What to Tell Your Patients: New High Blood Pressure Guidelines

Summary Points

  • The 2017 AHA/ACC guidelines for treating high blood pressure in adults are the first comprehensive set in the U.S. since the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) was issued in 2003.
  • The guidelines are based on a thorough and careful review of the very latest, highest quality clinical trial research.
  • They are intended to help clinicians deliver the best care possible, and improve cardiovascular health overall.
  • More American adults will be told they have high blood pressure based on the new, lower thresholds. And those who are already being treated will need to talk with their health care providers about whether their target blood pressure readings need to be adjusted. In some cases, lifestyle changes and/or medications will need to be intensified.

Top 5 Highlights

Based on the new guidelines, how we define and manage high blood pressure has changed. Here are the top 5 things you should tell your patients.

1. The cut points that tell us who has elevated blood pressure and who has high blood pressure have changed. Stage 1 high blood pressure is now defined as 130/80 mm Hg or greater.

The biggest change in the guidelines is a new way of grouping blood pressure categories. Overall, a lower blood pressure target is recommended and has been shown to improve heart health.

For example, people who were told they had “prehypertension” with a systolic pressure (top number) from 120-139 mm Hg or a diastolic pressure (lower number) from 80-89 mm Hg are now classified as having elevated blood pressure or stage 1 high blood pressure.

Infographic: Blood Pressure

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What’s behind these changes? Research shows that adults with blood pressure readings considered prehypertensive under the old guidelines are already at up to double the risk  of having a major cardiac event—a heart attack or stroke—compared to those with a normal blood pressure. In addition, recent clinical trials find that lowering systolic blood pressure to 120 mm Hg  results in significant cardiovascular benefit in high-risk patients compared with blood pressure control to <140 mm Hg.

What are the new blood pressure categories? There are four:

  • Normal
  • Elevated
  • High blood pressure, Stage 1
  • High blood pressure, Stage 2

 Pressure  (mm Hg)
     <120 120-129
 Normal  Elevated  Stage 1
 Stage 2
 Blood  80-89  Stage 1
 Stage 1
 Stage 1
 Stage 2
 Pressure (mm Hg)
 90  Stage 2
 Stage 2
 Stage 2
 Stage 2

What if you’re already being treated for hypertension?

The new guidelines lower the blood pressure target when treatment is needed. It’s a good time to revisit your treatment plan and decide whether your target blood pressure numbers should be lower than what you’re currently aiming for. Your medications, lifestyle changes or both may need to be intensified.

2. Of those who fall into the new elevated blood pressure and stage 1 high blood pressure categories, only a small number will need blood pressure-lowering medication. However, everyone in these groups should be making important lifestyle changes known to drive down blood pressure levels.

Having elevated blood pressure or stage 1 high blood pressure is a red flag that you must make purposeful lifestyle changes. Based on a number of studies the following changes—though not always easy—are proven to lower blood pressure, protect heart health and also carry other health benefits:

  • Losing weight. If you’re overweight, it’s important to try to get down to your recommended body weight.
  • Eating heart healthy and lowering your salt intake. For example, follow the Dietary Approaches to Stop Hypertension (DASH) diet.
  • Boosting your intake of potassium-rich foods. Good sources include banana, avocado, spinach, sweet potato, wild-caught salmon, acorn squash, and beans.
  • Getting regular physical activity.  Most types of activity count, for example brisk walking, cycling, swimming, dancing, gardening, and even housework.
  • Avoiding or limiting alcohol. The recommendation is to limit alcoholic beverages to no more than 2 “standard” drinks a day for men and 1 for women.

There are many resources available to help you be successful in adopting these changes into your life.

Lifestyle changes are key.

Making healthy lifestyle changes is an important part of treatment for everyone, regardless of how high your blood pressure is and whether or not you are taking one or more blood pressure-lowering medications. Lifestyle changes can lead to big improvements in your blood pressure and reduce your risk for heart problems.

3. If you have stage 1 high blood pressure, your risk of having a heart disease or stroke will help guide your treatment.

Based on the new guidelines, gauging someone’s risk for heart or vascular disease can help determine how to best manage blood pressure—that is, whether lifestyle changes alone or lifestyle changes coupled with a cholesterol-lowering medication are recommended.

How do we know your risk? We use something called the ASCVD risk calculator, which helps us to assess how likely you are to have a heart attack or stroke within the next 10 years. The calculator takes into account things like:

  • Your age
  • Gender
  • Total and HDL or “good” cholesterol
  • Systolic blood pressure (the top number)
  • If you smoke or have diabetes

Using this 10-year risk estimate helps us pinpoint who is likely to benefit most from blood pressure-lowering medications. If your risk of having a heart attack or stroke is 10% or higher—meaning that you have a 1 in 10 chance of developing cardiovascular disease or more—you should be taking a blood pressure-lowering medication in addition to adopting non-drug, lifestyle changes.

What is ASCVD?

Heart attack and stroke are often caused by atherosclerotic cardiovascular disease (ASCVD). ASCVD develops because of a buildup of sticky cholesterol-rich plaque. Over time, this plaque can harden and narrow the arteries.

Similar to earlier guidelines, the use of drugs in addition to lifestyle changes is recommended for everyone with stage 2 high blood pressure (now those with readings of 140 mm Hg or 90 mm Hg or greater).

 Blood Pressure Category  +
ASCVD Risk Level
=  Treatment Recommendation
Elevated blood pressure or stage 1 high blood pressure
Less than 10%
  • Lifestyle changes
  • Repeat blood pressure evaluation within 3 to 6 months
Stage 1 high blood pressure
10% or greater
  • Combination of lifestyle changes and antihypertensive drug therapy
  • Repeat blood pressure evaluation in 1 month

4. Learning how to take your blood pressure at home is important, and can provide valuable information to manage your numbers.

Blood pressure levels vary. Sometimes the blood pressure readings we get in the office are not always accurate, and it’s only a point in time. For some people, blood pressure may be falsely elevated in the doctor’s office (called white coat hypertension). For others, it may be misleadingly lower than it usually is (called masked hypertension). In an ideal world, we should be taking two blood pressure readings on two different occasions and taking the average of these measures.

Home blood pressure monitoring and knowing your numbers over time can give your health team a better picture of your true blood pressure. But it has to be taken correctly.

Some common mistakes include, but are not limited to: 

  • Only taking one reading. Ideally you should take at least two readings a few minutes apart.
  • Sitting on a bed or with feet dangling instead of straight up (best in a firm chair) with your feet flat on the floor.
  • Using a cuff that doesn’t fit right or positioning it incorrectly on your arm.
  • Drinking caffeine or exercising right before taking your blood pressure.

More: Tips on How to Take Your Blood Pressure at Home.

5. High blood pressure is treatable.

Changes are not always easy, but they are achievable. There are many strategies, including online tools, to support you in making lifestyle changes that you can sustain. In addition, there are many options for blood pressure-lowering medications, and it’s important for you to take them as prescribed and to help successfully control your blood pressure.

Bottom Line: Lowering your blood pressure can save your life.

High blood pressure is often called the “silent killer” because it has no symptoms. It puts you at a much greater risk for developing heart disease and other health issues. It is a leading cause of death from heart attacks and stroke. Hypertension is also second only to cigarette smoking as a preventable cause of death.

List of Questions Patients May Ask

  • I haven’t really been concerned about my blood pressure–it’s always been under 140/90 mm Hg, so what’s different now?
  • Will I need a medication?
  • I’m already on a cholesterol-lowering medication and have been doing well. Now based on the new guidelines, my blood pressure is no longer considered controlled. What do I need to do now?
  • How does my risk of heart disease or stroke factor into how my blood pressure is treated?
  • What home blood pressure monitor would you recommend? How often should I be taking my blood pressure and recording it?
  • How do I use my home BP cuff? How do I know if it is accurate?
  • How often should I have my blood pressure rechecked?
  • What lifestyle changes should I make? 
  • How much salt is safe for me to take when I have high blood pressure?
  • What is sodium in terms of amount of salt?
  • Should I see a dietitian?

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