Initiation of BP-lowering therapy with two first-line agents of different classes (as separate agents or in a fixed-dose combination) is recommended for adults with stage 2 hypertension and an average BP more than 20/10 mm Hg above their target. SEARCH BY SPECIALTY BY ORGANIZATION BY DATE Dec. 15, 2022, 1:40 p.m. News Staff The AAFP, following a review of several randomized, controlled trials, has published a new clinical practice guideline on appropriate blood pressure treatment targets for adults with hypertension. CARRIE ARMSTRONG, AFP Senior Associate Editor. Related editorial: ACC/AHA Hypertension Guideline: What Is New? Access to safe environments to exercise, healthful foods and financial resources are important factors in blood pressure control, she added. Home | AAFP Our current approach to routine office BP measurement should not be used to implement the targets recommended in this guideline. Copyright 2023 American Academy of Family Physicians. Youll see a combination of AAFP-developed guidelines and recommendations from external organizations (e.g. Lower blood pressure targets lead to a reduction in myocardial infarction, with a number needed to treat of 137 over 3.7 years. Editor's Note: The American Academy of Family Physicians (AAFP) does not endorse the 2017 ACC/AHA guideline on hypertension and continues to endorse the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Institute lifestyle measures. Editor's Note: The ISH guidelines are important because they successfully cut the Gordian knot of conflicting diagnosis thresholds and treatment targets in hypertension. They move us away from the 2017 American College of Cardiology/American Heart Association (ACC/AHA; https://www.aafp.org/afp/2018/0315/p413.html) guidelines, which recommended a diagnosis and treatment target of 130/80 mm Hg primarily based on a few large, well-controlled trials that are difficult to replicate in practice. 15 The 2014 Eighth Joint National Committee guideline, which is endorsed by the American Academy of Family . Intensive behavioral counseling results in an average decrease in systolic BP of about 2 mm Hg at 12 to 24 months.9 The easy path will be to make the leap to medication, rather than leave this disease uncontrolled. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. The AAFP states that: "The American Academy of Family Physicians is the national association of family doctors. Also in 2017, the American Heart Association, the American College of Cardiology and nine partnering organizations released a guideline on the prevention, detection, evaluation and management of hypertension in adults, but the AAFP chose not to endorse it, opting instead to continue endorsing the JNC8 guidelines. The. Home blood pressure monitoring is an alternative method and the focus of this article. What Do We Do?. A subsequent multicenter trial with more than 8,500 participants also demonstrated similar mortality with lower blood pressure targets. The guideline authors also advised clinicians and policymakers to consider how social determinants of health can affect patient care, leading Coles to recommend another well-known Academy resource. Other adverse effects such as syncope and hypotension are increased with a number needed to harm of 33 over 3.7 years. Adults with elevated blood pressure or stage 1 hypertension whose estimated 10-year risk of atherosclerotic cardiovascular disease is less than 10% should be treated with nonpharmacologic interventions. All Rights Reserved. The American Academy of Family Physicians (AAFP) was founded in 1947 to promote and maintain high-quality standards for family medicine, an offshoot of the classical general practitioner.It is headquartered in Leawood, Kansas.. AAFP is one of the largest medical organizations in the United States, with 136,700 members in 50 U.S. states and territories, in addition to international members. BP is a dynamicnot staticmeasurement, and varies based on when, where, and how it is measured. Many practices now use automated office blood pressure devices that were initially used in clinical studies. An average of multiple readings, ideally two readings in the morning and again in the evening separated by at least one minute each, is recommended for one week. Using the average of two or three measurements taken on two or more separate occasions will minimize random error and provide a more accurate basis for estimation of BP. ), Treatment is recommended for noninstitutionalized, ambulatory, community-dwelling adults 65 years and older with an average systolic BP of 130 mm Hg or above to achieve a target systolic BP of less than 130 mm Hg. Adults with stage 2 hypertension should be evaluated by or referred to a primary care physician within one month, receive a combination of nonpharmacologic interventions and BP-lowering medications (with two agents from different classes), and undergo repeat evaluation in one month. In adults with hypertension, does initiating treatment with antihypertensive pharmacologic monotherapy vs. combination therapy differ in comparative benefits and harms on specific health outcomes? About the AAFP | AAFP What Do We Do? More than 90% of participants in the SPRINT trial whose BP targets were reduced were already receiving treatment; few data exist for initiating pharmacologic therapy at this new threshold. When patients have grade 1 hypertension without cardiovascular disease, chronic kidney disease, diabetes, or signs of organ damage, lifestyle therapy for three to six months is recommended. No, Recommendations based on patient-oriented outcomes? American Academy of Family Physicians represents 129,600 family physicians, residents, & students, providing advocacy, education, patient & practice resources. What is the optimal BP target for antihypertensive therapy in adults? These recommendations cover topics across the lifespan of your patients. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. After diagnosing hypertension, further assessment is recommended to identify cardiovascular risk factors and signs of hypertension-mediated organ damage. The ACC/AHA recommendations were based on a systematic review that addressed the following questions: Is there evidence that home BP monitoring (HBPM) and/or ambulatory BP monitoring (ABPM) are superior to office-based BP measurement by a health care professional for preventing adverse outcomes and achieving better BP control? Yes, Guideline developed by participants without relevant financial ties to industry? Evidence shows that home blood pressure measurements are generally lower than blood pressure measured in a clinician's office.1,2 The current expansion of telemedicine has increased the need to monitor blood pressure at home and decreased the number of in-office blood pressure measurements. JEFFREY M. WEINFELD, MD, MBI, KATHRYN M. HART, MD, AND JOSE D. VARGAS, MD, PhD. Author disclosure: No relevant financial affiliations. Recommended long-term blood pressure targets are less than 130/80 mm Hg in patients younger than 65 years and less than 140/90 mm Hg in patients 65 years or older. People treated to a lower blood pressure target increased rates of adverse events, including syncope and hypotension, with a number needed to harm of 33 over 3.7 years. The2022 Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP, was developed by the American Academy of Family Physicians and approved by the Board of Directors in July 2022. Based on mortality, the standard target of 140/90 mm Hg is equivalent to lower targets, making this our primary goal. BP classification should be the average of two carefully measured office readings obtained on at least two occasions. In the interim, the Departments of Veterans Affairs and Defense, the National Institute for Health and Care Excellence and other organizations also published guidelines on hypertension with differing blood pressure targets. While the recent guidelines recommended to keep BP <130/80 mmHg in the elderly, more individualized approach should be considered to achieve this goal in order to avoid undesirable complications. After starting medication, target blood pressure is less than 140/90 mm Hg within three months, and after three months reduce target to less than 130/80 mm Hg in patients younger than 65 years. Recommendations for lifestyle modification alone apply only to adults younger than 65 years who have a 10-year CVD risk of less than 10%. This content is owned by the AAFP. Copyright 2018 by the American Academy of Family Physicians. Other studies, such as echocardiography, renal artery evaluation, or brain imaging, are not routinely recommended. The PPE in children and adolescents is reviewed here. See permissionsforcopyrightquestions and/or permission requests. Screening for masked hypertension with ABPM or HBPM is reasonable in adults whose untreated office BP is consistently 120 to 129 mm Hg systolic or 75 to 79 mm Hg diastolic. The systematic review found no significant differences in total serious adverse events between the lower and standard target groups, but did note a significant increase in all other adverse events (such as syncope and hypotension) when treating to a lower systolic target. Age Limit of Pediatrics | Pediatrics | American Academy of Pediatrics The name was changed in order to reflect more accurately the changing nature of primary health . Copyright 2021 by the American Academy of Family Physicians. ACC/AHA Hypertension Guideline: What Is New? and the American Academy of Family Physicians (AAFP) pub - lished recommendations for managing hypertension in adult patients 60 and older in early 2017, before release of the 2017 . In March 2017, the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) published a guideline for the treatment of hypertension in adults 60 years of age.1 Initiation of antihypertensive medi-cation is recommended by the ACP/AAFP guideline for adults 60 years of age with systolic blood pressure (SBP) 150 m. Treating a lower blood pressure target does not provide any additional benefit to mortality or stroke risk. ), Decisions regarding the intensity of pharmacologic therapy and choice of drugs can reasonably be made based on clinical judgment, patient preferences, and a team-based approach to assess risks and benefits for adults 65 years and older with hypertension, a high burden of comorbidities, and limited life expectancy. Second, the AAFP recommends that clinicians consider treating adults with hypertension to a lower blood pressure target of less than 135/85 mm Hg to reduce the risk of myocardial infarction. Adults 60 years or older with a history of stroke or TIA may be treated to a lower target blood pressure of <140 mm Hg to reduce the risk of recurrent stroke. Using a blood pressure target of 140/90 mm Hg reduces cardiovascular and all-cause mortality as much as lower targets. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. Long-term adherence is challenging, and suboptimal management is commonly related to poor adherence. Patients should be instructed to record their readings for three (minimum) to seven (ideal) days leading up to their clinic appointment. Adherence can be improved through strategies including combination pills, once-daily dosing, home BP monitoring, electronic reminders, and support from a multidisciplinary team. Treat them. Erectile dysfunction (ED) is when a man cannot get or keep an erection. See permissionsforcopyrightquestions and/or permission requests. This disparity can produce confusion and mixed messages. While treating to a lower blood pressure target of less than 135/85 mm Hg may be considered based on patient preferences and values, the lower target does not provide additional benefit at preventing mortality. Consider treating adults who have hypertension to a lower blood pressure target (less than 135/85 mm Hg) to reduce risk of myocardial infarction (weak recommendation; moderate-quality evidence). Copyright 2023 American Academy of Family Physicians. Yes, Available at:https://www.aafp.org/afp/aafphypertensionguideline.html. Other important modifications include smoking cessation and stress reduction (Table 2). Although treating to a standard blood pressure target of less than 140/90 mm Hg reduced the risk of MI, there was a small additional benefit observed with a lower blood pressure target; however, there was no observed additional benefit in preventing stroke. A single antihypertensive is recommended in low-risk grade 1 hypertension or in patients 80 years or older. See permissionsforcopyrightquestions and/or permission requests. To diagnose hypertension based on readings from a home blood pressure monitor, patients should obtain two measurements separated by at least one minute twice per day. The guideline is the signature piece of the Academys newly updated Hypertension Clinical Guidance and Practice Resources webpage, which features additional clinician resources, patient education materials and more. Treatment of Hypertension in Adults Over Age 60 to Higher Vs Lower The American College of Physicians and the American Academy of Family Physicians (AAFP) offer thoughtful and balanced guidance that incorporates the results of these trials for adults 60 years and . No, Guideline developed by participants without relevant financial ties to industry? Hypertension is one of the leading causes of death globally each year, accounting for up to 30% of myocardial infarctions. Nine trials contributed to the ACC/AHA meta-analysis on which the guideline was based.7 Trials selectively enrolled persons at high risk of cardiovascular disease (CVD), with follow-up ranging from 2.0 to 5.7 years. Initial assessment in a patient who is hypertensive should evaluate for cardiovascular risk and any hypertension-mediated organ damage. Home blood pressure monitoring received increased attention in 2015 when the U.S. Preventive Services Task Force recommended using out-of-office measurements to confirm hypertension before initiating treatment; this recommendation was reaffirmed in 2021.14 The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline for high blood pressure in adults also recommends out-of-office blood pressure monitoring for confirmation of hypertension and titration of pharmaceutical treatment. This content is owned by the AAFP. Screening less frequently (i.e., every three to five years) is appropriate for adults 18 to 39 years of age not at increased risk for hypertension and with a previous normal blood pressure reading . Redefining a cutoff point above which the value of a physiologic measurement reflects a disease has huge implications.1 The recently released guideline from the American College of Cardiology (ACC) and American Heart Association (AHA) on the prevention, detection, evaluation, and management of high blood pressure (BP) in adults,2 summarized in this issue of American Family Physician,3 lowers this cutoff from 140/90 to 130/80 mm Hg. The AAFP supports the U.S. Preventive Services Task Force (USPSTF) clinical preventive service recommendations on this topic. AAFP Issues New Clinical Practice Guideline on Hypertension The American Academy of Family Physicians (AAFP) updated a recent systematic review with a literature review of subsequent studies to recommend blood pressure targets for primary care management . Properly obtained measurements have been the standard in clinical trials, but require about 10 minutes and are not routinely obtained in the office setting (Table 1). This guideline provides a stepped framework for patient treatment and clarifies the risks and benefits of different targets.Michael J. Arnold, MD, Contributing Editor, Guideline source: American Academy of Family Physicians, Systematic literature search described? AAFP clinical guidance includes different types of evidence-based recommendations such as preventive services, clinical practice guidelines, and Choosing Wisely. In addition to history and physical examination, a cost-effective assessment includes serum chemistry levels, fasting glucose level, fasting lipid panel, urinalysis, and electrocardiography. Built on decades of proven representation, leadership, and advocacy, we support our members and the specialty . Musculoskeletal. Out-of-office BP measurement in conjunction with telehealth counseling or clinical interventions is recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication. On average, each patient would need to take one additional medication to get to the lower target. The group also used a modified version of the Grading of Recommendations Assessment, Development and Evaluation system to rate the quality of evidence for each outcome and the overall strength of each recommendation. Pill counting, pharmacy record review, and witnessed intake of medications are objective ways to monitor adherence. Author disclosure: No relevant financial affiliations. Based in part on these concerns, the AAFPs Commission on Health of the Public and Science appointed a guideline development group, which analyzed the evidence from a 2020 Cochrane systematic review and conducted a target literature search of additional trials. The ISH guidelines, which were assembled using reviews of the ACC/AHA guidelines and six other international guidelines, overcome this conflict by providing separate diagnostic thresholds based on measurement techniques. Guideline compares evidence for benefits and harms of higher vs. lower systolic blood pressure targets. Blood Family by Anne Fine | Goodreads 2. The hypertension clinical practice guideline contains 2 recommendations. Physicians caring for patients with high BP should focus on overall patient health, with an emphasis on reducing the risk of future adverse CVD outcomes. It is one of the largest national medical organization. Combining home blood pressure monitoring with remote or telephone physician monitoring of results (i.e., self-measured blood pressure with clinician support) is a strategy recommended by the Centers for Disease Control and Prevention Community Preventive Services Task Force.7. The risk of CVD and all-cause mortality in persons with masked hypertension is similar to that in those with sustained hypertension, and about twice as high as in persons with normal BP. Standardizing at least five minutes of rest and 30 minutes without caffeine before measurement can further reduce variability. Clinical Practice Guidelines | AAFP These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on . Go To USPSTF Recommendation American Board of Family Medicine - Wikipedia Copyright 2023 American Academy of Family Physicians. American Academy of Family Physicians - Wikipedia However, treating to a lower blood pressure target does come with harms. A heart-healthy diet and increased physical activity through a structured exercise program are recommended. Furthermore, further studies are required to evaluate BP target in very old patients or those with multiple comorbidities. Implementing Ambulatory Blood Pressure Monitoring in Primary Care Practice. Copyright 2023 American Academy of Family Physicians. The AAFP supports the U.S. Preventive Services Task Force (USPSTF) clinical preventive service recommendation on high blood pressure (hypertension). Musculoskeletal Injuries in Adults: A Clinical Guideline from the American College of Physicians and American Academy of Family Physicians (2020) . Clinical Practice Guidelines. The ISH recommends categorizing grade 1 hypertension for BP levels less than 160/100 mm Hg and grade 2 hypertension for any higher BP levels. Editor's Note:These recommendations by the AAFP provide some nuance to the decision of blood pressure targets in hypertension. Author disclosure: No relevant financial affiliations. Coles also served as the guideline panel chair. Yes, Published source:J Am Coll Cardiol. All Rights Reserved. First, the AAFP recommends that clinicians treat adults with hypertension to a standard blood pressure target of less than 140/90 mm Hg to reduce the risks of all-cause mortality and cardiovascular mortality.
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