazides, BB s, ACEIs, and CCB) drug classes. Exclusion criteria: Trials <2 wk duration, no placebo group, nonrandomized order of treatment.

Inclusion criteria: Collaboration was sought from the investigators of all prospective observational studies in which data on BP, blood cholesterol, date of birth (or age), and sex had been recorded at a baseline screening visit, and in which cause and date of death (or age at death) had been routinely sought for all screens during more than 5,000 person-y of followup (see appendix A). Relevant studies were identified through computer searches of Medline and Embase, by handsearches of meeting abstracts, and by extensive discussions with investigators. Exclusion criteria: To minimize the effects of reverse causality (whereby

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Results: SBP/DBP control was achieved by 66% at 5 y of follow-up and 63% of pts were on ≥2 drug classes. 1° endpoint: Following a titration schedule to reach a target SBP/DBP<140/90 mm Hg Results: Mean SBP/DBP at baseline was 174/98 mm Hg. Over 90% of pts required ≥2 drug classes during follow-up. 1° endpoint: Mean BP reduction. Results: Combination therapy vs. monotherapy produced larger SBP reductions: • Thiazide alone (7.3 mm Hg) • Thiazide+second drug class (14.6 mm Hg) • BB alone (9.3 mm Hg) • BB +second drug class (18.9 mm Hg) • ACE-inhibitor alone (6.8 mm Hg) • ACE-inhibitor+second drug class (13.9 mm Hg) • CCB alone (8.4 mm Hg) • CCB +second drug class (14.3 mm Hg) 1° endpoint: • Not completely clear, but for our purposes, stroke and IHD death would be co-1°. Also looked at other vascular deaths. • HRs for stroke mortality for a 20 mm Hg lower SBP by age-group 40–49: 0.36 (95% CI: 0.32–0.40) 50–59: 0.38 (95% CI: 0.35–0.40) 60–69: 0.43 (95% CI: 0.41–0.45) 70–79: 0.50 (95% CI: 0.48–0.52) 80–89: 0.67 (95% CI: 0.63–0.71) • HRs for IHD mortality for a 20 mm Hg lower SBP by age-group 40–49: 0.49 (95% CI: 0.45–0.53) 50–59: 0.50 (95% CI: 0.49–0.52) 60–69: 0.54 (95% CI: 0.53–0.55) 70–79: 0.60 (95% CI: 0.58–0.61)

• Pts with a mean SBP/DBP of 160–200/95–115 mm Hg will need ≥2 classes of antihypertensive medication to achieve SBP/DBP <140/90 mm Hg. • Combination therapy results in substantially larger SBP and DBP reductions compared with monotherapy, even after dose titration.

• Throughout middle and old age, usual BP is strongly and directly related to vascular (and overall) mortality, without any evidence of a threshold down to at least 115/75 mm Hg.

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2017 Hypertension Guideline Data Supplements established disease could change the usual BP), studies were excluded if they had selected pts on the basis of a positive history of stroke or heart disease, and individuals from contributing studies were excluded from the present analyses if they had such a history recorded at baseline.

Ettehad D, et al., 2016 (17) 26724178

Aim: This systematic review and meta-analysis aims to combine data from all published large-scale BP-lowering trials to quantify the effects of BP reduction on CV outcomes and death across various baseline BP levels, major comorbidities, and different pharmacological interventions. Study type: Metaanalysis of RCTs Size: 123 studies with 613,815 pts

Inclusion criteria: • RCTs of BP-lowering treatment that included a minimum of 1,000 pt-y of follow-up in each study arm. No trials were excluded because of presence of baseline comorbidities, and trials of antihypertensive drugs for indications other than HTN were eligible. • Eligible studies fell into 3 categories: 1st, random allocation of pts to a BP-lowering drug or placebo; 2nd, random allocation of pts to different BP-lowering drugs; and third, random allocation of pts to different BP-lowering targets. Exclusion criteria: <1,000 pt y of follow-up in each treatment group. Intervention: BP-lowering meds Comparator: Placebo, active comparator or less intensive treatment

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

80–89: 0.67 (95% CI: 0.64–0.70) • HRs for other vascular mortality for a 20 mm Hg lower SBP by age-group 40–49: 0.43 (95% CI: 0.38–0.48) 50–59: 0.50 (95% CI: 0.47–0.54) 60–69: 0.53 (95% CI: 0.51–0.56) 70–79: 0.64 (95% CI: 0.61–0.67) 80–89: 0.70 (95% CI: 0.65–0.75) • Similar results for DBP also in figure 1. • Similar results for men and women separately for stroke, figure 3, and IHD, figure 5. 1° endpoint: • CVD. • Major CVD events, CHD, stroke, HF, renal failure, and all-cause mortality. • Standardized RR for 10 mm Hg difference in SBP • CVD RR: 0.80 (95% CI: 0.77–0.83) Other endpoints: CHD RR: 0.83 (95% CI: 0.78–0.88) Stroke RR: 0.73 (95% CI: 0.68–0.77) HF RR: 0.72 (95% CI: 0.67–0.78) Total deaths RR: 0.87 (95% CI: 0.84–0.91) Other results: • Benefit for CVD and other endpoints not different by baseline SBP, including <130 mm Hg fig 4 in paper CVD: 0.63; 95% CI: 0.50–0.80; p=0.22 CHD: 0.55; 95% CI: 0.42–0.72; p=0.93 Stroke: 0.65; 95% CI: 0.27–1.57; p=0.38 HF: 0.83; 95% CI: 0.41–1.70; p=0.27 Total deaths: 0.53; 95% CI: 0.37–0.76; p=0.79 • More precision around estimates of benefits in SBP 130–139 at baseline, fig 4 in paper • Results similar in trials of people with and without CVD at baseline figure 5 CVD+ 0.77 (95% CI: 0.71–0.81)

• BP-lowering significantly reduces vascular risk across various baseline BP levels and comorbidities. Our results provide strong support for lowering BP to SBP<130 mm Hg and providing BP-lowering treatment to individuals with a history of CVD, CHD, stroke, DM, HF, and CKD. • In stratified analyses, we saw no strong evidence that proportional effects were diminished in trials that included people with lower baseline SBP (<130 mm Hg), and major CV events were clearly reduced in high-risk pts with various baseline comorbidities. Both of these major findings—the efficacy of BP-lowering below 130 mm Hg and the similar proportional effects in high risk populations—are consistent with and extend the findings of the SPRINT trial. Limitations: 14

2017 Hypertension Guideline Data Supplements

Law MR, et al., 2009 (18) 19454737

Study type: Metaanalysis of use of BPlowering drugs in prevention of CVD from 147 randomized trials Size: Of 147 randomized trials of 464,000 pts, 37 trials of BBs in CAD included 38,892 pts, and 37 trials of other antihypertensive drugs in CAD included 85,395 pts

Sundstrom J, et al., 2015 (19) 25531552

Aim: To investigate whether pharmacologic BP reduction prevents CV events and deaths in pts with grade 1 HTN.

Inclusion criteria: The database search used Medline (1966 to Dec. 2007) to identify randomized trials of BP-lowering drugs in which CAD events or strokes were recorded. The search also included the Cochrane Collaboration and Web of Science databases and the citations in trials and previous meta-analyses and review articles. Exclusion criteria: Trials were excluded if there were <5 CAD events and strokes or if treatment duration was <6 mo.

Inclusion criteria: RCTs of at least 1 y duration; pts ≥18 y, at least 80% of whom had grade 1 HTN and no previous CVD (MI, angina pectoris, CABG, PCI, stroke, TIA, carotid surgery, peripheral arterial

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

CVD- 0.74 (95% CI: 0.67–0.83) Total deaths CVD+ 0.90 (95% CI: 0.83–0.98) CVD- 0.84 (95% CI: 0.75–0.93) Other outcomes similarly in figure 5 • In appendix, in general, benefits for CVD prevention seen in groups with and without baseline CHD, Stroke, DM, CKD and HF when examined separately, but no absolute risks provided to enable estimation of how far down the absolute risk curve these findings have been demonstrated. • Some evidence of BB inferiority to other med classes in figure 6. • Did not report absolute risks so do not know lower level of risk in treated populations. 1° endpoint: CAD events; stroke Results: In 37 trials of pts with a history of CAD, BB reduced CAD events 29% (95% CI: 22%– 34%). In 27 trials in which BBs were used after acute MI, BB reduced CAD events 31% (95% CI: 24%–38%), and in 11 trials in which BB were used after long-term CAD, BB insignificantly reduced CAD events 13%. In 7 trials, BB reduced stroke 17% (95% CI: 1%–30%). CAD events were reduced 14% (95% CI: 2%–25%) in 11 trials of thiazide diuretics, 17% (95% CI: 11%–22%) in 21 trials of ACEIs, insignificantly 14% in 4 trials of angiotensin receptor blockers, and 15% (95% CI: 8%–22%) in 22 trials of CCB. Stroke was reduced 38% (95% CI: 28%–47%) in 10 trials of thiazide diuretics, 22% (95% CI: 8%–34%) in 13 trials of ACEI, and 34% (95% CI: 25%–42%) in 9 trials of CCB. 1° endpoint: Total major CV events, comprising stroke (nonfatal stroke or death from cerebrovascular disease), coronary events (nonfatal MI or death from CHD, including sudden death), HF (causing death or resulting in

• Lack of individual pt data, which would have allowed a more reliable assessment of treatment effects in different pt groups. • Interpretation: Lowering of BP into what has been regarded the normotensive range should therefore be routinely considered for the prevention of CVD among those deemed to be of sufficient absolute risk.

• With the exception of the extra protective effect of BB given shortly after a MI and the minor additional effect of CCBs in preventing stroke, all the classes of BP-lowering drugs have a similar effect in reducing CAD events and stroke for a given reduction in BP.

• BP-lowering therapy is likely to prevent stroke and death in pts with uncomplicated grade 1 HTN.

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2017 Hypertension Guideline Data Supplements

Study type: Metaanalysis of RCTs Size: 10 RTCs with 15,266 pts

Thomopoulos C, et al., 2014 (20) 25259547

Aim: Investigating whether all grades of HTN benefit from BP-lowering treatment and which are the target BP levels to maximize outcome reduction. Study type: Metaanalysis of RCTs Size: 32 RCTs with 104,359 pts

surgery, intermittent claudication, or renal failure); and compared an antihypertensive drug provided as monotherapy or a stepped-care algorithm vs. placebo or another control regimen. Exclusion criteria: Excluded trials did not contribute an event for any of the outcomes of interest.

Inclusion criteria: Intentional BP-lowering comparing active drug treatment with placebo, or less active treatment (intentional BP-lowering trials), or comparison of an active drug with placebo over baseline antihypertensive treatment, resulting in a BP difference of at least 2 mm Hg in either SBP or DBP (nonintentional BP-lowering trials); enrolling of hypertensive individuals only or a high proportion (at least 40%) of them. Exclusion criteria: N/A

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

hospitalization), or CV death; OR: 0.86 (95% CI: 0.74–1.01) Other endpoints: Each of the above outcomes independently; and total deaths.

• 5 y risks in BPLTTC control groups CVD events 7.4%, CVD deaths 3.1%

CHD 0.91 (95% CI: 0.74–1.12) Stroke 0.72 (95% CI: 0.55–0.99) HF 0.80 (95% CI: 0.57–1.12) CVD deaths 0.75 (95% CI: 0.57–0.98) Total deaths 0.78 (95% CI: 0.67–0.92) Only the first event for a pt was used for the analysis of each outcome, but a pt who had >1 outcome type could contribute to more than 1 analysis. They also tabulated overall withdrawals and withdrawals due to adverse events. 1° endpoint: • As some trials were done on low-risk pts, others on higher risk pts, no evaluation of absolute riskreduction was made. However, a 2º analysis was done including trials or trial subgroups with mean baseline SBP/DBP values in grade 1 range and a low-to-moderate risk (<5% CV deaths in 10 y in controls): FEVER stratum with baseline SBP below the median (<153 mm Hg); HTN Detection and Follow-up Program stratum with baseline DBP 90–94 mm Hg and no CVD; OSLO (e17); TOMHS (e28) and USPHS. Risks of stroke, CHD, the composite of stroke and CHD, and all-cause death were significantly reduced by BP-lowering in these low-to-moderate risk pts (control group: average CV mortality 4.5% in10 y) with a moderate BP elevation (average SBP/DBP 145.5/91 mm Hg) at randomization. Standardized RR associated with 10/5 reduction in BP: stroke 0.33 (95% CI: 0.11–0.98) CHD 0.68 (95% CI: 0.48–0.95)

• Meta-analyses favor BPlowering treatment even in grade 1 HTN at low-tomoderate risk, and lowering SBP/DBP to <140/90 mm Hg. • Achieving <130/80 mm Hg appears safe, but only adds further reduction in stroke.

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2017 Hypertension Guideline Data Supplements

Xie X, et al., 2015 (21) 26559744

Aim: To assess the efficacy and safety of intensive BP-lowering strategies. Study type: Metaanalysis of RCTs Size: 19 RCTs with 44,989 pts

Inclusion criteria: RCTs with at least 6 mo follow-up that randomly assigned pts to more intensive vs. less intensive BPlowering treatment, with different BP targets or different BP changes from baseline. Reference lists from identified trials and review articles were manually scanned to identify any other relevant studies. Exclusion criteria: N/A Intervention: BP-lowering meds Comparator: • Less intensive treatment • BP difference 6.8/3.5 • The mean follow-up BP levels in the less intensive BP-lowering

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

CVD death 0.57 (95% CI: 0.32–1.02) total death 0.53 (95% 0.35–0.80) • Compared outcomes of achieved on study SBP <130 vs. ≥130 Standardized Risk ratio associated with 10/5 reduction in BP: stroke 0.68 (95% CI: 0.57, 0.83) CHD 0.87 (95% CI: 0.76, 1.00) HF 0.92 (95% CI: 0.47, 1.77) CVD 0.81 (95% CI: 0.67, 1.00) CVD death 0.88 (95% CI: 0.77, 1.01) total death 0.88 (95% CI: 0.77, 0.99) • Outcomes of achieved on study SBP 130-139 vs. ≥140 Standardized RR associated with 10/5 reduction in BP: stroke 0.63 (95% CI: 0.52, 0.77) CHD 0.77 (95% CI: 0.70, 0.86) HF 0.76 (95% CI: 0.47, 1.25) CVD 0.74 (95% CI: 0.62, 0.88) CVD death 0.81 (95% CI: 0.67, 0.97) total death 0.87 (95% CI: 0.75, 1.00) • Similar pattern of results for on treatment DBP. 1° endpoint: • CVD, other major CV events, defined as a MI, stroke, HF, or CV death, separately and combined; nonvascular and all-cause mortality; ESKD, and adverse events. Progression of albuminuria (defined as new onset of microalbuminuria/macro-albuminuria or a change from micro-albuminuria to macro-albuminuria) and retinopathy (retinopathy progression of 2 or more steps) were also recorded for trials that were done in pts with DM • CVD RR: 0.86 (95% CI: 0.78–0.96) Other endpoints: MI RR: 0.87 (95% CI: 0.76–1.00) p=0.042 Stroke RR: 0.78 (95% CI: 0.68–0.90) HF RR: 0.85 (95% CI: 0.66–1.11) CVD death RR: 0.91 (95% CI: 0.74–1.11) Total deaths RR: 0.91 (95% CI: 0.81–1.03)

• Intensive BP-lowering, including to <130 mm Hg, provided greater vascular protection than standard regimens. • In high-risk pts, there are additional benefits from more intensive BP-lowering, including for those with SPB <140 mm Hg at baseline. • The net absolute benefits of intensive BP-lowering in highrisk individuals are large. Limitations: • Lack of individual pt data, which would have allowed a more reliable assessment of 17

2017 Hypertension Guideline Data Supplements regimen group were 140/81 mm Hg, compared with 133/76 mm Hg in the more intensive treatment group.

Other results: • Benefit for CVD not different by baseline SBP 120–139: 0.89 (95% CI: 0.76–1.05) 140–160: 0.83 (95% CI: 0.68–1.00) >160: 0.89 (95% CI: 0.73–1.09) p-heterogeneity: 0.60 • Benefit for CVD not different for more intensive and less intensive targets in intensive group <140 or <150 mm Hg: 0.76 (95% CI: 0.60–0.97) <120– <130 mm Hg: 0.91 (95% CI: 0.84–1.00; phetero: 0.06) • Absolute benefits were proportional to absolute risk. • For trials in which all pts had vascular disease, renal disease, or DM at baseline, the average control group rate of major vascular events was 2·9% per y compared with 0·9% per y in other trials, and the numbers needed to treat were 94 (95% CI: 44–782) in these trials vs. 186 (95% CI: 107–708) in all other trials. • Increase in Severe hypotension: 0.3% vs. 0.1% per person y OR: 2.68 (95% CI: 1.21–5.89)

treatment effects in different pt groups. • Interpretation: Supports treating pt with and without CVD at threshold of 130 to <130. Supports treating at threshold of about 130 even down to a CVD event rate of 0.9% per y.

Data Supplement 3. Out-of-Office and Self-Monitoring of BP (Section 4.2) Study Acronym; Author; Year Published Pickering TG, et al., 1988 (22) 3336140

Study Type/Design; Study Size (N) Study type: ● Observational Cohort ● 24-h ABPM <134/90 ● Systematic review ● Office vs. ABPM or HBPM

Patient Population (N) N/A

Primary Endpoint and Results (include P value; OR or RR; & 95% CI) 1° endpoint: WCH=21%

Summary/Conclusion Comment(s) ● Multiple methodologies used to define MH. Prevalence 8.5%–16.6% (general population), 14.7%–30.4% (nonelevated clinic population)

Size: 292 pts

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Uhlig K, et al., 2012 (23) 22439158

Study type: ● Systematic review ● Self-monitoring vs. usual care vs. selfmonitoring+support

N/A

1° endpoint: Change in clinic SBP/DBP

McManus RJ, et al., 2014 (24) 25157723

Study type: ● RCT ● Self-monitoring with selftitration vs. usual care.

Inclusion criteria: SBP/DBP ≥130/85 mm Hg

1° endpoint: Change in SBP/DBP at 12 mo

Inclusion criteria: Pts from 16 clinics in integrated health system in Minneapolis, MN

222 pts randomized to 8 usual care clinics and 228 randomized to 8 intervention clinics

Margolis KL, et al., 2013 (25) 23821088

Size: 552 pts Aim: Assess impact of follow-up and monitoring system including home BP tele-monitoring and pharmacist case management on BP control in pts treated for HTN

Intervention included 12 mo of home BP tele-monitoring and pharmacist case management, with 6 mo of follow-up afterward

Study type: Cluster RCT Size: 450 pts Margolis KL, et al., 2013 (25) 23821088

McManus RJ, et al., 2014 (24) 25157723

Study type: ● RCT ● Home BP telemonitoring with pharmacist case management vs. usual care. Size: 450 pts Study type: ● RCT ● Self-monitoring with selftitration vs. usual care.

Inclusion criteria: Uncontrolled BP

Inclusion criteria: SBP/DBP ≥130/85 mm Hg

1° endpoint: SBP/DBP <140/90 mm Hg (<130/80 mm Hg in DM or CKD) at 6 and 12 mo. 2° endpoint: Change in BP, pt satisfaction, and BP control at 18 mo (6 mo after intervention stopped). 1° endpoint: Change in SBP/DBP at 12 mo

• Self-monitoring vs. usual care resulted in lower SBP/DBP (-3.1/-2.0 mm Hg) at 6 mo • Self-monitoring + support vs. usual care resulted in lower SBP/DBP SBP/DBP -3.4– 8.9/-1.9– -4.4 mm Hg up to 12 mo. • Self-monitoring may confer a small benefit for BP control. • Self-monitoring with self-titration was associated with SBP and DBP differences of 9.2 mm Hg and 3.4 mm Hg, respectively.

• Intervention group achieved better BP control compared to usual care during 12 mo of intervention and persisting during 6 mo of follow-up • SBP was <140/90 in 57.2% (95% CI: 44.8%, 68.7%) of intervention pts at 6 and 12 mo vs. 30% (95% CI: 23.2%, 37.8%) in usual care (p=0.001) • Combination of home BP tele-monitoring and pharmacist case management helped control HTN better than usual care at 6, 12, and 18 mo.24 ● Telemonitoring resulted in better BP control (57% vs. 30%) at 6 and 12 mo and larger SBP declines at 6, 12, and 18 mo. ● Some aspects of pt satisfaction (e.g., clinicians listening carefully) improved with telemonitoring. ● Self-monitoring with self-titration was associated with SBP and DBP differences of 9.2 mm Hg and 3.4 mm Hg, respectively.

Size: 552 pts © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

19

2017 Hypertension Guideline Data Supplements Study type: U.S. Preventive Services Task Force commissioned systematic review and meta-analysis of office and out of office BP relationships for diagnostic accuracy of diagnosing high BP after an initial office-based classification of high BP.

Inclusion criteria: ● Adults ≥18 y. ● 24 studies based on “confirmation” by means of ABPM and 6 by means of HPBM.

Uhlig K, et al., 2012 (23) 22439158

Study type: ● Systematic review ● Self-monitoring vs. usual care vs. selfmonitoring+support

N/A

Yi SS, et al., 2015 (26) 25737487

Study type: ● RCT ● Self-monitoring of BP vs. usual care.

N/A

Siu AL, et al., 2015 26458123

Size: 900 pts

Agarwal R, et. al., 2011 (27) 21115879

Study type: ● Systematic review

N/A

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: ABPM or HBPM conformation of office-based diagnosis of high BP. ● CVD risk-relationships for ABPM, HBPM and office-based BPs also reviewed. ● ABPM was recommended as the best method to confirm an office-based diagnosis of high BP, with HBPM an acceptable alternative, based on “over diagnosis” of high BP with office BP measurements (White coat hypertension) and stronger relationships between out of office BP measurements (especially ABPM) with vascular events. 1° endpoint: Change in clinic SBP/DBP

1° endpoint: ● Change in clinic SBP/DBP and HTN control (SBP/DBP <140/90 mm Hg) ● Decline in SBP at 9 mo was 14.7 mm Hg and 14.1 mm Hg in the intervention and usual care groups (p=0.70); HTN was controlled in 38.9% and 39.1% in the intervention and control groups (p=0.91) 1° endpoint: ● Change in clinic SBP/DBP and MAP

● Screen for high BP in adults ≥18 y and confirm office-based high BP using out of office BP measurements 9preferably ABPM).

● Self-monitoring vs. usual care resulted in lower SBP/DBP (-3.1/-2.0 mm Hg) at 6 mo ● Self-monitoring + support vs. usual care resulted in lower SBP/DBP SBP/DBP -3.4– 8.9/-1.9– -4.4 mm Hg up to 12 mo. Self-monitoring may confer a small benefit for BP control. ● Self-monitoring of BP by itself does not improve BP above usual care.

● Self-monitoring is associated with a reduction in BP. This effect is larger when accompanied by telemonitoring.

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2017 Hypertension Guideline Data Supplements ● Self-monitoring vs. usual care vs. selfmonitoring+telemonitoring

● Mean reduction in SBP, DBP and MAP with home monitoring was 2.63 mm Hg (95% CI: 4.24– 1.02), 1.68 (95% CI: 2.58–0.79), 4.0 (95% CI: 1.79–6.22). The effect for SBP was larger when accompanied by telemonitoring (3.20; 95% CI: 4.66–1.73 vs. 1.26; 95% CI: 2.20–0.31). 1° endpoint: CVD events. The adjusted HR for CVD events was 1.12 (95% CI: 0.84–1.50) for WCH vs. sustained normotension (p=0.59) and 2.00 (95% CI: 1.58– 2.52) for MH vs. sustained normotension (p<0.001)

Size: 9,446 pts

Fagard RH, et. al., 2007 (28) 17921809

Study type: ● Systematic review ● MH and WCH vs. sustained normotension

N/A

Size: 11,502 pts

● MH is associated with increased CVD risk but WCH is not associated with increased risk.

Data Supplement 4. White Coat Hypertension (Section 4.4) Study Acronym; Author; Year Published Viera AJ, et al., 2010 (29) 20671718 Viera AJ, et al., 2014 (30) 24842491 Bayo B, et al., 2006 (31) 16534404

Study Type/Design; Definitions

Patient Population (N)

• Office BP ×3 • Duplicate measures of: 24-h ABPM >130/80 Daytime ABPM>135/85 HBPM >135/85 • Office BP ×3 • Duplicate measures of: 24-h ABPM >130/80 Daytime ABPM >135/85 HBPM >135/85 • Office BP ×3 • HBPM ×3 d

• 50 pts • Untreated • Borderline HTN and BP >110/70 and <160/110 • 420 pts • Untreated • Borderline HTN and BP >120/80 and <149/95 • 190 untreated pts • Spanish • Borderline

HBPM (%)

Daytime ABPM (%)

24-h ABPM (%)

Results/Comments

• MH=43/35

• MH=54/53

• MH=51/45

• For MH diagnosis • 95% agreement daytime and 24-h ABPM • Only 47%–53% agreement between HBPM and either daytime or 24-h ABPM

• MH=15–17

• MH=43–44

• MH=48–50

• For MH Diagnosis • 92%–94% agreement daytime and 24-h ABPM • 70% agreement between HBPM and either daytime K=0.3–0.36 ● Compared to ABPM, HBPM pulse pressure variation: 59% negative predictive value: 69%

• WCH=35 (95% CI: 28–42)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• WCH=42 (95% CI: 34, 48)

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2017 Hypertension Guideline Data Supplements Asayama K, et al., 2015 (32) 25135185

Conen D, et al., 2014 (33) 25185130

Nasothimiou EG, et al., 2012 (34) 22357523 Coll de TG, et al., 2011 (35) 21183853 Stergiou GS, et al., 2005 (36) 15925734

• Obs (IDACO) database

• 8,237 untreated pts

N/A

• CV outcomes risk by WCH, MH, NTN ABPM measured: Office BP ×2 >140/90 (office) >130/80 (24-h ABPM) >135/85 (daytime ABPM) >120/70 (nighttime ABPM • Obs 13 IDACO Cohorts

• 7,506 untreated pts

• WCH=2.2% age 18–30, increasing to 19.5% in both sexes age >70 y • MH=inverted U distribution (13% and 11% in 18–30 y 18% and 20% in those 30–50 y • Increased prevalence in men

• 613 pts (66% untreated, 34% treated)

• WCH=15% • MH=15%

• WCH=14% • MH=16%

• 403 untreated pts

• WCH=24%

• 438 untreated/ treated pts

• MH=12% • WCH=16%

• Office ×2 • Awake ABPM >135/85 • 24-h ABP >130/80 • Analyzed by decade in y

• Office BP ×3 × >140/90 • HBPM >135/85 • Daytime ABPM >135/85 • Office ×2 >140/90 • Daytime ABPM >135/85 • HBPM >135/85 • Office ×3 ×2 >140/90 • HBPM ≥135/85 awake • ABPM ≥135/85

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• WCH=10.7 • MH=9.7

● Overlap from daytime to 24-h ABPM: WCH=86% MH=61%

• WCH=3.0 in age 18–30 increasing to 19.1% both sexes age >70 y • MH=inverted U distribution (12% and 9% in youngest and oldest, 19% and 17% in those 30– 50 y • Increase prevalence in men N/A

● Similar prevalence using either 24-h or awake ABPM

• WCH=8.1%

N/A

N/A

• MH=14% • WCH=15%

N/A

● No difference in proportions of pts Dx with MH or WCH by HBPM or awake ABPM ● No difference between treated and untreated. However, only 44% overlap for MH, but 90%–95% if 5 mm Hg zone of uncertainty added.

• WCH=9.1 • MH=13.4

● WCH: 89% agreement daytime ABPM and HBPM, kappa=0.79 ● MH: 88% agreement, kappa=0.56

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2017 Hypertension Guideline Data Supplements Sega R, et al., 2001 (37) 11560854

• Population-based PAMELA Study

• 2,051 pts

• WCH=12% • MH=9%

• WCH=12% • MH=9%

N/A

● 70% agreement between ABPM and HBPM for WCH and 57% for MH

• Office ×3 >140/90 • HBPM >132/83 • ABPM >125/79 • LVMI by echo

Data Supplement 5. White Coat Hypertension (Prevalence) (Section 4.4) Study Acronym; Author; Year Published Vinyoles E et al., 2008 (38) 18300853 Pickering TG, et al., 1988 (22) 3336140

Piper MA, et al., 2015 (39) 25531400 Asayama K, et al., 2014 (32) 25135185

Study Type/Design; Study Size Study type: ● Cross-sectional, comparative multicenter descriptive study Size: 6,176 pts Study type: ● Observational cohort ● 24-h ABPM <134/90 ● Systematic review ● Office vs. ABPM or HBPM Size: 292 pts Study type: ● Systematic review ● Office vs. ABPM or HBPM Study type: ● Observational (IDACO) database ● ABPM measured: ● Office BP ×2 ● >140/90 (office) ● >130/80 (24-h ABPM) ● >135/85 (daytime ABPM) ● >120/70 (nighttime ABPM)

Patient Population

Primary Endpoint and Results (include P value; OR or RR; & 95% CI)

N/A

1° endpoint: WCH=21%

N/A

1° endpoint: WCH=21%

N/A

1° endpoint: ●WCH=5–35% (ABPM) ● WCH conversion to SH ~1%–5% y 1° endpoint: ● WCH=6.3%–12.5% ● MH=9.7%–19.6%

Inclusion criteria: Untreated, >18 y

Summary/Conclusion Comment(s) ● Multiple methodologies used to define MH. ● Prevalence 8.5%–16.6% (general population), 14.7%–30.4% (nonelevated clinic population) ● Multiple methodologies used to define MH. ● Prevalence 8.5%–16.6% (general population), 14.7%–30.4% (nonelevated clinic population) ● Prevalence of WCH sufficiently high to require ABPM confirmation of SH in those with elevated clinic BP ● Variable prevalence of both WCH and MH based on method of defining

Size: 8,237 © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Conen D, et al., 2014 (33) 25185130

Alwan H, et al., 2014 (40) 24663506

Stergiou GS, et al., 2014 (41) 24420553

Pierdomenico SD, et al., 2011 (42) 20847724 Hansen TW, et al., 2007 (43) 17620947

Study type: ● Observational ● 13 IDACO cohorts ● Office ×2 ● Awake ABPM >135/85 ● 24-h ABP >130/80 ● Analyzed by decade in y Size: 7,506 pts Study type: ● Observational ● SKIPOGH ● Office BP ×4 ● Daytime ABPM ● Office >140/90 ● Daytime >135/85 Size: 652 Study type: ● Observational ● 5 IDACO cohort Studies ● Office ×2 >140/90 ● Home >135/85 ● Median 8.3-y follow-up Size: 5,007 pts Study type: Meta-analysis of observational cohort studies (8 WCH, 5 MH) 24-h ABPM >130/80 Daytime >135/85 Size: 7,961 pts Study type: ● 4 observational studies ● Office <140/90 ● 24-h ABPM >135/85

Inclusion criteria: >18 y, untreated

1° endpoint: ● WCH=2.2% age 18–30 y, increasing to 19.5% both sexes age >70 y ● MH=inverted U distribution (13% and 11% in youngest and oldest, 18% and 20% in those 30–50 y) Increase prevalence in males

● Increase in WCH prevalence with increasing age in both sexes ● Peak MH prevalence age 30–50 y with drop at age extremes. Greater prevalence of MH in males. ● Similar prevalence when 24-h vs. awake ABPM used

Inclusion criteria: >18 y, untreated

1° endpoint: ● WCH=2.6% ● MH=15.8%

● Pts with pre-HTN had 7 times higher rate of MH

Inclusion criteria: >18 y, untreated

1° endpoint: Long-term follow-up for CVD events

● WCH=13.8% ● MH=8.1%

Inclusion criteria: >18 y, untreated

1° endpoint: Long-term follow-up for CVD events

● WCH=16.1% ● MH=5.8%

• 78% untreated

Study endpoints: ● F/NF CVD ● Median follow-up =9.5 y

N/A

Size: 7,030 pts

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° Results: ● Adj HR vs. NTN ● WCH=1.22 (CI: 0.96–1.53), p=0.09 ● MH=1.62 (CI: 1.35–1.96), p<0.001 24

2017 Hypertension Guideline Data Supplements ● SH=1.80 (CI: 1.59–2.03), p<0.001

Data Supplement 6. White Coat Hypertension (Correlation with Clinical Outcomes) (Section 4.4) Study Acronym; Author; Year Published NICE 2011 (44) 22855971

Pierdomenico SD, et al., 2011 (42) 20847724

Asayama K, et al., 2014 (32) 25135185

Study Type/Design; Study Size (N)

Patient Population

Study Endpoints and Length of Follow-up

Study type: • Systematic Review • 3 Meta-analyses • 11 observational studies ”best method” comparison of office vs. HBPM or ABPM that best predicted (i.e., statistically significant predictors and higher HR values) clinical outcomes (after adjustment for covariates in multivariate analyses)

• Home vs. office (n=7,685) • ABPM vs. office (n=33,158) • Home vs. ABPM vs. Office (n=2,442)

• Outcomes of interest: mortality, stroke, MI, HF, DM, vascular procedures, hospitalization for angina, and other MACCE

Study type: Meta-analysis (8 studies) • NTN vs. WCH or MH based mostly on daytime ABPM <135/85

Inclusion criteria: Untreated

• Follow-up 3.2–12.8 y • Composite CVD

Inclusion criteria: >18 y, untreated

• F/NF CVD/stroke, 729 CV events • Follow-up 10.6 y

Size: 7,961 Study type: Observational (IDACO) database • CV outcomes risk by WCH, MH, NTN • ABPM measured: Office BP ×2 >140/90 (office)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) For predicting clinical outcomes: ABPM vs. office (9 studies): • ABPM superior to office (8 studies) • No difference between ABPM and office (1 study)

Summary/Conclusions/ Comment • Overall recommendation for ABPM to confirm HTN diagnosis (HBPM recommended if ABPM not practical)

HBPM vs. office (3 studies): • HBPM superior to office (2 studies) • No difference between HBPM and office (1 study) HBPM vs. ABPM vs. office (2 studies): • HBPM similar to ABPM and both superior to office (1 study) • No difference between HBPM, ABPM and office (1 study) • WCH vs. NTN: OR: 0.96; 95% CI: 0.65–1.42 • MH vs. NTN: OR: 2.09; 95% CI: 1.55– 2.81 • SH vs. NTN: OR: 2.59; 95% CI: 2.00– 3.35 • WCH adjusted HR: 1.2; 95% CI: 0.93– 1.54; p=0.16 • MH adjusted HR: 1.81; 95% CI: 1.41– 2.32; p<0.0001 • SH adjusted HR: 2.31; 95% CI: 1.91– 2.80; p<0.0001

N/A

N/A

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2017 Hypertension Guideline Data Supplements (24-h ABPM) >130/80 (daytime ABPM) >135/85 (nighttime ABPM) >120/70 Verdecchia P, et al., 2005 (45) 15596572

Size: 8,237 Study type: Populationbased (4 international cohorts) • Office ×3 >140/90 • Awake ABPM >130/80

Hansen TW, et al., 2007 (43) 17620947

Size: 5,955 Study type: Observational 4 studies • Office <140/90 • 24-h ABPM >135/85

Fagard RH, et al., 2007 (28) 17921809

Size: 7,030 Study type: Meta-analysis 7 studies • Office <140/90 • 24-h ABPM or HBPM

Mancia G, et al., 2013 (46) 23716584

Tomiyama M, et al., 2006 (47) 16942927

Size: 11,502 Study type: Observational PAMELA Study • Office ×3<140/90 • HBPM>135/85 and-24-h • ABPM>130/80 Size: 2,051 Study type: Cross-sectional study assessing target organ damage by BP control status. Control: Office <140/90, daytime <135/85.

• 26% NTN

• Stroke • Follow-up 5.4 y

• WCH adjusted HR: 1.15; 95% CI: 0.61– 2.16; p=0.66 • SH adjusted HR: 2.01; 95% CI: 1.31– 3.08; p<0.001

• Stroke not increased in WCH but tended to approach systolic HTN risk 6 y after baseline ABPM.

• 78% untreated

• F/NF CVD • Median follow-up=9.5 y

N/A

• Treated and untreated

• F or F/NF CVD • Follow-up 3.2–12.3 y (mean=8 y)

• 22% treated

• CV and allcause mortality • Follow-up 16 y

• WCH adjusted HR: 1.22 (95% CI: 0.96, 1.53), p=0.09 • MH adjusted HR: 1.62; 95% CI: 1.35– 1.96; p<0.001 • SH adjusted HR: 1.80; 95% CI: 1.59– 2.03; p<0.001 • WCH adjusted HR: 1.12 (95% CI: 0.84– 1.50), p=0.59 • MH adjusted HR: 2.0; 95% CI: 1.58– 2.52; p<0.001 • Systolic HTN adjusted HR: 2.28; 95% CI: 1.87–2.78; p<0.001 • CV mortality in WCH adjusted HR: 2.04 (95% CI: 0.87–4.78), p=0.10 • All-cause mortality in WCH adjusted HR: 1.50; 95% CI: 1.03–2.18; p=0.03

• Treated pts

• LVMI, carotid IMT, UAE • Cross-sectional

• LVMI, carotid IMT and UAE increased in masked uncontrolled HTN compared to controlled HTN. LVMI and UAE increased in SH

• SH and masked uncontrolled HTN but not WCE associated with increased target organ damage

N/A

• Trend but insignificant increase in CV mortality and significant increase in total mortality in WCH • Risk of developing systolic HTN greater in those with WCH

Size: 332

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

26

2017 Hypertension Guideline Data Supplements Ohkubo T, et al., 2005 (48) 16053966

Tientcheu D, et al., 2015 (49) 26564592

Study type: Observational cohort • Office ×2 >140/90 • Awake ABPM >135/85 Size: 1,332 Study type: Observational cohort • Home readings ×5 ×2 visits taken by research staff • Office readings ×5 Size: 3,027

• Untreated (70%) • Treated (30%)

• CVD mortality/stroke • Follow-up 10 y

• Dallas Heart Study • 54% African American• 30%–39% treated

• Clinical CVD incl TIA, • UA

• WCH RH: 1.28; 95% CI: 0.76–2.14); p=0.4 • MH RH: 2.13; 95% CI:1.38–3.29; p<0.001 • SH RH: 2.26; 95% CI:1.77–4.54; p<0.0001 • WCH adj HR: 2.09; 95% CI: 1.05–4.15; p=0.035 • MH adj HR: 2.03; 95% CI: 1.36–3.03; p<0.001 SH adj HR: 3.12; 95% CI: 2.13–4.56; p<0.001

• Similar results treated and untreated, males, and females

• Higher CVD with SH, MH and WCH (African Americans only). CVD risk not increased in whites with WCH

Data Supplement 7. Renal Artery Stenosis (Section 5.4.3) Study Acronym (if applicable) Author Year Published Lawes CM, et al., 2003 (50) 12658016

Riaz IB, et al., 2014 (51) 25145333 Cooper CJ, et al., 2014 (52) 24245566

Study Type/Design; Study Size (N) Study type: Metaanalysis of RCTs of BP drugs recording CHD events and strokes Size: 464,000 pts Study type: 540 studies and 7 RCTs Size: 2,139 pts Study type: Residential treatment center medical therapy with or without renal stent Size: 947 pts

Patient Population

Primary Endpoint and Results (include P value; OR or RR; & 95% CI)

Summary/Conclusion Comment(s)

N/A

• CHD RR or 46% Stroke 64%

• All classes of BP meds confer benefit while BB confer greater benefit in those with CAD

N/A

• Incidence of nonfatal MI 6.74% in both the stenting and medical therapy groups: OR: 0.99; 95% CI: 0.70–1.43; p=0.99, incidence of renal events in stenting population was found to be 19.58% vs. 20.53% in medical therapy OR: 0.95; 95% CI: 0.76–1.18; p=0.62. • Composite endpoint of death from CV or renal causes, MI, stroke, hospitalization for congestive HF, progressive renal insufficiency, or the need for renal-replacement therapy. 35.1% and 35.8%, respectively; HR with stenting: 0.94; 95% CI: 0.76–1.17; p=0.58 Difference in SBP favoring the stent group: -2.3 mm Hg; 95% CI: -4.4– 0.2; p=0.03.

• BP effect, CV accident not specifically reported

Inclusion criteria: Atherosclerotic renal artery stenosis

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

N/A

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2017 Hypertension Guideline Data Supplements Xie X, et al., 2015 (21) 26559744

Study type: MA of RTC that randomly assigned individuals to different target BP levels

• 19 trials

• Achieved BP 133/76 mm Hg (intensive) 140/81 (less intense) • Major CV events: 14%; 95% CI: 4%–22% • MI: 13%; 95% CI: 0%–24% • Stroke: 22%; 95% CI: 10%–32% • Albuminuria: 10%; 95% CI: 3%–16% • Retinopathy progression: 19%; 95% CI: 0%–34%. • More intensive had no effects on HF: 15%; 95% CI: -11%–34% • CV death: 9%; 95% CI: –11%–26% • Total mortality: 9%; 95% CI: -3%–19% • ESKD: 10%; 95% CI: -6%–23%

• More intensive approach reduced major CV events (stroke and MI) except heat failure, CVD, ESRD, and total mortality.

• 49 trials ( most pts with DM-2)

Baseline SBP >150 RR for • All death: 0.89; 95% CI:0.80–0.99 • CVD: 0.75; 95% CI: 0.57–0.99 • MI: 0.74; 95% CI: 0.63–0.87 • Stroke: 0.77; 95% CI: 0.65–0.91 • ESRD: 0.82; 95% CI: 0.71–0.94

• BP lowering reduces major CV events in DM. Caution for initiating treatment in diabetics with SBP <140/90

Size: 44,989 pts

Brunström M, et al., 2016 (53) 26920333

Study type: Metaanalysis of levels of BP control in DM hypertensives. Size: 73,738 pts

Baseline SBP140–150 RR of • Death: 0.87; 95% CI: 0.78–0.98) • MI: 0.84; 95% CI: 0.76–0.9 • HF: 0.80; 95% CI: 0.66–0.97 If baseline SBP,140 mm Hg, however, further treatment increased the risk of CV mortality (1.15; 95% CI: 1.00–1.32 Ettehad D, et al., 2015 (17) 26724178

Study type: Metaanalysis of large RTCs of antihypertensive treatment Size: 613,815 pts

• 123 studies

Every 10 mm Hg reduction in SBP RR: • Major CV events: 0.80; 95% CI: 0.77–0.83 • CHD: 0.83; 95% CI: 0.78–0.88 • Stroke: 0.73; 95% CI: 0.68–0.77), HF (0.72, 0.67–0.78 • All-cause mortality: 0.87; 95% CI: 0.87; 0.84–0.91 • ESRD: 0.95; 0.84–1.07

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• BP lowering reduces CV risk across various baseline BP levels and comorbidities. Suggest lowering SBP <130 mm Hg and BP-lowering treatment to pts with a history of CVD, CHD, stroke, DM, HF, and CKD.

28

2017 Hypertension Guideline Data Supplements Thomopolous C, et al., 2016 (54) 26848994

Julius S, et al., 2006 (55) 16537662

Study type: Metaanalysis of RTCs of more vs. less intense BP control

Study type: RCT in preHTN; 16 mg candesartan vs. placebo

• 16 trials (52,235 pts) compared more vs. less intense treatment 34 (138,127 pts) active vs. placebo • 58% men

Size: 809 pts Ference BA, et al., 2014 (56) 24591335

Study type: Evaluated the effect of 12 polymorphisms (associated with BP) on the odds of CHD and compared it with the effect of lower SBP observed in both prospective cohort studies and BP-lowering randomized trials

• 63 studies

More intense BP • Stroke RR: 0.71; 95% CI: 0.60–0.84) • CHD RR: 0.80; 95% CI: 0.68–0.95) • Major CV events RR: 0.75; 95% CI: 0.68–0.85 • CV mortality RR: 0.79; 95% CI: 0.63–0.97

• Intensive BP reduction improves CV outcomes compared to less intense Achieved BP <130/80 may be associated with CV benefit.

Stratification of SBP cutoffs (150,140 and 130 mm Hg) showed that a SBP/DBP difference of 10/5 mm Hg across each cutoff reduced risk of all outcomes • During the first 2 y, HTN developed in 154 (40.4%) pts in the placebo group compared with only 53 (13.6%) of those in the candesartan group, for RR: 66.3% (p<0.0001). After 4 y, HTN developed in 240 (63.0%) in the placebo group vs. only 208 (53.2%) in the candesartan group RR: 15.6% (p<0.0069). • 12 polymorphisms were associated with a 0.32 mm Hg lower SBP (p=1.79×10-7) and a 0.093-mm Hg/decade slower age-related rise in SBP (p=3.05×10-5). The effect of long-term exposure to lower SBP on CHD mediated by these polymorphisms was 2-fold greater than that observed in prospective cohort studies (p=0.006) and 3-fold greater than that observed in short-term BP treatment trials (p=0.001).

• 2/3 of those with pre-HTN develop HTN within 4 y. Candesartan interrupts the onset and reduced by 15.6% • SBP may be causally associated with the rate of rise in SBP with age and has a cumulative effect on the risk of CHD.

Size: 199,477 pts

Data Supplement 8. RCTs Comparing Obstructive Sleep Apnea (Section 5.4.4) Study Acronym; Author; Year Published Barb F, et al., 2010 (57) 20007932

Aim of Study; Study Type; Study Size (N) Aim: Assess the effect on BP of 1 y of treatment with CPAP in nonsleepy pts with HTN and OSA.

Patient Population Inclusion criteria: Pts with HTN (on medications or ≥140/90) and

Study Intervention (# patients) / Study Comparator (# patients) Intervention: CPAP Comparator: Conservative treatment

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: Decrease in BP Results: At 12 mo, CPAP decreased SBP by 1.89 mm Hg (95% CI: 3.90–0.11 mm Hg; p=0.065) and DBP 2.19 mm Hg

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events; Summary Limitations: Not blinded; both groups consisted of pts with severe sleepapnea.

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Martinez-Garcia MA, et al., 2013 (58) 24327037

Study type: RCT

apnea-hypopnea index >19.

(dietary counseling and sleep hygiene advice).

Size: 359 pts; 12 mo of follow-up Aim: Assess the effect of CPAP on BP in pts with OSA and resistant hypertension.

(95% CI: 3.46– -0.93 mm Hg; p=0.001). The most significant reduction in BP was in pts who used CPAP for more than 5.6 h/night.

Conclusions: CPAP induced a significant reduction in BP, albeit small, in hypertensive pts with OSA.

Inclusion criteria: Pts with resistant hypertension and OSA.

Intervention: CPAP

1° endpoint: Change in 24-h ABPM from baseline to 12 wk.

Limitations: Did not use sham CPAP as placebo; open-label; short follow-up. Conclusions: Among pts with resistant hypertension and OSA, CPAP treatment for 12 wk compared with control resulted in a decrease in 24-h mean and DBP and improvement in nocturnal pressure pattern.

Inclusion criteria: Pts with resistant hypertension and OSA.

Intervention: CPAP + conventional drug treatment

Results: • When the changes in BP were compared between groups by intent to treat, the CPAP group achieved a greater decrease in 24-h mean BP (3.1 mm Hg (95% CI: 0.6, 5.6); p=0.02) and 24-h DBP (3.2 mm Hg (95% CI: 1.0, 5.4; p=0.005) but not in 24-h SBP (3.1 mm Hg (95% CI: -0.6–6.7; p=0.10) compared to control. • There was also a greater nocturnal BP dipping pattern in CPAP treated pts than control (35.9% vs. 21.6%; adjusted OR: 2.4; CI: 1.2–5.1; p=0.02). • There was a significant positive correlation between h of CPAP use and the decrease in mean 24-h BP (r=0.29; 0.006), SBP (r=0.25; p=0.02) and DBP (r=0.30; p=0.005). 1° endpoint: Decrease in 24-h ABPM from baseline to 12 wk. Results: Pts with ABPM confirmed resistant hypertension treated with CPAP, unlike those treated with conventional therapy, showed a decrease in 24-h DBP (-4.9±6.4 vs. 0.1±7.3 mm Hg; p=0.027). Pts who used CPAP >5.8 h showed a greater reduction in daytime DBP (-6.12 mm Hg; 95% CI: -1.45–10.82; p=0.004), 24-h DBP (-6.98 mm Hg; 95% CI: -1.86– 12.1; p=0.009) and 24-h SBP (-9.71 mm Hg; 95% CI: -0.20– -19.22; p=0.46).

Conclusions: CPAP as a complement to usual treatment improved mean 24-h DBP in pts with OSA and ABPMconfirmed resistant hypertension.

Comparator: No therapy

Study type: RCT Size: 194 pts; 3 mo follow-up

Lozano L, et al., 2010 (59) 20577130

Aim: Assess effect of CPAP on pts with OSA and resistant hypertension. Study type: RCT Size: 96 pts; 3 mo of follow-up

Comparator: Conventional drug treatment alone

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Limitations: Small study; only 3 mo follow-up; lack of sham control.

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2017 Hypertension Guideline Data Supplements Muxfeldt ES, et al., 2015 (60) 25601933

Aim: Evaluate the effect of CPAP on pts with resistant hypertension and OSA.

Inclusion criteria: Pts with resistant hypertension and OSA

Study type: RCT Size: 434 pts; 6 mo of follow-up

Pedrosa RP, et al., 2013 (61) 23598607

Aim: Evaluate the effect of CPAP on pts with resistant hypertension and OSA. Study type: RCT with Size: 40 pts; 6 mo follow-up

Inclusion criteria: Pts with resistant hypertension and OSA

Intervention: CPAP + conventional antihypertensive therapy Comparator: Antihypertensive therapy alone. Conventional antihypertensive therapy included spironolactone.

Intervention: CPAP + conventional antihypertensive therapy (n=20) Comparator: Antihypertensive therapy alone (n=20).

1° endpoint: BP reduction at 6 mo via ABPM Results: • On an intention-to-treat analysis, there was no significant difference in any BP change, neither in nocturnal BP fall, between CPAP and control groups. The best effect of CPAP was on night-time SBP in per-protocol analysis, with greater reduction of 4.7 mm Hg (95% CI: -1.6%– 5.8%; p=0.25, in comparison with the control group. • Median use of CPAP was 4.8 h.

1° endpoint: BP reduction at 6 mo by ABPM. Results: BP was 162±4/97±2 mm Hg prior to randomization. CPAP was used for 6 h/night. Compared with the control group, awake SBP/DBP decreased significantly in the CPAP group (6.5±3.3/-4.5±1.9 vs. +3.1±3.3/2.1±2/7 mm Hg; p<0.05). BP changes were significant only when pts were awake but not at night by ABPM.

Limitations: Nonblinded design; per protocol analysis underpowered to show the prespecified outcome of 6–7 mm Hg SBP differences between CPAP and control groups. Conclusions: CPAP had no significant effect on clinic or ambulatory BP in pts with resistant hypertension and moderately severe to severe OSA. However, in the specific subgroup of pts with uncontrolled ambulatory BP, CPAP may modestly reduce night-time SBP and improve the nocturnal BP fall pattern. The reason for lack of BP reduction in the overall study may have been due to excellent control of BP with median 5 medications, including spironolactone, in the majority of pts. Limitations: Small; but strength was rigorous exclusion of pts who were nonadherent; control arm did not undergo placebo treatment; nonblinded. Conclusions: Treatment of OSA with CPAP significantly reduces daytime BP in pts with resistant hypertension.

Data Supplement 9. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Dietary Fiber Intake) (Section 6.2) Study Acronym; Author; Year Published

Aim of Study; Study Type; Study Size (N)

Patient Population

Study Intervention (# patients) / Study Comparator (# patients)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events

31

2017 Hypertension Guideline Data Supplements Whelton SP, et al., 2005 (62) 15716684

Streppel MT, et al., 2005 (63) 15668359

Aim: Study the effect of dietary fiber intake on BP Study type: Systematic review and metaanalysis Size: • 21 RCTs (25 comparisons) with 1,477 pts • 20 of the RCTs were conducted in nonhypertensive persons • 13 double-blind; 3 single blind and 9 open label Aim: Study the effect of fiber supplementation on BP Study type: Systematic review and metaanalysis Size: • 23 RCTs (25 comparisons) in 1,404 pts • Mean duration=9 wk • Mean age=42 y • 16 double-blind, with 14 (67%) of the 21 comparisons conducted in normotensive pts • 3 trials based on plant protein and 4 trials based on animal protein

Inclusion criteria: • RCT • ≥16 y • English language publication before Feb. 2004 • No concurrent interventions Exclusion criteria: Missing key data

Intervention: Fiber supplementation, either as a pill (8 trials), cereal/fruit/veg (15 trials), Pectin (1 trial), Guar gum (1 trial) Comparator: Placebo or no fiber supplementation

1° endpoint: In a pooled analysis of the overall group (hypertensive and normotensive persons), the mean for change in SBP was -1.15 mm Hg; 95% CI: -2.68–0.39 mm Hg and for DBP was -1.65 mm Hg; 95% CI: -2.70– -0.61 mm Hg. In the subgroup of 20 trials conducted in nonhypertensives, the mean change in SBP was -0.14 mm Hg; 95% CI: -1.10–0.86 mm Hg. In the subgroup of 5 trials conducted in hypertensives, the mean change in BP was -5.95 mm Hg; 95% CI: -9.50– -2.40) mm Hg.

● This is the most detailed and comprehensive review of the topic. ● It provides limited evidence, overall, that fiber supplementation results in a significant in BP and suggests no evidence in support of an effect in normotensives.

1° Safety endpoint: N/A Inclusion criteria • Human RCT • BP 1° or 2° outcome • Publications between January 1966–January 2003 Exclusion criteria: • Inadequate reporting of the data • Concurrent intervention

Intervention: Fiber supplementation (average dose=11.5 g/d); soluble fiber in 11 trials, insoluble fiber in 7 trials, and a mixture in the remaining trials Comparator: Placebo or no fiber supplementation

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: In the overall group (hypertensive and normotensive pts), a pooled analysis identified a MD for change in SBP of -1.13 mm Hg; 95% CI: -2.49–0.23. In a subgroup of 17 trials conducted in “nonhypertensives” (mean baseline BP<140/90 mm Hg or <50% receiving antihypertensive medication), the mean treatment effect was -0.23 mm Hg; 95% CI: -1.43–0.98 in univariate analysis and -1.00 mm Hg; 95% CI: 1.94– -0.06 mm Hg in multivariate analysis that adjusted for age, sex, study design, duration of intervention, and fiber dose. The corresponding effects in 8 trials conducted in hypertensives were -4.53 mm Hg; 95% CI: -6.69– -2.38 mm Hg; and -2.42 mm Hg; 95% CI: -5.28–0.45 mm Hg.

● Findings consistent with experience in the meta-analysis by Whelton et al.

Safety endpoint: N/A

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2017 Hypertension Guideline Data Supplements Evans CE, et al., 2011 (64) 25668347

Aim: Study the effect of fiber supplementation on BP Study type: Systematic review and metaanalysis Size: 28 trials met the inclusion criteria and reported fiber intake and SBP and/or DBP. 18 trials were included in a meta-analysis.

Inclusion criteria • RCTs, in humans of at least 6 wk duration • Fiber isolate or fiber-rich diet against a control or placebo • Published between 1 January 1990 and 1 December 2013. Exclusion criteria: N/A

Intervention: Fiber supplementation (average dose =11.5 g/d) -soluble fiber in 11 trials, insoluble fiber in 7 trials, and a mixture in the remaining trials Comparator: Placebo or no fiber supplementation

1° endpoint: Studies were categorized into 1 of 12 fiber-type categories. The pooled estimates for all fiber types were -0.9 mm Hg (95% CI: -2.5–0.6 mm Hg) and -0.7 mm Hg (95% CI: -1.9–0.5  mm Hg) for SBP and DBP, respectively. The median difference in total fiber was 6 g. Analyses of specific fiber types concluded that diets rich in beta-glucans reduce SBP by 2.9 mm Hg (95% CI: 0.9, 4.9 mm Hg) and DBP by 1.5  mm Hg (95% CI: 0.2–2.7  mm Hg) for a median difference in beta-glucans of 4  g. Heterogeneity for individual fiber types was generally low.

● Higher consumption of betaglucan fiber is associated with lower SBP and DBP. ● The results of this review are consistent with recommendations to increase consumption of foods rich in dietary fiber, but some additional emphasis on sources of beta-glucans, such as oats and barley, may be warranted.

Safety endpoint: N/A

Data Supplement 10. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Fish Oil) (Section 6.2) Study Acronym; Author; Year Published Campbell F, et al., 2012 (65) 22345681

Aim of Study; Study Type; Study Size (N) Aim: Study the effect of fish oil supplementation on BP Study type: Systematic review and meta-analysis Size: • 17 RCTs (25 comparisons) with 1,524 pts. • 9 trials were conducted in normotensives (1,049

Patient Population

Inclusion criteria: • RCT • English language publication before January 2011 • Duration ≥8 wk Exclusion criteria: N/A

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Fish oil given in capsule form, with doses varying from 0.8–13.33 g/d. Comparator: Placebo (usually corn oil, olive oil, or safflower oil).

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events

1° endpoint: In a pooled analysis of the 8 trials conducted in hypertensive pts, the mean for change in SBP was 2.56 mm Hg; 95% CI: -4.53– -0.58 mm Hg. The corresponding SBP change for the 9 trials conducted in normotensives was -0.50 mm Hg; 95% CI: -1.44– 0.45.

● This is the most recent of many that have been published. ● Previous meta-analyses have been conducted by Appel et al (1993), Morris et al. (1993), Geleijnse et al (2002) and Dickinson et al. (2006). ● In general, the findings have been fairly consistent in demonstrating a relatively small (2 3/4 mm Hg SBP) but significant effect, with most of this being attributable to the results in trials conducted in hypertensive pts. 33

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RodriguezLeyva D, et al., 2013 (66) 24126178

pts with mean age of 47 y). Follow-up varied 2–26 wk. Aim: Study the effect of flaxseed on BP in hypertensive pts

Inclusion criteria: • >40 y • PAD for >6 mo, ABI <0.9

Study type: RCT Size: 110 pts with PAD

Exclusion criteria: Inability to walk, bowel disease, moderate to severe renal failure, life expectancy <2 y with high cardiac risk, allergy to any of the study products, pts who plan to undergo surgery during the course of the trial, and no more than 2 fish meals per wk

Intervention: Pts given 1 food item per day for 6 mo, containing either 30 g of milled flax seed or placebo. Flaxseed contains omega-3 fatty acids, lignans, and fiber. Comparator: Placebo

1° endpoint: SBP and DBP consistently decreased in the flaxseed group over the course of the study. After 6 mo, SBP in the flaxseed group dropped significantly to 136±22 mm Hg (p=0.04). On the contrary, in the placebo group, SBP rose slightly to 146±21 mm Hg. After 6 mo of intervention, DBP in the flaxseed group fell to 72±11 mm Hg (p=0.004), whereas DBP in the placebo group remained the same (79±10 mm Hg).

● Based on this 1 RCT, flaxseed appeared to have a significant BP lowering effect

Data Supplement 11. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Potassium Supplementation to Placebo or Usual Diet) (Section 6.2) Study Acronym; Author; Year Published Whelton PK, et al., 1997 (67) 9168293

Aim of Study; Study Type; Study Size (N)

Patient Population

Aim: Study the effect of potassium supplementation on BP

Inclusion criteria: • Human RCT • Without HTN • Potassium supplementation vs. control • No concurrent interventions

Study type: Systematic review and meta-analysis Size:

Exclusion criteria: Missing key data

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Potassium supplementation in 1,049 pts (potassium chloride tabs in 10 RCTs with 618 pts and diet in 2 RCT with 431 pts) Comparator: No potassium supplementation

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: • Significant reduction in BP. • Overall (hypertensives and normotensives), mean: 3.11 mm Hg; 95% CI: -4.32– -1.91 mm Hg. • In the 12 trials conducted in normotensives, mean: -1.8 mm Hg; 95% CI: -2.9– -0.6 mm Hg for SBP and -1.0 mm Hg; 95% CI: -2.1–0.0 for DBP

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events • This is the most comprehensive presentation of the effects of potassium on BP, including experience in normotensives. • Significant reduction in SBP overall and in the subgroups with and without HTN. • In a subsequent meta-analysis of 23 trials, Geleijnse JM, Kok FJ, and Grobbee DE (J Hum Hypertens. 2003;17:471-480) reported a similar effect of potassium on SBP in both hypertensives and nonhypertensives (mean of 3.2 and -1.4 mm Hg, respectively). 34

2017 Hypertension Guideline Data Supplements (placebo in 10 RCT and usual diet in 2 RCT)

• Overall, 33 RCT (n=2,609) • 2 RCTs (n=1,049) in normotensives

• In the 20 trials conducted in hypertensives, mean: -4.4 mm Hg; 95% CI: -6.6– -2.2 for SBP and -2.5 mm Hg; 95% CI: -4.9– -0.1 for DBP Safety endpoint: N/A

Aburto NJ, et al., 2013 (68) 23558164

Aim: Study the effect of potassium supplementation on BP Study type: Systematic review and meta-analysis Size: 21 RCTs (n=1,892); 16 in pts with HTN (n=818) and 3 RCTs in pts without HTN (n=757)

Geleijnse JM, et al., 2003 (69) 12821954

Aim: Study the effect of potassium supplementation on BP Study type: Systematic review and metaregression analysis Size: 27 RCTs; 19 in pts with HTN and 11 RCTs in pts without HTN

Inclusion criteria: • RCT in humans • Duration ≥4 wk • 24-h collections of urinary potassium • No concomitant interventions Exclusion criteria: Pts who were acutely ill, HIV positive, hospitalized, or had impaired urinary excretion of potassium Inclusion criteria: • RCT in adults • Published after 1966 • Duration ≥2 wk • No concomitant interventions

Intervention: Potassium supplementation in 20 trials, supplements plus diet/education in 1 trial, and diet/education alone in 2 trials. Comparator: No potassium supplementation (placebo or usual diet)

Intervention: Potassium supplementation Comparator: No potassium supplementation

Exclusion criteria: • Disease • Outlier results (1 trial)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: • Overall change in SBP=5.93; 95% CI: -10.15– -1.70. After removing outlier trials, the change was -3.49 mm Hg; 95% CI: -5.15– -1.82 mm Hg. • In 16 trials conducted in hypertensives, change in SBP was -5.32 mm Hg; 95% CI: -7.20– -3.43. • In the 3 trials conducted in persons without HTN, change in SBP was 0.09 mm Hg; 95% CI: -0.77–0.95. Safety endpoint: N/A 1° endpoint: • Overall change in SBP=2.42; 95% CI: -3.75– -1.08 • In the 19 trials conducted in hypertensives, change in SBP was -3.51 mm Hg; 95% CI: -5.31– -1.72 • In the 3 trials conducted in persons without HTN, change in SBP was 0.97 mm Hg; 95% CI: -3.07–1.14

• The 1 RCT conducted in African-Americans (n=87) identified a mean treatment effect size of -6.9 mm Hg; 95% CI: -9.3– -4.4 for SBP (p<0.001) and -2.5 mm Hg; 95% CI: -4.3– -0.8 for DBP (p=0.004). • In the entire cohort (trials conducted in pts with HTN and normotension), net changes in SBP and DBP were directly related to level of urinary sodium excretion during the trial. • 1 trial (TOHP Phase I) incorrectly entered twice so only 2 trials really available. However, this does not change overall finding. • The negative results for normotensives in this meta-analysis (and difference with the findings by Whelton et al) probably reflects the requirement for a duration of ≥4 wk and the fact that few trials of this duration have been conducted in normotensives.

• Imputation for missing data • In addition to the treatment effect difference by presence/absence of HTN, there was a trend toward a larger treatment effect in older age (≥45 y), and to a lesser extent higher baseline urinary Na (>150 mmol/24 h) and greater increase in urinary K (>44 mmol/24 h)

Safety endpoint: N/A 35

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Data Supplement 12. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Protein Intake on BP) (Section 6.2) Study Acronym; Author; Year Published

Aim of Study; Study Type; Study Size (N)

Rebholz CM, et al., 2012 (70) 23035142

Aim: Study the effect of protein intake on BP Study type: Systematic review and metaanalysis Size: • 40 RCTs (44 comparisons) with 3,277 pts • 32 comparisons of protein vs. carbohydrate • 12 comparisons of vegetable vs. animal protein • 35 of the RCTs were conducted in normotensive persons (28 with SBP in the prehypertensive range)

Tielemans SM, et al., 2013 (71) 23514841

Aim: Study the effect of protein intake on BP

Patient Population

Inclusion criteria: • RCT in humans • ≥18 y • Publication between January 1,1950 and April 1, 2011 • No concurrent interventions • No more than 10% difference in calories, sodium, potassium, fiber between the treatment arms • Duration ≥1 wk Exclusion criteria: Missing key data

Inclusion criteria • RCTs, in “generally healthy adults”

Study Intervention (# patients) / Study Comparator (# patients) Intervention: • Protein intake • 1st meta-analysis: any source of protein, with a median protein supplementation dose of 40 g/d (20–66 g/d) • 2nd meta-analysis: specifically vegetable or animal protein Comparator: • 1st meta-analysis: carbohydrate • 2nd meta-analysis: vegetable or animal protein

Intervention: Protein intake

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: • 1st meta-analysis There was a fairly consistent trend for a small BP lowering effect of protein compared to carbohydrate intake (86% of the trials). In a pooled analysis of the overall group (hypertensive and normotensive persons), the mean for change in SBP was -1.76 (95% CI: 2.33– -1.20). In a subgroup of 15 trials in which none of the participants were receiving antihypertensive medication, the mean change in SBP was -1.95 (95% CI: -2.62– -1.29). • 2nd meta-analysis For the comparison of vegetable vs. animal protein, there was no evidence of a difference in BP. In a pooled analysis of the overall group (hypertensive and normotensive pts) the mean change in SBP was -0.10 (95% CI: -2.31–2.11) mm Hg. In a subgroup of 8 trials in which none of the pts were receiving antihypertensive medication, the mean change in SBP was -0.55 (95% CI: -3.06–1.96). 1° Safety endpoint: N/A 1° endpoint: • At baseline, the mean for age and SBP were 50 (range: 31–74) and 128

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events ● This is the most detailed and comprehensive review of the topic. ● It provides strong evidence that protein supplementation results in a significant but modest reduction in BP and suggests that the effect size is similar following supplementation with protein from vegetables or animals.

• Findings consistent with experience in the metaanalysis by Rebholz et al. 36

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Dong JY, et al., 2013 (72) 23829939

Study type: Systematic review and metaanalysis

• Publications between January 1966–January 2012

Size: 16 RCT (210 comparisons) of protein vs. carbohydrate in 1,449 pts, with 14 (67%) of the 21 comparisons conducted in normotensive pts. -3 trials based on plant protein and 4 trials based on animal protein

Exclusion criteria: • Inadequate reporting of the data • Concurrent intervention

Aim: Study the effect of protein intake on BP in DM-2

Inclusion criteria: • RCTs in adults with DM2 • Publications up to August 2012 • High protein diet intervention and ≥5% difference in dietary protein intake between intervention and control groups • Trial duration ≥4 wk

Study type: Systematic review and metaanalysis Size: 9 RCTs with 418 pts

Dong JY, et al., 2013 (73) 23823502

Aim: Study the effect of probiotic fermented milk on BP. Study type: Systematic review and metaanalysis. All but 1

Exclusion criteria: Inadequate reporting of key data Inclusion criteria: • RCTs • Placebo controlled • Published prior to March 2012 Exclusion criteria:

Comparator: Carbohydrate intake

Intervention: High protein diet intervention and ≥5% difference in dietary protein intake between intervention and control groups

(range: 112–144). During the trials, the MD in protein intake was 48 g/d (range: 26–74 g/d). • In the overall group (hypertensive and normotensive participants), a pooled analysis of comparisons from 14 trials (1,208 pts) identified a MD for change in SBP of -2.11 (95% CI: -2.8– -1.37) for protein vs. carbohydrate. In 3 RCTs that employed plant protein (327 pts), the mean treatment effect was -1.95 (95% CI: -3.21– -0.69) and in 4 RCTs that employed animal protein (574 pts), the corresponding difference was -2.20 (95% CI: -3.36– -1.03). Safety endpoint: N/A 1° endpoint: Pooled experience in the 14 trials identified a nonsignificant reduction in mean SBP of -3.10 (95% CI: -4.63– -1.56). Safety endpoint: N/A

Comparator: N/A

Intervention: Probiotic fermented milk (100– 450 g/d) Comparator: Not specified but all of the trials reported to be

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: Pooled experience in the 9 trials identified a nonsignificant reduction in mean SBP of -3.59 (95% CI: -7.58–0.40). Safety endpoint: N/A

● Heterogeneous group of open label trials with a range of duration from 4–24 wk (median of 12 wk). In addition to DM-2, all of the participants were overweight or obese. ● The quality of the trials varied, drop-out rates ranged from 0%–0%, and only 1 trial was analyzed using an intent to treat approach.

● The most recent of several meta-analyses conducted by different groups of investigators that have reported a similar effect size following administration of lactopeptides, especially the 37

2017 Hypertension Guideline Data Supplements (cross-over) trial said to use a parallel design. Antihypertensive drug use reported in 3 trials and in an additional 3 trials mean SBP exceeded 150 mm Hg at baseline.

• Intervention with enzymatically hydrolysed milk • Cointervention

placebo controlled. However, 2 were single blind and 1 was open label.

lactotripeptides ValineProline-Proline and IsolucineProline-Proline. ● These findings may have special relevance for countries, like Japan, where consumption of fermented milk products is common.

Size: 14 RCTs with 702 pts (median size=40).

Data Supplement 13. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Sodium Reduction to Placebo or Usual Diet) (Section 6.2) Study Acronym; Author; Year Published

Aim of Study; Study Type; Study Size (N)

Patient Population

NUTRICODE Mozaffarian D, et al., 2014 (74) 25119608

Aim: Study the effect of sodium reduction on BP and CVD mortality

Inclusion criteria: RCT in 2 previous Cochrane meta-analyses

Study type: Metaregression analysis Size: 103 RCTs (107 comparisons) with 6,970 pts; 38 of the 107 comparisons were conducted in normotensive pts

Exclusion criteria: • Duration <1 wk • Mean 24-h collections or estimates of urinary sodium reduced <20 mmol in the intervention group compared to control • Concomitant interventions

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Sodium reduction Comparator: No sodium reduction

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events

1° endpoint: • Strong evidence for a linear relationship between reduction in sodium intake and lower levels of SBP throughout the entire distribution of sodium studied, with larger reductions in older persons, blacks (compared to whites) and hypertensives (compared to normotensives). For a white, normotensive population at age 50 y, each reduction of 100 mmol/d (2.3 g/d) in dietary sodium lowered SBP by a mean: 3.74 (95% CI: 5.18–2.29). • Modeling based on global estimates of sodium intake, effect of sodium reduction on BP, and effect of BP reduction on CVD mortality attributed 1.65 million CVD deaths annually due sodium intake >2 g/d. this would represent 9.5% (95% CI: 6.4–12.8) of all CVD mortality. Estimates were not

● RCT meta-regression analysis that provides evidence for BP lowering following a reduction in dietary sodium intake, overall and in normotensive persons, with a more pronounced effect in those who were older, black and had a higher starting level of BP. ● These findings are consistent with other reports. ● The modeling analysis suggested sodium reduction would yield important population health benefits but did not specify the magnitude of the potential benefit for pts within the normal BP range. 38

2017 Hypertension Guideline Data Supplements provided separately for hypertensive and normotensive persons. 1° Safety endpoint: N/A Aburto NJ, et al., 2013 (68) 23558164

Aim: Study the effect of sodium reduction on BP Study type: Systematic review and meta-analysis

He FJ, et al., 2013 (75) 22437256

Size: Overall study included 36 trials (49 comparisons) conducted in 6,736 pts. Of these, 3,263 were nonhypertensive. The results in normotensives in this table are based on experience in 7 RCTs conducted in 3,067 normotensive pts. Aim: Study the effect of sodium reduction on BP Study type: Systematic review, meta-analysis and meta-regression analysis Size: Overall study included 34 trials (37 comparisons) conducted in 3,230

Inclusion criteria: • RCT in humans • Trial duration ≥4 wk • 24-h urinary sodium ≥40 mmol/d less in treatment compared to control group • No concurrent interventions • Not acutely ill

Intervention: Sodium reduction Comparator: No sodium reduction

Safety endpoint: In the small number of relevant trials, there was no significant effect of sodium reduction on lipid levels (Total cholesterol, LDL-cholesterol, HDLcholesterol, triglyceride levels; 11 trials) or on plasma (7 trials) or urinary catecholamine levels (2 trials). Experience in 4 trials (3 which could not be included in the meta-analysis) suggested a beneficial effect of sodium reduction on urinary protein excretion.

Exclusion criteria: Lack of above

Inclusion criteria: • RCTs • Healthy adults ≥18 y • Trial duration ≥4 wk • Sodium intake only difference between treatment and control group • 24-h urine sodium ≥40 mmol less in treatment compared to control

1° endpoint: In pooled analysis, the overall change in SBP was -3.39 (95% CI: -4.31– 2.46) mm Hg. In the pts with HTN, the change was -4.06 (95% CI: -5.15– -2.96). In the normotensives, the change was -1.38 (95% CI: -2.74–0.02).

Intervention: Sodium reduction Comparator: No sodium reduction

Exclusion criteria: Lack of above

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: In an overall pooled analysis, the change for SBP was -4.18 (95% CI: 5.18– -3.18) mm Hg. In the trials of persons with HTN, the mean change was -5.39 (95% CI: -6.62– -4.15) mm Hg. In the trials conducted in normotensives, the change in SBP was -2.42 (95% CI: -3.56– -1.29) mm Hg. • In meta-regression analysis, change in 24-h urinary sodium was significantly associated with reduction in SBP (4.3 mm Hg for a 100 mmol reduction in 24-h urinary sodium).

● Study inclusion/exclusion criteria designed to yield a group of trials that would provide results that have relevance for clinical practice and public health. In this context, reduced sodium intake resulted in a statistically significant but small reduction in SBP.

● Study inclusion/exclusion criteria designed to yield a group of trials that would provide results that have relevance for clinical practice and public health. In this context, reduced sodium intake resulted in a significant and potentially important reduction in SBP. ● The meta-regression results were consistent with a doseresponse relationship in normotensive pts 39

2017 Hypertension Guideline Data Supplements pts. 12 of the RCTs (14 comparisons) were conducted in 2,240 normotensive pts.

Graudal NA, et al., 2012 (76) 22068710

Aim: Study the effect of sodium reduction on BP Study type: Systematic review and meta-analysis Size: Overall study included 167 trials. Of these, 71 RCTs were conducted in 5,577 normotensive pts, with the following characteristics: • Median age: 27 y (13–67 y) • Median trial duration: 7 d (4– 1,100 d) • 5,292 Whites (71 studies) • 268 Blacks (7 studies) • 215 Asians (3 studies)

Inclusion criteria: • RCTs • 24-h collections or estimates from ≥8 h collections of urinary sodium excretion

Intervention: Sodium reduction Comparator: No sodium reduction

Exclusion criteria: Systematic studies in unhealthy pts with diseases other than HTN

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Safety endpoint: In the small number of relevant trials (which included both hypertensive and normotensive pts) that provided safety endpoint measurements (4–14 trials), there was no change in total, LDL- or HDLcholesterol, or triglyceride levels. There were small significant increases in plasma renin activity, aldosterone, and noradrenaline levels but these were consistent with expected physiologic responses to sodium reduction. 1° endpoint: The overall effect of sodium reduction was not presented. A forest plot of 71 comparisons (from 61 trials) in the 4,919 normotensive whites assigned to sodium reduction compared to usual sodium intake identified a trend towards lower SBP in 50 (70%), no difference in 8 (11%), and higher SBP in 13 (19%). In a pooled analysis, sodium reduction compared to usual sodium intake in the normotensives yielded the following MDs in SBP: • Whites: -1.27 (95% CI: -1.88– -0.66) • Blacks: -4.02 (95% CI: -7.37– -0.68) • Asians: -1.27 (95% CI: -3.07– -0.54) A corresponding analysis in the hypertensives yielded the normotensives yielded the following MDs in SBP: • Whites: -5.48 (95% CI: -6.53– -4.43) • Blacks: -6.44 (95% CI: -8.85– -4.03) • Asians: -10.21 (95% CI: -16.98– -3.44)

● Heterogeneous group of trials that included many small studies of short duration in young persons. ● Overall finding of lower BP in those assigned to a reduced intake of dietary sodium, with an apparently greater effect in Blacks compared to Whites and Asians. ● The hormone changes in this meta-analysis likely reflect a physiologic response to sodium reduction, especially in studies of short duration and rapid changes in sodium intake. The increases in total cholesterol and triglyceride levels were not noted in the meta-analyses conducted by Aburto et al. and He et al.

Safety endpoint: In the relevant trials (all cross-over studies and including 40

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DASH-Sodium Trial Sacks FM, et al., 2001 (77) 11136953

Aim: Study the effect of sodium reduction on BP Study type: Randomized, controlled crossover trial Size: Overall study based on 412 pts, of whom 243 were normotensive

TOHP II Trial (Sodium component) Kumanyika SK, et al., 2005 (78) 15372064

Aim: Study the effect of sodium reduction on BP and prevention of HTN. Study type: Randomized,

Inclusion criteria: Adults ≥22 y Exclusion criteria: Taking antihypertensive medication, heart disease, renal disease, poorly controlled hyperlipidemia or DM, DM requiring insulin, special dietary requirements, >14 drinks/wk

Inclusion criteria: • Healthy communitydwelling adults 30–54 y • BMI between 110% and 165% of desirable body weight

Intervention: Feeding study in which pts were randomized to a DASH or control diet at 3 levels of assigned dietary sodium intake (High=210 mmol/d; Intermediate=100 mmol/d; Low=50 mmol/d) Comparator: Each pt served as their own control (crossover design)

Intervention: Behavior change intervention aimed at studying the effects of modest (25%–30%) reductions in dietary sodium intake during

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

comparisons in both hypertensive and normotensive participants) that provided safety endpoint measurements, significant increases in the standard MD for plasma renin activity (70 trials), aldosterone (51 trials), noradrenaline (31 trials), adrenaline (14 trials), and weighted MD for total cholesterol (24 trials), and triglyceride (18 trials) levels. There was no significant effect of sodium reduction on LDL-cholesterol (15 trials) and HDL-cholesterol (17 trials). 1° endpoint: • Reduced sodium intake resulted in a significant reduction in SBP, with a greater reduction during assignment to the Low compared to the Intermediate sodium intake diet. At every level of sodium intake, the achieved reduction in SBP was greater on the control group compared to the DASH diet and for Blacks compared to other pts. • Reducing sodium intake from the high to intermediate level decreased SBP by 2.1 mm Hg (p<0.001) during the control diet and 1.3 mm Hg (p=0.03) during the DASH diet. • Reducing sodium intake from the intermediate low level decreased SBP by a further 4.6 mm Hg (p<0.001) during the control diet and 1.7 mm Hg (p<0.01) during the DASH diet. Safety endpoint: N/A 1° endpoint: Change in SBP • Compared to usual care, the sodium reduction group experienced a significant mean reduction of 51 mmol for 24-h urinary excretion and -2.9 (SD: 0.5) mm Hg (p<0.001) in SBP at 6 mo (-5.1 mm Hg in

● This trial provides the best (direct) evidence for a doseresponse treatment relationship between sodium intake and level of BP. ● It also suggests the relative effect of reduced sodium intake is greater in persons with a typical U.S. diet but the combination of sodium reduction and consumption of a DASH-type diet results in a lower level of BP than can be achieved with either dietary modification on its own. • Consistent with other trials and meta-analyses, it suggests the effect of a reduced sodium intake is greater in Blacks compared to others, especially for those consuming a typical U.S. diet. ● This was the largest trial of sodium reduction in HTN prevention and also provides the longest duration of follow. ● The assumptions for a main effects factorial analysis (independence of the 41

2017 Hypertension Guideline Data Supplements controlled factorial trial. Size: 2,382 pts, of whom 594 were randomized to sodium reduction (alone) and 596 were randomized to usual care.

• Not taking BP-lowering medication • Mean SBP <140 mm Hg and DBP 83–89 mm Hg

up to 48 mo (minimum 36 mo) of follow-up. Comparator: Usual care group

Exclusion criteria: Taking antihypertensive medication, Heart disease, renal disease, poorly controlled hyperlipidemia or DM, DM requiring insulin, special dietary requirements, >14 drinks/wk.

the sodium reduction group and -2.2 mm Hg in the usual care group). • A progressive reduction in effect size for urinary sodium excretion and BP was noted over time, with mean for SBP at 18, 36 mo and termination of -2.0 (SD: 0.5) mm Hg (p<0.001), -1.2 (SD: 0.5) mm Hg (p=0.02), and -1.0 (SD: 0.5) mm Hg (p=0.5). Prevention of HTN • At 6 mo of follow-up the incidence of new onset HTN was 39% lower in the pts randomized to reduced dietary sodium intake compared to the usual care group (p=0.04). • During more prolonged follow-up, the effect size decreased but remained significant after 48 mo of follow-up (14% reduction; p=0.04). Overall, the incidence of HTN was reduced by 18% (p=0.048). Safety endpoint: N/A

TOHP Phase I 1992 (79) 1586398

Aim: Study the effect of sodium reduction on BP and prevention of HTN Study type: Randomized, controlled factorial trial. Size: Overall, 2,182 adults, with the 327 assigned to sodium reduction compared

Inclusion criteria: • Community-dwelling adults 30–54 y • Not on antihypertensive medication • DBP 80-89 mm Hg • Healthy

Intervention: Behavior change intervention Comparator: Usual care

Exclusion criteria: • Disease • Inability to comply with the protocol

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: Change in DBP 2° endpoint: Change in SBP Safety endpoint: CVD events, symptoms and general and well being

interventions) were not demonstrated. Given this finding, the most reliable analysis of this trial was comparison of the experience in each active intervention group with the usual care group. This results in a reduction in statistical power. ● Consistent with the pattern in the proceeding TOHP I trial sodium reduction reduced BP and the incidence of HTN but the effect sizes for sodium reduction and BP as well as the difficulty of maintaining the intervention in highly motivated and extensively counselled participants underscores the difficulty of achieving sodium reduction in the general population without changes in food processing and restaurant/fast food preparation practices. • Significantly lower DBP (0.9 mm Hg; p<0.05) and SBP (1.7 mm Hg; p<0.01) in the sodium reduction group compared to usual care • Few CVD events • No difference in symptoms • Significant improvement in general well-being at 6 and 18 mo (p<0.05)

42

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Cook NR, et al., 2007 (80) 17449506

to 417 usual care controls Aim: Study the effect of sodium reduction on CVD morbidity and mortality. Study type: 10–15 y post-trial follow-up of TOHP I and TOPH II pts that took advantage of the randomized trial design. Vital status was obtained for 100% of the pts and information on morbidity was obtained from 2,415 (77%) of the pts.

Inclusion criteria: Assigned to dietary sodium reduction or control in TOHP Phase I or TOHP Phase II. Exclusion criteria: None

Intervention: Behavior change intervention aimed at studying the effects of modest (25%–30%) reductions in dietary sodium intake during TOHP Phase I or TOHP Phase II. Comparator: No sodium reduction intervention.

1° endpoint: • 200 CVD events and 77 deaths during follow-up • Kaplan-Meier plots identified trends toward less morbidity and mortality in those who had been randomized to sodium reduction compared to usual care, with a consistent pattern for the TOHP I and TOHP II participants • Risk of a CVD event was 30% lower (RR: 0.70; 95% CI: 0.53–0.94; p=0.018) among those randomized to sodium reduction compared to usual care, after adjustment for trial, clinic, age, race, sex, baseline weight and sodium excretion • RR for total mortality was 0.80 (95% CI: 0.51–1.26).

● Dietary sodium reduction, previously shown to reduce BP and prevent HTN in the TOHP I and TOHP II trials, appeared to reduce CVD events during extended post-trial follow-up of the pts from these 2 trials.

Safety endpoint: N/A

Size: 744 TOHP Phase I and 2,382 TOHP Phase II pts

Data Supplement 14. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Stress Reduction) (Section 6.2) Study Acronym; Author; Year Published Canter PH, et al., 2004 (81) 15480084

Aim of Study; Study Type; Study Size (N) Aim: Study the effect of transcendental meditation on BP Study type: Systematic review Size:

Patient Population

Inclusion criteria: • RCT in humans • Publication in any language until May 2004 • No concurrent interventions

Study Intervention (# patients) / Study Comparator (# patients) Intervention: • Use of transcendental meditation techniques as taught by Maharishi Mahesh Yogi • Practiced on a regular basis over an extended period

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: Statistically significant reduction in SBP reported in 3 of 5 trials that provided such information. 1° Safety endpoint: N/A

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events ● Only a handful of RCTs available from the large number of publications on this topic. ● Trials had methodological weaknesses and were subject to potential bias due to the affiliation of authors to the transcendental meditation organization. 43

2017 Hypertension Guideline Data Supplements • 6 RCTs with wide range of pts: young to elderly; healthy volunteers to Blacks with HTN. • HTN: 2 trials • High normal BP: 2 trials • Normotensive: 1 trial • Not stated: 1 trial • Sample sizes ranging from 34–156 pts • Follow-up from 2 mo–1 y

Exclusion criteria: N/A

Comparator: No treatment, sham, alternative treatment

● A few trials reported small reductions in SBP but clinical relevance of findings is unclear. ● Most of the trials were underpowered and could have missed a significant finding. ● The authors concluded that “there is at present insufficient good quality information to conclude whether or not transcendental meditation has a cumulative positive effect on BP”

Data Supplement 15. RCTs and Meta-analyses Studying the Effect of Nonpharmacologic Interventions on BP (Dietary Patterns) (Section 6.2) Study Acronym; Author; Year Published Appel LJ, et al., 1997 (82) 9099655

Aim of Study; Study Type; Study Size (N) Aim: Study the effect of dietary patterns on BP Study type: • Multicenter RCT • 3 arm parallel design • 3 wk prerandomization run-in phase • Feeding study with 8 wk of intervention Size: 459 adults, mean age 44 y. (326 normotensive)

Patient Population

Inclusion criteria: • Adults ≥22 y • SBP<160 mm Hg and DBP 80–95 mm Hg • No antihypertensive medication Exclusion criteria: • CVD event within 6 mo • Poorly controlled DM or hyperlipidemia • BMI ≥35 • Pregnancy or lactation • Chronic illness that would interfere with participation • Unwillingness to stop taking vitamins, mineral supplements, Ca++ antacids

Study Intervention (# patients) / Study Comparator (# patients) Intervention: • Diet high in fruits and vegetables • “Combination” diet high in fruits, vegetables, low-fat dairy products, and reduced total fat, saturated fat and cholesterol. Comparator: Usual U.S. diet

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: Compared to the control diet, both intervention diets reduced BP, with an overall mean (95% CI) reduction of: • Fruits and Veg. Diet: SBP: -2.8 (95% CI: -4.7– -0.9) DBP: -1.1 (95% CI: -2.4– -0.3) • Combination Diet: SBP: -5.5 (95% CI: -7.4– -3.7) DBP: -3.0 (95% CI: -4.3– -1.6)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events ● This trial was the first of several to document the value of the combination diet (later renamed the DASH diet). ● The BP reductions noted with the DASH (combination) diet were substantial and well maintained. ● Generalizability was limited due to the nature of the intervention (feeding study) and the relatively short period of intervention experience (8 wk)

The BP changes in the subgroup with HTN were: • Fruits and Veg. Diet: SBP: -7.2 (-11.4, -3.0) DBP: -2.8 (-5.4, -0.3) • Combination Diet: SBP: -11.4 (-15.9, -6.9) DBP: -5.5 (-8.2, -2.7)

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2017 Hypertension Guideline Data Supplements The corresponding changes in the subgroup of normotensives were: • Fruits and Veg. Diet: SBP: -0.8 (-2.7, 1.1) DBP: -0.3 (-1.9, 1.3) • Combination Diet: SBP: -3.5 (-5.3, -1.6) DBP: -2.1 (-3.6, -0.5)

• Consuming ≥14 alcoholic drinks with • Renal insufficiency

Sacks FM, et al., 2001 (77) 11136953

Aim: Study the effect of different levels of sodium intake on BP during consumption of a DASH or usual U.S. diet Study type: • Multicenter RCT with 2 parallel diet arms (DASH diet or usual U.S. diet) • Within each arm, randomized cross-over trial with 3 periods testing different levels of sodium intake (no washout) Size: 412, with 59% (243) being normotensive

Inclusion criteria: • Adults ≥22 y • Average SBP between 120–159 mm Hg and average DBP between 80–95 mm Hg • No use of antihypertensive medication Exclusion criteria: Heart disease, renal insufficiency, poorly controlled hyperlipidemia or DM, DM requiring insulin, special dietary requirements, >14 alcoholic drinks /wk.

Intervention: 3 levels of dietary sodium while consuming a DASH or usual U.S. diet. The target sodium intake levels for a daily energy intake of 2,100 kcal were: High: 150 mmol (3,450 mg)/d Intermediate: 100 mmol (2,300 mg)/d Low: 50 mmol (1,150 mg)/d The mean achieved levels of sodium during the high, intermediate and low sodium periods were 144, 107 and 67 mmol/d in the DASH diet group and 141, 106, and 64 mmol/d in the usual U.S. diet group. Comparator: See description above

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° Safety endpoint: Infrequent and similar occurrence of gastrointestinal symptoms in each group 1° endpoint: • At each level of sodium intake, SBP and DBP were lower during consumption of the DASH diet compared to the usual U.S. diet, the difference being greatest with high sodium intake and lowest with low sodium intake, with the mean SBP difference between the DASH and usual US diets during high, intermediate and low sodium intake being -5.9 (95% CI: -8.0– -3.7), -5.0 (95% CI: -7.6– -2.5), and -2.2 (95% CI: -4.4– -0.1). The corresponding differences for DBP were -2.9 (95% CI: -4.3– -1.5), -2.5 (95% CI: -4.1– 0.8), and -1.0 (95% CI: -2.5, 0.4). • In both the DASH and usual U.S. diet arms, SBP and DBP were significantly lower during intermediate compared to high sodium intake, and during low compared to intermediate sodium intake, with the decrement being greater for the latter change. • In comparison to consumption of a usual U.S. diet at the high level of

● This trial provided additional documentation of the effectiveness of a DASH diet in lowering BP in normotensives (and hypertensives) and the complementary benefit of consuming a reduced intake of sodium.

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2017 Hypertension Guideline Data Supplements sodium intake, the normotensive group consuming the DASH diet at the low level of sodium intake had a mean SBP difference of 7.1 mm Hg (p<0.001).

PREMIER Appel LJ, et al., 2003 (83) 12709466

Aim: Study the effect of 2 behavioral interventions, aimed at dietary change, on BP Study type: • Multicenter RCT with 3 parallel arms: • Established • Established plus DASH diet • Advice only Size: 810 adults, with 62% (506) normotensive. At baseline, mean age, BMI and SBP/DBP were 50 y, 33 kg/m2, and 135/85 mm Hg, respectively. Duration: 6 mo, with observations at 3 and 6 mo.

Inclusion criteria: • Adults ≥25y • Average SBP between 120–159 mm Hg and average DBP between 80–95 mm Hg • No use of antihypertensive medication • BMI between 18.5 and 45 kg/m2 Exclusion criteria: • Regular use of drugs that affect BP • Target organ damage or DM • Use of weight-loss meds • Hx CVD event • HF, angina, cancer, within 2 y • Consumption of >21 alcoholic drinks /wk • Pregnancy, planned pregnancy, lactation

Intervention: • Structured behavioral interventions that used an identical format (4 individual and 14 group sessions) to facilitate adoption of “established” dietary recommendations for reduction in BP or “established” plus the DASH diet. The “established” dietary recommendations used in PREMIER were a) weight loss in overweight participants, b) sodium reduction, increased physical activity, reduced alcohol intake in pts consuming alcohol. • Compared to experience in the advice only (control) group, there was only modest achievement of

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° Safety endpoint: Participants tended to report less symptoms during periods of reduced sodium intake, with a statistically significant reduction in reports of headache (p<0.05) consistent with prior experience in the TONE trial. 1° endpoint • Compared to control (advice only), SBP and DBP were significantly reduced with both active interventions but there was no significant difference in the effect size between the 2 active intervention groups. This was true for both the normotensive and hypertensive pts, with the effect size being larger in the hypertensive group. In the normotensives, the MD for change in SBP was identical for the “established” compared to “established plus DASH Diet” groups: -3.1 (95% CI: -5.1– -1.1) mm Hg The corresponding changes for DBP were -1.6 (95% CI: -2.9– -0.2) for the “established” intervention group and -2.0 (95% CI: -3.4– -0.6) for the “established intervention plus DASH Diet) group. • Overall, the incidence of HTN was lowest and the percent with optimal BP was highest in the “established plus DASH” diet but the incidence of

● This was an interesting trial which employed a behavior change approach to implement both active interventions. ● The investigators goal was to determine the additive value of the DASH Diet in persons already following key elements of conventional (established) recommendations for nonpharmacologic intervention to lower BP. ● The intervention approach in this trial was less effective in achieving weight loss and reduction in dietary sodium compared to the corresponding experience in the TOHP and TONE trials and the DASH Diet effects on intermediate variables (such as fruit and vegetable consumption) was less than that achieved in the DASH Diet feeding studies. ● Despite the modest intervention effects, both SBP and DBP were significantly reduced with the conventional intervention approach (in normotensives as well as overall) and addition of the DASH diet did not have a

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2017 Hypertension Guideline Data Supplements intervention goals in the “established” group, with a MDs of 3.8 kg (8.4 lbs) for body weight, 11.6 mmol (267 mg)/d) for urinary sodium excretion, no change in physical activity (but better fitness), and no change in alcohol consumption (but very low alcohol consumption at baseline). • Weight loss was somewhat greater in the “established” plus DASH diet group, with a MD of 4.8 kg (10.6 lbs) for body weight. This group also manifested expected effects of the DASH diet, with significantly higher urinary potassium and phosphorous levels, greater consumption of fruits and vegetables, dietary calcium, dairy products, and a lower consumption of total fat and saturated fat.

Appel LJ, et al., 2005 (84) 16287956

Aim: Compare effects of 3 diets, each with a reduced intake of saturated fats, on BP and serum lipids

Inclusion criteria: • Adults ≥30 y • Average SBP between 120–159 mm Hg and

Comparator: Advice only Intervention: • High protein with reduced fat/saturated fat content

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

HTN was significantly less and the percent with optimal BP was higher in both active intervention groups compared to advice only. The difference between the 2 active intervention groups was not significant. In the normotensives, there was a nonsignificant trend towards less HTN and a significantly higher percent with optimal BP in both active intervention groups compared to advice only, with no significant difference for percent with optimal BP in the 2 active intervention groups.

significant effect on reduction of SBP or DBP. ● There were some nonsignificant trends for slightly lower BP, less HTN, and more optimal BP in the “established plus DASH Diet” group compared to “established” group. The authors also cited use of the DASH Diet as a means to beneficially influence CVD risk factors in addition to BP.

1° Safety endpoint: N/A

1° endpoint Compared with the high carbohydrate diet, the high protein diet:

● This clinical trial demonstrated that substituting either protein or monounsaturated fat in place of carbohydrate resulted in a small

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Study type: • 2 center RCT • 3 period crossover design • Each 8 wk period was separated by a 2– 4 wk wash-out phase Size: 161–164 included in analyses (191 pts randomized). 132 (80.5%) of the 164 included in the BP analyses were normotensive. Mean age and BMI were 54 y and 30.2 kg/m2, respectively.

Bazzano LA, et al., 2014 (85) 25178568

Aim: Compare the effects of a lowcarbohydrate and a low-fat diet on body weight and CVD risk factors (including BP) Study type: Single center parallel arm RCT that compared the 2 diets over 12 mo of intervention. Size: 148 pts, with a mean age of 46.8 y at

average DBP between 80–95 mm Hg • No use of antihypertensive medication

• High unsaturated fats (predominantly monounsaturated fat) with low saturated fat content

Exclusion criteria: DM, CVD (current or H/O), LDL cholesterol >220 mg/dL, fasting triglycerides >750 mg/dL, weight >350 lb., taking that effect BP or lipids, unwillingness to stop vitamin/mineral supplements, >14 alcoholic drinks/wk.

Comparator: High carbohydrate with reduced fat/saturated fat content

Inclusion criteria: • 22–75 y • BMI: 30–45 kg/m2

Intervention: • Low-carbohydrate diet, with digestible carbohydrate (total carbohydrate minus total fiber) <40 g/d • Behavioral counselling that employed a mix of 20 individual and group meetings

Exclusion criteria: • CVD • DM-2 • Kidney disease • Use of prescription weight loss meds/surgery • Weight loss >6.8 kg during prior 6 mo

Comparator: • Low fat diet, with <30% of daily energy

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• Reduced SBP by -1.4 mm Hg (p=0.002) overall and by -0.9 mm Hg (p=0.047) in the normotensives • Reduced LDL cholesterol by 3.3 mg/dL (p=0.01) overall and by -2.1 mg/dL (p=0.14) in the normotensives • Reduced HDL-C by -1.3 mg/dL (p=0.02) overall • Reduced serum Triglycerides by 15.7 mg/dL (p<0.001) overall Compared with the high carbohydrate diet, the high unsaturated fat diet: • Reduced SBP by -1.3 mm Hg (p=0.005) overall and by -0.9 (p=0.06) in the normotensives • Reduced LDL cholesterol by -1.5 mg/dL (p=0.01) and by -2.1 (p=0.14) in the normotensives • Increased HDL-C by 1.1 mg/dL (p=0.03) overall • Reduced serum Triglycerides by 9.6 (p=0.02) overall 1° endpoint: • Compared to the low-fat diet group, the low-carbohydrate diet group had a mean decrease at 12 mo of: Body weight: -3.5 (95% CI: -5.6– 1.4) kg Fat mass: -1.5 (95% CI: -2.6– -0.4) HDL-C: 7.0 (11.0–3.0) mg/dL Ratio total/HDL-C: -0.44 (95% CI: 0.71– -0.16) Sr. triglyceride: -14.1 (95% CI: 27.4– -0.8) mg/dL

reduction in SBP and improvement in lipid profile.

● This clinical trial provides 1 of the longest follow-up experiences related to the topic. ● It suggests low carbohydrate diets may be somewhat better than traditional low fat diets in achievement of weight loss, improvement of lipid profile, inflammation, and CHD risk. ● Although the BP differences were not significant, there was a consistent trend toward lower BPs in the lowcarbohydrate diet group.

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2017 Hypertension Guideline Data Supplements baseline. Mean SBP/DBP at baseline were 124.9/79.4 and 120.3/77.5 mm Hg in the low-fat and lowcarbohydrate groups, respectively. The corresponding BMIs were 97.9 and 96.3 kg/m2. All 148 pts were included in the analysis (intention to treat)

Nordmann AJ, et al., 2006 (86) 16476868

Aim: Compare effects of low-carbohydrate and low-fat diets on weight loss and CVD risk factors Study type: • Systematic review and meta-analysis • Cochrane Collaboration strategy Size: 5 trials (447 pts)

intake from fat (<7% from saturated fat) • Behavioral counselling that used identical format to that employed in the low carbohydrate group

Inclusion criteria: • RCT • Adults ≥16 y • Low-carbohydrate diet and low-fat diet interventions • BMI ≥25 kg/m2 • Follow-up ≥6 m

Intervention: Lowcarbohydrate diet: maximum of 60 g/d carbohydrate Comparator: Low-fat diet: maximum of 30% energy from fat

Exclusion criteria: • Cross-over or sequential design • Missing data

• At 3, 6, and 12 mo, BP tended to be lower in the low-carbohydrate group but none of the differences in SBP or DBP were significant. • CRP was reduced in both diet groups but to a significantly greater extent in the low-carbohydrate group. • At 6 and 12 mo pts in the low carbohydrate group experienced a significant improvement in their 10-y Framingham CHD risk score. In contrast, there was no change in Framingham CHD risk in the low-fat diet group. 1° Safety endpoint: No serious side effects noted 1° endpoint: At 6 mo, the lowcarbohydrate diet pts, compared to the low-fat diet participants, had a mean reduction in body weight that was greater by -3.3 (95% CI: -5.3– 1.4) kg, and a more favorable profile for HDL-cholesterol and triglyceride levels. In contrast, the profile for total-cholesterol and HDLcholesterol was more favorable in those assigned to a low-fat diet. The profile for SBP tended to be better in the low carbohydrate diet pts but the differences were not significant: MD at 6 mo: -2.4 (95% CI: -4.9–0.1) mm Hg.

● This systematic review/meta-analysis tends to suggest low-carbohydrate diets are somewhat more effective in reducing body weight compared to the traditionally recommended low-fat diets. ● Although the BP differences were not significant they would probably have reached a conventional level of significance had subsequent clinical trials (including the Bazzano et al. trial) been included in the analysis.

1° Safety endpoint: N/A

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Nordmann AJ, et al., 2011 (87) 21854893

Aim: Compare effects of Mediterranean and low-fat diets on weight loss and CVD risk factors Study type: • Systematic review and meta-analysis • Cochrane Collaboration strategy

Inclusion criteria: • RCT • Intent to treat analysis • Overweight/obese with at least 1 additional CVD risk factor • Follow-up ≥6 mo

Intervention: Mediterranean diet: moderate fat intake (main sources olive oil and nuts), rich in vegetables, and low in red meat.

Exclusion criteria: N/A

Comparator: Low fat diet: ≤30% of energy intake from fat

Inclusion criteria: • Adults ≥20 y • English language publications between Jan 1946-Nov 2013

Intervention: • Lacto-ovo in 4 trials • Lacto in 1 trial • Vegan in 2 trials

Size: 6 trials (2,650 pts)

Yokoyama Y, et al., 2014 (88) 24566947

Aim: Compare the effects of vegetarian and omnivorous diets on BP Study type: Systematic review and meta-analysis

PREDIMED Toledo E, et al., 2013 (89) 24050803

Size: • 7 trials (n=311). • 6 were RCT (n=198) • 4 parallel and 3 cross-over designs • All were open • Follow-up ≥6 wk (mean=15.7 wk) • Mean age=44.5 y Aim: Compare the effects of a Mediterranean and lower-fat diet on BP

Exclusion criteria: • Twin pt studies • Multiple interventions • Only categorical BP results

Comparator: Omnivorous diet in all trials

1° endpoint: Compared to the lowfat diet, the Mediterranean diet resulted in MDs of: • Body weight: -2.2 (95% CI: -3.9 – -0.6) kg • BMI: -0.6 (95% CI: -1.0– -0.1) kg/m2 • SBP: -1.7 (95% CI: -3.3– -0.05) mm Hg • DBP: -1.5 (95% CI: -2.1– -0.8) • Fasting Plasma Glucose: -3.8 (95% CI: -7.0– -0.6) mg/dL • Total-Cholesterol.: -7.4 (95% CI: 10.3– -4.4) • CRP: -1.0 (95% CI: -1.5– -0.5) 1° Safety endpoint: N/A 1° endpoint: Compared to the omnivorous diet, the vegetarian diet resulted in MDs of: • SBP: -4.8 (95% CI: -6.6– -3.1) mm Hg • DBP: -2.2 (95% CI: -3.5– -1.0) SBP was lower in the vegetarian diet group in 5 of the 7 trials (significant in 3) and DBP was lower in 6 of the 7 trials (significant in 2).

● Overall, this study suggests the Mediterranean diet compared to the traditional low fat diet results in greater weight loss, a better CVD risk factor profile (including better BP control), and less inflammation. ● The number of eligible trials was small and the study samples were heterogeneous (2 2º and 4 1° prevention trials).

● Overall, this meta-analysis of clinical trials suggested BP was lower in those who consumed a vegetarian diet compared to their counterparts who consumed an omnivorous diet. ● However, the trials were generally small, heterogeneous in their design and conduct, and of questionable quality. ● Even greater reductions in SBP and DBP were noted in a MA of 32 observational studies.

1° Safety endpoint: N/A

Inclusion criteria: • Adults, men 5,580 y, women 60–80 y • Free from CVD

Intervention: Pts assigned to a control group or to 1 of 2 Mediterranean diets.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: The percentage of pts with controlled BP increased in all 3 intervention groups (p-value for within-group changes: p<0.001). Pts

● Both the traditional Mediterranean diet and a low-fat diet exerted beneficial effects on BP and could be part of advice to pts for controlling BP. 50

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Study type: RCT, single-blinded, in Spanish primary healthcare centers Size: 7,447 men (55– 80 y) and women (60– 80 y) at high risk for CVD.

• DM or at least 3 major CVD risk factors (smoking, HTN, elevated LDL cholesterol, low HDL, overweight/obese, family history of early CHD) Exclusion criteria: Do not meet criteria listed above

The control group received education on following a low-fat diet, while the groups on Mediterranean diets received nutritional education and also free foods; either extra virgin olive oil, or nuts. Comparator: Lower fat diet

allocated to either of the 2 Mediterranean diet groups had significantly lower DBP than the pts in the control group (-1.53 mm Hg (95% CI: -2.01– -1.04) for the Mediterranean diet supplemented with extra virgin olive oil, and -0.65 mm Hg (95% CI: -1.15– -0.15) mm Hg for the Mediterranean diet supplemented with nuts). No between-group differences in changes of SBP were seen

● However, lower values of DBP were noted in the 2 groups following the Mediterranean diet with extra virgin olive oil or with nuts than in the control group.

Data Supplement 16. RCTs and Meta-analysis RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Alcohol Reduction) (Section 6.2) Study Acronym; Author; Year Published Xin X, et al., 2001 (90) 11711507

Aim of Study; Study Type; Study Size (N)

Patient Population

Aim: Study the effect of alcohol reduction on BP

Inclusion criteria: • RCT in humans • Publication between 1966-1999 • Duration ≥1 wk • Only pts regularly consuming alcohol • Only difference between the comparison groups was alcohol intake

Study type: Systematic review and meta-analysis Size: • 15 RCTs (25 comparisons) with 2,234 pts. • 6 trials were conducted in normotensives (269 pts with a mean age ranging from 26.5– 45.5 y). Average

Exclusion criteria: Comparison of different doses of alcohol intake

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Reduction in alcohol consumption. In most trials this was achieved by randomization to “light” alcohol but some RCT were based on a behavioral intervention aimed at reducing the number of drinks consumed. Comparator: Usual consumption of alcohol

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events

1° endpoint: • Overall, alcohol reduction was associated with a significant reduction in mean SBP of -3.31 (95% CI: -4.10– -2.52) and DBP of -2.04 (95% CI: -2.58– -1.49). • In the subgroup of 7 RCTs in persons with HTN, the mean changes in SBP and DBP were -3.9 (95% CI: -5.04– -2.76) and -2.41 (95% CI: -3.25– -1.57). • In the subgroup of 6 RCTs in normotensives the corresponding changes in SBP and DBP were -3.5 (95% CI: 4.61– -2.51) and -1.80 (95% CI: -3.03– -0.58).

• This is the most recent meta-analysis of this topic. Although this meta-analysis reports % reduction in alcohol intake, most trials aimed at reducing the number of alcoholic drinks consumed achieved a reduction of about 3 drinks/d. • The intervention results were consistent with the relationship alcohol and BP in observational epidemiology – about a 1 mm Hg higher SBP per alcoholic drink consumed. In observational studies, type of alcohol does not seem to matter and at lower levels of alcohol consumption (<1 standard size alcoholic drink per day in women and <2 in men) there does not

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2017 Hypertension Guideline Data Supplements consumption of alcohol at baseline was not reported. Follow-up varied from 1–18 wk

• In a meta-regression analysis, a dose-response was noted between % reduction in alcohol consumption and mean reduction in BP. 1° Safety endpoint: N/A

Stewart SH, et al., 2008 (91) 18821872

Aim: Study the effect of reduced alcohol intake on BP. Study type: Randomized, controlled factorial trial. Size: 1,383 pts.

Inclusion criteria: • Alcohol dependence. • 4—21 d of abstinence. • Men: >21 drinks/wk; Women >14 drinks/wk. • At least 2 heavy drinking days within a consecutive 30-d period during 90 d prior to baseline.

Intervention: Pharmacotherapy (naltrexone, acamprosate, or both) and counseling strategies (behavioral and/or medical management). Comparator: Placebo.

Exclusion criteria: • Other substance abuse. • Psychiatric disorder requiring medication. • Unstable medical condition Dickenson HO, et al., 2006 (92) 16508562

Aim: Study effectiveness of lifestyle

Inclusion criteria: • Only parallel trials

Intervention: Lifestyle change aimed at reduced consumption of alcohol

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Change in BP: • Based on up to 5 repeated measures of BP over 16 wk. Data modeled to estimate change in BP over time. • For pts with higher than average baseline SBP (>132 mm Hg), SBP declined by an average of 12 mm Hg (149— 137) in the intervention arm compared to placebo, with a corresponding decline in DBP of 8 mm Hg. For those with a baseline SBP ≤132 mm Hg there was no change in SBP (120—121 mm Hg) or DBP. Safety endpoint: N/A 1° endpoint: -Net reduction (95% CI): SBP -3.8 (-6.1— -1.4)

seem to be an important biological effect of alcohol on BP. • The relationship between alcohol consumption and BP is predictable and consistent in observational and RCT studies. However, the relationship between alcohol consumption and CVD is more complex as alcohol is associated with an apparently beneficial effect on CVD risk, possibly mediated by an increase in HDL-cholesterol. • Pregnant women, pts with HTN and those at risk of a drinking problem should not drink alcohol. Established light drinkers (<2 standard drinks/d in men and <1/d in women) who are normotensive are in a favorable risk category for CVD. • This trial was designed to evaluate interventions for treatment of alcohol dependence. • BP measurements were not standardized. • About 20% of the observations were missing and assumed to be random.

• Relatively small number of trials • Limited details provided 52

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Wallace P, et al., 1988 (93) 3052668

interventions, including reduced alcohol intake, for treatment of HTN.

• SBP ≥140 mm Hg and/or DBP ≥85 mm Hg • ≥8 wk duration • BP outcome

Study type: 1 of 10 meta-analyses.

Exclusion criteria: • 2º HTN or renal disease • Pregnant women • Change in BP meds during trial

Size: 4 trials which collectively studied 305 pts Aim: Study effectiveness of general practitioner advice to reduce heavy drinking. Study type: • RCT

Comparator: Usual care

Inclusion criteria: Heavy drinking during wk prior to screening interview.

Intervention: Physician counselling aimed at reduced consumption of alcohol.

Exclusion criteria: None mentioned

Comparator: Usual care

Size: 909 adults (641 men and 268 women) Lang T, et al., 1995 (94) 8596098

Aim: Worksite study of reduced alcohol intake effect on BP in heavy drinkers with HTN. Study type: RCT Size: 14 site physicians; 129 adults (95% men)

Inclusion criteria: • Heavy drinking (documented by history and liver enzyme elevation). • HTN (SBP/DBP >140/90 mm Hg)

Intervention: Physician and worker counselling aimed at reduced consumption of alcohol.

Exclusion criteria: • 2º HTN • Severe liver disease • Planned move/retirement.

Duration: Follow-up visits at 1, 3, 6, and 18 mo.

Comparator: Usual care.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

DBP -3.2 (-5.0— -1.4) Safety endpoint: N/A

Endpoints: • 1° outcome was reduction in percent with heavy consumption of alcohol (mean net change=46%). Liver enzymes and BP also measured at 6 and 12 mo. • Pretreatment SBP/DBP=133.5/79.9 mm Hg. • Net reduction SBP=-2.12 (95% CI: -4.19– -0.00) Safety endpoint: N/A Endpoints: • Baseline SBP/DBP=162.5/98.0. Although all of the workers had HTN, only about 20% were being treated with antihypertensive medications at baseline. • At 1 y, the net change in SBP=-5.5 (p<0.05). When 5 sites with <5 workers/site were excluded, the net change in SBP=-7.3 mm Hg (p<0.01). • At 2 y, the net change in SBP=-6.6 (p<0.05).

● The goal was to blind those conducting the outcome assessment to treatment assignment but by 6 mo assignment was known in 20-30% of the participants. ● A reduction in SBP was noted despite use of a modest intervention.

● Behavioral intervention state of the art for its time ● Careful measurements of BP using Hawksley RZ sphygmomanometer. ● Main analyses do not seem to have accounted for cluster design.

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Roerecke M, et al., 2017 Lancet Public Health. 2017;2:e108-120.

Aim: Study the effect of reduced alcohol intake on BP. Study type: Systematic review and meta-analysis. Size: 36 RCT with 2865 participants. Design: • 15 parallel-arm trials • 21 crossover trials

Inclusion criteria: • RCT in adult humans • Publication on or before July 13, 2016. • Full text articles. • Change in alcohol intake for ≥1 wk

Intervention: Reduction in alcohol consumption. Strategy varied from controlled inpatient administration to randomization to “light” alcohol to pragmatic primary care trials with counselling to reduce alcohol intake. Duration: Follow-up from 1 wk to 2 y (median 4 wk).

Setting: • 13 in hypertension • 13 in normotension • 12 HTN and NT • Only 3 trials presented data for women.

Safety endpoint: N/A 1° endpoint: • Overall, alcohol reduction was associated with a significant reduction in mean SBP of -3.31 (95% CI: -4.10– -2.52) and DBP of -2.04 (95% CI: -2.58– -1.49). • In the subgroup of 7 RCTs in persons with HTN, the mean changes in SBP and DBP were SBP: -3.13 (95% CI: -3.93– 2.32) DBP: -2.00 (95% CI: -2.65– 1.35). • In meta-regression analysis, there was a strong relationship between the extent of BP reduction and change in BP, with no reduction in BP for those consuming 2 or less drinks at baseline but increasing reductions in BP for those with progressively higher intakes of alcohol at baseline. For instance, in those consuming ≥6 drinks/day and reducing their alcohol intake by approximately 50%, the estimated reduction in SBP and DBP were: SBP: -5.5 (95% CI: -6.70– 4.30) DBP: -3.97 (95% CI: -4.70– 3.25). Similar patterns of the effect of baseline alcohol intake on treatment effect were noted for a variety of subgroups.

N/A

1° Safety endpoint: N/A

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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Data Supplement 17. RCTs and Meta-analysis RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Calcium Supplementation) (Section 6.2) Study Acronym; Author; Year Published Van Mierlo LA, et al., 2006 (95) 16673011

Aim of Study; Study Type; Study Size (N)

Patient Population

Aim: Study the effect of calcium supplementation on BP

Inclusion criteria: • RCT in humans • Publication between 1996 and 2003 • Nonpregnant normotensive pts or hypertensive pts • Only difference between the comparison groups was magnesium intake • Follow-up ≥2 wk

Study type: Systematic review and meta-analysis Size: • 40 RCTs with 2,492 pts. • 27 RCTs in pts <140/90 mm Hg (n=1,728) • Follow-up varied from 3–208 wk (median=8.5 wk) • Age range 11–77 y (mean=43.7 y)

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Increased calcium intake, with a range from 355–2,000 mg/d (mean=1,200 mg/d; median=1,055 mg/d), primarily as a gluconate or carbonate salt. Comparator: Placebo or usual intake – 32 double-blind.

Exclusion criteria: Study pts having renal disease or hyperparathyroidism

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events

1° endpoint: • Overall, increased calcium intake was associated with a significant reduction in mean SBP of -1.86 (95% CI: -2.91– -0.81) and DBP of -0.99 (95% CI: -1.61– -0.37). • The reduction was slightly less but still significant in the subset of 32 double-blind trials, with a mean SBP of -1.67 (95% CI: 2.87– -0.47) and DBP of -0.93 (95% CIL -1.64– -0.22). • There was no significant difference between the effect size in those with a baseline BP ≥ or<140/90 mm Hg. - The mean change in SBP and DBP for those with a baseline BP≥140/90 mm Hg (23 comparisons) was -2.17 (95% CI: -3.78– -0.55) and -0.95 (95% CI: 1.89– -0.01), respectively. - The mean in SBP and DBP for those with a baseline BP <140/90 mm Hg was -1.67 (95% CI: -3.01– -0.27) and -1.02 (95% CI: -1.85– 0.19) mm Hg, respectively. • The authors reported slightly larger effect sizes in those with a lower initial calcium intake, in trials that employed a dietary

• This is the most recent SR/MA on this topic to include RCT conducted in both normotensive and hypertensive pts. The authors interpreted their results as being consistent with a beneficial effect of calcium supplementation on BP, with about a 2 mm Hg reduction in SBP for a 1 g increase in calcium intake. This is slighter larger effect size than noted in several earlier meta-analyses. • A subsequent Cochrane Collaboration meta-analysis was confined to 13 RCT in 485 adults (≥18 y) with HTN studied for ≥8 wk (Dickinson HO et al. Cochrane Database of Systematic Reviews. 2006; CD004639). The authors noted a significant reduction in mean of -2.5 (95% CI: -4.5– -0.6) for SBP but a more modest insignificant change of -0.8 (95% CI: -2.1– 0.4) for DBP. Due to the poor quality of the RCT and heterogeneity of the results, the authors concluded the reduction in SBP was likely an artifact due to bias. • Although not included in most metaanalyses, calcium supplementation has been effective as a treatment in pregnant women at risk for pre-eclampsia. • Several of the meta-analyses (including the 1 by van Mierlo et al) have suggested a bigger effect size in persons with a lower intake of calcium at baseline and in trials that utilized a dietary intervention. 55

2017 Hypertension Guideline Data Supplements intervention (compared to a supplement), and in the 4 trials conducted in Asians. 1° Safety endpoint: N/A

• Most of the trials were of short duration and did not (have the capacity) report on potential adverse effects such renal stones. • In addition to being small, several trials were of uncertain quality. • Overall, RCT experience provides limited and inconsistent evidence from trials of variable quality in support of calcium supplementation for prevention (or treatment) of HTN. Better evidence supports the role of calcium supplements, in conjunction with vitamin D, in strengthening bone density.

Data Supplement 18. RCTs and Meta-analyses RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Physical Activity) (Section 6.2) Study Acronym; Author; Year Published Whelton SP, et al., 2002 (96) 11926784

Aim of Study; Study Type; Study Size (N) Aim: Study the effect of aerobic exercise on BP Study type: Systematic review and meta-analysis Size: 38 reports (54 comparisons) with 2,419 pts; 27 of the comparisons were conducted in normotensive pts

Patient Population

Inclusion criteria: • English language publication between 1966–2001 • RCT in adults ≥18 y • Duration ≥2 wk • No concurrent interventions

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Aerobic exercise Comparator: No exercise prescribed

Exclusion criteria: Missing BP data

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events

1° endpoint: • For the overall group, a pooled analysis of experience in 53 trials identified a mean net change in SBP of 3.84 (95% CI: -4.97– -2.72). In subgroup analysis, the effect was noted in different ethnic groups, in trials that employed different designs, durations, and sample sizes, in trials with obese, overweight or normal weight pts, and in trials that employed different types, intensity levels, and duration of aerobic exercise. • In the subgroup of 15 trials in hypertensives, the mean net change in SBP was -4.94 (95% CI: -7.17– -2.70).

● This meta-analysis provides the most comprehensive analysis of the effect of aerobic exercise on BP and provides strong evidence in support of aerobic exercise as an intervention to lower BP in normotensives. ● Recognizing this, many of the trials were small and of short duration.

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2017 Hypertension Guideline Data Supplements • In the subgroup of 27 trials conducted in normotensives, the mean net change in SBP was -4.04 (95% CI: -5.32– -2.75). Cornelissen VA, et al., 2013 (97) 23525435

Rossi AM, et al., 2013 (98) 23541664

Aim: Study the effect of different types of physical activity on BP • Dynamic aerobic endurance • Resistance training - Dynamic - Static (Isometric)

Inclusion criteria: • Parallel arm RCTs • Adults≥18 y • Peer reviewed journals up to February 2012 • Trial duration ≥4 wk

Study type: Systematic review and meta-analysis

Exclusion criteria: Inadequate reporting of the data

Size: Overall, 93 studies (>5,000 pts) • 59 Dynamic Aerobic Endurance studies • 13 Dynamic Resistance Training studies • 5 Combined Dynamic Aerobic and Resistance training • 4 Static (Isometric) Resistance • 12 Different interventions within 1 trial Aim: Study the effect of resistance exercise on BP Study type: Systematic review and meta-analysis

Intervention: Physical activity Comparator: No prescription of physical activity

1° Safety endpoint: N/A 1° endpoint: Overall (trials in hypertensives and normotensive), pooled experience identified a significant reduction in BP with all forms of physical activity (aerobic and both forms of resistance training), with mean reductions in SBP of -3.5 mm Hg following aerobic endurance training, 1.8 mm Hg following dynamic resistance training, and -10.9 mm Hg following static (isometric) resistance training (p<0.001 for the difference between the effect size following static [isometric] and other forms of physical activity). In subgroup analysis, dynamic aerobic endurance and dynamic resistance training resulted in mean SBP changes of -2.1 (95% CI: -3.3– -0.83) and -4.3 (95% CI: -7.7– -0.90), respectively, in the pts with pre-HTN and smaller, nonsignificant reductions in the remaining pts with a normal BP.

• Most recent in a series of progressively updated publications from Dr. Cornelissen and her colleagues. • The findings suggest a beneficial effect of all forms of physical activity on BP, with a disproportionately large effect of resistance training on BP. • Many of the available RCTs have been small, of short duration, and of uncertain quality.

Safety endpoint: N/A

Inclusion criteria: • RCTs in adults (≥18 y) • BP-lowering 1° outcome

Intervention: Dynamic resistance training but overall reporting of the details was poor.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: Pooled experience (hypertensive and normotensive pts) identified a small, nonsignificant reduction in mean SBP of -1.03 (95% CI: -3.44–0.39). The corresponding finding

• Suggests resistance training is effective in lowering BP and was the basis for recommending this intervention in the Canadian HTN Education Program recommendations. 57

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Garcia-Hermosa A, et al., 2013 (99) 23786645

Carlson DJ, et al., 2014 (100) 24582191

Size: 9 RCTs (11 intervention groups and 14 comparisons) conducted in 452 pts. 10 (71%) of the 14 comparisons were conducted in normotensives Aim: Study the effect of exercise on BP in obese children. Study type: Systematic review and meta-analysis.

• Trial duration ≥4 wk • Resistance training only intervention

Inclusion criteria: • Children ≤14 y with obesity • RCT • Duration ≥8 wk • 1° outcome: change in BP Exclusion criteria: Concomitant intervention

Aim: Study the effect of physical activity on BP in children with obesity.

Inclusion criteria: • Adults ≥18 y • RCT, including cross-over trials. • Duration ≥4 wk • Published in a peer reviewed journal between January 1, 1966 and July 31, 2013

Size: 9 RCTs (223 pts: 127 intervention and 96 controls): 6 were conducted in normotensives.

for DBP was -2.19 (95% CI: -3.87– 0.51).

Intervention: Physical activity, principally aerobic exercise.

1° endpoint: Change in SBP: In pooled analysis, mean change in SBP was -0.4 (95% CI: -0.66– -0.24).

Safety endpoint: N/A

Exclusion criteria: Handgrip/isometric exercise

Size: 9 RCTs (410 pts).

Study type: Systematic review and meta-analysis.

Comparator: No resistance training but not detailed in this article

Comparator: No physical exercise, nutrition, education, or dietary restriction intervention

Intervention: Pure isometric exercise. Comparator: Use of a control group was a requirement but no additional specific information provided.

Exclusion criteria: Studies that employed any intervention other

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Safety endpoint: N/A

1° endpoint: • In the overall pooled analysis (hypertensive and normotensive trials), mean change in SBP was -6.77 (95% CI: -7.93– -5.62) mm Hg. • In the subgroup of 3 trials with hypertensive pts (all on antihypertensive medication), the mean change in SBP was -4.31 (95% CI: -6.42– -2.21) mm Hg. • In the subgroup of 6 trials with normotensive pts, the mean change in SBP was -7.83 (95% CI: -9.21– -6.45) mm Hg.

• The discrepancy in effect size between this meta-analysis and the 1 conducted by Cornelisson et al may have been due to the more restrictive requirement by Rossi et al that change in BP be the 1° outcome.

• This meta-analysis focused specifically on the effect of physical activity on BP in children with obesity. Although it is not stated explicitly, it seems likely that all of the participants were normotensive and not receiving medication that could influence level of BP. • The findings are consistent with other meta-analyses of the effect of physical activity on BP. • Only limited information regarding study details is provided in this publication. The interventions were heterogeneous in type, duration, and quality. • This study provides information regarding the effect of pure isometric exercise interventions on BP in adults. • The BP reductions reported in this meta-analysis are surprisingly large but the overall effect pattern is quite consistent with other meta-analyses of isometric exercise.

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Cornelissen VA, et al., 2011 (101) 21896934

Aim: Study the effect of resistance training on BP. Study type: Metaanalysis Size: 28 randomized, controlled trials, involving 33 study groups and 1,012 pts.

than pure isometric exercise (e.g., dynamic resistance) Inclusion criteria: • Adults ≥18 y • RCT, including cross-over trials. • Duration ≥4 wk • Published in a peer reviewed journal up to June 2010 Exclusion criteria: Interventions other than pure isometric exercise (e.g. dynamic resistance)

Safety endpoint: N/A Intervention: Resistance training, including isometric and dynamic modalities. Comparator: Use of a control group was a requirement but no additional specific information provided.

1° endpoint: Resistance training induced a significant SBP/DBP reduction in 28 normotensive or prehypertensive study groups of -3.9 (-6.4, -1.2)/-3.9 (5.6, -2.2] mm Hg). In the 5 hypertensive study groups, the change in mean SBP/DBP was -4.1 (95% CI: -0.63–1.4)/1.5 (95% CI: -3.4–0.40) mm Hg. When the study groups were divided according to the mode of training, isometric handgrip training in 3 groups resulted in a larger decrease in SBP/DBP (-13.5 [95% CI: -16.5– -10.5]/-6.1[95% CI: -8.3– -3.9] mm Hg) than dynamic resistance training in 30 groups (-2.8 [95% CI: -4.3– -1.3]/-2.7 [95% CI: -3.8– -1.7] mm Hg).

● This meta-analysis supports the BP-lowering potential of dynamic resistance training and isometric handgrip training. ● Results further suggest that isometric handgrip training may be more effective for reducing BP than dynamic resistance training. ● However, given the small amount of isometric studies available, additional studies are warranted to confirm this finding.

Safety endpoint: N/A

Data Supplement 19. RCTs and Meta-analysis RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Magnesium Supplementation) (Section 6.2) Study Acronym; Author; Year Published Kass L, et al., 2012 (102) 22318649

Aim of Study; Study Type; Study Size (N) Aim: Study the effect of magnesium supplementation on BP Study type: Systematic review and meta-analysis

Patient Population

Inclusion criteria: • RCT in humans • Parallel or crossover design • Publication before July 2010 • Adults >18 y • Only difference between the

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Increased magnesium intake, with a range in elemental magnesium of 120 to 973 mg/d and a mean of 410 mg/d. Comparator: Placebo or usual intake

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: • Overall, increased magnesium intake was associated with a small nonsignificant reduction in mean SBP of -0.32 (95% CI: 0.41– -0.23) and DBP of -0.36 (95% CI: -0.44– -0.27).

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events • This is the most recent systematic review/meta-analysis on this topic. The authors interpreted their results as being consistent with a beneficial effect of magnesium supplementation on BP. However, this interpretation seems at odds with the data. • In an earlier meta-analysis of 20 RCT (6 in normotensives) by Jee Systolic 59

2017 Hypertension Guideline Data Supplements Size: 22 RCTs (23 comparisons) with 1,173 pts. Data for RCTs conducted in normotensive pts were not presented. However, most RCTs were conducted in normotensives and only 6 of the RCTs included some (or all) pts who were being treated with antihypertensive medication. Overall mean age was ~50 y. Follow-up varied from 3–24 wk, with a mean of 11.3 wk.

comparison groups was magnesium intake Exclusion criteria: Comparison of different doses of alcohol intake

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• Forest plots revealed considerable heterogeneity in effect size. • The authors reported slightly larger effect sizes in subgroup analysis of cross-over RCT and RCT that employed a dose of magnesium >370 mg/d. 1° Safety endpoint: N/A

HTN et al (Am J Hyperts. 2002;15:691696) magnesium supplementation resulted in small mean NS reductions of -0.6 (95% CI: -2.2–1.0) mm Hg in SBP and -0.8 (95% CI: -1.9–0.4) in DBP. In meta-regression analysis, there was an apparent dose-response with SBP and DBP reductions of -4.3 (95% CI: -6.3– 2.2) and -2.3 (95% CI: -4.9–0) mm Hg for each 10 mmol/d higher level of magnesium intake. • A Cochrane systematic review/metaanalysis of magnesium supplementation for treatment of HTN in adults (Dickinson HO et al. Cochrane Database Systematic Review 2006: CD 004640) included 12 RCT (n=545) with follow-up of 8–26 wk. Overall, mean SBP and DBP were reduced by -1.3 (95% CI: 4.0–1.5) and -2.2 (95% CI: -3.4– -0.9) mm Hg, respectively. The authors noted the studies were of poor quality, with considerable heterogeneity, and felt the results were likely biased. • Some authors have suggested there may be a greater BP effect when the intervention is by means of diet change but there is insufficient RCT evidence to support this position. • Magnesium sulfate is the drug of choice for prevention of seizures in the pre-eclamptic woman, or prevention of recurrence of seizures in the eclamptic woman, as demonstrated in RCT and a 2010 Cochrane review (Duley L et al. Cochrane Database of Systematic Reviews. CD000127, 2010). • Overall, RCT experience provides insufficient evidence to recommend oral

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2017 Hypertension Guideline Data Supplements magnesium supplementation as a means to prevent (or treat) HTN.

Data Supplement 20. RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Weight Loss) (Section 6.2) Study Acronym; Author; Year Published Neter JE, et al., 2003 (103) 12975389

Aim of Study; Study Type; Study Size (N) Aim: Study the effect of weight loss on BP Study type: Systematic review and meta-analysis Size: 25 RCTs (34 comparisons) with 4,874 pts; 17 of the comparisons were conducted in normotensive pts

Ho M, et al., 2012 (104) 23166346

Aim: Study the effect of lifestyle weight loss interventions in obese/overweight children on weight

Patient Population

Inclusion criteria: • RCT in humans • English language publication between 1966– 2002 • Nonpharmacologic intervention

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Weight loss (calorie reduction, physical activity, or combination of both) Comparator: No weight loss prescription

Exclusion criteria: • Duration <8 wk • Missing data • Objective not weight loss • Concomitant intervention(s)

Inclusion criteria: • RCTs, in obese/overweight children and adolescents ≤18 y

Intervention: Lifestyle weight loss program with a dietary component Comparator: No treatment, usual care or

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; and 95% CI) 1° endpoint: • For the overall group, mean baseline body weight was 88.3 kg and mean change in body weight following the application of the weight loss intervention was -5.1 (95% CI: -6.03– 4.25) kg. This represents a mean percent change of -5.8%. • There was strong evidence for a BP lowering effect of weight loss on BP, overall and in normotensive subgroup. In the normotensive group, the mean for change in SBP was 4.08 (95% CI: 6.01– -2.16). • Overall, a 1 kg reduction in body weight was associated with a mean change in SBP of -1.05 (95% CI: -1.43– -0.66) mm Hg. 1° Safety endpoint: N/A 1° endpoint: Pooled experience in the 7 RCTs with BP experience identified a significant reduction in mean SBP of 3.40 (95% CI: -5.19– -1.61). The pooled SBP MD was -3.72 (95% CI: -4.74– 2.69) in the 3 RCTs with a duration >1 y

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events • Substantial evidence for a reduction in BP, overall and in normotensives. • With the exception of the mean (95% CI) changes in BP, this paper provides limited data for the normotensive group

• Findings in children are consistent with experience in adult normotensives and with experience in hypertensive pts.

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2017 Hypertension Guideline Data Supplements change and cardiometabolic risk factors Study type: Systematic review and meta-analysis

Cai L, et al., 2014 (105) 24552832

Size: • Overall, 38 studies • 33 included in various meta-analyses • Effect on SBP studied in 7 RCTs that included 554 pts Aim: Study the effect of childhood obesity prevention programs on BP Study type: Systematic review and meta-analysis Size: Overall study included 23 studies (28 comparisons) conducted in 18,925 pts.

TOHP, Phase II Hypertension Prevention Collaborative Research Group,

Aim: Study the effect of weight loss on BP and prevention of HTN.

•English language publications between 1975– 2010 • Trial duration ≥2 mo Exclusion criteria: • Studies that targeted prevention/weight maintenance • Drug trials • Trials in persons with an eating disorder • Inadequate reporting of the data Inclusion criteria: • RCTs, quasi-experimental studies, and natural experiments in humans • Children and adolescents 2–18 y • Conducted in a developed country • English language publications • Trial duration ≥1 y (≥6 mo for school-based intervention studies) Exclusion criteria: • Studies that only targeted obese/overweight children or those with a medical condition • Inadequate reporting of the data Inclusion criteria: • Healthy community-dwelling adults 30–54 y

written education materials

Intervention: • Weight loss • 15 school-based • 12 some combination of school, home and/or community-based • 1 child care Comparator: No weight loss

Intervention: Behavior change intervention (combination of diet change and physical activity) aimed at

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Safety endpoint: N/A

1° endpoint: Pooled experience in 19 studies (20 comparisons) identified a small but significant reduction in mean SBP of -1.65 (95% CI: -2.56– -0.71). The effect size was greater in studies that employed an intervention that combined diet and physical activity (mean change in SBP of -2.11 mm Hg). Safety endpoint: N/A

1° endpoint: Change in SBP • Compared to usual care, the weight loss group experienced a significant mean reduction of -4.5 kg in body

• Considerable heterogeneity in the data

• Study included a mix of RCTs (13), quasiexperimental studies (9), and natural experiments (1). • Included studies conducted over several decades (1985–2012). A significant reduction in BP was only noted in the studies conducted between 2000–2009: mean change in SBP of -3.73 (95% CI: 5.37– -2.09) • Findings of a BP reduction in childhood consistent with evidence from the publications by Neter and Ho. • Largest trial of weight loss in prevention of HTN and also provides the longest duration of follow-up

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2017 Hypertension Guideline Data Supplements 1997 (106) 9080920

Study type: Randomized, controlled factorial trial. Size: 2,382 pts, of whom 1,192 were randomized to a weight loss intervention and 1,190 were randomized to a no weight loss intervention.

• BMI between 110% and 165% of desirable body weight • Not taking BP-lowering medication • Mean SBP <140 mm Hg and DBP 83-89 mm Hg Exclusion criteria: • Taking antihypertensive medication • Heart disease, renal disease, poorly controlled hyperlipidemia or DM, DM requiring insulin, special dietary requirements • >14 drinks/wk

studying the effects of a modest reduction in body weight during up to 48 mo (minimum 36 mo) of follow-up. Comparator: Usual care group

weight and -3.7 (SD: 0.5; p<0.001) mm Hg in SBP at 6 mo (-6.0 mm Hg in the weight loss group and -2.2 mm Hg in the usual care group). • A progressive reduction in the effect sizes for body weight and BP was noted over time, with mean for SBP at 18, 36 mo and termination of -1.8 (SD: 0.5; p<0.001), -1.3 (SD: 0.5; p=0.01), and 1.1 (SD: 0.5; p=0.04). Prevention of HTN • At 6 mo of follow-up the incidence of new onset HTN was 42% lower in the participants randomized to weight loss compared to the usual care group (p=0.02). • During more prolonged follow-up, the effect size decreased but remained borderline significant after 48 mo of follow-up (13% reduction; p=0.06). Overall, the incidence of HTN was reduced by 21% (p=0.02). Safety endpoint: N/A

TOHP, Phase I 1992 (79) 1586398

Aim: Study the effect of weight loss on BP and prevention of HTN Study type: Randomized, controlled factorial trial. Size: Overall, 2,182 adults, with the 308

Inclusion criteria: • Communitydwelling adults 30–54 y • Not on antihypertensive medication • DBP 80-89 mm Hg • Healthy

Intervention: Behavior change intervention (combination of diet change and physical activity) Comparator: Usual care

Exclusion criteria: • Disease

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: Change in DBP 2° endpoint: Change in SBP Safety endpoint: CVD events, symptoms and general and well being

• The assumptions for a main effects factorial analysis (independence of the interventions) were not demonstrated. Given this finding, the most reliable analysis of this trial was comparison of the experience in each active intervention group with the usual care group. This results in a reduction in statistical power. • Consistent with the pattern in the proceeding TOHP I trial weight loss reduced BP and the incidence of HTN but the effect sizes for weight loss and BP as well as the difficulty of maintaining the intervention in highly motivated and extensively counselled participants underscores the difficulty of achieving and maintaining ideal body weight in the general population by means of lifestyle change. • Significantly lower DBP (2.3 mm Hg; p<0.01) and SBP (2.9 mm Hg; p<0.01) in the weight loss group compared to usual care • Few CVD events • No difference in symptoms • Significant improvement in general well-being at 6 and 18 mo (p<0.05) 63

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TONE Whelton PK, et al., 1998 (107) 9515998

assigned to weight loss compared to 256 usual care controls

• Inability to comply with the protocol

Aim: Study the effect of weight loss on BP and need for antihypertensive drug therapy

Inclusion criteria: • Community-dwelling adults 60–80 y • SBP <145 mm Hg and DBP <85 mm Hg on 1 antihypertensive medication

Study type: RCT, factorial design Size: 585 (obese) participants

Exclusion criteria: • Heart attack or stroke within 6 mo • Current angina, HF, insulindependent DM • Inability to comply with protocol

Intervention: Behavior change intervention (combination of diet change and physical activity) Comparator: Usual care, with similar level of contact compared to active intervention group

1° endpoint: Recurrence of HTN following withdrawal of antihypertensive medication (or CVD event) 2° endpoint: BP (while still on antihypertensive medication prior to tapering of medication) Safety endpoint: CVD events, symptoms (including headaches), dietary composition

• Significant reduction in SBP prior to withdrawal of antihypertensive medication (mean±SE=-4.0±1.3 mm Hg) • 1° outcome significantly less common in weight loss group compared to usual care – Rel. HR: 0.70; 95% CI, 0.57–0.87; p<0.001 • No overt evidence for adverse effects of intervention

Data Supplement 21. RCTs and Systematic Reviews for RCTs Studying the Effect of Nonpharmacologic Interventions on BP (Section 6.2) Study Acronym; Author; Year Published TOHP, Phase II (Weight Loss component) 1997 (1) 9080920

Aim of Study; Study Type; Study Size (N) Aim: Study the effect of weight loss on BP and prevention of HTN. Study type: Randomized, controlled factorial trial.

Patient Population

Inclusion criteria: • Healthy communitydwelling adults 30–54 y • BMI between 110% and 165% of desirable body weight • Not taking BP-lowering medication • Mean SBP <140 mm Hg and DBP 83-89 mm Hg

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Behavior change intervention (combination of diet change and physical activity) aimed at studying the effects of a modest reduction in body weight during up to 48 mo (minimum 36 mo) of follow-up.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events

1° endpoint: Change in SBP • Compared to usual care, the weight loss group experienced a significant mean (standard error) reduction of -4.5 kg in body weight and -3.7 (0.5) (p<0.001) mm Hg in SBP at 6 mo (-6.0 mm Hg in the weight loss group and -2.2 mm Hg in the usual care group). • A progressive reduction in the effect sizes for body weight and BP

• This was the largest trial of weight loss in prevention of HTN and also provides the longest duration of follow-up • The assumptions for a main effects factorial analysis (independence of the interventions) were not demonstrated. Given this finding, the most reliable analysis of this trial was comparison of the experience in each active intervention group with the usual care group. This results in a reduction in statistical power.

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TONE (Weight Loss component) Whelton PK, et al., 1998 (3) 9515998

Size: 2,382 pts, of whom 1,192 were randomized to weight loss and 1,190 were randomized to no weight loss intervention

Exclusion criteria: • Taking antihypertensive medication • Heart disease, renal disease, poorly controlled hyperlipidemia or DM, DM requiring insulin, special dietary requirements • >14 drinks/wk.

Comparator: Usual care group

Aim: Study the effect of weight loss on BP and need for antihypertensive drug therapy

Inclusion criteria: • Community-dwelling adults 60-80 y • SBP <145 mm Hg and DBP <85 mm Hg on 1 antihypertensive medication

Intervention: Behavior change intervention (combination of diet change and physical activity)

Study type: RCT, factorial design Size: 585 (obese) participants TOHP, Phase I (Weight Loss component) 1992 (4) 1586398

Aim: Study the effect of weight loss on BP and prevention of HTN

Exclusion criteria: • Heart attack or stroke within 6 mo • Current angina, HF, insulin-dependent DM • Inability to comply with protocol Inclusion criteria: • Community-dwelling adults 30–54 y

was noted over time, with mean (SD) for SBP at 18, 36 mo and termination of -1.8 (0.5) (p<0.001), 1.3 (0.5) (p=0.01), and -1.1 (0.5) (p=0.04). Prevention of HTN • At 6 mo of follow-up the incidence of new onset HTN was 42% lower in the participants randomized to weight loss compared to the usual care group (p=0.02). • During more prolonged follow-up, the effect size decreased but remained borderline significant after 48 mo of follow-up (13% reduction; p=0.06). Overall, the incidence of HTN was reduced by 21% (p=0.02).

Comparator: Usual care, with similar level of contact compared to active intervention group

Intervention: Behavior change intervention (combination of diet change and physical activity)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Safety endpoint: N/A 1° endpoint: Recurrence of HTN following withdrawal of antihypertensive medication (or CVD event) 2° endpoint: BP (while still on antihypertensive medication prior to tapering of medication)

• Consistent with the pattern in the proceeding TOHP I trial weight loss reduced BP and the incidence of HTN but the effect sizes for weight loss and BP as well as the difficulty of maintaining the intervention in highly motivated and extensively counselled participants underscores the difficulty of achieving and maintaining ideal body weight in the general population by means of lifestyle change.

• Significant reduction in SBP prior to withdrawal of antihypertensive medication (mean±standard error=-4.0±1.3 mm Hg) • 1° outcome significantly less common in weight loss group compared to usual care – Rel. HR: 0.70; 95% CI: 0.57– 0.87; p<0.001 • No overt evidence for adverse effects of intervention

Safety endpoint: CVD events, symptoms (including headaches), dietary composition

1° endpoint: Change in DBP 2° endpoint: Change in SBP

• Significantly lower DBP (2.3 mm Hg; p<0.01) and SBP (2.9 mm Hg; p<0.01) in the weight loss group compared to usual care • Few CVD events 65

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Study type: Randomized, controlled factorial trial. Size: Overall, 2,182 adults, with the 308 assigned to weight loss compared to 256 usual care controls

• Not on antihypertensive medication • DBP 80-89 mm Hg • Healthy

Comparator: Usual care

Safety endpoint: CVD events, symptoms and general and well being

• No difference in symptoms • Significant improvement in general wellbeing at 6 and 18 mo

Exclusion criteria: • Disease • Inability to comply with the protocol

Data Supplement 22. Observational Studies of CV Target Organ Damage Including LVH (Section 7.2) Study Acronym; Author; Year Published

Study Type/Design; Study Size (N)

Patient Population

LIFE Devereux RB, et al., 2004 (108) 15547162

Study type: Substudy of pts with HTN and ECG LVH

Inclusion criteria: • 55–80 y • BP 160–200/95–115 mm Hg • No MI or stroke within 6 mo • Had echo • Did not require treatment with BB, ACE or AT-1 antagonist for other reasons

Size: 941

CARDIA Armstrong AC, et al., 2014 (109) 24507735

Study type: Observational study of population-based cohorts

Intervention: Treatment to BP of 140/90 mm Hg beginning with pts randomized to losartan or atenolol Inclusion criteria: African American and white men and women stratified by education (above/below high school) 18– 30 y at study start and followed for over 20 y; previously healthy

Primary Endpoint and Results (include P value; OR or RR; & 95% CI) 1° endpoint: Change in LV mass assessed by echo and change in BP in relation to CVD events Results: • Composite endpoint of CV death, MI, or stroke reached in 104 in 4.8 y of follow-up • Reduction in 1° endpoint per SD reduction in LV mass independent of BP change OR: 0.74 (95% CI: 0.6–0.91; p=0.003) • Reductions for each composite endpoint component and total mortality were also significant; results independent of change in ECG LVH 1° endpoint: Composite of hard CVD events Results: • LV mass indexed to body surface area or to height predicted CV events independently of the Framingham risk score (HR: 1.21; 95% CI: 1.05–1.39; p<0.007)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Summary/Conclusion Comment(s) • Reduction in LV mass by echo independently related to CVD outcomes

• LV mass measured at age 18– 30 y leads to modest risk reclassification later in life • Low number of events limits generalizability

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ARIC Okwuosa TM, et al., 2015 (110) 25497261

Study type: Observational study of population-based cohorts Size: 14,489

MESA Zalawadiya SK, et al., 2015 (111) 24699336

Study type: Observational study of population-based cohorts

• Net reclassification improvement for LVM/height was 0.13 (p<0.01) and for LVM/BSA was 0.11 (p=0.02).

Inclusion criteria: African American and white men and women population-based cohort mean age 54.7 ± 5.7 y at study start and followed for over 25 y; previously healthy

Inclusion criteria: Multi-ethnic cohort of men and women followed for a mean follow-up of 4.5 y

Size: 4,921

1° endpoint: Pooled cohort CV events and 10-y Framingham CVD events Results: • 792 (5.5%) 10-y Pooled Cohort CV events and 690 (4.8%) 10-y Framingham CHD events. • LVH was associated with CVD events (HR: 1.62; 95% CI: 1.38– 1.90) and CHD events (HR: 1.56; 95% CIL 1.32–1.86. • LVH by ECG did not significantly reclassify or improve C statistic compared with Framingham risk score (C statistics 0.767/0.719; net reclassification index =0.001 [p=not significant]), compared with (C statistics 0.770/0.718), respectively. 1° endpoint: Hard CVD endpoints Results: MRI calculated LVH (indexed to BSA or height; >95th percentile) predicted hard CVD events (LVH-BSA: HR: 2.36; 95% CI: 1.37–4.04; p=0.002; LVH-height [1.7]: HR: 1.95; 95% CI: 1.17– 3.26; p=0.01). but did not improve risk reclassification beyond conventional risk factors

• ECG LVH does not improve risk reclassification

• Though LVH predicted events it did not improve risk reclassification

Data Supplement 23. RCTs on Use of Risk Estimation to Guide Treatment of Hypertension (Section 8.1.2) Study Acronym; Author; Year Published Sundstrom J, et al., 2014 (112) 25131978

Aim of Study; Study Type; Study Size (N) Aim: We aimed to investigate whether the benefits of BPlowering drugs are proportional to baseline CV risk, to

Patient Population

Study Intervention (# patients) / Study Comparator (# patients)

Inclusion criteria: BPLTTC: trials were eligible if they met the original inclusion criteria specified in the protocol, 11 and were part of the subset of studies that randomly allocated

Intervention: BP-lowering meds Comparator: Placebo or less intensive treatment

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: • Total major CV events, consisting of stroke (nonfatal stroke or death from cerebrovascular disease), CHD (nonfatal MI or death from CHD

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events Summary Summary: • Lowering BP provides similar relative protection at all levels of baseline CV risk, but progressively greater absolute risk reductions as baseline risk 67

2017 Hypertension Guideline Data Supplements establish whether absolute risk could be used to inform treatment decisions for BP-lowering therapy, as is recommended for lipid-lowering therapy. Study type: Metaanalysis of RCTs

Sundstrom J, et al., 2015 (19) 25531552

pts to either a BP-lowering drug or placebo, or to a more intensive or less intensive BP regimen. Trials had to have a minimum of 1,000 pt-y of planned follow-up in each randomized group, and should not have presented their main results before the protocol was finalized in July, 1995.

Size: 11 trials and 26 randomized groups with 67,475 pts (51,917 pts data available for the calculation of the risk equations)

Exclusion criteria: Not stated

Aim: To investigate whether pharmacologic BP reduction prevents CV events and deaths in pts with grade 1 HTN.

Inclusion criteria: RCTs of at least 1 y duration; pts ≥18 y, at least 80% of whom had grade 1 HTN and no previous CVD (MI, angina pectoris, CABG, PCI, stroke, TIA, carotid surgery, peripheral arterial surgery, intermittent claudication, or renal failure); and compared an antihypertensive drug provided as monotherapy or a stepped-care algorithm vs. placebo or another control regimen.

Study type: Metaanalysis of RCTs Size: 10 RTCs with 15,266 pts

Intervention: BP-lowering meds Comparator: • Placebo or less intensive treatment • The difference in average achieved BP between the active and control groups was 3.6/2.4 mm Hg in the BPLTTC (Appendix Table 2, available at www.annals.org) but is unknown for the other contributing trial subgroups.

Exclusion criteria: Excluded trials did not contribute an event

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

including sudden death), HF (resulting in death or admission to hospital), or CV morbidity. • The mean estimated baseline levels of 5-y CV risk for each of the 4 risk groups were 6.0% (SD: 2–0), 12.1% (1–5), 17.7% (1–7), and 26.8% (5–4). • In each consecutive higher risk group, BP-lowering treatment reduced the risk of CV events relatively by 18% (95% CI: 7–27), 15% (95% CI: 4–25), 13% (95% CI: 2–22), and 15% (95% CI: 5– 24), respectively (p=0·30 for trend) in each group with BP-lowering treatment for 5 y would prevent 14 (95% CI: 8–21), 20 (95% CI: 8–31), 24 (95% CI: 8–40), and 38 (95% CI: 16–61) CV events, respectively (p=0.04 for trend). 1° endpoint: Total major CV events, comprising stroke (nonfatal stroke or death from cerebrovascular disease), coronary events (nonfatal MI or death from CHD, including sudden death), HF (causing death or resulting in hospitalization), or CV death; OR: 0.86 (95% CI: 0.74–1.01)

increases. These results support the use of predicted baseline CVD risk equations to inform BP-lowering treatment decisions. • Lowest risk group had >83% with a risk that exceeds 4%.

Summary: • BP-lowering therapy is likely to prevent stroke and death in pts with uncomplicated grade 1 HTN. • 5 y risks in BPLTTC control groups CVD events 7.4% CVD deaths 3.1%

Other endpoints: Each of the above outcomes independently; and total deaths. • CHD 0.91 (95% CI: 0.74–1.12) • Stroke 0.72 (95% CI: 0.55–0.99) • HF 0.80 (95% CI: 0.57–1.12) • CVD deaths 0.75 (95% CI: 0.57– 0.98) 68

2017 Hypertension Guideline Data Supplements for any of the outcomes of interest.

Thompson AM, et al., 2011 (113) 21364140

Aim: To evaluate the effect of antihypertensive treatment on 2º prevention of CVD events and all-cause mortality among pts without clinically defined HTN.

Inclusion criteria: Studies were eligible for inclusion if they were RCTs of antihypertensive treatment among pts with BP <140 mm Hg systolic or <90 mm Hg diastolic for the prevention of CVD events (fatal or nonfatal stroke, fatal or nonfatal MI, CHF, or CVD mortality).

Study type: Metaanalysis of RCTs

Exclusion criteria: Studies were excluded if CVD events were not reported by HTN status in studies that included pts with and without HTN; the study population did not include pts with BP in the normal or prehypertensive ranges; the study population did not include pts with preexisting CVD or CVD equivalents, such as diabetes; antihypertensive treatment was not part of the intervention; treatment allocation was not random; a measure of variance (p-value or CI) was not reported or could not be calculated from the information provided; pts <18 y; or there were differences between

Size: 25 RCTs with 64,162 pts

• Total deaths 0.78 (95% CI: 0.67– 0.92)

Intervention: BP-lowering meds, the majority were studies of ACEI, next most common were BBs. Comparator: Placebo or active comparator

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Only the first event for a pt was used for the analysis of each outcome, but a pt who had >1 outcome type could contribute to more than 1 analysis. They also tabulated overall withdrawals and withdrawals due to adverse events. 1° endpoint: • Composite CVD (fatal or nonfatal stroke, fatal or nonfatal MI, CHF, or CVD mortality): • CVD RR: 0.85 (95% CI: 0.80– 0.90), absolute risk reduction: 27.1/1,000. • This implies that a 2.7% absolute risk reduction reflects a 15% RR reduction, so the baseline risk for CVD would have been about 18%, but the follow-up interval is unclear. Other endpoints: • Stroke RR: 0.77 (95% CI: 0.61, 0.98) • MI RR: 0.80 (95% CI: 0.69, 0.93) • HF RR: 0.71 (95% CI: 0.65, 0.77) • CVD death RR: 0.83 (95% CI: 0.69, 0.99) • Total deaths RR: 0.87 (95% CI: 0.80, 0.95) Other results: Table 4 shows similar results for CVD from studies of pts with CAD vs. other, HF vs. other, and DM vs. non-DM. Similar results from studies of ACEI vs. other. These results support the

Summary: Among pts with clinical history of CVD but without HTN, antihypertensive treatment was associated with decreased risk of stroke, CHF, composite CVD events, and all-cause mortality. Limitations: • Difference in achieved BP was not reported. • Average baseline SBP not reported. No information on the entry levels of BP other than not hypertensive. Difficult to use to establish a treatment threshold or goal. • Many of these studies were designed to try to demonstrate specific drug benefits rather than BP-lowering benefits. Can we attribute the benefits to BPlowering? We know these pts did not have HTN but we do not know the lower limit of the BP inclusion ranges or the treatment associated difference in SBP between groups making it difficult to

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2017 Hypertension Guideline Data Supplements intervention and control groups other than antihypertensive treatment. Xie X, et al., 2015 (21) 26559744

Aim: To assess the efficacy and safety of intensive BP-lowering strategies. Study type: Metaanalysis of RCTs Size: 19 RCTs with 44,989 pts

Inclusion criteria: RCTs with at least 6 mo follow-up that randomly assigned pts to more intensive vs. less intensive BPlowering treatment, with different BP targets or different BP changes from baseline. Reference lists from identified trials and review articles were manually scanned to identify any other relevant studies. Exclusion criteria: N/A

Intervention: BP-lowering meds Comparator: • Less intensive treatment • BP difference 6.8/3.5 • The mean follow-up BP levels in the less intensive BP-lowering regimen group were 140/81 mm Hg, compared with 133/76 mm Hg in the more intensive treatment group.

conclusion that the effect is not a drug effect, but is a BP-lowering effect, and that the effect is seen in people with CVD broadly defined, not just in HF pts. 1° endpoint: • CVD, other major CV events, defined as a MI, stroke, HF, or CV death, separately and combined; nonvascular and all-cause mortality; ESKD, and adverse events. Progression of albuminuria (defined as new onset of microalbuminuria/macro-albuminuria or a change from micro-albuminuria to macro-albuminuria) and retinopathy (retinopathy progression of 2 or more steps) were also recorded for trials that were done in pts with DM • CVD RR: 0.86 (95% CI: 0.78– 0.96) Other endpoints: MI RR: 0.87 (95% CI: 0.76–1.00; p=0.042) Stroke RR: 0.78 (95% CI: 0.68– 0.90) HF RR: 0.85 (95% CI: 0.66–1.11) CVD death RR: 0.91 (95% CI: 0.74–1.11) Total deaths RR: 0.91 (95% CI: 0.81–1.03)

establish a treatment initiation threshold or goal.

Summary: Intensive BPlowering, including to <130 mm Hg, provided greater vascular protection than standard regimens. In high-risk pts, there are additional benefits from more intensive BPlowering, including for those with SPB <140 mm Hg at baseline. The net absolute benefits of intensive BPlowering in high-risk individuals are large. Limitations: • Lack of individual pt data, which would have allowed a more reliable assessment of treatment effects in different pt groups. • Interpretation: Supports treating pt with and without CVD at threshold of 130 to <130. Supports treating at threshold of about 130 even down to a CVD event rate of 0.9% per y.

Other results: • Benefit for CVD not different by baseline SBP 120–139: 0.89 (95% CI: 0.76–1.05) 140–160: 0.83 (95% CI: 0.68–1.00) >160: 0.89 (95% CI: 0.73–1.09) © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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Ettehad D, et al., 2015 (17) 26724178

Aim: This systematic review and metaanalysis aims to combine data from all published large-scale BP-lowering trials to quantify the effects of BP reduction on CV outcomes and death across various baseline BP levels, major comorbidities, and different pharmacological interventions.

Inclusion criteria: • RCTs of BP-lowering treatment that included a minimum of 1,000 pt-y of followup in each study arm. No trials were excluded because of presence of baseline comorbidities, and trials of antihypertensive drugs for indications other than HTN were eligible. • Eligible studies fell into 3 categories: 1st, random allocation of pts to a BP-lowering drug or placebo; 2nd, random allocation of pts to different BP-

Intervention: BP-lowering meds Comparator: Placebo, active comparator or less intensive treatment

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

p-heterogeneity: 0.60 • Benefit for CVD not different for more intensive and less intensive targets in intensive group <140 or <150 mm Hg: 0.76 (95% CI: 0.60–0.97) <120– <130 mm Hg: 0.91 (95% CI: 0.84–1.00) p-hetero: 0.06 • Absolute benefits were proportional to absolute risk. • For trials in which all pts had vascular disease, renal disease, or DM at baseline, the average control group rate of major vascular events was 2·9% per y compared with 0·9% per y in other trials, and the numbers needed to treat were 94 (95% CI: 44–782) in these trials vs. 186 (95% CI: 107– 708) in all other trials. • Increase in severe hypotension: 0.3% vs. 0.1% per person y OR: 2.68 (95% CI: 1.21–5.89) 1° endpoint: • CVD. • Major CVD events, CHD, stroke, HF, renal failure, and all-cause mortality. • Standardized RR for 10 mm Hg difference in SBP • CVD RR: 0.80 (95% CI: 0.77– 0.83) Other endpoints: • CHD RR: 0.83 (95% CI: 0.78– 0.88) • Stroke RR: 0.73 (95% CI: 0.68– 0.77)

Summary: • BP-lowering significantly reduces vascular risk across various baseline BP levels and comorbidities. Our results provide strong support for lowering BP to SBP <130 mm Hg and providing BP-lowering treatment to individuals with a history of CVD, CHD, stroke, DM, HF, and CKD. • In stratified analyses, we saw no strong evidence that proportional effects were diminished in trials that included people with lower 71

2017 Hypertension Guideline Data Supplements Study type: Metaanalysis of RCTs Size: 123 studies with 613,815 pts

lowering drugs; and third, random allocation of pts to different BP-lowering targets.

• HF RR: 0.72 (95% CI: 0.67–0.78) • Total deaths RR: 0.87 (95% CI: 0.84–0.91)

Exclusion criteria: <1,000 pt-y of follow-up in each treatment group.

Other results: • Benefit for CVD and other endpoints not different by baseline SBP, including <130 mm Hg fig 4 in paper CVD: 0.63; 95% CI: 0.50–0.80; p=0.22 CHD: 0.55; 95% CI: 0.42–0.72; p=0.93 Stroke: 0.65; 95% CI: 0.27–1.57; p=0.38 HF: 0.83; 95% CI: 0.41–1.70; p=0.27 Total deaths: 0.53; 95% CI: 0.37– 0.76; p=0.79 • More precision around estimates of benefits in SBP 130–139 at baseline, fig 4 in paper • Results similar in trials of people with and without CVD at baseline figure 5 CVD+ 0.77 (95% CI: 0.71–0.81) CVD- 0.74 (95% CI: 0.67–0.83) Total deaths CVD+ 0.90 (95% CI: 0.83–0.98) CVD- 0.84 (95% CI: 0.75–0.93) Other outcomes similarly in figure 5 • In appendix, in general, benefits for CVD prevention seen in groups with and without baseline CHD, Stroke, DM, CKD and HF when examined separately, but no absolute risks provided to enable estimation of how far down the absolute risk curve these findings have been demonstrated.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

baseline SBP (<130 mm Hg), and major CV events were clearly reduced in high-risk pts with various baseline comorbidities. Both of these major findings—the efficacy of BP-lowering below 130 mm Hg and the similar proportional effects in high risk populations—are consistent with and extend the findings of the SPRINT trial. Limitations: • Lack of individual pt data, which would have allowed a more reliable assessment of treatment effects in different pt groups. • Interpretation: Lowering of BP into what has been regarded the normotensive range should therefore be routinely considered for the prevention of CVD among those deemed to be of sufficient absolute risk.

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SPRINT Wright JT Jr, et al., 2015 (114) 26551272

Aim: To test the effectiveness of a goal SBP<120 mm Hg vs. a goal SBP<140 mm Hg for the prevention of CVD in pts with SBP≥130 mm Hg at baseline. Study type: RCT Size: 9361 pts followed median of 3.26 y.

Inclusion criteria: SBP≥130 mm Hg, with upper limit varying as number of pre-trial BPlowering meds increased. age ≥50 y Presence of at least 1 of the following: • Clinical or subclinical CVD • CKD stage ≥3 • Age≥75 • Framingham General CVD risk≥15% in 10 y Exclusion criteria: DM, history of stroke, ESRD (eGFR <20)

Intervention: Intensive BPlowering treatment to goal SBP <120 mm Hg Comparison: • Standard BP-lowering treatment to goal SBP<140 mm Hg • Net treatment difference ~3 drugs (2.8) on average vs. 2 drugs (1.8) on average • During the trial, mean SBP was 121.5 vs. 134.6.

• Some evidence of BB inferiority to other med classes in figure 6. • Did not report absolute risks so do not know lower level of risk in treated populations. 1° endpoint: CVD (MI, ACS, stroke, HF, CVD death) HR: 0.75 (95% CI: 0.64, 0.89) Other endpoints: • Total deaths HR: 0.73 (95% CI: 0.60–0.90) • 1° or death HR: 0.78 (95% CI: 0.67–0.90) • Components of 1° composite mostly consistent in direction other than ACS – no difference. CKD outcomes: • 1° in CKD pts: reduction in GFR of ≥50% or ESRD HR: 0.89 (95% CI: 0.42, 1.87) • Incident albuminuria HR: 0.72 (95% 0.48, 1.07) • In pts without CKD: reduction in GFR ≥30% and to <60 • HR: 3.49 (95% CI: 2.44–5.10) • Incident albuminuria HR: 0.81 (95% CI: 0.63–1.04) Adverse events: • SAEs: 1.04; p=0.25 • Significant absolute increases seen in intensive group for hypotension (1%), syncope (0.6%), electrolyte abnormality (0.8%), acute kidney injury/acute renal failure (1.6%) over the study period.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Summary: • More intensive SBP lowering to a goal of <120 mm Hg with achieved mean of approximately 121 mm Hg resulted in less CVD and lower total mortality over 3.26 y in comparison with a goal SBP <140 mm Hg and achieved SBP of ~135 mm Hg. • There were small increases in some expected SAEs. Perhaps unexpected, a sizable increase in reduced eGFR in the non-CKD group and AKI/ARF overall was observed in the intensive group. While of uncertain etiology and significance, there is speculation this could be an acute hemodynamic effect, especially given the findings regarding albuminuria. Limitations: Few pts were untreated at baseline ~9%, so SPRINT provides little if any insight at present regarding BP-lowering medication initiation for untreated people with SBP 130–139.

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Lawes MR, et al., 2009 (115) 16222626

Aim: • To determine the quantitative efficacy of different classes of BP-lowering drugs in preventing CHD and stroke, and who should receive treatment. • 5 questions encapsulate this uncertainty. 1st, do BBs have a special effect over and above lowering BP in preventing CHD events in people with a history of CHD? 2nd, does the effect of BPlowering drugs in preventing CHD and stroke differ in people with and without a history of CVD (i.e., is there a different effect in 2° and 1° prevention)? 3rd, does BP reduction alone explain the effect of BP-lowering drugs in preventing CHD and stroke? 4th, should the use of BP-lowering drugs be limited to people with high BP and not given to those at high risk of CVD

Inclusion criteria: The database search (by MRL) used Medline (1966 to December 2007; any language) to identify randomized trials of BP-lowering drugs in which CHD events or strokes were recorded (irrespective of whether BP reduction was considered the mechanism of action). Search terms were “antihypertensive agents” or “HTN” or “diuretics, thiazide” or “adrenergic betaantagonists” or “angiotensinconverting enzyme inhibitors” or “receptors, angiotensin/antagonists & inhibitors” or “tetrazoles” or “CCB s” or “vasodilator agents” or the names of all BP-lowering drugs listed in the British National Formulary as keywords or text words. Limits were Medline publication type “clinical trial” or “controlled clinical trial” or “RCT” or “meta-analysis”. We also searched the Cochrane Collaboration and Web of Science databases and the citations in trials and previous meta-analysis and review articles.

Intervention: BP-lowering medications Comparison: Placebo or less intensive treatment

Exclusion criteria: We excluded nonrandomized trials and trials in which treated groups but not control groups

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• 1.7% fewer pts had orthostatic hypotension in intensive group; p=0.01. 1° endpoint: • CHD and stroke co-1° • Standardized to a 10/5 mm Hg BP reduction Overall CHD: 0.78 (95% CI: 0.73–0.83) Stroke: 0.59 (95% CI: 0.52–0.67) • In absence of vascular disease CHD: 0.79 (95% CI: 0.72–0.86) Stroke: 0.54 (95% CI: 0.45–0.65) • History of CHD CHD: 0.76 (95% CI: 0.68–0.86) Stroke: 0.65 (95% CI: 0.53–0.80) • History of stroke CHD: 0.79 (95% CI: 0.62–1.00) Stroke: 0.66 (95% CI: 0.56–0.79) • No big drug class effects except more benefit for BBs shortly after MI. • Treatment benefits seen down to pre-treatment SBP of 110–119 mm Hg for CHD events RR: 0.78 (95% CI: 0.63–0.96) and 130–139 mm Hg for stroke RR: 0.75 (95% CI: 0.63–0.89)

Summary: The effect of BPlowering drugs in reducing the risk of disease is entirely or largely due to BP reduction, with 1 main exception, a special extra effect of BBs in people who have had a recent MI The proportional reduction in CHD events and stroke for a given reduction in BP, an approximate halving in risk for each 10 mm Hg diastolic reduction, is the same in people with and without a history of vascular disease and in people without high BP as well as in those with high BP There is benefit in lowering BP in anyone at sufficient CV risk whatever their BP, so avoiding the need to measure BP routinely. Limitation: • Most of the pts without HTN were in the trials of people with pre-existing CVD; hence, most of the results of BP lowering in people with SBP<140 are in people with CVD. • No absolute risks or benefits provided. Not possible to estimate how far down the risk curve these results apply. Interpretation: This MA provides stronger support for 74

2017 Hypertension Guideline Data Supplements who have a lower BP? A corollary is whether BP should be reduced to a limited extent only, a treat to target approach. Although cohort (prospective\observati onal) studies do not show a lower BP limit below which risk ceases to decline (“the lower the better”), this has not been shown in randomized trials across a wide range of BP. Finally, what is the quantitative effect of taking ≥1 BP-lowering drugs in lowering BP and preventing CHD events and stroke according to dose, pretreatment BP, and age? To date no such quantitative summary of effect, taking account of these determining factors, has been made.

had other interventions as well as BP reduction, such as cholesterol reduction. We excluded trials in pts with chronic renal failure because these pts typically have high BP and high rates of CVD and their response to standard BPlowering therapy may differ from other people. We also excluded trials in which fewer than 5 CHD events and strokes were recorded or the duration of treatment was less than 6 mo, as these data would contribute little to the overall results and substantially increase the complexity of the analyses. RCTs were otherwise included irrespective of pt age, disease status, BP before treatment, or use of other drugs.

treating at levels <140 for people with CVD than for people without CVD.

Study type: Metaanalysis of RCTs Size: 147 RCTs of BPlowering meds and CHD events (22,000) and stroke (12,000).

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Lewington S, et al., 2002 (16) 12493255

Aim: To describe the age-specific relevance of BP to cause-specific mortality Study type: Metaanalysis of cohort studies Size: 61 prospective studies with 12.7 million person-y of observation, 56,000 vascular deaths in 40– 89 y.

Thomopoulos C, et al., 2014 (20) 25259547

Aim: Investigating whether all grades of HTN benefit from BPlowering treatment and which are the target

Inclusion criteria: Collaboration was sought from the investigators of all prospective observational studies in which data on BP, blood cholesterol, date of birth (or age), and sex had been recorded at a baseline screening visit, and in which cause and date of death (or age at death) had been routinely sought for all screens during more than 5,000 person-y of follow-up (see appendix A; http://image.thelancet.com/extra s/01art8300webappendixA.pdf). Relevant studies were identified through computer searches of Medline and Embase, by handsearches of meeting abstracts, and by extensive discussions with investigators. Exclusion criteria: To minimize the effects of reverse causality (whereby established disease could change the usual BP), studies were excluded if they had selected pts on the basis of a positive history of stroke or heart disease, and individuals from contributing studies were excluded from the present analyses if they had such a history recorded at baseline. Inclusion criteria: Intentional BP-lowering comparing active drug treatment with placebo, or less active treatment (intentional BP-lowering trials), or comparison of an active drug

Intervention: N/A Comparator: N/A • The exposures of interest were the level of SBP and DBP and age-group.

Intervention/Comparator: Criteria of eligibility were intentional BP-lowering comparing active drug treatment with placebo, or less active treatment

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: • Not completely clear, but for our purposes, stroke and IHD death would be co-1°. Also looked at other vascular deaths. • HRs for stroke mortality for a 20 mm Hg lower SBP by age-group 40–49: 0.36 (95% CI: 0.32–0.40) 50–59: 0.38 (95% CI: 0.35–0.40) 60–69: 0.43 (95% CI: 0.41–0.45) 70–79: 0.50 (95% CI: 0.48–0.52) 80–89: 0.67 (95% CI: 0.63–0.71) • HRs for IHD mortality for a 20 mm Hg lower SBP by age-group 40–49: 0.49 (95% CI: 0.45–0.53) 50–59: 0.50 (95% CI: 0.49–0.52) 60–69: 0.54 (95% CI: 0.53–0.55) 70–79: 0.60 (95% CI: 0.58–0.61) 80–89: 0.67 (95% CI: 0.64–0.70) • HRs for other vascular mortality for a 20 mm Hg lower SBP by agegroup 40–49: 0.43 (95% CI: 0.38–0.48) 50–59: 0.50 (95% CI: 0.47–0.54) 60–69: 0.53 (95% CI: 0.51–0.56) 70–79: 0.64 (95% CI: 0.61–0.67) 80–89: 0.70 (95% CI: 0.65–0.75) • Similar results for DBP also in figure 1. • Similar results for men and women separately for stroke, figure 3, and IHD, figure 5.

Summary: Throughout middle and old age, usual BP is strongly and directly related to vascular (and overall) mortality, without any evidence of a threshold down to at least 115/75 mm Hg.

1° endpoint: • As some trials were done on lowrisk pts, others on higher risk pts, no evaluation of absolute riskreduction was made. However, a 2º analysis was done including

Summary: Meta-analyses favor BP-lowering treatment even in grade 1 HTN at low-tomoderate risk, and lowering SBP/DBP to <140/90 mm Hg. Achieving <130/80 mm Hg 76

2017 Hypertension Guideline Data Supplements BP levels to maximize outcome reduction. Study type: Metaanalysis of RCTs Size: 32 RCTs with 104,359 pts

with placebo over baseline antihypertensive treatment, resulting in a BP difference of at least 2 mm Hg in either SBP or DBP (nonintentional BP-lowering trials); enrolling of hypertensive individuals only or a high proportion (at least 40%) of them. Exclusion criteria: N/A

(intentional BP-lowering trials), or comparison of an active drug with placebo over baseline antihypertensive treatment, resulting in a BP difference of at least 2 mm Hg in either SBP or DBP (nonintentional BP-lowering trials); enrolling of hypertensive individuals only or a high proportion (at least 40%) of them. Other inclusion criteria can be found in the preceding paper. 51 trials were found eligible either for assessing BP-lowering effects in different HTN grades or for assessing the effects of achieving different BP levels

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

trials or trial subgroups with mean baseline SBP/DBP values in grade 1 range and a low-to-moderate risk (<5% CV deaths in 10 y in controls): FEVER stratum with baseline SBP below the median (<153 mm Hg) (e7); HTN Detection and Follow-up Program stratum with baseline DBP 90–94 mm Hg and no CVD (e9); OSLO (e17); TOMHS (e28) and USPHS (e29). Risks of stroke, CHD, the composite of stroke and CHD, and all-cause death were significantly reduced by BP-lowering in these low-to-moderate risk pts (control group: average CV mortality 4.5% in10 y) with a moderate BP elevation (average SBP/DBP 145.5/91 mm Hg) at randomization. Standardized risk ratio associated with 10/5 reduction in BP: stroke 0.33 (95% CI: 0.11–0.98) CHD 0.68 (95% CI: 0.48–0.95) CVD death 0.57 (95% CI: 0.32– 1.02) total death 0.53 (95% 0.35– 0.80) • Compared outcomes of achieved on study SBP <130 vs. ≥130 Standardized Risk ratio associated with 10/5 reduction in BP: stroke 0.68 (95% CI: 0.57, 0.83) CHD 0.87 (95% CI: 0.76, 1.00) HF 0.92 (95% CI: 0.47, 1.77) CVD 0.81 (95% CI: 0.67, 1.00) CVD death 0.88 (95% CI: 0.77, 1.01) total death 0.88 (95% CI: 0.77, 0.99) • Outcomes of achieved on study SBP 130–139 vs. ≥140

appears safe, but only adds further reduction in stroke.

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Lonn EM, et al., 2016 (116) 27041480

Aim: To assess efficacy of fixed-dose antihypertensive therapy in adults with intermediate CVD risk. Study type: Doubleblind, placebocontrolled RCT, factorial design Size: 12,705 pts

Neaton JD et al., 1993 (117) 8336373

Aim: To compare 6 antihypertensive drugs (representing different drug classes) Study type: Doubleblind, placebocontrolled RCT Size: 902 pts with stage 1 HTN

Inclusion criteria: Men ≥55 y and women ≥60 y at intermediate risk for CVD. No BP restrictions. Exclusion criteria: • Known CVD • Indications or contraindications to study meds • Mod/advanced CKD • Symptomatic hypotension

Inclusion criteria: • Men and women 45–69 y • Not taking antihypertensive medications, with DBP 90–99 mm Hg • Taking 1 antihypertensive medication, with DBP <95 mm Hg and between 85–99 mm Hg after withdrawal of BP medications

Intervention: FDC of ARB (candesartan 16 mg/d) and diuretic (hydrochlorothiazide 12.5 mg/d) or placebo Follow-up: Median=5.6 y

Intervention: Treatment (number): Once daily (AM): • Placebo (234) • Chlorthalidone 15 mg/d (136) • Acebutolol 400 mg/d (132) • Doxazosin 2 mg/d (134) • Amlodipine 5 mg/d (131) • Enalapril 5 mg/d (135)

Standardized Risk ratio associated with 10/5 reduction in BP: stroke 0.63 (95% CI: 0.52–0.77) CHD 0.77 (95% CI: 0.70–0.86) HF 0.76 (95% CI: 0.47–1.25) CVD 0.74 (95% CI: 0.62–0.88) CVD death 0.81 (95% CI: 0.67– 0.97) total death 0.87 (95% CI: 0.75–1.00) • Similar pattern of results for on treatment DBP. 1° endpoint: 1 co-1° CVD composite outcomes • CVD mortality, nonfatal MI, nonfatal stroke • Above plus cardiac arrest, HF, revascularization

1° endpoint: BP, QoL, side effects, chemistries, ECG, clinical events

Summary: • SBP/DBP reduction of 6.0/3.0 mm Hg • No difference in treatment effect • 1st co-1° 0.93 (0.79–1.10) • 2nd co-1° 0.95 (0.81–1.11) • Suggestion of a subgroup effect in tertile with the highest baseline BP and increased CVD risk. Summary: • Drugs (plus diet) more effective compared to placebo (plus diet) for control of BP. • Minimal differences between drug regimens

Follow-up: Median=4.4 y © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Van Dieren S, et al., 2012 (118) 22677192

Aim: To assess differences in treatment effects of a fixed combination of perindopril– indapamide on major clinical outcomes in pts with type 2 DM across subgroups of CV risk. Study type: RCT

Montgomery AA, et al., 2003 (119) 12923409

Size: 11,140 pts with DM-2, from the ADVANCE trial Aim: To estimate the effectiveness and cost-effectiveness of BP-lowering treatment over a lifetime. Study type: Markov decision analysis model comparing treatment and nontreatment of HTN. Size: Hypothetical cohorts for 20 different strata of sex, age (30– 79 y, in 10-y bands), and CV risk (low and high)

Inclusion criteria: DM-2, aged ≥55 y, with a history of major macrovascular or microvascular disease, or at least 1 other risk factor for vascular disease

Intervention: Perindopril– indapamide or matching placebo

1° endpoint: • The Framingham equation was used to calculate 5-y CVD risk and to divide participants into 2 risk groups, moderate-to-high risk (<25% and no history of macrovascular disease), very high risk (>25% and/or history of macrovascular disease). • Endpoints were macrovascular and microvascular events.

Summary: Relative effects of BP-lowering with perindopril– indapamide on CV outcomes were similar across risk groups whilst absolute effects trended to be greater in the high-risk group.

Intervention: Treatment and nontreatment of HTN.

1° endpoint: Life expectancy, and incremental cost: effectiveness ratios for treatment and nontreatment strategies

• Probabilities of clinical events were obtained from published literature.

Exclusion criteria: A definite indication for, or contraindication to, any of the study treatments, a definite indication for long-term insulin treatment or were participating in any other clinical trial.

Inclusion criteria: We created models for 20 different strata of sex, age (age 30–70 y in 10-y bands), and 2 risk profiles (designated as ‘low’ and ‘high’ risk). These example risk profiles represent the extremes of absolute CV risk, based on data from the Health Survey for England and using a Framingham risk function. We recognize that the risk of most individuals seen in primary care will be somewhere between the examples presented here. The data included were as follows: age- and sex-specific mean SBP of untreated individuals with SBP>0.160 mm Hg were used for both high-risk and low-risk profiles. In addition, low-risk profile was defined as nonsmoker, 10th percentile total cholesterol 90th percentile HDL

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Summary: • Incremental cost per qualityadjusted life y among low-risk groups ranged from £1,030 to £3,304. Cost-effectiveness results for low-risk pts were sensitive to the utility of receiving antihypertensive treatment. Treatment of highrisk individuals was highly costeffective, such that it was the dominant strategy in the oldest age group, and resulted in incremental costs per qualityadjusted life y ranging from £34–£265 in younger age groups. • Policy decisions about which pts to treat depend on whether a life-expectancy or cost79

2017 Hypertension Guideline Data Supplements cholesterol, no DM, and no LVH, and high-risk profile was defined as smoker, 90th percentile total cholesterol, 10th percentile HDL cholesterol, DM, and LVH. Exclusion criteria: N/A

Kassai B, et al., 2005 (120) 17315403

Aim: Consideration of absolute risk has been recommended for making decisions concerning preventive treatment in HTN. Aim to estimate the benefit of antihypertensive therapy over a lifetime. Study type: Metaanalysis on individual data in HTN and specific cause of death from national statistics. Disease-free survival curves until all pts have died were built using the “life-table” method. The treatment effect estimated from INDANA was applied to this curve to obtain the disease-free

Inclusion criteria: To estimate the rate of cv and non-CV deaths in a hypothetical U.S. population of untreated hypertensive pts, we used the following procedure: age-specific death rates in the U.S. general population were obtained from national vital statistics (1994), and in untreated hypertensive population they were obtained from the control groups of the INDANA database. This latter group represents a unique cohort of 14 942 untreated or placebo-treated hypertensive pts, 26–96 y with an average follow-up of 5 y

Intervention: The gain in life expectancy without stroke, CHD, and CV events was estimated from the area between the 2 survival curves of treated and control groups. The relative gain in life expectancy was defined as the ratio of gain in life expectancy to life expectancy.

Exclusion criteria: N/A

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: Stroke and CHD co1° Results: CHD Age ABb RGLEe Y RRa (%) NNTc GLEd (%) 40 0.86 0.3 333 20 4.1 50 0.88 1.0 100 17 4.3 60 0.90 1.9 53 13 3.4 70 0.91 3.9 26 10 5.4 Stroke Age ABb RGLEe Y RRa (%) NNTc GLEd (%) 40 0.80 0.4 250 32 5.9 50 0.84 1.0 100 26 5.7 60 0.86 2.3 44 21 7.1 70 0.87 5.7 18 17 9.1

effectiveness perspective is taken. Treatment increases life expectancy in all strata of age, sex, and CV risk. However, younger individuals stand to gain proportionately more from BP treatment than do the elderly. In terms of costeffectiveness, pts at high risk of CVD are a highly costeffective group to treat. In pts at lower risk of CVD, consideration should be given to issues of pt preference and cost. Summary: Absolute gains in life expectancy are likely to be greater for younger, lower risk people with HTN than for older, higher risk people with HTN. However, the NNT to prevent an event will likely be greater especially in the short term in younger, lower risk people. This modeling analysis provides support for treating younger, lower risk individuals with HTN, but relies on the assumption that the relative benefits of treatments observed in short-term trials of higher risk individuals applies over a longer term to lower risk individuals.

a RR at 10 y b Absolute benefit at 10 y c NNT to avoid 1 event. d Gain in life expectancy in mo without events. 80

2017 Hypertension Guideline Data Supplements survival curve of the life-long treated population. Gains in event-free life expectancy were estimated from survival curves. A sensitivity analysis was performed to assess the impact of possible death misclassifications.

Czernichow S et al., 2011 (121) 20881867

Size: 6 RCTs, ~30,000 pts Aim: The objective of this systematic review and meta-analysis was to compare the relative reductions in risk achieved with different starting levels of BP (and treatment regimens). Study type: Metaanalysis of RCTs

e Relative gain in life expectancy without events.

Inclusion criteria: RCTs of BPlowering (drug vs. control or less intensive treatment) or different classes of drug therapy that included a minimum of 1,000 pty of follow-up in each study arm.

Intervention: BP-lowering meds Comparator: Placebo, active comparator or less intensive treatment

Exclusion criteria: <1,000 pt-y of follow-up in each treatment group.

1° endpoint: • Major CVD events (stroke, CHD, and HF. • No evidence of differences in the ratio of risk across varying levels of baseline BP (with all classes of BPlowering medications).

Size: 32 trials with 201,566 pts (20,079 1° outcome events)

Summary: • Effectiveness of BP-lowering regiments in reducing RR of major CVD events does not seem to be influenced by starting level of BP. Limitations: • The majority of the participants studied were at high risk for CVD. • Information pertaining to the effect of treatment on absolute risk was not presented in this manuscript.

Data Supplement 24. Follow-Up After Initial BP Evaluation (Section 8.1.3) Study Acronym; Author; Year Published

Aim of Study; Study Type; Study Size (N)

Patient Population

Study Intervention (# patients) / Study Comparator (# patients)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events; Summary 81

2017 Hypertension Guideline Data Supplements Ambrosius WT, et al., 2014 (122) 24902920

Aim: To describe the study design of the SPRINT Study type: SPRINT RCT

Cushman WC, et al., 2007 (123) 17599425

Aim: To describe the study design of the BP trial of the ACCORD Trial Study type: Description of study design and protocol for the ACCORD RCT

Inclusion criteria: Adults ≥50 y, average SBP ≥130 mm Hg and evidence of CVD, CKD, or 10-y Framingham risk score ≥15%, or ≥75 y

Intervention: 9,361 pts randomized to 2 treatment groups: • Standard treatment group, SBP target <140 mm Hg • Intensive treatment group: SBP target <120 mm Hg.

1° endpoint: MI, ACS, stroke, HF, or CVD death.

Inclusion criteria: Adults with a diagnosis of DM-2 for at least 3 mo and at high risk for CVD events, who meet the following BP criteria: (1) SBP 130–160 mm Hg and taking 0–3 antihypertensive medications; (2) SBP 161–170 and on 0–2 antihypertensive medications; or (3) SBP 171-180 and taking 0-1 antihypertensive medication. Other entry criteria included spot urine sample <2+, protein–Cr ratio <700 mg protein/1 g Cr, or 24-h protein excretion <1.0 g/24 h.

Intervention: • Unmasked, openlabel, factorial design, randomized trial with a sample size of 4,733 pts • Pts randomized to intensive SBP control (<120 mm Hg) or standard control (<140 mm Hg)

1° endpoint: Major CVD event (nonfatal MI or stroke, or CV death)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Relevant 2° endpoint: All-cause mortality, decline in kidney function or development of ESRD, incident dementia, decline in cognitive function, and small-vessel cerebral ischemic disease Summary: This paper describes the protocol followed in the SPRINT trial that was successful in helping participants to attain and maintain BP targets in the study groups. Once treated, participants had follow-up visits to assessment BP control monthly until BP was at target. Medications were titrated and added as per protocol, when target BP was not attained. Relevant 2° endpoint: Expanded macrovascular outcome (1° outcome plus coronary revascularization or HF hospitalization), total mortality, each of the separate components of the 1° outcome, HF death or hospitalization, and composite microvascular disease outcome (kidney and eye disease). Summary: This paper describes the protocol followed in the ACCORD trial that was successful in helping participants to attain and maintain BP targets in the study groups. Once treated, participants had follow-up visits to assessment BP control monthly until BP was at target. Medications were titrated and added as per protocol, when target BP was not attained.

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Data Supplement 25. RCTs for General Principles of Drug Therapy (Combination Therapies that Inhibit the RAAS) (Section 8.1.4) Study Acronym; Author; Year Published

Aim of Study; Study Type; Study Size (N)

VA NEPHRON-D Fried LF, et al., 2013 (124) 24206457

Aim: Assess the efficacy of combination of an ACEI and an ARB vs. ARB monotherapy in reducing the progression of proteinuric diabetic nephropathy Study type: Multicenter, doubleblind, RCT at 32 VA Medical Centers

Patient Population

Inclusion criteria: Pts with type 2 DM, a urinary albumin-to-creatinine ratio of ≥300, and an eGFR 30.0–89.9 mL/min/1.73 m2 Exclusion criteria: • Subjects with known nondiabetic kidney disease • Serum K+ >5.5 mmol/L • Current treatment with sodium polystyrene sulfonate • Inability to stop prescribed medication that increases the risk of hyperkalemia

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Losartan 100 mg daily plus lisinopril 10–40 mg daily (n=724) Comparator: Losartan 100 mg daily plus placebo (n=724)

Size: 1448 pts

ALTITUDE Parving HH, et al., 2012 (125) 23121378

Aim: Determine if addition of aliskiren as an adjunct to an ACEI or ARB reduces the risk of CV and renal events in pts with type 2 DM

Inclusion criteria: • ≥35 y with type 2 DM • On ACEI or ARB • At least 1 of the following: persistent macroalbuminuria (urine microalbumin to creatinine ratio ≥200 mg/g) and eGFR ≥30 mL/min/1.73 m2, persistent microalbuminuria (≥20 mg/g and <200 mg/g) and a mean eGFR ≥30 and <60

Intervention: Aliskiren 300 mg daily added to conventional treatment with an ACEI or ARB (n=4,274) Comparator: Placebo (n=4,287)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: After a median follow-up of 2.2 y, the study was stopped early due to safety concerns. There was no difference in the 1° outcome of first occurrence of change in eGFR (decrease of ≥30 mL/min/1.73 m2 if initial GFR was ≥60 mL/min/1.73 m2 or a decline of ≥50% if initial eGFR was <60 mL/min/1.73 m2), ESRD, or death (HR with combination therapy: 0.88; 95% CI: 0.70–1.12; p=0.30). Safety endpoint: Combination therapy increased the risk of hyperkalemia (HR: 2.8; 95% CI: 1.8–4.2; p<0.001) and acute kidney injury (HR: 1.7; 95% CI: 1.3–2.2; p<0.001). 1° endpoint: After a median follow-up of 32.9 mo the study was stopped early. There was no difference in the 1° composite outcome death from CV causes or first occurrence of cardiac arrest with resuscitation; nonfatal MI; nonfatal stroke;

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events 2° endpoint: There was no difference in the 2º endpoint of first occurrence of change in eGFR or ESRD (HR: 0.78; 95% CI: 0.58–1.05; p=0.10). There were no differences between combination therapy or losartan monotherapy for the endpoints of ESRD, death, composite of MI, HF, or stroke, MI, CHF, and stroke (p>0.05 for all). Summary: Combination therapy of losartan plus lisinopril did not improve renal outcomes compared to losartan alone, and was associated with greater risk of acute kidney injury and hyperkalemia.

2° endpoint: • There was no difference between aliskiren and placebo for the individual components of the composite 1° outcome (all p>0.05) other than cardiac arrest with resuscitation, which was increased significantly with aliskiren (HR: 2.40; 95% CI: 1.05–5.48; p=0.04). 83

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ONTARGET Yusuf S, et al., 2008 (126) 18378520

Study type: Doubled-blind, multicenter RCT

mL/min/1.73 m2, or history of CVD (e.g., MI, stroke, HF, or CAD) and a mean eGFR ≥30 and <60 mL/min/1.73 m2

Size: 8561

Exclusion criteria: • Serum K+ >5.0 mmol/L • Type 1 DM • Unstable serum Cr • CV history (NYHA Class III or IV, SBP ≥170 mm Hg or DBP ≥110 mm Hg or SBP ≥135 and <170 mm Hg or DBP ≥82 and <100 mm Hg with at least 3 agents, 2nd or third degree heart block, renal artery stenosis • Surgical or medical conditions (malignancy in last 5 y, <2 y life expectancy, renal transplant or immunosuppressive therapy, drug/alcohol abuse, hypersensitivity/allergy/contraindication to study drugs, pregnancy) • Concomitant treatment with ≥2 agents blocking RAAS or K+-sparing diuretics. Inclusion criteria: • ≥55 y • Coronary, peripheral, or cerebrovascular disease or DM with end-organ damage

Aim: Evaluate whether use of an ARB was noninferior to ACEI, and whether the combination was superior to ACE alone in the prevention of vascular events in pts with CVD or DM but not HF. Study type: Multicenter, double-blind, RCT

Exclusion criteria: • Inability to discontinue ACEI or ARB • Known hypersensitivity or intolerance to ACEI or ARB • Selected CVDs (congestive HF, hemodynamically significant valvular or outflow tract obstruction, constrictive pericarditis, complex congenital heart disease, syncopal episodes of unknown etiology <3 mo, planned cardiac surgery

unplanned hospitalization for HF; ESRD; death attributable to kidney failure or need for renalreplacement therapy with no dialysis or transplantation available or initiated; or doubling of the baseline serum Cr between aliskiren or placebo (HR: 1.08; 95% CI: 0.98–1.20; p=0.12). Safety endpoint: The combination of aliskiren added to an ACEI or an ARB was associated with greater risk of hyperkalemia and hypotension (11.2% vs. 7.2% and 12.8% vs. 8.3%; p<0.001 for both, respectively).

Intervention: Ramipril 10 mg daily (n=8,576) Comparator: • Telmisartan 80 mg daily (n=8,542) • Combination of telmisartan and ramipril (n=8,502)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: After a median follow-up of 56 mo, there was no difference between ramipril vs. telmisartan or combination therapy vs. ramipril in the 1° composite outcome of death from CV causes, MI, stroke, or hospitalization for HF (RR: 1.01; 95% CI: 0.94– 1.09 and RR: 0.99; 95% CI: 0.92–1.07, respectively) Safety endpoint: • Combination therapy was associated with greater risk of hyperkalemia than

• There was no differences in CV composite outcome, renal composite outcome, or death from any cause (p>0.05 for all) Summary: Aliskiren added to background treatment of an ACEI or ARB did not decrease CV or renal outcomes, and was associated with increased risk of cardiac arrest with resuscitation, hyperkalemia, and hypotension.

2° endpoint: • There was no difference in composite of death from CV causes, MI, or stroke in the ramipril vs. telmisartan groups RR: 0.99; 95% CI: 0.9–1.07); p=0.001 or ramipril vs. combination RR: 1.00; 95% CI: 0.93–1.09 • There were no differences between ramipril vs. telmisartan or ramipril vs. combination therapy in 2º outcomes including MI, stroke, hospitalization for HF, death from CV causes, death from non-CV causes, or death from any cause (p>0.05 for all). 84

2017 Hypertension Guideline Data Supplements Size: 25,620

or PTCA <3 mo, uncontrolled HTN on treatment [e.g., BP >160/100 mm Hg], heart transplant recipient, stroke due to subarachnoid hemorrhage) • Other conditions (significant renal artery disease, hepatic dysfunction, uncorrected volume or sodium depletion, 1° hyperaldosteronism, hereditary fructose intolerance, other major noncardiac illness or expected to reduce life expectancy or significant disability interfere with study participation, simultaneously taking another experimental drug, unable to provide written informed consent).

ramipril monotherapy (480 pts vs. 283 pts; p<0.001) • Hypotensive symptoms were cited as reason for permanent discontinuing more in telmisartan vs. ramipril (RR: 1.54; p<0.001) and combination therapy vs. ramipril monotherapy (RR: 2.75; p<0.001) • Renal impairment was more common in combination therapy vs. ramipril monotherapy RR: 1.33; 95% CI: 1.2–1.44

Summary: Combination therapy with telmisartan and ramipril did not decrease the risk of CV events in pts at high risk compared to monotherapy with ramipril. In addition, combination therapy was associated with increased risk of hypotension, hyperkalemia, and renal impairment.

Data Supplement 26. BP Goal for Patients with Hypertension (Section 8.1.5) Study Acronym (if applicable) Author Year Published Lawes CM, et al., 2003 (50) 12658016

LV J, et al., 2013 (127) 23798459

Study Type/Design; Study Size (N) Study type: Metaanalysis of RCTs of BP drugs recording CHD events and strokes Size: 464,000 pts Study type: MA of RTC that randomly assigned individuals to different target BP levels

Patient Population

N/A

Study Intervention (# patients) Study Comparator (# patients) N/A

Primary Endpoint and Results (include P value; OR or RR; & 95% CI) • CHD RR or 46% Stroke 64%

N/A

N/A

7.5/4.5 mm Hg BP difference. Intensive BP lowering achieved. RR for • Major CV events: 11%; 95% CI: 1%–21%) • MI: 13%; 95% CI: 0%– 25%

Size: 15 trials including a total of 37,348 pts © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Summary/Conclusion Comment(s) • All classes of BP meds confer benefit while BB confer greater benefit in those with CAD

• More intensive strategy for BP control reduced cardiorenal endpoint

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Xie X, et al., 2015 (21) 26559744

Study type: MA of RTC that randomly assigned individuals to different target BP levels

N/A

N/A

Size: 19 trials (n=44,989)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• Stroke: 24%; 95% CI: 8%–37% • ESRD: 11%; 95% CI: 3%–18% • Albuminuria: 10%; 95% CI: 4%–16% • Retinopathy 19%; 95% CI: 0%–34% p=0.051 Achieved BP 133/76 mm Hg (intensive) 140/81 (less intense) • Major CV events: 14%; 95% CI: 4%–22% • MI: 13%; 95% CI: 0%– 24% • Stroke: 22%; 95% CI: 10%–32% • Albuminuria: 10%; 95% CI: 3%–16% • Retinopathy progression: 19%; 95% CI: 0%–34%. • More intensive had no effects on HF: 15%; 95% CI: -11%–34% • CV death: 9%; 95% CI: 11%–26% • Total mortality: 9%; 95% CI: -3%–19% • ESKD: 10%; 95% CI: 6%–23%

• More intensive approach reduced major CV events (stroke and MI) except heat failure, CVD, ESRD, and total mortality.

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2017 Hypertension Guideline Data Supplements Verdecchia P et al., 2016 27456518

Study type: Cumulative metaanalysis of RCTs to study benefit of more vs. less intensive BP lowering

N/A

N/A

N/A

N/A

Size: 18 trials (n=53,405)

Bangalore S, et al., 2017 28109971

Study type: Network metaanalysis in which the authors attempted to compare the benefits and adverse effects resulting from intensive reduction in SBP Size: 17 trials (n=55,163)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• Stroke, MI, HF, CVD mortality, and all-cause mortality • Difference in achieved SBP/DBP=7.6/4.5 mm Hg • For stroke and MI the cumulative Z score crossed the efficacy boundary after addition of the SPRINT results • For CVD mortality and HF, the cumulative Z curve crossed the conventional significance boundary (but not the sequential monitoring boundary) • For all-cause mortality, the cumulative Z curve did not reside in the futility are but did not cross the conventional significance boundary • There was a significant reduction in stroke (RR: 0.54) and MI (RR: 0.68) • The point estimate favored all-cause mortality, CVD mortality and HF but the results did not achieve significance • SBP targets <120 and <130 mm Hg ranked #1 and #2 as the most efficacious • Serious adverse effects were more common at a lower SBP (120 vs. 150 or 140 mm Hg)

• The results strongly supported the benefit of intensive BP reduction for prevention of stroke and MI and suggested benefit for prevention of CVD mortality and HF

• Overall, the beneficial effects of treatment were consistent with other reports. The cluster plots of treatment benefit vs. risk are difficult to interpret due to limitations of the available data base and the authors’ decision to weight treatment benefits and potential adverse effects equally.

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2017 Hypertension Guideline Data Supplements • Cluster plots for combined efficacy and safety suggested a SBP <130 mm Hg as the optimal target for SBP reduction during treatment

Bundy JD, et al., 2017 28564682

Lawes CMM, et al., 2002 16222626

Study type: Systematic review and network metaanalysis to assess the benefits of intensive SBP reduction during treatment of hypertension Size: 42 trials (n=144,220) Study type: Review of observational reports and randomized controlled trials

N/A

N/A

• In general, there were linear associations between achieved SPB and risk of CVD and allcause mortality, with the lowest risk at a SBP of 120–124 mm Hg.

N/A

N/A

• The relative benefits of BP lowering for CHD prevention likely to be consistent across a wide range of different populations • Likely to be considerable benefit for BP lowering beyond traditional thresholds, especially in those at high risk for CVD • BP lowering is likely to be more important than choice of initial agent • A large majority of patients being treated for

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• This was by far the largest and best powered metaanalysis to assess the relationship between SBP reduction and major outcomes during treatment of hypertension. The findings provided strong evidence for the “lower is better” approach to treatment in patients with a high SBP who are at high risk for CVD. • Strongly supports lower BPs during BP treatment, especially in those at high risk of CVD

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2017 Hypertension Guideline Data Supplements hypertension have suboptimal BPs. Initiatives to lower their BP further are essential

Study Acronym; Author; Year Published Xie X, et al., 2015 (21) 26559744

Aim of Study; Study Type; Study Size (N)

Patient Population

Aim: To assess the efficacy and safety of intensive BPlowering strategies.

Inclusion criteria: RCTs with at least 6 mo follow-up that randomly assigned pts to more intensive vs. less intensive BP-lowering treatment, with different BP targets or different BP changes from baseline. Reference lists from identified trials and review articles were manually scanned to identify any other relevant studies.

Study type: Metaanalysis of RCTs Size: 19 RCTs with 44,989 pts

Exclusion criteria: N/A

Study Intervention (# patients) / Study Comparator (# patients) Intervention: BP-lowering meds Comparator: • Less intensive treatment • BP difference 6.8/3.5 • The mean follow-up BP levels in the less intensive BPlowering regimen group were 140/81 mm Hg, compared with 133/76 mm Hg in the more intensive treatment group.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (include Absolute Event Rates, P value; OR or RR; and 95% CI) 1° endpoint: • CVD, other major CV events, defined as a MI, stroke, HF, or CV death, separately and combined; nonvascular and allcause mortality; ESKD, and adverse events. Progression of albuminuria (defined as new onset of microalbuminuria/macro-albuminuria or a change from microalbuminuria to macroalbuminuria) and retinopathy (retinopathy progression of 2 or more steps) were also recorded for trials that were done in pts with DM • CVD RR: 0.86 (95% CI: 0.78– 0.96)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events Summary: Intensive BPlowering, including to <130 mm Hg, provided greater vascular protection than standard regimens. In highrisk pts, there are additional benefits from more intensive BP-lowering, including for those with SPB <140 mm Hg at baseline. The net absolute benefits of intensive BPlowering in high-risk individuals are large. Limitations: • Lack of individual pt data, which would have allowed a more reliable assessment of

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Other endpoints: • MI RR: 0.87 (95% CI: 0.76– 1.00) p=0.042 • Stroke RR: 0.78 (95% CI: 0.68–0.90) • HF RR: 0.85 (95% CI: 0.66– 1.11) • CVD death RR: 0.91 (95% CI: 0.74–1.11) • Total deaths RR: 0.91 (95% CI: 0.81–1.03)

treatment effects in different pt groups. • Interpretation: Supports treating pt with and without CVD at threshold of 130 to <130. Supports treating at threshold of about 130 even down to a CVD event rate of 0.9% per y.

Other results: • Benefit for CVD not different by baseline SBP 120–139: 0.89 (95% CI: 0.76– 1.05) 140–160: 0.83 (95% CI: 0.68– 1.00) >160: 0.89 (95% CI: 0.73–1.09) p-heterogeneity: 0.60 • Benefit for CVD not different for more intensive and less intensive targets in intensive group <140 or <150 mm Hg: 0.76 (95% CI: 0.60–0.97) <120– <130 mm Hg: 0.91 (95% CI: 0.84–1.00; p-hetero: 0.06) • Absolute benefits were proportional to absolute risk. • For trials in which all pts had vascular disease, renal disease, or DM at baseline, the average control group rate of major vascular events was 2·9% per y compared with 0·9% per y in other trials, and the numbers needed to treat were 94 (95% © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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Julius S, et al., 2006 (55) 16537662

Study type: RCT in pre-HTN16 mg candesartan vs. placebo

• 58% men

N/A

N/A

N/A

• CHD RR or 46% Stroke 64%

• All classes of BP meds confer benefit while BB confer greater benefit in those with CAD

Inclusion criteria: Men ≥55 y and women ≥60 y at intermediate risk for CVD. No BP restrictions.

Intervention: FDC of ARB (candesartan 16 mg/d) and diuretic (hydrochlorothiazide 12.5 mg/d) or placebo

1° endpoint: 1 co-1° CVD composite outcomes • CVD mortality, nonfatal MI, nonfatal stroke • Above plus cardiac arrest, HF, revascularization

Summary: • SBP/DBP reduction of 6.0/3.0 mm Hg

Size: 809 pts

Lawes CM, et al., 2003 (50) 12658016

Lonn EM, et al., 2016 (116) 27041480

Study type: Metaanalysis of RCTs of BP drugs recording CHD events and strokes Size: 464,000 pts Aim: To assess efficacy of fixed-dose antihypertensive therapy in adults with intermediate CVD risk. Study type: Doubleblind, placebocontrolled RCT, factorial design

CI: 44–782) in these trials vs. 186 (95% CI: 107–708) in all other trials. • Increase in severe hypotension: 0.3% vs. 0.1% per person y OR: 2.68 (95% CI: 1.21–5.89) • During the first 2 y, HTN developed in 154 (40.4%) pts in the placebo group compared with only 53 (13.6%) of those in the candesartan group, for a RR of 66.3% (p<0.0001). After 4 y, HTN developed in 240 (63.0%) in the placebo group vs. only 208 (53.2%) in the candesartan group RR 15.6% (p<0.0069).

Exclusion criteria: • Known CVD • Indications or contraindications to study meds • Mod/advanced CKD • Symptomatic hypotension

Follow-up: Median=5.6 y

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• 2/3 of those with pre-HTN develop HTN within 4 y. Candesartan interrupts the onset and reduced by 15.6%

• No difference in treatment effect • 1st co-1° 0.93 (0.79–1.10) • 2nd co-1° 0.95 (0.81–1.11)

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Neaton JD, et al., 1993 (117) 8336373

Aim: To compare 6 antihypertensive drugs (representing different drug classes) Study type: Doubleblind, placebocontrolled RCT Size: 902 pts with stage 1 HTN

• Suggestion of a subgroup effect in tertile with the highest baseline BP and increased CVD risk. Inclusion criteria: • Men and women 45–69 y • Not taking antihypertensive medications, with DBP 90–99 mm Hg • Taking 1 antihypertensive medication, with DBP <95 mm Hg and between 85–99 mm Hg after withdrawal of BP medications

Intervention: Treatment (number): Once daily (AM): • Placebo (234) • Chlorthalidone 15 mg/d (136) • Acebutolol 400 mg/d (132) • Doxazosin 2 mg/d (134) • Amlodipine 5 mg/d (131) • Enalapril 5 mg/d (135)

1° endpoint: BP, QoL, side effects, chemistries, ECG, clinical events

Summary: • Drugs (plus diet) more effective compared to placebo (plus diet) for control of BP. • Minimal differences between drug regimens

Follow-up: Median=4.4 y

Data Supplement 27. Choice of Initial Medication (Section 8.1.6) Study Acronym Author Year Published

Aim of Study; Study Type; Study Size (N)

Psaty BM, et al., 2003 12759325

Study type: Network metaanalysis to compare value of different first-line antihypertensive drugs in prevention of major CVD and all-cause mortality Size: 42 trials (n=192,478)

Patient Population

N/A

Study Intervention (# patients) / Study Comparator (# patients)

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI)

• For all outcomes, low-dose diuretics were better than placebo • None of the other first-line agents (β-blockers, ACEI, CCBs, α-receptor blockers and ARBs) were superior to lowdose diuretics • For several outcomes, lowdose diuretics were superior to other agents

• Low-dose diuretics were identified as the most effective first-line treatment for prevention of CVD and all-cause mortality during treatment of hypertension

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events; Summary N/A

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Study type: Metaanalysis of levels of BP control in DM hypertensives.

• 49 trials (most pts with DM-2)

Size: 73,738 pts

Ettehad D, et al., 2015 (17) 26724178

Study type: Metaanalysis of large RTCs of antihypertensive treatment

N/A

Size: 123 studies (613,815 pts)

Thomopolous C, et al., 2016 (54) 26848994

Study type: Metaanalysis of RTCs of more vs. less intense BP control

• 16 trials (52,235 pts) compared more vs. less intense treatment 34 (138,127 pts) active vs. placebo

Baseline SBP >150 RR for • All death: 0.89; 95% CI:0.80– 0.99 • CVD: 0.75; 95% CI: 0.57– 0.99 • MI: 0.74; 95% CI: 0.63–0.87 • Stroke: 0.77; 95% CI: 0.65– 0.91 • ESRD: 0.82; 95% CI: 0.71– 0.94 Baseline SBP140–150 RR of • Death: 0.87; 95% CI: 0.78– 0.98) • MI: 0.84; 95% CI: 0.76–0.9 • HF: 0.80; 95% CI: 0.66–0.97 If baseline SBP,140 mm Hg, however, further treatment increased the risk of CV mortality (1.15; 95% CI: 1.00– 1.32 Every 10 mm Hg reduction in SBP RR: • Major CV events: 0.80; 95% CI: 0.77–0.83 • CHD: 0.83; 95% CI: 0.78– 0.88 • Stroke: 0.73; 95% CI: 0.68– 0.77), HF (0.72, 0.67–0.78 • All-cause mortality: 0.87; 95% CI: 0.87; 0.84–0.91 • ESRD: 0.95; 0.84–1.07 More intense BP • Stroke RR: 0.71; 95% CI: 0.60–0.84) • CHD RR: 0.80; 95% CI: 0.68–0.95)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• BP lowering reduces major CV events in DM. Caution for initiating treatment in diabetics with SBP <140/90

N/A

• BP lowering reduces CV risk across various baseline BP levels and comorbidities. Suggest lowering SBP <130 mm Hg and BP-lowering treatment to pts with a history of CVD, CHD, stroke, DM, HF, and CKD.

N/A

• Intensive BP reduction improves CV outcomes compared to less intense • Achieved BP <130/80 may be associated with CV benefit.

N/A

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Julius S, et al., 2006 (55) 16537662

Study type: RCT in pre-HTN 16 mg candesartan vs. placebo

• 58% men

Size: 809 pts

Ference BA, et al., 2014 (56) 24591335

Study type: Evaluated the effect of 12 polymorphisms (associated with BP) on the odds of CHD and compared it with the effect of lower SBP observed in both prospective cohort studies and BP-lowering randomized trials Size: 199,477 pts in 63 studies

N/A

Stratification of SBP cutoffs (150,140 and 130 mm Hg) showed that a SBP/DBP difference of 10/5 mm Hg across each cutoff reduced risk of all outcomes • During the first 2 y, HTN developed in 154 (40.4%) pts in the placebo group compared with only 53 (13.6%) of those in the candesartan group, for a RR of 66.3% (p<0.0001). After 4 y, HTN developed in 240 (63.0%) in the placebo group vs. only 208 (53.2%) in the candesartan group RR 15.6% (p<0.0069). •12 polymorphisms were associated with a 0.32 mm Hg lower SBP (p=1.79×10-7) and a 0.093-mm Hg/decade slower age-related rise in SBP (p=3.05×10-5). The effect of long-term exposure to lower SBP on CHD mediated by these polymorphisms was 2fold greater than that observed in prospective cohort studies (p=0.006) and 3-fold greater than that observed in shortterm BP treatment trials (p=0.001).

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• 2/3 of those with pre-HTN develop HTN within 4 y. Candesartan interrupts the onset and reduced by 15.6%

N/A

• SBP may be causally associated with the rate of rise in SBP with age and has a cumulative effect on the risk of CHD.

N/A

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Data Supplement 28. Follow-Up After Initiating Antihypertensive Drug Therapy (Section 8.3.1) Study Acronym Author Year Published

Aim of Study; Study Type; Study Size (N)

Patient Population

Study Intervention (# patients) / Study Comparator (# patients)

Ambrosius WT, et al., 2014 (122) 24902920

Aim: To describe the study design of the SPRINT trial

Inclusion criteria: Adults ≥50 y, average SBP ≥130 mm Hg and evidence of CVD, CKD, or 10-y Framingham risk score ≥15%, or age ≥75 y

Intervention: 9361 participants randomized to 2 treatment groups: (1) Standard treatment group, SBP target <140 mm Hg, and (2) Intensive treatment group: SBP target <120 mm Hg.

Study type: description of study design and protocol for the SPRINT RCT

Cushman WC, et al., 2007 (123) 17599425

Aim: To describe the study design of the BP trial of the ACCORD trial. Study type: description of study design and protocol

Inclusion criteria: Adults with a diagnosis of type 2 DM for at least 3 mo and at high risk for CVD events, who meet the following BP criteria: (1) SBP 130–160 mm Hg and taking 0–3 antihypertensive medications; (2) SBP 161–170 and on 0–2 antihypertensive

Intervention: • Unmasked, open-label, factorial design, randomized trial with a sample size of 4,733 pts • Patients were randomized to intensive SBP control (<120 mm Hg) or standard control (<140 mm Hg)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: MI, ACS, stroke, HF, or CVD death.

1° endpoint: Major CVD event (nonfatal MI or stroke, or CV death)

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events; Summary Relevant 2° endpoint: Allcause mortality, decline in kidney function or development of ESRD, incident dementia, decline in cognitive function, and smallvessel cerebral ischemic disease Summary: This paper describes the protocol followed in the SPRINT trial that was successful in helping participants to attain and maintain BP targets in the study groups. Once treated, participants had follow-up visits to assessment BP control monthly until BP was at target. Medications were titrated and added as per protocol, when target BP was not attained. Relevant 2° endpoint: Expanded macrovascular outcome (1° outcome plus coronary revascularization or HF hospitalization), total mortality, each of the separate components of the 1° outcome, HF death or hospitalization, and 95

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Xu W, et al., 2015 (128) 25655523

Aim: Retrospective assessment of the impact of follow-up intervals and treatment intensification thresholds on CVD events

medications; or (3) SBP 171– 180 and taking 0–1 antihypertensive medication. Other entry criteria included spot urine sample <2+, protein–Cr ratio <700 mg protein/1 g creatinine, or 24-h protein excretion <1.0 g/24 h.

Inclusion criteria: Primary care practices in the U.K., 1986–2010.

composite microvascular disease outcome (kidney and eye disease).

N/A

Study type: Retrospective cohort Size: 88,756 adult pts with HTN from The Health Improvement Network database

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• Median follow-up of 37.4 mo after the treatment strategy assessment period • 9,985 (11.3%) pts had an acute CV event or died. • No difference in risk of the outcome with systolic intensification thresholds 130– 150 mm Hg, but HR: 1.21 for thresholds >150 mm Hg • Outcome risk increased progressively from the lowest (0–1.4 mo) to the highest 5th of time to medication intensification (HR: 1.12; 95% CI: 1.05–1.20; p=0.009) for intensification between 1.4 and 4.7 mo after detection of elevated BP). The highest fifth of time to follow-up (>2.7 mo) was also associated with increased outcome risk HR:

Summary: This paper describes the protocol followed in the ACCORD trial that was successful in helping pts to attain and maintain BP targets in the study groups. Once treated, pts had follow-up visits to assessment BP control monthly until BP was at target. Medications were titrated and added as per protocol, when target BP was not attained. • Increased risk of acute CVD event or death with: • Systolic intensification thresholds >150 mm Hg • Delays of >1.4 mo before medication intensification after SBP elevation • Delays of >2.7 mo before BP follow-up after antihypertensive medication intensification • Timely medical management and follow-up impacts outcomes in the treatment of pts with HTN. • Retrospective study, but still sheds important light on the impact of follow-up actions

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Birtwhistle RV, et al., 2004 (129) 14726370

Aim: Assess impact of follow-up intervals on BP control in stable, treated pts with HTN

Inclusion criteria: 50 family practices in southeastern Ontario, Canada.

• 302 pts randomized to followup every 3 mo, 307 randomized to follow-up every 6 mo.

Study type: RCT Size: 609 pts, 30– 74 y with essential HTN, on drug treatment, with HTN controlled for ≥3 mo prior to entry into study.

1.18; 95% CI: 1.11–1.25; p<0.001 • Pts in both groups visited doctor more frequently than their assigned interval. • Mean BP was similar in the groups, as was control of HTN. • Pt satisfaction and adherence to treatment were similar in the groups. • About 20% of pts in each group had BPs that were out of control during the study.

• Study addresses follow-up interval for pts with treated, stable, and controlled HTN. No difference in BP control or pt satisfaction between 3 and 6 mo follow-up groups. • May be helpful with recommendations for pts with treated, stable HTN.

Data Supplement 29. Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP (Section 8.3.2) Study Acronym Author Year Published Brennan T, et al., 2010 (130) 20415618

Aim of Study; Study Type; Study Size (N) Aim: Assess impact of follow-up and monitoring system including home BP monitoring and telephonic nurse case management on BP control in pts treated for HTN Study type: RCT Size: 638 African American pts with high BP from a national health maintenance organization plan

Patient Population Inclusion criteria: HTN

Study Intervention (# patients) / Study Comparator (# patients) Intervention: Intervention group received telephonic nurse case management, pt education materials, lifestyle counseling, and a home BP monitor

Endpoint Results (include Absolute Event Rates, P value; OR or RR; & 95% CI) • Intervention group achieved lower SBP (123.6 vs. 126.7 mm Hg, p=0.03) and was 50% more likely than the control group to achieve BP control OR: 1.50; 95% CI: 0.997–2.27; p=0.052

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events; Summary • Combination of home BP monitoring and nurse case management controlled HTN better than home BP alone

Comparator: Control group received a home BP monitor only

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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2017 Hypertension Guideline Data Supplements Bosworth, et al., 2009 (131) 19920269

Aim: Assess impact of telephone follow-up intervention and/or home BP monitoring on BP control in pts with treated HTN Study type: RCT

Inclusion criteria: Pts with HTN, from 2 universityaffiliated primary care clinics.

• 636 pts randomized to usual care or 1 of 3 intervention groups: (1) Nurse-administered telephone intervention targeting HTN -related behaviors, (2) home BP monitoring 3 times weekly, and (3) both interventions

Inclusion criteria: Primary care clinics at a VA Medical Center

• 593 pts randomized to either usual care or to 1 of 3 telephone follow-up groups: (1) nurse-administered behavioral management, (2) nurse- and physicianadministered medication management, or (3) a combination of both

Size: 636 pts were randomized; 475 pts completed the trial, including 24-mo follow-up period.

Bosworth, et al., 2011 (132) 21747013

Aim: Assess impact of telephone follow-up interventions on BP control in pts with treated HTN Study type: RCT Size: Of 1551 eligible pts, 593 randomized

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• 475 pts (75%) completed the 24mo BP follow-up. • At 24 mo, improvements in the proportion of pts with BP control relative to the usual care group were 4.3% (95% CI: -4.5%, 12.9%) in the behavioral intervention group, 7.6% (95% CI: -1.9%, 17.0%) in the home BP monitoring group, and 11.0% (95% CI: 1.9%, 19.8%) in the combined intervention group. • Relative to usual care, the 24-mo difference in SBP was 0.6 mm Hg (95% CI: -2.2, 3.4 mm Hg) for the behavioral intervention group, -0.6 mm Hg (95% CI: -3.6, 2.3 mm Hg) for the BP monitoring group, and 3.9 mm Hg (95% CI: -6.9– -0.9 mm Hg) for the combined intervention group; patterns were similar for DBP • 1° endpoint: BP control measured every 6 mo for 18 mo • Behavioral management and medication management alone showed significant improvements at 12 mo-12.8% (95% CI: 1.6%, 24.1%) and 12.5% (95% CI: 1.3%, 23.6%), respectively-but not at 18 mo. • In subgroup analyses, among those with poor baseline BP control, SBP decreased in the combined intervention group by 14.8 mm Hg (95% CI: -21.8– -7.8 mm Hg) at 12 mo and 8.0 mm Hg (95% CI: -15.5– -0.5 mm Hg) at 18 mo, relative to usual care.

• Home BP monitoring and tailored behavioral telephone intervention improved BP control, SBP, and DBP at 24 mo relative to usual care. Combined therapy was significantly better than either therapy alone.

• Telephone-based case management for high BP control effectively lowers BP for up to 1 y, but then BP control slackens. • Interventions had the most impact on pts with worst BP control at study entry. • Study carried out in the Veteran’s Administration outpatient practice; unclear if results would apply to other practice settings.

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Aim: Assess impact of follow-up and monitoring system including home BP monitoring, Internet-based BP management tool, and pharmacist care management on BP control in pts treated for HTN

Inclusion criteria: Uncontrolled HTN and Internet access

• 2 intervention groups: one with home BP monitoring and Internet tool, and the other with home BP monitoring, Internet tool, and pharmacist care management • Compare to usual care • 1 y follow-up

• Intervention group with all components achieved better BP control vs. usual care • 56% (95% CI: 49%–62%) or combination intervention group achieved BP control vs. usual care (p<0.001) and intervention with only home BP monitor and Internet tool (p<0.001)

• Combination of home BP monitoring, Internet-based BP management tools, and pharmacist case management helped control HTN better than usual care and better than BP monitoring and Internet-based tool alone.

Inclusion criteria: Uncontrolled HTN and Internet access

• 14-mo intervention period • BP 6 mo prior to and 6 mo after intervention period were compared in intervention and control groups

• Mean SBP was 2.4 mm Hg lower (95% CI: -3.4– -1.5), p<0.001 in the intervention group immediately after the intervention period, compared to the control group

• Pharmacist care management system in a “real world” setting was more effective than usual care in lowering BP in the short-term, but in the longer-term follow-up did not differ significantly from usual care. • This study is one of very few studies to show no significant longer term impact of a care management system on BP control in pts with HTN.

• 222 pts randomized to 8 usual care clinics and 228 randomized to 8 intervention clinics • Intervention included 12 mo of home BP telemonitoring and pharmacist case management, with 6 mo of follow-up afterward

• Intervention group achieved better BP control compared to usual care during 12 mo of intervention and persisting during 6 mo of follow-up • SBP was <140/90 in 57.2% (95% CI: 44.8%, 68.7%) of intervention pts at 6 and 12 mo vs. 30% (95% CI: 23.2%, 37.8%) in usual care (p=0.001)

Study type: Cluster RCT

Heisler M, et al., 2012 (134) 22570370

Size: 778 pts from 16 clinics in integrated group practice in Washington state. Aim: Assess impact of follow-up pharmacist care management system on BP control in pts treated for HTN Study type: Cluster RCT

Margolis KL, et al., 2013 (25) 23821088

Size: 1797 intervention and 2303 control pts from 16 primary care clinics at 5 medical centers (3 VA and 2 Kaiser Permanente) Aim: Assess impact of follow-up and monitoring system including home BP tele-monitoring and pharmacist case management on BP control in pts treated for HTN Study type: Cluster RCT Size: 450 pts from 16 clinics in integrated health system in Minneapolis, MN

Inclusion criteria: Uncontrolled HTN

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

BP decrease was the same in the intervention and control groups (9 mm Hg).

• Combination of home BP telemonitoring and pharmacist case management helped control HTN better than usual care at 6, 12, and 18 mo

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Data Supplement 30. RCTs Comparing Stable Ischemic Heart Disease (Section 9.1) Study Acronym; Author; Year Published INVEST Bangalore S, et al., 2014 (135) 25145522

Aim of Study; Study Type; Study Size (N)

Patient Population

Aim: To investigate optimal BP in pts ≥60 y with CAD and SBP >150 mm Hg treated with antihypertensive drugs

Inclusion criteria: Pts ≥60 y with CAD and SBP >150 mm Hg treated with antihypertensive therapy

Study type: Posthoc analysis of PROBE trial (INVEST study— atenolol/HCTZ or verapamilSR/trandolapril)

Exclusion criteria: N/A

Size: 8,354 pts

Study Intervention (# patients) / Study Comparator (# patients) Intervention: • 4,787 pts (57%) achieved SBP<140 mm Hg (group 1) • SBP achieved was <140 mm Hg (group 1) Comparator: • 1,747 pts (21%) achieved SBP of 140– 149 mm Hg (group 2); 1,820 pts (22%) achieved SBP ≥150 mm Hg (group 3) • SBP achieved was 140–149 mm Hg (group 2) and 150 mm Hg or higher (group 3)

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: All-cause death, nonfatal MI, or nonfatal stroke. Multiple propensity score-adjusted 1° outcome showed that compared with group 1, the risk of 1° outcome adjusted HR: 1.12 (95% CI: 0.95– 1.32; p=0.19); for group 2 adjusted HR: 1.85 (95% CI: 1.59, 2.14), p<0.0001; for group 3 adjusted HR: 1.64 (95% CI: 1.40, 1.93), p<.0001 1° Safety endpoint: No significant difference between the 3 groups

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events; Summary Relevant 2° endpoint: Multiple propensity scoreadjusted analysis: •Compared with group 1, no significant difference in all-cause mortality in group 2 but increased all-cause mortality in group 3 (HR: 1.64; 95% CI: 1.40–1.93; p<0.0001). • Compared with group 1, increase CV mortality in group 2 (HR: 1.34; 95% CI: 1.01–1.77; p=0.04) and in group 3 (HR: 2.29; 95% CI: 1.79–2.93; p<0.0001). • Compared with group 1, total MI was in group 2 (HR: 1.20; 95% CI: 0.90–1.60; p=0.21) but was increased in group 3 (HR: 2.39; 95% CI: 1.87-3.05; p<0.0001). • Compared with group 1, no significant difference with group 2 but an increase in nonfatal MI in group 3 (adjusted HR: 2.45; 95% CI: 1.02–3.71; p<0.0001). • Compared with group 1, an increase in total stroke in group 2 (HR: 1.89; 95% CI: 1.26–2.82; p=0.002) and in group 3 (HR: 2.93; 95% CI: 2.01–4.27; p<0.001). • Compared with group 1, an increase in nonfatal stroke in group 2 (HR: 1.70; 95% CI: 1.06–2.72; p=0.03) and in group 3 (HR: 2.78; 95% CI: 1.80–4.30; p<0.001). • HF and revascularization not significant Study limitations and adverse events: The present study was not designed to test whether pts ≥60 y with CAD and a SBP of 140–149 mm Hg would benefit

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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Law MR, et al., 2009 (18) 19454737

Study type: Metaanalysis of use of BP-lowering drugs in prevention of CVD from 147 randomized trials Size: Of 147 randomized trials of 464,000 pts, 37 trials of BBs in CAD included 38,892 pts, and 37 trials of other antihypertensive drugs in CAD included 85,395 pts

Inclusion criteria: The database search used Medline (1966 to Dec. 2007) to identify randomized trials of BPlowering drugs in which CAD events or strokes were recorded. The search also included the Cochrane Collaboration and Web of Science databases and the citations in trials and previous meta-analyses and review articles.

N/A

Exclusion criteria: Trials were excluded if there were <5 CAD events and strokes or if treatment duration was <6 mo.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: CAD events; stroke Results: In 37 trials of pts with a history of CAD, BBs reduced CAD events 29% (95% CI: 22%, 34%). In 27 trials in which BBs were used after acute MI, BBs reduced CAD events 31% (95% CI: 24%–38%), and in 11 trials in which BBs were used after long-term CAD, BBs insignificantly reduced CAD events 13%. In 7 trials, BBs reduced stroke 17% (95% CI: 1%– 30%). CAD events were reduced 14% (95% CI: 2%–25%) in 11 trials of thiazide diuretics, 17% (95% CI: 11%–22%) in 21 trials of ACEIs, insignificantly 14% in 4 trials of angiotensin receptor blockers, and 15% (95% CI: 8%–22%) in 22 trials of CCBs. Stroke was reduced 38% (95% CI: 28%–47%) in 10 trials of thiazide diuretics, 22% (95% CI: 8%–34%) in 13 trials of ACEIs, and 34%

Summary: The optimal SBP in pts ≥60 y with CAD and SBP >150 mm Hg treated with antihypertensive therapy was <140 mm Hg • With the exception of the extra protective effect of BBs given shortly after a MI and the minor additional effect of CCBs in preventing stroke, all the classes of BP-lowering drugs have a similar effect in reducing CAD events and stroke for a given reduction in BP.

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HOPE Yusuf S, et al., 2000 (136) 10639539

Aim: To investigate effect of ACE-I (Ramipril 10 mg) on CV events in high risk pts. over 5y with a mean entry BP of 139/79 mm Hg in both groups

Inclusion criteria: Pts ≥55 y with history of CAD, stroke, PVD or DM with either HTN, elevated total cholesterol, low LDL cholesterol, smoking, or micro albuminuria.

Study type: RCT, 2×2 factorial design

Exclusion criteria: HF, <0.40 EF, on ACE-I or Vitamin E, uncontrolled HTN /overt nephropathy, Had MI or stroke <4 wk Inclusion criteria: Pts (21–80 y) surviving 3 d after MI, EF≤40%.

Size: 9,297 SAVE Pfeffer M., et al., 1992 (137) 1386652

Aim: To assess if captopril decrease morbidity and mortality in pts with LV dysfunction after MI. Study type: RCT Size: 2,231

EUROPA Fox KM, et al., 2003 (138) 13678872

Aim: To investigate efficacy of perindopril in CV events in pts with stable CAD. Study type: RCT

Exclusion criteria: Pts not randomized within 16 d after MI, contra. to ACE-I use, Serum Cr. >2.5 mg/dL, severe comorbidities, unstable infarction, need for revascularization Inclusion criteria: Pts ≥18 y (women) with CAD >mo before screening, revascularization >6 mo before screening, ≥70% narrowing of major

Intervention: Ramipril (10 mg) (4,645) Comparator: Placebo (4,652)

Intervention: Captopril (titrated doses) (115) Comparator: Placebo (1116)

Intervention: Perindopril (6,110) Comparator: Placebo (6,108)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: Composite of MI, stroke, or mortality from CV causes. Results: Endpoint reduction Ramipril group vs. Placebo (14% vs. 17.8%; RR: 0.78; CI: 0.70–0.86; p<0.001)

1° endpoint and results: All-cause mortality: 20% vs. 25%, RR: 19%; 95% CI: 3%–32%; p=0.019 Other endpoints: Fatal and nonfatal major CV events were reduced in the captopril group.

1° endpoint: Composite of CV death, nonfatal MI, cardiac arrest with successful CPR Results: RR 20%; 95% CI: 9%–29; p=0.0003

• Death from cardiac causes reduced (6.1% vs. 8.1%; p<0.001) • Death from MI reduced (9.9% vs. 12.3%; p<0.001) • Death from any cause (10.4 % vs. 12.2%; p=0.005)

• Captopril vs. Placebo group BP at 1 y (125±18 / 77±10 mm Hg for placebo vs. 119±18/74±10 mm Hg for captopril; p<0.001) • Dizziness, alteration in taste, cough and diarrhea were reported significantly more in the captopril group • Ventricular size on Echo studies was independent predictor of adverse CV outcomes

• Perindopril resulted reduction in all these outcomes: composite of total mortality, nonfatal MI, hospital admission for UA, and cardiac arrest with successful CPR; CV mortality and nonfatal MI, the individual components these outcomes and revascularization, stroke, and admission for HF

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2017 Hypertension Guideline Data Supplements Size: 12,218 pts

MERIT-HF Goldstein S, et al., 1999 (139) 10526701

Aim: To investigate if metoprolol (CR/XL) once daily with std. treatment lowers mortality in pts with HFrEF Study type: RCT Size: 3,991 pts

coronary artery. Men with history of chest pain, positive ECG, echo or nuclear test Exclusion criteria: HF, planned revascularization, <110 mm Hg SBP, uncontrolled HTN, >100 mm Hg DBP, 150 µmol/L, serum K>5.5 mmol/L Inclusion criteria: Pts 40–80 y with NYHA class II-IV HF for 3 mo before randomization and on standard treatment 2 wk before entry, Stable clinical condition during 2 wk run-in phase, EF ≤0.40.

Intervention: Metoprolol CR/XL (1,990)

1° endpoint: All-cause mortality in the intent to treat

Comparator: Placebo (2,001)

Results: 145 vs. 217 deaths [11.0 %], RR: 0.66 (95% CI: 0.53–0.81; p=0.00009) or adjusted for interim analyses p=0.0062.

Exclusion criteria: Acute MI, UA <28 d of entry, contra to beta blockade <6 mo, HF due to systemic disease/alcohol abuse, heart transplant candidate, ICD, planned revascularization in past 4 mo, decompensated heart, SBP <100 mm Hg, CCB treatment, amiodarone use within 6 mo

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• Fewer sudden deaths in the metoprolol group (p=0.0002) • Lesser deaths from HFrEF in the metoprolol group (p=0.002) • Metoprolol improved survival and was well tolerated

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2017 Hypertension Guideline Data Supplements Packer M, et al., 2001 (140) 11386263

Aim: To assess survival in severe chronic HF pts by the use of carvedilol. Study type: RCT Size: 2,289 pts

CAPRICORN Dargie HJ, et al., 2001 (141) 11356434

Aim: To investigate outcomes after carvedilol after MI in pts with LV dysfunction. Study type: RCT Size: 1,959 pts

Inclusion criteria: HF pts with dyspnea/exertion for 2 mo at least and left EF<25% despite treatment clinically euvolemic; allowed on digitalis, nitrates, hydralazine, spironolactone, or amiodarone. Hospitalized pts with no acute illness. Exclusion criteria: HF due to uncorrected prim. valvular disease or reversible cardiomyopathy cardiac transplant pts., coronary revasc. <2 mo, acute MI or stroke, ventricular tachycardia, on alpha blocker or CCB or on antiarrythmics class I <4 wk, SBP <85 mm Hg, serum Cr >2.8 mg/dL, change in body weight >1.5 kg during screening. Inclusion criteria: Pts ≥18 y, MI within 3–21 d of entry, LVEF≤40%, concurrent ACEI stable dose for at least 24 h, HF pts treated and controlled with ACEI and diuretics but not inotropes.

Intervention: Carvedilol (1,156) Comparator: Placebo (1,133)

1° endpoint: ● Death from any cause 130 vs. 190 deaths RR: 35%; 95% CI: 19%–48%; p=0.00013 ● Combined risk of death/hospitalization (24% lower risk in the carvedilol; (95% CI: 13%–33%; p<0.001

• Study stopped early (1.3-y follow-up) due to benefit on survival • Long-term treatment is very valuable. • Not all the pts with severe HF were allowed in the study

Safety endpoint: Lesser pts in carvedilol group required permanent discontinuation because of adverse events or for reasons other than death (p=0.02)

Intervention: Carvedilol (975) Comparator: Placebo (984)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: All-cause mortality or hospital admissions for CV issues Results: 12% vs. 15%; RR: 23%; 95% CI: 0.60– 0.98; p=0.03 No difference between groups for death or CV hospital admissions

• CV mortality, nonfatal MI reduced in the carvedilol group • No difference between groups SCD and admission due to HF

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MERIT-HF HTN Herlitz J, et al., 2002 (142) 11862577

Aim: To assess metoprolol CR/XL influence on mortality and hospitalizations in HF and HTN pts. Study type: RCT

CIBIS-II 1999 (143) 10023943

Size: 1,747 pts Aim: To determine efficacy of bisoprolol in reducing mortality in chronic HF. Study type: RCT Size: 2,647 pts

Elkayam U, et al., 1990 (144) 2242521

Aim: To assess comparative efficacy and safety of nifedipine and ISDN alone and the combination for treating for chronic CHF.

Exclusion criteria: SBP<90 mm Hg, uncontrolled HTN, bradycardia, insulindependent DM, BBs not for HF, Beta-2 agonists and steroids Inclusion criteria: Same as above MERITHF, 1999 study (HTN subgroup) Exclusion criteria: Same as above MERITHF Inclusion criteria: 18– 80 y, LVEF≤35%, dyspnea, orthopnea, fatigue, NYHA class IIIIV Exclusion criteria: Uncontrolled HTN, MI, UA <3 mo revascularization. treatment, heart transplant, AV block <1 degree, SBP <100 mm Hg, renal failure, reversible obstructive lung disease Inclusion criteria: 18– 75 y HF pts, NYHA class II and III, LVEF<40%, clinically stable, maintenance dose of Digitalis and diuretics.

Intervention: Metoprolol CR/XL (871) Comparator: Placebo (876)

1° endpoint: Total mortality Results: RR: 0.61; 95% Cl: 0.44–0.84; p=0.0022

Intervention: Bisoprolol (1,327)

1° endpoint: All-cause mortality

Comparator: Placebo (1,320)

Results: 11.8% vs. 17.3% deaths with a RR: 0.66; 95% CI: 0.54–0.81; p<0.0001

Intervention: Nifedipine (21), ISDN (20), Nifedipine+ISDN (23)

Endpoints and Results: HF-worsening: 9 in Nifedipine group vs. 3 in ISDN group (p<0.09); and 21 in nifedipine-ISDN group (p<0.001 vs. nifedipine, p<0.0001 vs. ISDN)

Comparator: Placebo

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• Total mortality reduction was driven by reduction in the SCD and death from worsening HF • 12.5% pts had earlier discontinuation due to any cause. Lesser no. of pts in the metoprolol group (n=21) discontinued due to worsening HF The mean reduction in BP (adjusted) was 1.7 mm Hg in the metoprolol group vs. 4.8 mm Hg in placebo group (p=0.0001) • The trial stopped early due to benefit. Bisoprolol group had significantly fewer SCDs. • Mean age was 61 y so more data on elderly pts is needed

• In clinical deterioration nifedipine pts (8) vs. rest of the pts (No difference in LVEF or VO2 max) • Although all the 3 drug regimens improved exercise capacity, nifedipine treatment alone or in combination resulted in clinical deterioration and worsening of CHF

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Study type: RCT with a crossover design Size: 28 pts

The Multicenter Dilitiazem Postinfarction Research Group 1988 (145) 2899840

Aim: To assess dilitiazem effect on recurrent infarction and death after acute MI Study type: RCT Size: 2,466 pts

MDPIT Goldstein RE, et al., 1991 (146) 1984898

Aim: To determine if dilitiazem increases late onset CHF in post-MI pts with early decline in EF. Study type: RCT

Exclusion criteria: Pregnancy, nursing, history of MI <1 mo before entry, valvular disease, Angina, significant pulmonary, hepatic, renal and hematologic disease, unable to walk on the treadmill, noncompliance Inclusion criteria: 25–75 y admitted to CCU, MI with enzyme confirmation. Exclusion criteria: • Cardiogenic shock, • Symptomatic hypotension, • PH with right HF, • 2nd/3rd degree heart block, • HR <50 bpm, • Contraceptives, • WPW syndrome, • CCBs, • Severe comorbidities or • Cardiac surgery Inclusion criteria: Same as above Exclusion criteria: Same as above

Clinical deterioration discontinuation: Nifedipine 29% vs. ISDN group 5% (p<0.05) DBP: Nifedipine alone or combination with ISDN (reduction, p<0.05) Intervention: Dilitiazem 240 mg (1,234) Comparator: Placebo (1,232)

Intervention: Dilitiazem 240 mg (1,234) Comparator: Placebo (1,232)

Size: 2,466 pts © 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoints and results: • Total mortality: identical in both groups • Cardiac death and nonfatal MI: 11% fewer in dilitiazem but difference was NS

• No combined benefit from dilitiazem on mortality or cardiac events

1° endpoint and results: Same as above

• Life table analysis confirmed increased frequency of late CHF in pts taking dilitiazem (p=0.0017) • Dilitiazem related CHF exclusively associated with systolic LVD with or without BBs

Follow-up Results: Pts with BL EF<0.40, late CHF in Dilitizam group (21%) vs. Placebo (12%) [p=0.004].

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2017 Hypertension Guideline Data Supplements Freemantle N, et al., 1999 (147) 10381708

de Peuter OR, et al., 2009 (148) 19841485

Aim: To evaluate BBs effectiveness for short-term treatment and long-term 2° prevention in acute MI.

Inclusion criteria: RCTs with treatment lasting >1 d and with follow-ups on clinical effectiveness in pts with MI

Study type: Metaanalysis of RCTs

Exclusion criteria: Cross-over RCTs

Size: 54,234 pts (82 RCTs) Aim: To determine influence of beta-2 blockade in addition to beta-1 blockade for preventing vascular events in pts with ACS or HF. Study type: Metaanalysis of RCTs Size: 34,360 pts (33 RCTs)

Leon MB, et al., 1981 (149) 7246435

Aim: To evaluate effectiveness of verapamil as a single agent and in combination with propranolol in pts with stable AP.

Inclusion criteria: ● RCTs comparing Beta-1 blockers vs. BBs 1 + 2 directly (5) ● RCTs comparing Beta-1 blockers vs. Beta 1 + 2 blockers with a control group (28)

Intervention: BBs (mostly propranolol, timolol, metoprolol) Comparator: Controls (placebo/other treatment)

Results: • Long-term trials RR reduction: 23% (95% CI: 15%–31%) • Short-term trials RR reduction: 4%; 95% CI: 8%–5%

Intervention: Beta-1 blockers

1° endpoint: Total mortality, vascular events.

Comparator: BBs 1+2 with or without control group

Results: ACS Population: 1 study with different BBs underpowered to detect difference. Beta-1 vs. Placebo NS reduced mortality or vascular events

Exclusion criteria: Studies not prespecifying total mortality and vascular event as outcomes <3 mo followup, duplicate data, sub studies.

Inclusion criteria: Symptomatic angina pectoris pts, 1) not sufficiently controlled on BBs and nitrates and noncardiac

1° endpoint: All-cause mortality

Intervention: Propranolol, verapamil, Combination of propranolol and verapamil

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

HF population: Beta 1 + 2 blockers vs. Beta 1 blockers decreased mortality RR: 0.86; 95% CI: 0.78–0.94 Beta 1 and Beta 1+2 decreased total mortality. Only Beta 1+2 blockers reduced vascular events. Results: Large dose verapamil significantly lowered BP. Propranolol and verapamil combined (at best dose) further lowered BP, improved

• Meta-regression in long-term trials indicated a near significant trend for decreased benefit in drugs with ISA. • NS in withdrawal between BBs of different cardio selectivity.

• Supplementary beta 2 blockade may be more beneficial. • Indirect comparisons and heterogeneity among studies

• HR and pressure-rate product lowered significantly on combination therapy • PR interval increased on combination treatment Regarding antianginal properties, verapamil seemed to be more effective than propranolol.

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Study type: RCT (triple crossover) Size: 11 pts

Staessen JA, et al., 1997 (150) 9297994

Aim: To determine if active treatment reduces complications from isolated systolic HTN in the elderly. Study type: RCT Size: 4,965 pts

Wright JT, et al., 2015 (114) 26551272

Aim: To compare in pts with a SBP of 130–180 mm Hg and an increased CV risk but without DM the effect of a target SBP of <140 mm Hg vs. a target SBP of <120 mm Hg on the 1° composite outcome of MI, other ACSs,

effects from propranolol hindering treatment 2) who could stay 4 wk in hospital Exclusion criteria: LVD with CHF or LVEF<30% at rest and <25% for exercise, HR<50 b/min, ≥first degree heart block Inclusion criteria: Pts ≥60 y, sitting SPB 160– 219 mm Hg, sitting DBP 95 mm Hg, and standing SBP ≥140 mm Hg. Exclusion criteria: Systolic HTN 2nd to a disorder, retinal hemorrhages/papillede ma, CHF, aneurysms, serum Cr ≥180 µmol/L, history of nosebleed, stroke, MI <1 y, dementia, substance abuse, severe comorbidities Inclusion criteria: 9,361 pts, mean 67.9 y (28.2% ≥75 y; 35.6% women; 57.7% nonHispanic white; 31.5% African American; 10.5% Hispanic) with a SBP of 130–180 mm Hg and an increased CV risk but without DM, history of stroke, symptomatic HF within

Comparator: Placebo

exercise time by 4.7 ± 0.7 min (p<0.001)

Intervention: Active treatment (2,398)

1° endpoint: Fatal and nonfatal strokes combined.

Comparator: Placebo (2,297)

Intervention: 4,678 pts were randomized to intensive BP treatment Comparator: 4,683 pts were randomized to standard BP treatment

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Results: 13.7 vs. 7.9 endpoints/ 1,000 pts-y (42% reduction; p=0.003)

1° endpoint: • At 1 y, the mean SBP was 121.4 mm Hg with intensive treatment (mean number of antihypertensive drugs was 2.8) and 136.2 mm Hg with standard treatment (mean number of antihypertensive drugs was 1.8)

• All fatal and nonfatal cardiac endpoints (with sudden death) decreased in the active treatment group (p=0.03) • Cardiac mortality was lower in active treatment (27%; p=0.07). All-cause mortality was not different. • Nitrendipine used for active arm.

• At 3.26-y median follow-up, compared with standard BP treatment, intensive BP treatment reduced allcause mortality 27% (p=0.003), HF 38% (p=0.002), CV mortality 43% (p=0.005), and the 1° composite outcome or death 22% (p<0.001) • Intensive BP treatment reduced the 1° composite endpoint 33% (14% to 49%) in pts aged 75 y and older and 20% (0% to 36%) in pts 50–74 y • Serious adverse events were similar in both treatment groups. However, intensive BP treatment caused more hypotension (2.4% vs. 1.4%; p=0.001), more syncope (2.3% vs. 1.7%; p=0.05), more 108

2017 Hypertension Guideline Data Supplements stroke, HF, or CV death

ALLHAT Collaborative Research Group, 2003 12925554

Aim: In a follow-up analysis, to compare diuretic vs. alphablocker as first step treatment of hypertension.

Zanchetti A, et al., 2006 17053536

Aim: To provide additional analyses of the primary endpoint in the VALUE trial, including sex, age, race, geographic region, smoking status, type 2 diabetes, total cholesterol, left ventricular hypertrophy, proteinuria, serum creatinine, history of coronary heart disease, stroke or transient ischemic attack and history of peripheral artery disease.

past 6 mo, LVEF <35%, and eGFR <20 mL/min/1.73 mm2; CVD was present in 20.1%, and the Framingham 10-y CVD risk score was ≥15% in 61.3% of pts Inclusion criteria: Men and women ≥ 55 y with BP ≥140/90 mm Hg or on medications for hypertension with at least one additional risk factor for coronary heart disease. Inclusion criteria: The 15,245 patients participating in VALUE were divided into subgroups according to baseline characteristics.

Intervention: 15,255 patients were randomized to chlorthalidone and 9,061 to doxazosin and followed for 3.2 y.

Statistical analysis: Subgroup interaction analyses were conducted by the Cox proportion hazard model. Within each subgroup, treatment effects were assessed by hazard ratios and 95% CIs.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

• At 3.26-y median followup, the 1° composite outcome was reduced 25% (p<0.001) by intensive BP treatment

electrolyte abnormality (3.1% vs. 2.3%; p=0.02), and more acute kidney injury or acute renal failure (4.1% vs. 2.5%; p<0.001). The incidence of bradycardia, injurious falls, and orthostatic hypotension with dizziness was similar in both treatment groups

Primary endpoint: Combined fatal coronary heart disease or non-fatal MI, analyzed by intention to treat.

• There was no difference in primary outcome between the arms (RR: 1.02; 95% CI: 0.94–1.13). • However, the doxazosin arm compared with the chlorthalidone arm had a higher risk for stroke (RR: 1.26; 95% CI: 1.10–1.46) and combined cardiovascular disease (RR: 1.20; 95% CI: 1.13– 1.27). • The findings confirmed the superiority of diureticbased over alpha blocker based antihypertensive treatment in the prevention of cardiovascular disease. • For cardiac morbidity and mortality, the only significant subgroup by treatment interaction was of sex (p=0.016) with HR indicating a relative excess of cardiac events in women but not in men, but SBP differences in favor of amlodipine were greater in women. • In the VALUE cohort, in no subgroup of patients were there differences in the incidence of the composite cardiac endpoint with valsartan and amlodipine treatment despite greater BP reduction in the amlodipine group.

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2017 Hypertension Guideline Data Supplements Leenen FHH, et al., 2006 16864749

Aim: To compare the long-term relative safety and outcomes of ACE inhibitor- and CCB-based regimens in older hypertensive individuals in ALLHAT.

Inclusion criteria: men and women age ≥55 y with untreated (BP 140– 180/90–110 mm Hg) or treated hypertension (BP ≤160/100 mm Hg on ≤2 antihypertensive drugs) with ≥ 1 additional risk factor for coronary heart disease.

Intervention: Patients (were randomized to amlodipine (9,048) or Lisinopril (9,054).

Primary outcome: Combined fatal coronary heart disease or non-fatal MI, analyzed by intention to treat. Follow-up: 4.9 y

• Risk of coronary heart disease was similar between amlodipine and Lisinopril • For stroke, combined cardiovascular disease, gastrointestinal bleeding and angioedema, risks are higher with Lisinopril compared to amlodipine. • For heart failure, risks are higher with amlodipine compared to Lisinopril.

Data Supplement 31. Meta-analyses of ischemic heart disease (Section 9.1) Study Acronym; Author; Year Published Bundy JD, et al., 2017 28564682

Study Type/Design; Study Size Study type: Network metaanalysis Size: 144,220 patients in 42 RCTs.

Patient Population

Primary Endpoint and Results (include P value; OR or RR; and CI)

Inclusion criteria: • Random allocation into an antihypertensive medication, control or treatment target • Allocation to antihypertensive Antihypertensive treatment was independent of other treatment regimens • ≥100 patients in each treatment group • Trial duration ≥ 6 mo • One or more events for each treatment group reported • Minimum 5 mm Hg difference in SBP level between the 2 treatment groups • Outcomes included major CVD, stroke, CHD, CVD mortality or allcause mortality

• There were linear associations between mean achieved SBP and risk of cardiovascular disease and mortality, with the lowest risk at 120 to 124 mm Hg. Randomized groups with a mean achieved SBP of 120 to 124 mm Hg had a hazard ratio (HR) for major cardiovascular disease of 0.71 (95% CI: 0.60–0.83) compared with randomized groups with a mean achieved SBP of 130 to 134 mm Hg, an HR of 0.58 (95% CI: 0.48–0.72) compared with those with a mean achieved SBP of 140 to 144 mm Hg, an HR of 0.46 (95% CI: 0.34–0.63) compared with those with a mean achieved SBP of 150 to 154 mm Hg, and an HR of 0.36 (95% CI: 0.26–0.51) compared with those with a mean achieved SBP of 160 mm Hg or more.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Summary/Conclusion Comment(s) • This study suggests that reducing SBP to levels below currently recommended targets significantly reduces the risk of cardiovascular disease and allcause mortality and strongly support more intensive control of SBP among adults with hypertension.

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Data Supplement 32. Nonrandomized Trials, Observational Studies, and/or Registries of Ischemic Heart Disease (Section 9.1) Study Acronym; Author; Year Published PROVE IT-TIMI 22 Bangalore S, et al., 2010 (151) 21060068

Study Type/Design; Study Size (N) Study type: Nonrandomized trial of optimal BP after ACS Size: 4,162 pts

Patient Population Inclusion criteria: Pts with acute MI or high-risk UA within 10 d randomized to pravastatin or atorvastatin and to gatifloxacin or placebo treated with standard medical and interventional treatment for ACS Exclusion criteria: N/A

Law MR, et al., 2009 (18) 19454737

Study type: Metaanalysis of use of BP-lowering drugs in prevention of CVD from 147 randomized trials Size: Of 147 randomized trials of 464,000 pts, 37 trials of BBs in CAD included 38,892 pts, and 37 trials of other antihypertensive drugs in CAD included 85,395 pts

Inclusion criteria: The database search used Medline (1966 to Dec. 2007) to identify randomized trials of BP-lowering drugs in which CAD events or strokes were recorded. The search also included the Cochrane Collaboration and Web of Science databases and the citations in trials and previous meta-analyses and review articles. Exclusion criteria: Trials were excluded if there were <5 CAD events and strokes or if treatment duration was <6 mo.

Primary Endpoint and Results (include P value; OR or RR; and 95% CI) 1° endpoint: Composite of all-cause death, MI, UA requiring rehospitalization, revascularization after 30 d, and stroke with a mean follow-up of 24 mo Results: The relationship between SBP and DBP followed a J- or U-shaped curve association with the 1° outcome with increased events rates at both low and high BP values. A nonlinear Cox proportional hazards model showed a nadir of 136/85 mm Hg (range 130–140/80–90 mm Hg) at which the incidence of 1° outcome was lowest. There was a relatively flat curve for SBP of 110–130 mm Hg and for DBP of 70–90 mm Hg, suggesting a BP <110/70 mm Hg may be dangerous. 1° endpoint: CAD events; stroke Results: In 37 trials of pts with a history of CAD, BBs reduced CAD events 29% (95% CI: 22%, 34%). In 27 trials in which BBs were used after acute MI, BBs reduced CAD events 31% (95% CI: 24%–38%), and in 11 trials in which BBs were used after long-term CAD, BBs insignificantly reduced CAD events 13%. In 7 trials, BBs reduced stroke 17% (95% CI: 1%–30%). CAD events were reduced 14% (95% CI: 2%–25%) in 11 trials of thiazide diuretics, 17% (95% CI: 11%– 22%) in 21 trials of ACEIs, insignificantly 14% in 4 trials of angiotensin receptor blockers, and 15% (95% CI: 8%–22%) in 22 trials of CCBs. Stroke was reduced 38% (95% CI: 28%–47%) in 10 trials of thiazide diuretics, 22% (95% CI: 8%–34%) in 13 trials of ACEIs, and 34% (95% CI: 25%–42%) in 9 trials of CCBs.

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Summary/Conclusion Comment(s) • After an ACS, a J- or U-shaped association existed between BP and the incidence of new CV events. The lowest incidence of CV events occurred with a BP of 130–140/80–90 mm Hg and a relatively flat curve for SBP of 110–130 mm Hg and of DBP of 70–90 mm Hg, suggesting a BP <110/70 mm Hg may be dangerous.

• With the exception of the extra protective effect of BBs given shortly after a MI and the minor additional effect of CCBs in preventing stroke, all the classes of BP-lowering drugs have a similar effect in reducing CAD events and stroke for a given reduction in BP.

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Data Supplement 33. RCTs Comparing Heart Failure (Section 9.2) Study Acronym (if applicable) Author Year Published LV J, et al., 2013 (127) 23798459

Study Type/Design; Study Size (N) Study type: MA of RTC that randomly assigned individuals to different target BP levels

Patient Population •15 trials

Size: 37,348 pts

Xie X, et al., 2015 (21) 26559744

Study type: MA of RTC that randomly assigned individuals to different target BP levels

• 19 trials

Size: 44,989 pts

Thomopolous C, et al., 2016 (54) 26848994

Study type: Metaanalysis of RTCs of more vs. less intense BP control

• 16 trials (52,235 pts) compared more vs. less intense treatment 34 (138,127 pts) active vs. placebo

Primary Endpoint and Results (include P value; OR or RR; and 95% CI)

Summary/Conclusion Comment(s)

7.5/4.5 mm Hg BP difference. Intensive BP lowering achieved. RR for • Major CV events: 11%; 95% CI: 1%–21%) • MI: 13%; 95% CI: 0%–25% • Stroke: 24%; 95% CI: 8%–37% • ESRD: 11%; 95% CI: 3%–18% • Albuminuria: 10%; 95% CI: 4%–16% • Retinopathy 19%; 95% CI: 0%–34% p=0.051 Achieved BP 133/76 mm Hg (intensive) 140/81 (less intense) • Major CV events: 14%; 95% CI: 4%–22% • MI: 13%; 95% CI: 0%–24% • Stroke: 22%; 95% CI: 10%–32% • Albuminuria: 10%; 95% CI: 3%–16% • Retinopathy progression: 19%; 95% CI: 0%–34%. • More intensive had no effects on HF: 15%; 95% CI: -11%–34% • CV death: 9%; 95% CI: -11%–26% • Total mortality: 9%; 95% CI: -3%–19% • ESKD: 10%; 95% CI: -6%–23%

• More intensive strategy for BP control reduced cardio-renal endpoint

More intense BP • Stroke RR: 0.71; 95% CI: 0.60–0.84) • CHD RR: 0.80; 95% CI: 0.68–0.95) • Major CV events RR: 0.75; 95% CI: 0.68–0.85 • CV mortality RR: 0.79; 95% CI: 0.63–0.97

• Intensive BP reduction improves CV outcomes compared to less intense Achieved BP <130/80 may be associated with CV benefit.

• More intensive approach reduced major CV events (stroke and MI) except heat failure, CVD, ESRD, and total mortality.

Stratification of SBP cutoffs (150,140 and 130 mm Hg) showed that a SBP/DBP difference of 10/5 mm Hg across each cutoff reduced risk of all outcomes

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

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Data Supplement 34. RCTs Comparing HFrEF (Section 9.2.1) Study Acronym; Author; Year Published Herlitz J, et al., 2002 (142) 11862577

Aim of Study; Study Type; Study Size (N)

Patient Population

Aim: To see effect of metoprolol vs. placebo on mortality and hospitalizations among pts with history of HTN and HF with reduced LVEF

Inclusion criteria: NYHA class II–IV HF with LVEF ≤40% within 3 mo of enrollment; supine resting HR ≥68 bpm; stable clinical condition

Study type: RCT Size: 1,747 pts

Packer M, et al., 2001 (140) 11386263

Aim: To assess survival in severe

Exclusion criteria: Acute MI or UA within 28 d of randomization; indication or contraindication for treatment with BBs or drugs with beta-blocking properties; poor compliance; CABG surgery or PTCA in past 4 mo

Inclusion criteria: HF pts with dyspnea/exertion for 2 mo at least and left EF<25% despite

Study Intervention (# patients) / Study Comparator (# patients) Intervention: • Administration of metoprolol • 871 pts randomized to metoprolol Comparator: • Administration of placebo • 876 pts randomized to placebo

Intervention: Carvedilol (1,156)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: At 1-y follow-up, compared with placebo, metoprolol reduced all-cause mortality 39% (95% CI: 16%– 56%; p=0.002) and all-cause mortality or all-cause hospitalization 24% (95% CI: 11%–35%; p=0.0007) 1° Safety endpoint: Early permanent cessation of drug was 12.5% for metoprolol and 15.9% for placebo (p=0.048); 21 pts on metoprolol and 35 pts on placebo had early cessation because of worsening

1° endpoint: ● Death from any cause 130 vs. 190 deaths (RR: 35%;

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events; Summary Relevant 2° endpoint: At 1-y followup, compared with placebo, metoprolol reduced CV death 41% (95% CI: 17%–57%; p=0.002), death from HF: 51% (95% CI: 1%–75%; p=0.042), sudden cardiac death 49% (95% CI: 21%–67%; p=0.002), allcause mortality or HF hospitalization 28% (95% CI: 11%–42%; p=0.002), and cardiac death or nonfatal acute MI 44% (95% CI: 23%–60%; p=0.0003) Study limitations and adverse events: Early permanent cessation of drug was 12.5% for metoprolol and 15.9% for placebo (p=0.048); 21 pts on M and 35 pts on placebo had early cessation because of worsening HF; all-cause withdrawals were 22% less with metoprolol; (p=0.048); adverse events were 28% less with metoprolol (p=0.026); worsening HF was 41% less with metoprolol (p=0.056) Summary: In an RCT of pts with HF with reduced EF and a history of HTN, compared with placebo, metoprolol succinate reduced allcause mortality and all-cause mortality or all-cause hospitalization • Study stopped early (1.3 y followup) due to benefit on survival 113

2017 Hypertension Guideline Data Supplements chronic HF pts by the use of carvedilol. Study type: RCT Size: 2,289 pts

CAPRICORN Dargie HJ, et al., 2001 (141) 11356434

Aim: To investigate outcomes after carvedilol after MI in pts with LV dysfunction. Study type: RCT Size: 1,959 pts

Elkayam U, et al., 1990 (144) 2242521

Aim: To assess comparative efficacy and safety of nifedipine and ISDN alone and the combination for treating for chronic CHF.

treatment clinically euvolemic; allowed on digitalis, nitrates, hydralazine, spironolactone, or amiodarone. Hospitalized pts with no acute illness. Exclusion criteria: HF due to uncorrected prim. valvular disease or reversible cardiomyopathy, cardiac transplant pts., coronary revasc. <2 mo, acute MI or stroke, ventricular tachycardia, on alpha blocker or CCB or on antiarrythmics class I <4 wk, SBP <85 mm Hg, serum Cr >2.8 mg/dL, change in body weight >1.5 kg during screening. Inclusion criteria: Pts ≥18 y, MI within 3–21 d of entry, LVEF ≤40%, concurrent ACEI stable dose for at least 24 h, HF pts treated and controlled with ACEI and diuretics but not inotropes. Exclusion criteria: SBP <90 mm Hg, uncontrolled HTN, bradycardia, insulin-dependent DM, BBs not for HF, Beta-2 agonists, and steroids Inclusion criteria: 18–75 y old HF pts, NYHA class II and III, LVEF<40%, clinically stable, maintenance dose of Digitalis and diuretics. Exclusion criteria: Pregnancy, nursing, history of MI <1 mo before entry, valvular disease, angina, significant pulmonary,

Comparator: Placebo (1,133)

95% CI: 19%–48%; p=0.00013) ● Combined risk of death/hospitalization (24% lower risk in the carvedilol; 95% CI: 13%–33%; p<0.001)

• Long-term treatment is very valuable. • Not all the pts with severe HF were allowed in the study

Safety endpoint: Lesser pts in carvedilol group required permanent discontinuation because of adverse events or for reasons other than death (p=0.02)

Intervention: Carvedilol (975) Comparator: Placebo (984)

Intervention: Nifedipine (21), ISDN (20), Nifedipine+ISDN (23) Comparator: Placebo

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: All-cause mortality or hospital admissions for CV issues Results: 12% vs. 15%; RR: 23% (95% CI: 0.60–0.98; p=0.03) No difference between groups for death or CV hospital admissions Endpoints and Results: • HF-worsening: 9 in Nifedipine group vs. 3 in ISDN group (p<0.09); and 21 in nifedipine-ISDN group (p<0.001 vs. nifedipine, p<0.0001 vs. ISDN) • Clinical deterioration discontinuation:

• CV mortality, nonfatal MI reduced in the carvedilol group • No difference between groups sudden death and admission due to HF

• In clinical deterioration nifedipine pts (8) vs. rest of the pts (No difference in LVEF or VO2 max.) • Although all the 3 drug regimens improved exercise capacity, nifedipine treatment alone or in combination resulted in clinical deterioration and worsening of CHF

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2017 Hypertension Guideline Data Supplements Study type: Crossover RCT Size: 28 pts MDPIT Goldstein RE, et al., 1991 (146) 1984898

hepatic, renal and hematologic disease., unable to walk on the treadmill, noncompliance

Aim: To determine if dilitiazem increases late onset CHF in post-MI pts with early decline in EF.

Inclusion criteria: 18–75 y HF pts, NYHA class II and III, LVEF <40%, clinically stable, maintenance dose of digitalis and diuretics.

Study type: RCT

Exclusion criteria: Pregnancy, nursing, history of MI <1 mo before entry, valvular disease, Angina, significant pulmonary, hepatic, renal and hematologic disease., unable to walk on the treadmill, noncompliance

Size: 2,466 pts

Intervention: Dilitiazem 240 mg (1,234) Comparator: Placebo (1,232)

Cohn JN, et al., 2001 (152) 11759645

Aim: To determine the effect of valsartan vs. placebo on mortality plus morbidity in pts with HFrEF

Inclusion criteria: 5,010 pts, mean age 63 y, with NYHA class II-IV HFrEF

Intervention/Compar ator: 5,010 pts on standard therapy for HF were randomized to valsartan or placebo

SOLVD Investigators, 1991 (153) 2057034

Aim: To determine the effect of enalapril vs. placebo on mortality and on mortality plus

Inclusion criteria: 2,569 pts, mean age 61 y, with HFrEF (90% with NYHA class II and III HF)

Intervention/Compar ator: 2,569 pts on standard therapy for

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Nifedipine 29% vs. ISDN group 5% (p<0.05) • DBP: Nifedipine alone or combination with ISDN (reduction, p<0.05) 1° endpoint and results: • HF-worsening: 9 in Nifedipine group vs. 3 in ISDN group (p<0.09); and 21 in nifedipine-ISDN group (p<0.001 vs. nifedipine, p<0.0001 vs. ISDN) • Clinical deterioration discontinuation: Nifedipine 29% vs. ISDN group 5% (p<0.05) • DBP: Nifedipine alone or combination with ISDN (reduction, p<0.05) Follow-up Results: Pts with BL EF<0.40, late CHF in Dilitizam group (21%) vs. Placebo (12%) p=0.004. 1° endpoint and results: • At 23-mo follow-up, mortality was similar in pts treated with valsartan or placebo • The combined endpoint of mortality plus morbidity was reduced 13.2% (p=0.009) by valsartan because of a lower rate of HF hospitalization for HF (13.8% vs. 18.2%; p<0.001) 1° endpoint and results: At 41.4-mo follow-up, compared with placebo, enalapril

• Life table analysis confirmed increased frequency of late CHF in pts taking dilitiazem (p=0.0017) • Dilitiazem related CHF exclusively associated with systolic LVD with or without BB s

• Treatment with valsartan resulted in improvements in NYHA class, LVEF, signs and symptoms of HF, and quality of life compared with placebo (p<0.01).

• At 41.4-mo follow-up, compared with placebo, enalapril reduced mortality by 16% (p=0.0036) 115

2017 Hypertension Guideline Data Supplements hospitalization for HF in pts with HFrEF

HF were randomized to enalapril or placebo

1993 (154) 8104270

Aim: To determine the effect of ramipril vs. placebo on mortality in pts with HFrEF

Inclusion criteria: 2,006 pts, mean age 65 y, with HFrEF after MI and without NYHA class0HF

Intervention/Compar ator: 2,006 pts were randomized to ramipril or placebo

Garg R, et al., 1995 (155) 7654275

Aim: A meta-analysis was performed to determine the effect of ACEIs vs. placebo on mortality and on mortality plus hospitalization for HF in pts with HFrEF

Inclusion criteria: The metaanalysis included 32 trials of 7,105 pts with HFrEF treated with ACEIs vs. placebo

Pfeffer MA, et al., 2003 (156) 14610160

Aim: To determine the effect of valsartan, captopril, or both on mortality in pts with MI complicated by HF, LV dysfunction, or both

Inclusion criteria: 14,703 pts, mean age 65 y, with MI complicated by HF, LV dysfunction, or both

Intervention/Compar ator: In 25 trials, pts were treated with digoxin and/or diuretics, 4 trials only used diuretics, 1 trial used only digoxin, and 2 trials used no background therapy Intervention: 4,909 pts were randomized to valsartan, 4,909 pts were randomized to captopril

Aim: A subgroup analysis of the ValHeFT study was performed to determine the effect of valsartan vs. placebo on mortality and on mortality plus morbidity in pts with HFrEF not receiving ACEIs

Inclusion criteria: 366 pts, mean age 67 y, with HFrEF not receiving ACEIs

Maggioni AP, et al., 2002 (157) 12392830

Comparator: 4,885 pts were randomized to valsartan plus captopril. Intervention/Compar ator: 185 pts were randomized to valsartan and 181 pts were randomized to placebo

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

reduced mortality or hospitalization for worsening HF by 26% (p<0.0001) 1° endpoint and results: At 15-mo mean follow-up, compared with placebo, ramipril reduced all-cause mortality 27% (p=0.002) 1° endpoint and results: Compared with placebo, ACEIs reduced all-cause mortality 23% (p<0.001) and all-cause mortality or hospitalization for HF 35% (p<0.001).

• Analysis of prespecified 2º outcomes showed that ramipril reduced the first validated outcome (death, severe/resistant HF, MI, or stroke) by 19% (p=0.008). • The reduction in mortality was primarily due to a 31% (17%–42%) reduction in death from progressive HF.

1° endpoint and results: At 24.7-mo median follow-up, mortality was similar in the 3 treatment groups.

• The incidence of adverse events causing discontinuation of drug was 5.8% with valsartan, 7.7% with captopril, and 9.0 % with valsartan plus captopril (p<0.05 comparing valsartan with captopril and valsartan plus captopril with captopril).

1° endpoint and results: Compared with placebo, valsartan reduced mortality 33% (p=0.017) and mortality plus morbidity 44% (p<0.001).

• Compared with placebo, valsartan reduced first hospital admission for HF 53% (p=0.0006).

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2017 Hypertension Guideline Data Supplements Granger CB, et al., 2003 (158) 13678870

Aim: To determine the effect of candesartan vs. placebo on mortality in pts with HFrEF intolerant to ACEIs

Inclusion criteria: 2,028 pts, mean age 67 y, with HFrEF intolerant to ACEIs

Intervention/Compar ator: 1,013 pts were randomized to candesartan and 1,015 pts were randomized to placebo

Pitt B, et al., 2003 (159) 12668699

Aim: To determine the effect of eplerenone vs. placebo on mortality and on CV death or hospitalization for CV events in pts with MI complicated by HFrEF Aim: To determine the effect of ISDN plus hydralazine vs. placebo on mortality, first hospitalization for HF, and change in quality of life in black pts with HFrEF

Inclusion criteria: 6,632 pts, mean age 64 y, with HFrEF after MI

Intervention/Compar ator: 3,313 pts were randomized to eplerenone and 3,319 pts were randomized to placebo

Inclusion criteria: 1,050 African American pts, mean age 57 y, with HFrEF and NYHA class III or IV HF.

Intervention/Compar ator: 518 pts were randomized to ISDN plus hydralazine and 532 pts were randomized to placebo

1° endpoint and results: At 10-mo mean follow-up, compared with placebo, the mean 1° endpoint of mortality, first hospitalization for HF, and change in quality of life was reduced by ISDN plus hydralazine (p=0.01).

Aim: To assess dilitiazem effect on recurrent infarction and death after acute MI

Inclusion criteria: 25–75 y admitted to CCU, MI with enzyme confirmation.

Intervention: Dilitiazem 240 mg (1,234)

Exclusion criteria: Cardiogenic shock, symptomatic hypotension, PH with right HF, 2nd/3rd degree heart block, HR <50 bpm, contraceptives, WPW syndrome, CCBs, severe comorbidities or cardiac surgery Inclusion criteria: • ≥55 y • Coronary, peripheral, or cerebrovascular disease or DM

Comparator: Placebo (1,232)

1° endpoints and results: • Total mortality: identical in both groups • Cardiac death and nonfatal MI: 11% fewer in dilitiazem but difference was NS

Taylor AL, et al., 2004 (160) 15533851

The Multicenter Dilitiazem Postinfarction Research Group, 1988 (145) 2899840

Study type: RCT Size: 2,466 pts

ONTARGET Investigators, et al., 2008 (126) 18378520

Aim: Evaluate whether use of an ARB was noninferior to ACEI, and whether the combination was

Intervention: Ramipril 10 mg daily (n=8,576) Comparator:

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint and results: At 33.7-mo median follow-up, compared with placebo, the 1° endpoint of CV death or hospital admission for HF was reduced 30% by candesartan (p<0.0001). 1° endpoint and results: At 16-mo mean follow-up, eplerenone reduced mortality 15% (p=0.008) and CV death or hospitalization for CV events 17% (p=0.005).

1° endpoint: After a median follow-up of 56 mo, there was no difference between ramipril vs. telmisartan or combination therapy vs. ramipril in the 1°

• Compared with placebo, candesartan reduced CV death, hospital admission for HF, MI, stroke, or coronary revascularization 24% (p<0.0001). • Compared with placebo, eplerenone reduced death from any cause or any hospitalization 8% (p=0.02) and sudden cardiac death 21% (p=0.03), reduced hypokalemia from 13.1% to 8.4% (p<0.001), and increased serious hyperkalemia from 3.9%–5.5% (p=0.002). • Compared with placebo, ISDN plus hydralazine reduced mortality from 10.2%–6.2% (p=0.02) causing cessation of the study. • Compared with placebo, ISDN plus hydralazine reduced all-cause mortality 43% (first hospitalization for HF 33% (p=0.001), and improved quality of life (p=0.02). • No combined benefit from dilitiazem on mortality or cardiac events

• Telmisartan was equivalent to ramipril in pts with vascular disease or high-risk DM and was associated with less angioedema. The combination of the 2 drugs was associated with more 117

2017 Hypertension Guideline Data Supplements superior to ACE alone in the prevention of vascular events in pts with CVD or DM but not HF. Study type: Multicenter, double-blind, RCT Size: 25,620 pts

with end-organ damage Exclusion criteria: • Inability to discontinue ACEI or ARB • Known hypersensitivity or intolerance to ACEI or ARB • Selected CVDs (congestive HF, hemodynamically significant valvular or outflow tract obstruction, constrictive pericarditis, complex congenital heart disease, syncopal episodes of unknown etiology <3 mo, planned cardiac surgery or PTCA <3 mo, uncontrolled HTN on treatment [e.g., BP >160/100 mm Hg], heart transplant recipient, stroke due to subarachnoid hemorrhage) • Other conditions (significant renal artery disease, hepatic dysfunction, uncorrected volume or sodium depletion, 1° hyperaldosteronism, hereditary fructose intolerance, other major noncardiac illness or expected to reduce life expectancy or significant disability interfere with study participation, simultaneously taking another experimental drug, unable to provide written informed consent).

• Telmisartan 80 mg daily (n=8,542) • Combination of telmisartan and ramipril (n=8,502)

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

composite outcome of death from CV causes, MI, stroke, or hospitalization for HF (RR: 1.01; 95% CI: 0.94–1.09 and RR: 0.99; 95% CI: 0.92–1.07, respectively)

adverse events without an increase in benefit

Safety endpoint: • Combination therapy was associated with greater risk of hyperkalemia than ramipril monotherapy (480 pts vs. 283 pts; p<0.001) • Hypotensive symptoms were cited as reason for permanent discontinuing more in telmisartan vs. ramipril (RR: 1.54; p<0.001) and combination therapy vs. ramipril monotherapy (RR: 2.75; p<0.001) • Renal impairment was more common in combination therapy vs. ramipril monotherapy (RR: 1.33; 95% CI: 1.22–1.44)

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2017 Hypertension Guideline Data Supplements

Data Supplement 35. RCTs Comparing HFpEF (Section 9.2.2) Study Acronym; Author; Year Published TOPCAT Pfeffer MA, et al., 2015 (161) 25406305

Aim of Study; Study Type; Study Size (N)

Patient Population

Aim: To investigate variation in pts and outcome in TOPCAT between pts from the Americas vs. Russia/Georgia

Inclusion criteria: NYHA class II–IV HF with LVEF ≤40% within 3 mo of enrollment; supine resting heart rate ≥68 bpm; stable clinical condition

Study type: Posthoc analysis of prospective, doubleblind, RCT Size: 3,445 pts

Exclusion criteria: Acute MI or UA within 28 d of randomization; indication or contraindication for treatment with BBs or drugs with betablocking properties; poor compliance; CABG surgery or PTCA in past 4 mo

Study Intervention (# patients) / Study Comparator (# patients) Intervention: • Americas 886 on spironolactone • Russia/Georgia 836 on spironolactone • Spironolactone 15–45 mg daily Comparator: • Americas 881 on placebo • Russia/Georgia 842 on placebo • Placebo

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) 1° endpoint: Composite of CV death, aborted cardiac arrest, or HF hospitalization at 3.3 y follow-up was: Americas: 27.3% for spironolactone and 31.8% for placebo HR: 0.82; 95% CI: 0.69– 0.98; p=0.026; Russia/Georgia 9.3% for spironolactone and 8.4% for placebo HR: 1.10; 95% CI: 0.79– 1.51; p=0.58 1° Safety endpoint: • Doubling of serum creatinine: Americas: 17.8% for spironolactone and 11.6% for placebo HR: 1.60; 95% CI: 1.25–2.05; p<0.001 • Russia/Georgia 2.0% for S and 2.1% for p HR: 0.95; 95% CI: 0.49– 1.85; p=0.89 • Creatinine >3.0 mg/dL • Americas 9.8% for spironolactone and 9.1% for placebo HR: 1.10; 95% CI: 0.81–1.49; p=0.55 • Russia/Georgia 0.2% for spironolactone and 0.4% for placebo HR: 0.5; 95% CI: 0.09–2.75; p=0.43 • Hyperkalemia (potassium >5.5 mmol/L) • Americas 25.2% for spironolactone and 8.9% for placebo OR: 3.46; 95% CI: 2.62–4.56; p<0.001

Relevant 2° Endpoint (if any); Study Limitations; Adverse Events; Summary Relevant 2° endpoint: CV mortality: Americas 10.8% for spironolactone and 14.4% for placebo HR: 0.74; 95% CI 0.57–0.97; p=0.027; Russia/Georgia 7.7% for spironolactone and 5.8% for placebo HR: 1.31; 95% CI: 0.91–1.90; p=0.15. Aborted cardiac arrest: NS between groups. HF hospitalization: 20.8% for spironolactone and 24.5% for placebo HR: 0.82; 95% CI: 0.67–0.99; p=0.042; Russia/Georgia 2.6% for spironolactone and 3.4% for placebo HR: 0.76; 95% CI: 0.44–1.32; p=0.327; Recurrent HF: 361 events for spironolactone and 438 events for placebo (IRR: 0.75; 95% CI: 0.58– 0.96; p=0.024) Russia/Georgia 33 events for spironolactone and 37 events for placebo (IRR: 0.83; 95% CI: 0.42–1.62; p=0.58) All-cause mortality: NS between groups in Americas and Russia/Georgia. All-cause hospitalization: NS between groups in Americas and Russia/Georgia. MI: NS between groups; Stroke: NS between groups Study limitations and adverse events: The pts enrolled in Russia/Georgia in the TOPCAT trial did not demonstrate either the expected morbidity and mortality associated with symptomatic HF or 119

2017 Hypertension Guideline Data Supplements • Russia/Georgia 11.8% for spironolactone and 9.4% for placebo OR: 1.30; 95% CI: 0.95–1.77; p=0.10 • Hypokalemia (potassium <3.5 mmol/L) Americas 15.2% for spironolactone and 26.2% for placebo) 0.51 (95% CI: 0.40–0.64; p<0.001) • Russia/Georgia 17.2% for S and 19.4% for p OR: 0.87 (95% CI: 0.68–1.11; p=0.26)

Aronow WS, et al., 1997 (162) 9230162

Kostis JB, et al., 1997 (163) 9218667

Beckett NS, et al., 2008 (164) 18378519

Aim: To determine effect of propranolol vs. no propranolol on mortality plus nonfatal MI in pts with prior MI and HFpEF

Aim: To determine the effect of antihypertensive drug therapy vs. placebo in prevention of HF in pts with isolated systolic HTN Aim: To determine the effect of antihypertensive drug therapy on fatal or nonfatal stroke in pts ≥80 y

Inclusion criteria: Pts ≥62 y with MI and LVEF ≥40% and HF NYHA class II or III treated with diuretics and ACEIs for 2 mo

Inclusion criteria: Pts ≥60 y with isolated systolic HTN in the SHEP program

Inclusion criteria: Pts ≥80 y with a SBP≥160 mm Hg

Intervention: 79 pts were randomized to treatment with propranolol Comparator: 79 pts were randomized to no propranolol. • All pts continued diuretic and ACEI therapy. Intervention/Comparator: 4,736 pts were randomized to antihypertensive drug therapy or placebo

Intervention/Comparator: 3,845 pts were randomized to antihypertensive drug therapy or placebo

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

1° endpoint: At 32-mo mean followup, multivariate Cox regression analysis showed that compared with no propranolol, propranolol reduced mortality 35% (p=0.03) and mortality plus nonfatal MI 37% (p=0.018)

most pharmacological responses to spironolactone Summary: In pts with HF with preserved EF, spironolactone reduced the 1° endpoint of composite of CV death, aborted cardiac arrest, or HF hospitalization in the Americas group but not in the Russia/Georgia group. The pts enrolled in the Russia/Georgia group did not demonstrate either the expected morbidity and mortality associated with symptomatic HF with preserved EF or most pharmacological responses to spironolactone Relevant 2° endpoint: At 1-y followup, LVEF was increased by propranolol from 57% to 63% (p<0.001) and LV mass was decreased by propranolol from 312 grams to 278 grams (p=0.001) Propranolol was stopped because of adverse effects in 11 of 79 pts (14%)

1° endpoint: At 4.5-y follow-up, fatal or nonfatal HF was reduced 49% (p<0.001) by antihypertensive drug therapy (NNT to prevent 1 event =48)

Relevant 2° endpoint: CV mortality and nonfatal hospitalized HF was reduced 30% (p=0.002) by antihypertensive drug therapy

1° endpoint: The 1° endpoint of fatal or nonfatal stroke was reduced 30% (p=0.06) by antihypertensive drug therapy

Relevant 2° endpoint: Antihypertensive drug therapy reduced HF 64% (p<0.001) all-cause mortality 21% (p=0.02), and CV death 23% (p=0.06)

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2017 Hypertension Guideline Data Supplements Van Veldhuisen DJ, et al., 2009 (165) 19497441

Aim: To determine the effect of nebivolol vs. placebo in pts with HFrEF and HFpEF

Inclusion criteria: Pts ≥70 y, history of HF, and HFrEF or HFpEF

Intervention/Comparator: 1,359 pts with a history of HFrEF and 752 pts with a history of HFpEF were randomized to nebivolol or to placebo

Yusef S, et al., 2003 (166) 13678871

Aim: To determine the effects of candesartan vs. placebo in pts with HFpEF Aim: To determine the effect of irbesartan vs. placebo on allcause mortality or hospitalization for a CV cause in pts with HFpEF Aim: To determine mortality rates in pts who developed HF in ALLHAT

Inclusion criteria: 3,032 pts, mean age 67 y, with HFpEF and NYHA class II-IV HF Inclusion criteria: Pts 60 y and older with HFpEF and NYHA class II, III, or IV HF

Intervention/Comparator: 3,032 pts were randomized to candesartan or placebo

Study type: Metaanalysis of use of BP-lowering drugs in prevention of CVD from 147 randomized trials

Massie BM, et al., 2008 (167) 19001508

Piller LB, et al., 2011 (168) 21969009

Law MR, et al., 2009 (18) 19454737

Size: Of 147 randomized trials of 464,000 pts, 37 trials of BBs in CAD included 38,892 pts, and 37 trials of

1° endpoint: At 21-mo follow-up, the 1° endpoint of all-cause mortality or CV hospitalization was reduced by nebivolol 14% (95% CI: 0.72– 1.04) in pts with HFrEF and 19% (95% CI: 0.63, 1.04) in pts with HFpEF 1° endpoint: At 36.6 m follow-up, the 1° outcome of CV death or hospitalization for HF was reduced 11% (p=0.118) by candesartan

Relevant 2° endpoint: HR for reduction of all-cause mortality by nebivolol: 0.84 (95% CI: 0.86–1.08) for HFrEF and 0.91 (95% CI: 0.62–1.33) for HFpEF

Intervention/Comparator 4,128 pts were randomized to irbesartan or placebo

1° endpoint: At 49.5-mo follow-up, the 1° outcome of all-cause mortality or hospitalization for CV cause was reduced 5% by irbesartan (p=0.35)

Relevant 2° endpoint: Irbesartan did not significantly reduce the 2º outcomes of death from HF or hospitalization for HF, death from any cause and from CV causes, and quality of life

Inclusion criteria: 1,761 pts, mean age 70 y, developed HF during ALLHAT

Intervention/Comparator At 8.9-y mean follow-up, 1,348 of 1,761 pts (77%) with HF died

Relevant 2° endpoint: All-cause mortality rates were similar for those with HFrEF (84%) and for those with HFpEF (81%) with no significant differences by randomized treatment arm

Inclusion criteria: The database search used Medline (1966Dec. 2007 in any language) to identify randomized trials of BP-lowering drugs in which CAD events or strokes were recorded. The search also included the Cochrane Collaboration and

1° endpoint: CAD events; stroke

1° endpoint: Post-HF all-cause mortality was similar for pts treated with chlorthalidone, amlodipine, and lisinopril. 10-y adjusted rates for mortality were 86% for amlodipine, 87% for lisinopril, and 83% for chlorthalidone • With the exception of the extra protective effect of BBs given shortly after a MI and the minor additional effect of CCBs in preventing stroke, all the classes of BP-lowering drugs have a similar effect in reducing CAD events and stroke for a given reduction in BP.

Results: In 37 trials of pts with a history of CAD, BBs reduced CAD events 29% (95% CI: 22%–34%). In 27 trials in which BBs were used after acute MI, BBs reduced CAD events 31% (95% CI: 24%–38%), and in 11 trials in which BBs were used after long-term CAD, BBs

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Relevant 2° endpoint: Hospitalization was reduced 16% (p=0.047) by candesartan

N/A

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2017 Hypertension Guideline Data Supplements other antihypertensive drugs in CAD included 85,395 pts

Web of Science databases and the citations in trials and previous metaanalyses and review articles. Exclusion criteria: Trials were excluded if there were <5 CAD events and strokes or if treatment duration was <6 mo.

insignificantly reduced CAD events 13%. In 7 trials, BBs reduced stroke 17% (95% CI: 1%–30%). CAD events were reduced 14% (95% CI: 2%– 25%) in 11 trials of thiazide diuretics, 17% (95% CI: 11%–22%) in 21 trials of ACEIs, insignificantly 14% in 4 trials of angiotensin receptor blockers, and 15% (95% CI: 8%–22%) in 22 trials of CCBs. Stroke was reduced 38% (95% CI: 28%– 47%) in 10 trials of thiazide diuretics, 22% (95% CI: 8%– 34%) in 13 trials of ACEIs, and 34% (95% CI: 25%– 42%) in 9 trials of CCBs.

Data Supplement 36. Nonrandomized Trials, Observational Studies, and/or Registries of HFpEF (Section 9.2.2) Study Acronym; Author; Year Published Law MR, et al., 2009 (18) 19454737

Study Type/Design; Study Size (N) Study type: Metaanalysis of use of BPlowering drugs in prevention of CVD from 147 randomized trials Size: Of 147 randomized trials of 464,000 pts, 37 trials of BBs in CAD included 38,892 pts, and 37 trials of other antihypertensive drugs in CAD included 85,395 pts

Patient Population Inclusion criteria: The database search used Medline (1966–Dec. 2007 in any language) to identify randomized trials of BP-lowering drugs in which CAD events or strokes were recorded. The search also included the Cochrane Collaboration and Web of Science databases and the citations in trials and previous meta-analyses and review articles.

Primary Endpoint and Results (include P value; OR or RR; & 95% CI) 1° endpoint: CAD events; stroke Results: In 37 trials of pts with a history of CAD, BBs reduced CAD events 29% (95% CI: 22%, 34%). In 27 trials in which BBs were used after acute MI, BBs reduced CAD events 31% (95% CI: 24%, 38%), and in 11 trials in which BBs were used after long-term CAD, BBs insignificantly reduced CAD events 13%. In 7 trials, BBs reduced stroke 17% (95% CI: 1%–30%). CAD events were reduced 14% (95% CI: 2%–25%) in 11 trials of thiazide diuretics, 17% (95% CI: 11%–22%) in 21 trials of ACEIs, insignificantly 14% in 4 trials of angiotensin receptor blockers, and 15% (95% CI: 8%–22%) in 22 trials of CCBs. Stroke was reduced 38% (95% CI: 28%–47%) in 10 trials of

© 2017 American College of Cardiology Foundation and American Heart Association, Inc.

Summary/Conclusion Comment(s) • With the exception of the extra protective effect of BBs given shortly after a MI and the minor additional effect of CCBs in preventing stroke, all the classes of BPlowering drugs have a similar effect in reducing CAD events and stroke for a given reduction in BP. 122

2017 Hypertension Guideline Data Supplements Exclusion criteria: Trials were excluded if there were <5 CAD events and strokes or if treatment duration was <6 mo.

thiazide diuretics, 22% (95% CI: 8%–34%) in 13 trials of ACEIs, and 34% (95% CI: 25%–42%) in 9 trials of CCBs.

Data Supplement 37. RCTs Comparing CKD (Section 9.3) Study Acronym; Author; Year Published MDRD Klahr S, et al., 1994 (169) 8114857

Aim of Study; Study Type; Study Size (N) Aim: To determine whether restricted protein intake or tighter HTN control would delay progression of CKD Study type: Randomized management to low or usual BP goal and usual, low or very low protein intake Size: • Total n=840 Study 1 n=585 Study 2 n=255 • Mean follow-up 2.2 y • Mean MAP, mm Hg (SD): Study 1: 98 (11) Study 2: 98 (11) • Mean SBP, mm Hg (SD): Study 1: 131 (18) Study 2: 133 (18)