Guideline-Driven Management of Hypertension: An Evidence-Based Update

Abstract

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Keywords: American Heart Association; antihypertensive agents; blood pressure; cardiovascular disease; hypertension; mortality.

Figure:

Schematic representation of the mechanisms of autonomous aldosterone production in primary hypertension. Aldosterone production from the adrenal zona glomerulosa is independent of the renin-angiotensin system and is not suppressible with dietary sodium loading. Excess aldosterone expands extracellular fluid volume by augmenting sodium reabsorption in the renal cortical collecting duct. Expanded fluid volume leads to hypertension and suppression of renin and the entire renin-angiotensin cascade. Increased aldosterone production is abnormal in the face of renin suppression but plasma aldosterone concentrations are lower than those of patients with classical overt primary aldosteronism. ACE, angiotensin converting enzyme; Ang, angiotensin; AT₁, angiotensin type-1. Dashed line and grey tone indicates suppression.