Hypertension



Hypertension

New ACC/AHA High Blood Pressure Guidelines

Lower Definition of Hypertension

High blood pressure should be treated earlier with lifestyle changes and in some patients with medication – at 130/80 mm Hg rather than 140/90 – based on new ACC and American Heart Association (AHA) guidelines for the detection, prevention, management and treatment of high blood pressure.

The new guidelines – the first comprehensive set since 2003 – lower the definition of high blood pressure to account for complications that can occur at lower numbers and to allow for earlier intervention. The new definition will result in nearly half of the U.S. adult population (46 percent) having high blood pressure, with the greatest impact expected among younger people. Additionally, the prevalence of high blood pressure is expected to triple among men under age 45, and double among women under 45, the guideline authors note. However, only a small increase is expected in the number of adults requiring antihypertensive medication.

"You've already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure," said Paul K. Whelton, MB, MD, MSc, FACC, lead author of the guidelines. "We want to be straight with people – if you already have a doubling of risk, you need to know about it. It doesn't mean you need medication, but it's a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches."

Blood pressure categories in the new guideline are:
• Normal: Less than 120/80 mm Hg;
• Elevated: Systolic between 120-129 and diastolic less than 80;
• Stage 1: Systolic between 130-139 or diastolic between 80-89;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

The guidelines eliminate the category of prehypertension, categorizing patients as having either Elevated (120-129 and less than 80) or Stage I hypertension (130-139 or 80-89).
While previous guidelines classified 140/90 mm Hg as Stage 1 hypertension, this level is classified as Stage 2 hypertension under the new guidelines.
In addition, the guidelines stress the importance of using proper technique to measure blood pressure; recommend use of home blood pressure monitoring using validated devices; and highlight the value of appropriate training of health care providers to reveal "white-coat hypertension." Other changes include:

• Only prescribing medication for Stage I hypertension if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease or calculation of atherosclerotic risk (using the same risk calculator used in evaluating high cholesterol).
• Recognizing that many people will need two or more types of medications to control their blood pressure, and that people may take their pills more consistently if multiple medications are combined into a single pill.
• Identifying socioeconomic status and psychosocial stress as risk factors for high blood pressure that should be considered in a patient's plan of care.

In a corresponding analysis of the guidelines' impact, Paul Muntner, PhD, et al., suggests "the 2017 ACC/AHA hypertension guideline has the potential to increase hypertension awareness, encourage lifestyle modification and focus antihypertensive medication initiation and intensification on US adults with high CVD risk."

The new ACC/AHA guidelines were developed with nine other health professional organizations and were written by a panel of 21 scientists and health experts who reviewed more than 900 published studies. They are the successor to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7), issued in 2003 and overseen by the National Heart, Lung, and Blood Institute (NHLBI). In 2013, the NHLBI asked the AHA and ACC to continue the management of guideline preparation for hypertension and other cardiovascular risk. The guidelines were published in the Journal of the American College of Cardiology and Hypertension. For a wide array of ACC-developed tools, resources and commentary for both clinicians and patients, visit the ACC's High Blood Pressure Guidelines Hub.

 


Measurement of BP

Proper methods of BP measurement, which are detailed in the guideline, are fundamental to categorizing BP, ascertaining BP-related CVD risk, and managing hypertension. The guideline urges clinicians to obtain accurate measurements and base their estimates of BP on an average of at least 2 readings obtained on at least 2 separate occasions (Table 2).

Table 2. Recommendations for Measurement of BP

The guideline recommends greater use of out-of-office BP measurements to confirm the diagnosis of hypertension and titrate medication.
In adults who are not using antihypertensive drugs, ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) should be used to detect white coat hypertension (high office BP but normal out-of-office BP) and masked hypertension (normal office BP but high out-of-office BP) (Figure 1).
White coat hypertension is associated with a CVD risk approximating that of normal BP, whereas masked hypertension carries a CVD risk similar to that of sustained hypertension.

Figure 1. Algorithm for detection of white coat hypertension or masked hypertension
in patients not receiving antihypertensive drug therapy.
Colors correspond to class of recommendation in the Appendix Figure. ABPM = ambulatory blood pressure monitoring; BP = blood pressure; HBPM = home blood pressure monitoring.

In adults already using antihypertensive drugs, the guideline recommends screening for masked uncontrolled hypertension if the office BP is at goal but CVD risk is increased or target organ damage is present. If the office BP is more than 5 to 10 mm Hg above goal in a patient using 3 or more antihypertensive drugs, the guideline recommends HBPM to detect a white coat effect (Figure 2).

Figure 2. Algorithm for detection of white coat effect or masked uncontrolled hypertension
in patients receiving drug therapy.
Colors correspond to class of recommendation in the Appendix Figure. ABPM = ambulatory blood pressure monitoring; BP = blood pressure; CVD = cardiovascular disease; HBPM = home blood pressure monitoring.

Appendix Figure. Applying class of recommendation and level of evidence
to clinical strategies, interventions, treatments, or diagnostic testing in patient care*.
COR (class (strength) of recommendation) and LOE (level (quality) of evidence) are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. (Reproduced with permission of the American College of Cardiology and the American Heart Association.) COR = class (strength) of recommendation; EO = expert opinion; LD = limited data; LOE = level (quality) of evidence; NR = nonrandomized; R = randomized; RCT = randomized controlled trial.

* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).

† For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

‡ The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools and, for systematic reviews, the incorporation of an Evidence Review Committee.


Secondary Hypertension

A secondary cause of hypertension can be identified in approximately 10% of hypertensive adults, and specific treatment of the cause reduces CVD risk. Screening for a secondary cause is recommended in the circumstances listed in Table 3, with referral to a clinician with relevant expertise when screening results are positive.


Secondary Hypertension

 

Nonpharmacologic Interventions

Lifestyle changes alone are recommended for most adults newly classified as having stage 1 hypertension (130 to 139/80 to 89 mm Hg), and lifestyle changes plus drug therapy are recommended for those with existing CVD or increased CVD risk. Recommended lifestyle interventions are listed in Table 4.

Table 4. Recommendations for Nonpharmacologic and Pharmacologic Treatment and BP Goals*

BP Thresholds and Risk Estimation to Guide Pharmacologic Treatment

Figure 3 shows BP thresholds and recommendations for follow-up and treatment of normal BP, elevated BP, and stage 1 and 2 hypertension. Intensive BP-lowering therapies should be directed toward patients with the highest atherosclerotic cardiovascular disease (ASCVD) risk. Although drug treatment based on BP alone is cost-effective, basing treatment decisions on absolute ASCVD risk combined with BP is even more efficient and cost-effective in reducing CVD risk. Benefits of using a combination approach to guide drug treatment include focusing treatment on patients most likely to have CVD events and a larger absolute CVD risk reduction, preventing more CVD events, and saving more quality-adjusted life-years.

Figure 3. BP thresholds and recommendations for treatment and follow-up.
Colors correspond to class of recommendation in the Appendix Figure. ASCVD = atherosclerotic cardiovascular disease; BP = blood pressure; CVD = cardiovascular disease.

* Using the American College of Cardiology/American Heart Association Pooled Cohort Equations. Patients with diabetes mellitus or chronic kidney disease are automatically placed in the high-risk category. For initiation of use of a renin–angiotensin system inhibitor or diuretic therapy, clinicians should assess blood tests for electrolytes and renal function 2 to 4 wk after initiating therapy.

† Clinicians should consider initiation of pharmacologic therapy for stage 2 hypertension with 2 antihypertensive agents from 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 patients or those with postural symptoms), identification of white coat hypertension or a white coat effect, documentation of adherence, monitoring of response to therapy, reinforcement of the importance of adherence, reinforcement of the importance of treatment, and assistance with treatment to achieve the BP target.

For high-risk adults with stage 1 hypertension who have preexisting CVD or an estimated 10-year ASCVD risk of at least 10%, the guideline recommends initiating drug treatment for those with an average BP of 130/80 mm Hg or higher (class I recommendation, high-quality evidence). For lower-risk adults without preexisting CVD and an estimated 10-year ASCVD risk less than 10%, the BP threshold for drug treatment is 140/90 mm Hg or higher (class I recommendation, low-quality evidence) (Table 4).

The ACC/AHA Pooled Cohort Equations (http://tools.acc.org/ASCVD-Risk-Estimator), which are based on age, race, sex, cholesterol levels (total, low-density lipoprotein, and high-density lipoprotein), statin use, SBP, treatment for hypertension, history of diabetes mellitus (DM), current smoking, and aspirin use, are recommended to estimate 10-year risk for ASCVD, which is defined as a first nonfatal myocardial infarction, coronary heart disease death, or fatal or nonfatal stroke among adults without CVD. Adults with DM, those with chronic kidney disease (CKD), and those aged 65 years or older are in the high–risk category for ASCVD.

BP Goals for Patients With Hypertension

Table 4 summarizes recommendations on BP thresholds and goals for treatment of adults with hypertension.
After initiation of antihypertensive drug therapy, regardless of ASCVD risk, the recommended BP target is less than 130/80 mm Hg.
The quality of evidence supporting this target is stronger for patients with known CVD or an estimated 10-year ASCVD risk of at least 10% than for patients without elevated risk.
A recent systematic review and network meta-analysis showed continuing reduction in CVD risk (major cardiovascular events, stroke, coronary heart disease, and all-cause mortality) at progressively lower levels of achieved SBP. A sensitivity analysis demonstrated a similar pattern when the results of SPRINT (Systolic Blood Pressure Intervention Trial) were excluded


Choice of Antihypertensive Drug Therapy

The evidence review conducted to inform the recommendations found some differences but general similarity in the efficacy and safety of drugs traditionally considered first-line agents, underscoring the importance of BP lowering above the choice of drug.
Recommendations on initial agents are summarized in Table 4. For adults without a compelling indication for use of a specific drug, clinicians should initiate therapy with thiazide diuretics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers.
Thiazide diuretics (especially chlorthalidone) and calcium-channel blockers are the preferred options for first-line therapy in most U.S. adults because of their efficacy.
In black patients, including those with DM, thiazide diuretics and calcium-channel blockers are recommended as first-line agents, whereas β-blockers and renin–angiotensin system inhibitors are less effective at lowering BP.

For patients with stage 2 hypertension, initiation of 2 antihypertensive agents from different classes is recommended when the average SBP and DBP are more than 20 and 10 mm Hg above target, respectively.
Patients with stage 2 hypertension and an average BP of 160/100 mm Hg or higher should be treated promptly, should be carefully monitored, and should have prompt adjustment of their regimen until control is achieved.

After initiation of drug therapy, management should include monthly evaluation of adherence and therapeutic response until control is achieved. Interventions to promote control, such as HBPM, team-based care, and telehealth, are useful in improving BP control.


Goals for treatment of adults with hypertension

 

Management of Resistant Hypertension

Resistant hypertension is defined as an average office BP of 130/80 mm Hg or higher in patients adhering to 3 or more antihypertensive agents from different classes at optimal doses, including a diuretic, or in those requiring 4 or more antihypertensive medications.
Using the former BP target of less than 140/90 mm Hg, the prevalence of resistant hypertension has been estimated to be 13% among hypertensive adults. Estimates suggest that the prevalence of resistant hypertension will be about 4% higher with the new BP target of less than 130/80 mm Hg.
Risk for myocardial infarction, stroke, end-stage renal disease, and death in adults with resistant hypertension (using the previous definition) is 2- to 6-fold higher than in adults with hypertension that is not resistant to treatment.

Clinicians caring for patients who fulfill the criteria for resistant hypertension should ensure that the diagnosis is based on accurate office BP measurements, assess for nonadherence to the prescribed antihypertensive medications, and obtain home or ambulatory BP readings to rule out the white coat effect. Contributing lifestyle factors should be identified and addressed. Use of substances that interfere with antihypertensive therapy, such as nonsteroidal anti-inflammatory drugs, stimulants, and oral contraceptives, should be discontinued or minimized, and secondary causes of hypertension should be excluded.

Treatment of resistant hypertension includes maximization of diuretic therapy (chlorthalidone or indapamide instead of hydrochlorothiazide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), addition of other agents with different mechanisms of action, use of loop diuretics in patients with CKD, and referral to a hypertension specialist if BP remains uncontrolled (Table 5).

Table 5. Recommendations for Managing Resistant Hypertension
and Improving Hypertension Management*

Strategies to Improve Hypertension Treatment and Control

Every adult with hypertension should have an evidence-based care plan that promotes treatment and self-management goals, effective management of comorbid conditions, timely follow-up, and CVD guideline–directed management (Table 5).
Up to 25% of patients do not fill their initial prescription for antihypertensive drug therapy, and only 1 in 5 patients has sufficiently high adherence to achieve the benefits observed in randomized controlled trials.
Once-daily dosing of antihypertensive medication and use of combination pills can improve adherence.

A team-based care approach is recommended for adults with hypertension.
In addition, use of the electronic health record and patient registries is beneficial in recognizing uncontrolled hypertension and guiding initiatives for quality improvement in hypertension control.
Telehealth strategies also can be useful adjuncts to interventions shown to lower BP for adults with hypertension.

Summary

Hypertension is a leading risk factor for death and disability-adjusted life-years worldwide.
Blood pressure of 120/80 mm Hg or higher is linearly related to risk for fatal and nonfatal stroke, ischemic heart disease, and noncardiac vascular disease, and each increase of 20/10 mm Hg doubles the risk for a fatal CVD event.
The 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults is the first comprehensive hypertension clinical practice guideline since 2003.
The 2017 guideline uses a different classification system for BP than previous guidelines; emphasizes out-of-office BP measurements to confirm the diagnosis of and monitor success in control of hypertension; advocates team-based care and use of the electronic health record and telehealth strategies for improved care; recommends nonpharmacologic interventions; and recommends addition of antihypertensive drug therapy based on a combination of average BP, ASCVD risk, and comorbid conditions.

 

 

Key points to remember
2017 Guideline for High Blood Pressure in Adults


May 07, 2018 | Melvyn Rubenfire, MD, FACC
Authors: Whelton PK, Carey RM, Aronow WS, et al.
Citation: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. J Am Coll Cardiol 2018;71:e127-e248.

The following are key points to remember from the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:

Part 1: General Approach, Screening, and Follow-up

1. The 2017 guideline is an update of the “Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7), published in 2003. The 2017 guideline is a comprehensive guideline incorporating new information from studies regarding blood pressure (BP)-related risk of cardiovascular disease (CVD), ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), BP thresholds to initiate antihypertensive drug treatment, BP goals of treatment, strategies to improve hypertension treatment and control, and various other important issues.

2. It is critical that health care providers follow the standards for accurate BP measurement. BP should be categorized as normal, elevated, or stages 1 or 2 hypertension to prevent and treat high BP. Normal BP is defined as <120/<80 mm Hg; elevated BP 120-129/<80 mm Hg; hypertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥140 or ≥90 mm Hg. Prior to labeling a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP. Out-of-office and self-monitoring of BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with clinical interventions and telehealth counseling. Corresponding BPs based on site/methods are: office/clinic 140/90, HBPM 135/85, daytime ABPM 135/85, night-time ABPM 120/70, and 24-hour ABPM 130/80 mm Hg. In adults with an untreated systolic BP (SBP) >130 but <160 mm Hg or diastolic BP (DBP) >80 but <100 mm Hg, it is reasonable to screen for the presence of white coat hypertension using either daytime ABPM or HBPM prior to diagnosis of hypertension. In adults with elevated office BP (120-129/<80) but not meeting the criteria for hypertension, screening for masked hypertension with daytime ABPM or HBPM is reasonable.

3. For an adult 45 years of age without hypertension, the 40-year risk for developing hypertension is 93% for African Americans, 92% for Hispanics, 86% for whites, and 84% for Chinese adults. In 2010, hypertension was the leading cause of death and disability-adjusted life-years worldwide, and a greater contributor to events in women and African Americans compared with whites. Often overlooked, the risk for CVD increases 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. A 20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. In persons ≥30 years of age, higher SBP and DBP are associated with increased risk for CVD, angina, myocardial infarction (MI), heart failure (HF), stroke, peripheral arterial disease, and abdominal aortic aneurysm. SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, SBP; this is not true for DBP.

4. It is important to screen for and manage other CVD risk factors in adults with hypertension: smoking, diabetes, dyslipidemia, excessive weight, low fitness, unhealthy diet, psychosocial stress, and sleep apnea. Basic testing for primary hypertension includes fasting blood glucose, complete blood cell count, lipids, basic metabolic panel, thyroid stimulating hormone, urinalysis, electrocardiogram with optional echocardiogram, uric acid, and urinary albumin-to-creatinine ratio.

5. Screening for secondary causes of hypertension is necessary for new-onset or uncontrolled hypertension in adults including drug-resistant (≥3 drugs), abrupt onset, age <30 years, excessive target organ damage (cerebral vascular disease, retinopathy, left ventricular hypertrophy, HF with preserved ejection fraction [HFpEF] and HF with reserved EF [HFrEF], coronary artery disease [CAD], chronic kidney disease [CKD], peripheral artery disease, albuminuria) or for onset of diastolic hypertension in older adults or in the presence of unprovoked or excessive hypokalemia. Screening includes testing for CKD, renovascular disease, primary aldosteronism, obstructive sleep apnea, drug-induced hypertension (nonsteroidal anti-inflammatory drugs, steroids/androgens, decongestants, caffeine, monoamine oxidase inhibitors), and alcohol-induced hypertension. If more specific clinical characteristics are present, screening for uncommon causes of secondary hypertension is indicated (pheochromocytoma, Cushing’s syndrome, congenital adrenal hyperplasia, hypothyroidism, hyperthyroidism, and aortic coarctation). Physicians are advised to refer patients screening positive for these conditions to a clinician with specific expertise in the condition.

6. Nonpharmacologic interventions to reduce BP include: weight loss for overweight or obese patients with a heart healthy diet, sodium restriction, and potassium supplementation within the diet; and increased physical activity with a structured exercise program. Men should be limited to no more than 2 and women no more than 1 standard alcohol drink(s) per day. The usual impact of each lifestyle change is a 4-5 mm Hg decrease in SBP and 2-4 mm Hg decrease in DBP; but diet low in sodium, saturated fat, and total fat and increase in fruits, vegetables, and grains may decrease SBP by approximately 11 mm Hg.

7. The benefit of pharmacologic treatment for BP reduction is related to atherosclerotic CVD (ASCVD) risk. For a given magnitude reduction of BP, fewer individuals with high ASCVD risk would need to be treated to prevent a CVD event (i.e., lower number needed to treat) such as in older persons, those with coronary disease, diabetes, hyperlipidemia, smokers, and CKD. Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP ≥130 mm Hg or a DBP ≥80 mm Hg, or for primary prevention in adults with no history of CVD but with an estimated 10-year ASCVD risk of ≥10% and SBP ≥130 mm Hg or DBP ≥80 mm Hg. Use of BP-lowering medication is also recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and a SBP ≥140 mm Hg or a DBP ≥90 mm Hg. The prevalence of hypertension is lower in women compared with men until about the fifth decade, but is higher later in life. While no randomized controlled trials have been powered to assess outcome specifically in women (e.g., SPRINT), 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 compared with men. For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of <130/80 mm Hg is recommended. For adults with confirmed hypertension, but without additional markers of increased CVD risk, a BP target of <130/80 mm Hg is recommended as reasonable.

8. Follow-up: In low-risk adults with elevated BP or stage 1 hypertension with low ASCVD risk, BP should be repeated after 3-6 months of nonpharmacologic therapy. Adults with stage 1 hypertension and high ASCVD risk (≥10% 10-year ASCVD risk) should be managed with both nonpharmacologic and antihypertensive drug therapy with repeat BP in 1 month. Adults with stage 2 hypertension should be evaluated by a primary care provider within 1 month of initial diagnosis, and be treated with a combination of nonpharmacologic therapy and 2 antihypertensive drugs of different classes with repeat BP evaluation in 1 month. For adults with a very high average BP (e.g., ≥160 mm Hg or DBP ≥100 mm Hg), prompt evaluation and drug treatment followed by careful monitoring and upward dose adjustment is recommended.

Part 2: Principles of Drug Therapy and Special Populations

9. Principles of drug therapy: Chlorthalidone (12.5-25 mg) is the preferred diuretic because of long half-life and proven reduction of CVD risk. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors should not be used in combination. ACE inhibitors and ARBs increase the risk of hyperkalemia in CKD and with supplemental K+ or K+-sparing drugs. ACE inhibitors and ARBs should be discontinued during pregnancy. Calcium channel blocker (CCB) dihydropyridines cause edema. Non-dihydropyridine CCBs are associated with bradycardia and heart block and should be avoided in HFrEF. Loop diuretics are preferred in HF and when glomerular filtration rate (GFR) is <30 ml/min. Amiloride and triamterene can be used with thiazides in adults with low serum K+, but should be avoided with GFR <45 ml/min.

Spironolactone or eplerenone is preferred for the treatment of primary aldosteronism and in resistant hypertension. Beta-blockers are not first-line therapy except in CAD and HFrEF. Abrupt cessation of beta-blockers should be avoided. Bisoprolol and metoprolol succinate are preferred in hypertension with HFrEF and bisoprolol when needed for hypertension in the setting of bronchospastic airway disease. Beta-blockers with both alpha- and beta-receptor activity such as carvedilol are preferred in HFrEF.

Alpha-1 blockers are associated with orthostatic hypotension; this drug class may be considered in men with symptoms of benign prostatic hyperplasia. Central acting alpha2-agonists should be avoided, and are reserved as last-line due to side effects and the need to avoid sudden discontinuation. Direct-acting vasodilators are associated with sodium and water retention and must be used with a diuretic and beta-blocker.

10. Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, CCBs, and ACE inhibitors or ARBs. Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target. Improved adherence can be achieved with once-daily drug dosing, rather than multiple dosing, and with combination therapy rather than administration of the free individual components.

For adults with confirmed hypertension and known stable CVD or ≥10% 10-year ASCVD risk, a BP target of <130/80 mm Hg is recommended. The strategy is to first follow standard treatment guidelines for CAD, HFrEF, previous MI, and stable angina, with the addition of other drugs as needed to further control BP. In HFpEF with symptoms of volume overload, diuretics should be used to control hypertension, following which ACE inhibitors or ARBs and beta-blockers should be titrated to SBP <130 mm Hg. Treatment of hypertension with an ARB can be useful for prevention of recurrence of atrial fibrillation.

11. CKD: BP goal should be <130/80 mm Hg. In those with stage 3 or higher CKD or stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated.

12. Adults with stroke and cerebral vascular disease are complex. 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, which along with ideal antihypertensive therapeutic class have not been fully studied in clinical trials. In adults with acute intracranial hemorrhage and SBP >220 mm Hg, it may be reasonable to use continuous intravenous drug infusion with close BP monitoring to lower SBP. Immediate lowering of SBP to <140 mm Hg from 150-220 mm Hg is not of benefit to reduce death, and may cause harm. In acute ischemic stroke, BP should be lowered slowly to <185/110 mm Hg prior to thrombolytic therapy and maintained to <180/105 mm Hg for at least the first 24 hours after initiating drug therapy. Starting or restarting antihypertensive therapy during the hospitalization when patients with ischemic stroke are stable with BP >140/90 mm Hg is reasonable. In those who do not undergo reperfusion therapy with thrombolytics or endovascular treatment, if the BP is ≥220/120 mm Hg, the benefit of lowering BP is not clear, but it is reasonable to consider lowering BP by 15% during the first 24 hours post onset of stroke. However, initiating or restarting treatment when BP is <220/120 mm Hg within the first 48-72 hours post-acute ischemic stroke is not effective.

Secondary prevention following a stroke or transient ischemic attack (TIA) should begin by restarting treatment after the first few days of the index event to reduce recurrence. Treatment with ACE inhibitor or ARB with thiazide diuretic is useful. Those not previously treated for hypertension and who have a BP ≥140/90 mm Hg should begin antihypertensive therapy a few days after the index event. Selection of drugs should be based on comorbidities. A goal of <130/80 mm Hg may be reasonable for those with a stroke or TIA. For those with an ischemic stroke and no previous treatment for hypertension, there is no evidence of treatment benefit if the BP is <140/90 mm Hg.

13. Diabetes mellitus (DM) and hypertension: Antihypertensive drug treatment should be initiated at a BP ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg. In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs may be considered in the presence of albuminuria.

14. Metabolic syndrome: 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. Chlorthalidone was at least as effective for reducing CV events as the other antihypertensive agents in the ALLHAT study. Traditional beta-blockers should be avoided unless used for ischemic heart disease.

15. Valvular heart disease: Asymptomatic aortic stenosis with hypertension should be treated with pharmacotherapy, starting at a low dose, and gradually titrated upward as needed. In patients with chronic aortic insufficiency, treatment of systolic hypertension is reasonable with agents that do not slow the heart rate (e.g., avoid beta-blockers).

16. Aortic disease: Beta-blockers are recommended as the preferred antihypertensive drug class in patients with hypertension and thoracic aortic disease.

17. Race/ethnicity: In African American adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults, especially in African American adults, with hypertension.

18. Age-related issues: Treatment of hypertension is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age), with an average SBP ≥130 mm Hg with SBP treatment goal of <130 mm Hg. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. BP lowering is reasonable to prevent cognitive decline and dementia.

19. Preoperative surgical procedures: Beta-blockers should be continued in persons with hypertension undergoing major surgery, as should other antihypertensive drug therapy until surgery. Discontinuation of ACE inhibitors and ARBs perioperatively may be considered. For patients with planned elective major surgery and SBP ≥180 mm Hg or DBP ≥110 mm Hg, deferring surgery may be considered. Abrupt preoperative discontinuation of beta-blockers or clonidine may be harmful. Intraoperative hypertension should be managed with intravenous medication until oral medications can be resumed.

20. For discussion regarding hypertensive crises with and without comorbidities, refer to Section 11.2: Hypertensive Crises–Emergencies and Urgencies in the Guideline.

21. 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; effective management of comorbid conditions; timely follow-up with the healthcare team; and adheres to CVD evidence-based guidelines. Effective behavioral and motivational strategies are recommended to promote lifestyle modification. A structured team-based approach including a physician, nurse, and pharmacist collaborative model is recommended, along with integrating home-based monitoring and telehealth interventions. Outcome may be improved with quality improvement strategies at the health system, provider, and patient level. Financial incentives paid to providers can be useful.

 


Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults


Table of Contents Preamble e130
1. Introduction e133
1.1. Methodology and Evidence Review e133
1.2. Organization of the Writing Committee e133
1.3. Document Review and Approval e134
1.4. Scope of the Guideline e134
1.5. Abbreviations and Acronyms e134

2. BP and CVD Risk e134
2.1. Observational Relationship e134
2.2. BP Components e136
2.3. Population Risk e136
2.4. Coexistence of Hypertension and Related Chronic Conditions e136

3. Classification of BP e137
3.1. Definition of High BP e137
3.2. Lifetime Risk of Hypertension e138
3.3. Prevalence of High BP e138
3.4. Awareness, Treatment, and Control e139

4. Measurement of BP e140
4.1. Accurate Measurement of BP in the Office e140
4.2. Out-of-Office and Self-Monitoring of BP e141
4.3. Ambulatory BP Monitoring e142
4.4. Masked and White Coat Hypertension e143

5. Causes of Hypertension e146
5.1. Genetic Predisposition e146
5.2. Environmental Risk Factors e146
5.2.1. Overweight and Obesity e146
5.2.2. Sodium Intake e147
5.2.3. Potassium e147
5.2.4. Physical Fitness e147
5.2.5. Alcohol e147
5.3. Childhood Risk Factors and BP Tracking e147
5.4. Secondary Forms of Hypertension e148
5.4.1. Drugs and Other Substances With Potential to Impair BP Control e151
5.4.2. Primary Aldosteronism e152
5.4.3. Renal Artery Stenosis e153
5.4.4. Obstructive Sleep Apnea e154

6. Nonpharmacological Interventions e154
6.1. Strategies e154
6.2. Nonpharmacological Interventions e155

7. Patient Evaluation e158
7.1. Laboratory Tests and Other Diagnostic Procedures e159
7.2. Cardiovascular Target Organ Damage e159

8. Treatment of High BP e160
8.1. Pharmacological Treatment e160
8.1.1. Initiation of Pharmacological BP Treatment in the Context of Overall CVD Risk e160
8.1.2. BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension e160
8.1.3. Follow-Up After Initial BP Evaluation e163
8.1.4. General Principles of Drug Therapy e164
8.1.5. BP Goal for Patients With Hypertension e167
8.1.6. Choice of Initial Medication e168
8.2. Achieving BP Control in Individual Patients e169
8.3. Follow-Up of BP During Antihypertensive Drug Therapy e170
8.3.1. Follow-Up After Initiating Antihypertensive Drug Therapy e170
8.3.2. Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP e171

9. Hypertension in Patients With Comorbidities e171
9.1. Stable Ischemic Heart Disease e172
9.2. Heart Failure e173
9.2.1. Heart Failure With Reduced Ejection Fraction e174
9.2.2. Heart Failure With Preserved Ejection Fraction e174
9.3. Chronic Kidney Disease e175
9.3.1. Hypertension After Renal Transplantation e177
9.4. Cerebrovascular Disease e178
9.4.1. Acute Intracerebral Hemorrhage e178
9.4.2. Acute Ischemic Stroke e180
9.4.3. Secondary Stroke Prevention e182
9.5. Peripheral Artery Disease e184
9.6. Diabetes Mellitus e184
9.7. Metabolic Syndrome e185
9.8. Atrial Fibrillation e186
9.9. Valvular Heart Disease e187
9.10. Aortic Disease e188

10. Special Patient Groups e188
10.1. Race and Ethnicity e188
10.1.1 Racial and Ethnic Differences in Treatment e189
10.2. Sex-Related Issues e189
10.2.1. Women e190
10.2.2. Pregnancy e190
10.3. Age-Related Issues e191
10.3.1. Older Persons e191
10.3.2. Children and Adolescents e192

11. Other Considerations e193
11.1. Resistant Hypertension e193
11.2. Hypertensive Crises—Emergencies and Urgencies e194
11.3. Cognitive Decline and Dementia e197
11.4. Sexual Dysfunction and Hypertension e198
11.5. Patients Undergoing Surgical Procedures e199

12. Strategies to Improve Hypertension Treatment and Control e200
12.1. Adherence Strategies for Treatment of Hypertension e200
12.1.1. Antihypertensive Medication Adherence Strategies e201
12.1.2. Strategies to Promote Lifestyle Modification e202
12.1.3. Improving Quality of Care for Resource-Constrained Populations e202
12.2. Structured, Team-Based Care Interventions for Hypertension Control e203
12.3. Health Information Technology–Based Strategies to Promote Hypertension Control e204
12.3.1. EHR and Patient Registries e204
12.3.2. Telehealth Interventions to Improve Hypertension Control e204
12.4. Improving Quality of Care for Patients With Hypertension e205
12.4.1. Performance Measures e205
12.4.2. Quality Improvement Strategies e205
12.5. Financial Incentives e206

13. The Plan of Care for Hypertension e207
13.1. Health Literacy e207
13.2. Access to Health Insurance and Medication Assistance Plans e207
13.3. Social and Community Services e207

14. Summary of BP Thresholds and Goals for Pharmacological Therapy e208

15. Evidence Gaps and Future Directions e208

Appendix 1
Author Relationships With Industry and Other Entities (Relevant) e238
Appendix 2
Reviewer Relationships With Industry and Other Entities (Comprehensive) e240

 

2017 Guideline for High Blood Pressure in Adults
(A Selection of Tables and Figures) 

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (2017)
(Executive Summery)   Full Text
(Executive Summery)  
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA

 

Treatment

Changing your lifestyle can go a long way toward controlling high blood pressure. Your doctor may recommend you make lifestyle changes including:
• Eating a heart-healthy diet with less salt
• Getting regular physical activity
• Maintaining a healthy weight or losing weight if you're overweight or obese
• Limiting the amount of alcohol you drink

But sometimes lifestyle changes aren't enough. In addition to diet and exercise, your doctor may recommend medication to lower your blood pressure.
Your blood pressure treatment goal depends on how healthy you are.

Your blood pressure treatment goal should be less than 130/80 mm Hg if: • You're a healthy adult age 65 or older
• You're a healthy adult younger than age 65 with a 10 percent or higher risk of developing cardiovascular disease in the next 10 years
• You have chronic kidney disease, diabetes or coronary artery disease

Although 120/80 mm Hg or lower is the ideal blood pressure goal, doctors are unsure if you need treatment (medications) to reach that level.

If you're age 65 or older, and use of medications produces lower systolic blood pressure (such as less than 130 mm Hg), your medications won't need to be changed unless they cause negative effects to your health or quality of life.

The category of medication your doctor prescribes depends on your blood pressure measurements and your other medical problems. It's helpful if you work together with a team of medical professionals experienced in providing treatment for high blood pressure to develop an individualized treatment plan.

Medications to treat high blood pressure
• Thiazide diuretics. Diuretics, sometimes called water pills, are medications that act on your kidneys to help your body eliminate sodium and water, reducing blood volume.

Thiazide diuretics are often the first, but not the only, choice in high blood pressure medications. Thiazide diuretics include chlorthalidone, hydrochlorothiazide (Microzide) and others.

If you're not taking a diuretic and your blood pressure remains high, talk to your doctor about adding one or replacing a drug you currently take with a diuretic.

Diuretics or calcium channel blockers may work better for people of African heritage and older people than do angiotensin-converting enzyme (ACE) inhibitors alone.
A common side effect of diuretics is increased urination.

• Angiotensin-converting enzyme (ACE) inhibitors. These medications — such as lisinopril (Zestril), benazepril (Lotensin), captopril (Capoten) and others — help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels. People with chronic kidney disease may benefit from having an ACE inhibitor as one of their medications.

• Angiotensin II receptor blockers (ARBs). These medications help relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. ARBs include candesartan (Atacand), losartan (Cozaar) and others. People with chronic kidney disease may benefit from having an ARB as one of their medications.

• Calcium channel blockers. These medications — including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and others — help relax the muscles of your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for older people and people of African heritage than do ACE inhibitors alone.
Grapefruit juice interacts with some calcium channel blockers, increasing blood levels of the medication and putting you at higher risk of side effects. Talk to your doctor or pharmacist if you're concerned about interactions.

Additional medications sometimes used to treat high blood pressure
If you're having trouble reaching your blood pressure goal with combinations of the above medications, your doctor may prescribe:
• Alpha blockers. These medications reduce nerve impulses to blood vessels, reducing the effects of natural chemicals that narrow blood vessels. Alpha blockers include doxazosin (Cardura), prazosin (Minipress) and others.

• Alpha-beta blockers. In addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow the heartbeat to reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).

• Beta blockers. These medications reduce the workload on your heart and open your blood vessels, causing your heart to beat slower and with less force. Beta blockers include acebutolol (Sectral), atenolol (Tenormin) and others.
Beta blockers aren't usually recommended as the only medication you're prescribed, but they may be effective when combined with other blood pressure medications.

• Aldosterone antagonists. Examples are spironolactone (Aldactone) and eplerenone (Inspra). These drugs block the effect of a natural chemical that can lead to salt and fluid retention, which can contribute to high blood pressure.

• Renin inhibitors. Aliskiren (Tekturna) slows down the production of renin, an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure.
Aliskiren works by reducing the ability of renin to begin this process. Due to a risk of serious complications, including stroke, you shouldn't take aliskiren with ACE inhibitors or ARBs.

• Vasodilators. These medications, including hydralazine and minoxidil, work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and your arteries from narrowing.

• Central-acting agents. These medications prevent your brain from signaling your nervous system to increase your heart rate and narrow your blood vessels. Examples include clonidine (Catapres, Kapvay), guanfacine (Intuniv, Tenex) and methyldopa.

To reduce the number of daily medication doses you need, your doctor may prescribe a combination of low-dose medications rather than larger doses of one single drug. In fact, two or more blood pressure drugs often are more effective than one. Sometimes finding the most effective medication or combination of drugs is a matter of trial and error.

Resistant hypertension: When your blood pressure is difficult to control
If your blood pressure remains stubbornly high despite taking at least three different types of high blood pressure drugs, one of which usually should be a diuretic, you may have resistant hypertension.

People who have controlled high blood pressure but are taking four different types of medications at the same time to achieve that control also are considered to have resistant hypertension. The possibility of a secondary cause of the high blood pressure generally should be reconsidered.

Having resistant hypertension doesn't mean your blood pressure will never get lower. In fact, if you and your doctor can identify what's behind your persistently high blood pressure, there's a good chance you can meet your goal with the help of treatment that's more effective.

Your doctor or hypertension specialist may:
• Evaluate potential causes of your condition and determine if those can be treated
• Review medications you're taking for other conditions and recommend you not take any that worsen your blood pressure
• Recommend that you monitor your blood pressure at home to see if you may have higher blood pressure in the doctor's office (white coat hypertension)
• Suggest healthy lifestyle changes, such as eating a healthy diet with less salt, maintaining a healthy weight and limiting how much alcohol you drink
• Make changes to your high blood pressure medications to come up with the most effective combination and doses
• Consider adding an aldosterone antagonist such as spironolactone (Aldactone), which may lead to control of resistant hypertension

Some experimental therapies such as catheter-based radiofrequency ablation of renal sympathetic nerves (renal denervation) and electrical stimulation of carotid sinus baroreceptors are being studied.

If you don't take your high blood pressure medications exactly as directed, your blood pressure can pay the price. If you skip doses because you can't afford the medications, because you have side effects or because you simply forget to take your medications, talk to your doctor about solutions. Don't change your treatment without your doctor's guidance.

 

Angiotensin II receptor blockers

Angiotensin II receptor blockers (ARBs) are used to treat conditions such as high blood pressure and heart failure.

Angiotensin II receptor blockers (ARBs) help relax your blood vessels, which lowers your blood pressure and makes it easier for your heart to pump blood.

Angiotensin is a chemical in your body that affects your cardiovascular system in various ways, including narrowing your blood vessels. This narrowing can increase your blood pressure and force your heart to work harder.

Angiotensin II receptor blockers block the action of angiotensin II, allowing blood vessels to widen (dilate).

Examples of angiotensin II receptor blockers

Several ARBs are available. Which one is best for you depends on your health and the condition being treated.

Examples of angiotensin II receptor blockers include:
•Azilsartan (Edarbi)
•Candesartan (Atacand)
•Eprosartan
•Irbesartan (Avapro)
•Losartan (Cozaar)
•Olmesartan (Benicar)
•Telmisartan (Micardis)
•Valsartan (Diovan)

Uses for angiotensin II receptor blockers

Doctors prescribe these drugs to prevent, treat or improve symptoms in various conditions, such as:
•High blood pressure
•Heart failure
•Kidney failure in diabetes
•Chronic kidney diseases

Side effects and cautions

Few people have side effects when taking angiotensin II receptor blockers. Possible side effects include:
•Dizziness
•Elevated blood potassium level (hyperkalemia)
•Localized swelling of tissues (angioedema)

There have been some reports of intestinal problems in those taking olmesartan. Talk to your doctor if you develop severe diarrhea or lose a lot of weight while taking olmesartan.

Because angiotensin II receptor blockers can injure a developing fetus, don't take them if you are pregnant or plan to become pregnant.

Angiotensin-converting enzyme (ACE) inhibitors

ACE inhibitors treat a variety of conditions, such as high blood pressure, scleroderma and migraines.

Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that narrows your blood vessels and releases hormones that can raise your blood pressure. This narrowing can cause high blood pressure and force your heart to work harder.

Examples of ACE inhibitors

Many ACE inhibitors are available. Which one is best for you depends on your health and the condition being treated. People with chronic kidney disease may benefit from having an ACE inhibitor as one of their medications. People of African heritage and older people respond less well to ACE inhibitors than do white and younger people.

Examples of ACE inhibitors include:
•Benazepril (Lotensin)
•Captopril
•Enalapril (Vasotec)
•Fosinopril
•Lisinopril (Prinivil, Zestril)
•Moexipril
•Perindopril (Aceon)
•Quinapril (Accupril)
•Ramipril (Altace)
•Trandolapril (Mavik)

Uses for ACE inhibitors

Doctors prescribe ACE inhibitors to prevent, treat or improve symptoms in conditions such as:
•High blood pressure
•Coronary artery disease
•Heart failure
•Diabetes
•Certain chronic kidney diseases
•Heart attacks
•Scleroderma
•Migraines

Your doctor may prescribe other medications in addition to an ACE inhibitor, such as a diuretic or calcium channel blocker, as part of your high blood pressure treatment. ACE inhibitors are usually taken once daily.

Side effects and cautions

Doctors commonly prescribe ACE inhibitors because they don't often cause side effects.

Possible ACE inhibitor side effects include:
•Dry cough
•Increased blood-potassium level (hyperkalemia)
•Fatigue
•Dizziness
•Headaches
•Loss of taste

In rare cases — but more commonly in people of African heritage and in smokers — ACE inhibitors can cause some areas of your tissues to swell (angioedema). If it occurs in the throat, the swelling can be life-threatening.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), decrease the effectiveness of ACE inhibitors. Taking an occasional dose of these medications shouldn't change the effectiveness of your ACE inhibitor, but talk to your doctor if you regularly take NSAIDs.

Because ACE inhibitors can cause birth defects, talk to your doctor about other options to treat your blood pressure if you're pregnant or you plan to become pregnant.

 

Calcium channel blockers

Calcium channel blockers, or calcium antagonists, treat a variety of conditions, such as high blood pressure, chest pain and Raynaud's disease.

Calcium channel blockers prevent calcium from entering cells of the heart and blood vessel walls, resulting in lower blood pressure. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls.

Some calcium channel blockers have the added benefit of slowing your heart rate, which can further reduce blood pressure, relieve chest pain (angina) and control an irregular heartbeat.

Examples of calcium channel blockers

Some calcium channel blockers are available in short-acting and long-acting forms. Short-acting medications work quickly, but their effects last only a few hours. Long-acting medications are slowly released to provide a longer lasting effect.

Several calcium channel blockers are available. Which one is best for you depends on your health and the condition being treated.

Examples of calcium channel blockers include:
•Amlodipine (Norvasc)
•Diltiazem (Cardizem, Tiazac, others)
•Felodipine
•Isradipine
•Nicardipine
•Nifedipine (Adalat CC, Afeditab CR, Procardia)
•Nisoldipine (Sular)
•Verapamil (Calan, Verelan)

In some cases, your doctor might prescribe a calcium channel blocker with other high blood pressure medications or with cholesterol-lowering drugs such as statins.

Uses for calcium channel blockers

Doctors prescribe calcium channel blockers to prevent, treat or improve symptoms in a variety of conditions, such as:
•High blood pressure
•Coronary artery disease
•Chest pain (angina)
•Irregular heartbeats (arrhythmia)
•Some circulatory conditions, such as Raynaud's disease

For people of African heritage and older people, calcium channel blockers might be more effective than other blood pressure medications, such as beta blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers.

Side effects and cautions

Side effects of calcium channel blockers may include:
•Constipation
•Headache
•Palpitations
•Dizziness
•Rash
•Drowsiness
•Flushing
•Nausea
•Swelling in the feet and lower legs

Certain calcium channel blockers interact with grapefruit products.

Beta blockers

Beta blockers, also called beta-adrenergic blocking agents, treat a variety of conditions, such as high blood pressure and migraines.

Beta blockers, also known as beta-adrenergic blocking agents, are medications that reduce your blood pressure. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline.

When you take beta blockers, your heart beats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels open up to improve blood flow.

Examples of beta blockers

Some beta blockers mainly affect your heart, while others affect both your heart and your blood vessels. Which one is best for you depends on your health and the condition being treated.

Examples of oral beta blockers include:
•Acebutolol (Sectral)
•Atenolol (Tenormin)
•Bisoprolol (Zebeta)
•Metoprolol (Lopressor, Toprol-XL)
•Nadolol (Corgard)
•Nebivolol (Bystolic)
•Propranolol (Inderal LA, InnoPran XL)

Uses for beta blockers

Doctors prescribe beta blockers to prevent, treat or improve symptoms in a variety of conditions, such as:
•High blood pressure
•Irregular heart rhythm (arrhythmia)
•Heart failure
•Chest pain (angina)
•Heart attacks
•Migraine
•Certain types of tremors

Beta blockers aren't usually prescribed for blood pressure until other medications, such as diuretics, haven't worked effectively. Your doctor may prescribe beta blockers as one of several medications to lower your blood pressure, including angiotensin-converting enzyme (ACE) inhibitors, diuretics or calcium channel blockers.

Beta blockers may not work as effectively for people of African heritage and older people, especially when taken without other blood pressure medications.

Side effects and cautions

Side effects may occur in people taking beta blockers. However, many people who take beta blockers won't have any side effects.
Common side effects of beta blockers include:
•Fatigue
•Cold hands or feet
•Weight gain

Less common side effects include:
•Shortness of breath
•Trouble sleeping
•Depression

Beta blockers generally aren't used in people with asthma because of concerns that the medication may trigger severe asthma attacks. In people who have diabetes, beta blockers may block signs of low blood sugar, such as rapid heartbeat. It's important to monitor your blood sugar regularly.

Beta blockers can also affect your cholesterol and triglyceride levels, causing a slight increase in triglycerides and a modest decrease in high-density lipoprotein, the "good" cholesterol. These changes often are temporary. You shouldn't abruptly stop taking a beta blocker because doing so could increase your risk of a heart attack or other heart problems