This dose can be repeated every 4 6 h. Contraindicated in reactive airways disease or chronic obstructive pulmonary disease. Especially useful in hyperadrenergic syndromes. May worsen HF and should not be given in patients with second- or third-degree heart block or bradycardia. Adrenergic blockers nonselective alpha receptor antagonist Phentolamine IV bolus dose 5 mg. Additional bolus doses every 10 min as needed to lower BP to target. Used in hypertensive emergencies induced by catecholamine excess (pheochromocytoma, interactions between monamine oxidase inhibitors and other drugs or food, cocaine toxicity, amphetamine overdose, or clonidine withdrawal). -receptor selective agonist Fenoldopam Initial 0.1 0.3 mcg/kg/min; may be increased in increments of 0.05 0.1 mcg/kg/min every 15 min until target BP is reached. Maximum infusion rate 1.6 mcg/ kg/min. Contraindicated in patients at risk of increased intraocular pressure (glaucoma) or intracranial pressure and those with sulfite allergy. ACE inhibitor Enalaprilat Initial 1.25 mg over a 5-min period. Doses can be increased up to 5 mg every 6 h as needed to achieve BP target. Contraindicated in pregnancy and should not be used in acute MI or bilateral renal artery stenosis. Mainly useful in hypertensive emergencies associated with high plasma renin activity. Dose not easily adjusted. Relatively slow onset of action (15 min) and unpredictability of BP response. BP indicates blood pressure; CCB, calcium channel blocker; HF, heart failure; IV, intravenous; and MI, myocardial infarction. include aortic dissection, severe preeclampsia or eclamp- sia, and pheochromocytoma with hypertensive crisis. 3. There is no RCT evidence comparing different strategies to reduce BP, except in patients with ICH.S11.2-9,S11.2-13 Neither is there RCT evidence to suggest how rapidly or how much BP should be lowered in a hypertensive emergency.S11.2-9 However, clinical experience indicates that excessive re- duction of BP may cause or contribute to renal, cerebral, or coronary ischemia and should be avoided. Thus, com- prehensive dosing of intravenous or even oral antihyper- tensive agents to rapidly lower BP is not without risk. Oral loading doses of antihypertensive agents can engender cumulative effects, causing hypotension after discharge from the emergency department or clinic. 11.3. Cognitive Decline and Dementia Recommendation for Prevention of Cognitive Decline and Dementia References that support the recommendation are summarized in Online Data Supplement 56. COR LOE Recommendation IIa B-R 1. In adults with hypertension, BP lowering is reasonable to prevent cognitive decline and Synopsis Dementia is a leading cause of mortality and placement into nursing homes and assisted living facilities, affecting >46 mil- lion individuals globally and 5 million persons in the United States, a number that is expected to double by 2050.S11.3-7 A 5-year delay in onset of dementia would likely decrease the number of cases of incident dementia by about 50% after Vascular disease and its risk factors are implicated in a large proportion of patients with demen- tia, including those with Alzheimer s dementia.S11.3-9 S11.3-11 Hypertension is also the primary risk factor for small-vessel Most observational studies have suggested that better control of SBP may reduce Alzheimer s disease and other dementias, and the evidence is stronger for BP lowering in middle age than in older adults.S11.3-9,S11.3-16 Clinical trials with dementia assessment have evaluated all-cause dementia but not Alzheimer s disease specifically. However, all of these trials have methodological issues, such as low power, insuf- ficient follow-up length, and inadequately designed dementia assessment batteries. Recommendation-Specific Supportive Text 1. Five clinical trials of BP lowering have included as- sessment for incident dementia. Of these 5 trials, 4 Table 20. Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies in Patients With Selected Comorbidities Comorbidity Preferred Drug(s)* Comments Acute aortic dissection Esmolol, labetalol Requires rapid lowering of SBP to 120 mm Hg.Beta blockade should precede vasodilator (eg, nicardipine or nitroprusside) administration, if needed for BP control or to prevent reflex tachycardia or inotropic effect; SBP 120 mm Hg should be achieved within 20 min. Acute pulmonary edema Clevidipine, nitroglycerin, nitroprusside Beta blockers contraindicated. Acute coronary syndromes Esmolol, labetalol, nicardipine, nitroglycerin Nitrates given in the presence of PDE-5 inhibitors may induce profound hypotension. Contraindications to beta blockers include moderate-to-severe LV failure with pulmonary edema, bradycardia (<60 bpm), hypotension (SBP <100 mm Hg), poor peripheral perfusion, second- or third-degree heart block, and reactive airways disease. Acute renal failure Clevidipine, fenoldopam, nicardipine N/A Eclampsia or preeclampsia Hydralazine, labetalol, nicardipine Requires rapid BP lowering.ACE inhibitors, ARBs, renin inhibitors, and nitroprusside contraindicated. Perioperative hypertension (BP 160/90 mm Hg or SBP elevation 20% of the preoperative value that persists for Clevidipine, esmolol, nicardipine, nitroglycerin Intraoperative hypertension is most frequently seen during anesthesia induction and airway manipulation. Acute sympathetic discharge or catecholamine excess states (eg, pheochromocytoma, post-carotid endarterectomy status) Clevidipine, nicardipine, phentolamine Requires rapid lowering of BP. Acute ICH Section 9.4.1 Section 9.4.1 Acute ischemic stroke Section 9.4.2 Section 9.4.2 *Agents are listed in alphabetical order, not in order of preference. Agent of choice for acute coronary syndromes. ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; bpm, beats per minute; ICH, intracerebral hemorrhage; LV, left ventricular; PDE-5, phosphodiesterase type-5; and SBP, systolic blood pressure. Whelton et al 2017 High Blood Pressure Clinical Practice Guideline e69 demonstrated a reduction in dementia incidence, with 2 of these 4 demonstrating statistical significance (746-751). SYST-EUR (Systolic Hypertension in and PROGRESS (Perindopril Protection Against Recurrent Stroke)S11.3-18 both showed statis- tically significant reductions in incident dementia. SYST-EUR achieved an SBP of 152 mm Hg in the treatment arm (8.3 mm Hg lower than placebo arm) during its blinded phase and an SBP of 149 mm Hg (7.0 mm Hg lower than comparison group) during its open-label follow-up phase.S11.3-2,S11.3-3 PROGRESS achieved an SBP of 138 mm Hg in the treatment group (9 mm Hg lower than the placebo group) and demon- strated dementia prevention in patients with a recent The trial showing no benefit in the direc- tion of dementia reduction achieved an SBP reduction of only 3.2 mm Hg, whereas the other 4 trials achieved SBP reductions of 7 to 15 mm Hg (746-751). When the rate of cognitive decline (not dementia) has been a trial outcome, 7 clinical trials of BP-lowering ther- apy have been completed, and 2 of these have shown No randomized trial of BP lowering has demonstrated an adverse impact on dementia incidence or cognitive function. However, the anticipated results from SPRINT, the first ad- equately powered RCT to test whether intensive BP control reduces dementia, may help clarify this issue in the near future. 11.4. Sexual Dysfunction and Hypertension An association among sexual dysfunction, atherosclerosis, and hypertension can be constructed from several epidemi- ology surveys, clinical trials, and cohort studies. Although these data converge to suggest that endothelial dysfunc- tion is a common denominator, the story is incomplete. Sexual dysfunction represents several domains in desire or interest, as well as physical limitations such as erectile dysfunction. In addition, beta blockers, mineralocorticoid receptor antagonists, and other antihypertensive drugs can have negative effects on libido and erectile function. There are emerging data on the association between erectile dys- function and CVD compared with other domains of sexual dysfunction. Experimental and clinical studies describe a role for angiotensin II, endothelin, and hydrogen sulfide on cavernous tissue function.S11.4-1 Many of the signaling path- ways for the increased production of oxidative stress and the subsequent deleterious effects of oxidative stress on vascular tissue have been described. Accordingly, it is rea- sonable to suggest that hypertension might lead to vascu- lar changes that cause erectile dysfunction but, conversely, erectile dysfunction may be part of the causal pathway to Although there is insufficient evidence to rec- ommend screening for CVD risk factors in all men with erectile dysfunction, it has been reported as a sole precur- sor for CVD in men.S11.4-2 S11.4-6 With the introduction of the phosphodiesterase-5 inhibi- tors, which can be coadministered with antihypertensive medications, there is now effective therapy for erectile dysfunction that has implications for systemic vascular These drugs have additive effects on lowering BP and are recommended as a primary therapy for pulmonary Although data are available to suggest that some antihypertensive medications affect erectile dysfunc- tion more than others, the use of phosphodiesterase-5 inhibi- tors make drug class distinctions for erectile dysfunction less The long-term safety and efficacy of chronic administration of phosphodiesterase-5 inhibitors for the mit- igation of CVD has yet to be determined and represents an important knowledge gap. 11.5. Patients Undergoing Surgical Procedures Recommendations for Treatment of Hypertension in Patients Undergoing Surgical Procedures References that support recommendations are summarized in Online Data Supplements 57 and 58. COR LOE Recommendations Preoperative I B-NR 1. In patients with hypertension undergoing major surgery who have been on beta blockers chronically, beta blockers should be IIa C-EO 2. In patients with hypertension undergoing planned elective major surgery, it is reasonable to continue medical therapy for hypertension until surgery. IIb B-NR 3. In patients with hypertension undergoing major surgery, discontinuation of ACE inhibitors or ARBs perioperatively may be IIb C-LD 4. In patients with planned elective major surgery and SBP of 180 mm Hg or higher or DBP of 110 mm Hg or higher, deferring surgery may be considered.S11.5-11,S11.5-12 III: Harm B-NR 5. For patients undergoing surgery, abrupt preoperative discontinuation of beta blockers or clonidine is potentially III: Harm B-NR 6. Beta blockers should not be started on the day of surgery in beta blocker na ve Intraoperative I C-EO 7. Patients with intraoperative hypertension should be managed with intravenous medications (Table 19) until such time as oral medications can be resumed. Synopsis Hypertension in the perioperative period increases the risk of CVD, cerebrovascular events, and bleeding.S11.5-15,S11.5-16 As many as 25% of patients who undergo major noncar- and 80% of patients who have cardiac surgery experience perioperative hypertension.S11.5-16,S11.5-18 In general, the level of risk is related to the severity of the hypertension. No high-quality RCTs were identified relating to the treatment of hypertension in patients undergoing major surgical procedures. One analysis evaluated data from 3 prospective, randomized, open-label, parallel-comparison studies in patients undergoing cardiac surgery and concluded that clevidipine is a safe and effective treatment for acute hypertension in patients undergoing cardiac surgery.S11.5-19 Another systematic review and meta-analysis, including 4 studies, concluded that clevidipine is more effective than other antihypertensive drugs in the management of periop- erative hypertension without adverse events.S11.5-20 Several general strategies and principles based on experience and observation are recommended for this section. In the man- agement of patients with perioperative hypertension, it is important to assess other potential contributing factors, such as volume status, pain control, oxygenation, and bladder distention, when the use of pharmacological therapy to con- trol BP is under consideration. Uncontrolled hypertension is associated with increased perioperative and postopera- tive complications. Certain medications (eg, beta blockers, clonidine) may be associated with rebound hypertension if Therefore, several general strat- egies and principles based on experience and observation are recommended for this section. These recommendations for beta blockers, ACE inhibi- tors, and ARBs are generally consistent with the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery and are provided to assist in the man- agement of patients undergoing major noncardiac surgical Recommendation-Specific Supportive Text 1. If well tolerated, beta blockers should be continued in patients who are currently receiving them for longitu- dinal reasons, particularly when longitudinal treatment is provided according to GDMT, such as for MI.S11.5-22 Multiple observational studies support the benefits of continuing beta blockers in patients who are undergo- ing surgery and who are on these agents for longitudinal 2. In the absence of conclusive RCTs, the expert opinion of this writing committee is that control of BP to lev- els recommended by the present guideline (BP <130/80 mm Hg) or other target levels specified for a particular individual is reasonable before undertaking major elec- tive procedures in either the inpatient or outpatient set- ting. If the patient is unable to take oral medications, it is reasonable to use intravenous medications (Table 19) as necessary to control BP. Special consideration of paren- teral therapy usually occurs for patients taking clonidine or beta blockers because of the risk of stopping these medications acutely. Withdrawal syndromes, accompa- nied by sympathetic discharge and acute hypertension, can occur on cessation of these agents.S11.5-13 3. Data on the potential risk and benefit of ACE inhibi- tors in the perioperative setting are limited to observa- tional analyses, and this area is controversial. Recent evidence from a large cohort study demonstrates that patients who stopped their ACE inhibitors or ARBs 24 hours before noncardiac surgery were less likely to suf- fer the primary composite outcome (all-cause death, stroke, or myocardial injury) and intraoperative hypo- tension than were those continuing these medications noted conflicting evidence for patients with DBP >110 mm Hg and recommended delay of surgery for gradual reduction in DBP before proceeding with surgery. In a systematic review and meta-analysis of 30 observational studies, preoperative hypertension was associated with a 35% increase in cardiovascular An increase in complications, in- cluding dysrhythmias, myocardial ischemia or infarc- tion, neurological complications, and renal failure, has been reported in patients with DBP 110 mm Hg immediately before surgery.S11.5-24 In contrast, patients with DBP <110 mm Hg do not appear to be at signifi- cantly increased risk.S11.5-25 The relationship of systolic hypertension to surgical risk is less certain. Among patients undergoing carotid endarterectomy, increased risk of postoperative hypertension and neurologi- cal defects were observed,S11.5-26 and an increased risk of CVD morbidity after coronary artery bypass graft surgery has been observed in patients with isolated During induction of an- esthesia for surgery, sympathetic action can result in a 20 to 30 mm Hg increase in BP and a 15- to 20- bpm increase in heart rate among patients with normal Exaggerated responses may occur in patients with poorly treated or untreated hypertension by as much as 90 mm Hg and 40 bpm.S11.5-24 With further anesthesia, the accompanying inhibition of the sympa- thetic nervous system and loss of baroreceptor control may result in intraoperative hypotension. Lability in BP appears more likely in patients with poorly controlled whereas studies have observed that patients with controlled hypertension respond similarly to those who are normotensive.S11.5-28 Early work indicated that patients with severe hypertension (SBP >210 mm Hg and DBP >105 mm Hg) had exaggerated responses in BP during the induction of anesthesia.S11.5-28 5. Although few studies describe risks of withdrawing beta blockers in the perioperative time period,S11.5-2,S11.5-5 longstanding evidence from other settings suggests that abrupt withdrawal of long-term beta blockers is There are fewer data to describe whether short-term (1 to 2 days) perioperative use of beta blockers, followed by rapid discontinuation, is 6. The 2014 ACC/AHA perioperative guideline specifically recommends against starting beta blockers on the day of surgery in beta-blocker naive patients,S11.5-5,S11.5-21,S11.5-30 particularly at high initial doses, in long-acting form, and if there are no plans for dose titration or monitoring for adverse events. Data from the POISE (Perioperative Ischemic Evaluation) study demonstrate the risk of initiating long-acting beta blockers on the day Whelton et al 2017 High Blood Pressure Clinical Practice Guideline e71 7. Several antihypertensive agents in a variety of pharmaco- logical classes are available for the treatment of hyperten- sive emergencies (Table 19). 12. Strategies to Improve Hypertension Treatment and Control In addition to promoting pharmacological and nonpharmaco- logical treatment adherence in individual patients with hyper- tension, several population-based systems approaches can play an important role in treatment goals. 12.1. Adherence Strategies for Treatment of Hypertension Therapeutic nonadherence (not following recommended medical or health advice, including failure to persist with medications and recommended lifestyle modifications) is a major contributor to poor control of hypertension and a key barrier to reducing CVD deaths. Adherence rates vary substantially in different populations and, in general, are lower for lifestyle change and more behaviorally demanding regimens. 12.1.1. Antihypertensive Medication Adherence Strategies Recommendations for Antihypertensive Medication Adherence Strategies References that support recommendations are summarized in Online Data Supplements 59 and 60. COR LOE Recommendations I B-R 1. In adults with hypertension, dosing of antihypertensive medication once daily rather than multiple times daily is beneficial to improve adherence.S12.1.1-1 S12.1.1-3 IIa B-NR 2. Use of combination pills rather than free individual components can be useful to improve adherence to antihypertensive Synopsis Up to 25% of patients do not fill their initial prescription for During the first year of treatment, the average patient has possession of antihyperten- sive medications only 50% of the time, and only 1 in 5 patients has sufficiently high adherence to achieve the benefits observed in clinical trials.S12.1.1-11,S12.1.1-12 Factors contributing to poor adherence are myriad, com- plex, and multilevel.S12.1.1-11,S12.1.1-13,S12.1.1-14 Therefore, solu- tions to improve adherence may be introduced at patient, provider, and healthcare system levels.S12.1.1-13,S12.1.1-15,S12.1.1-16 Several systematic reviews and meta-analyses have assessed the impact of interventions on adherence to antihyperten- sive medications, including modification of antihypertensive No single inter- vention is uniquely effective, and a sustained, coordinated effort that targets all barriers to adherence in an individual is likely to be the most effective approach. See Online Data Supplement F for barriers to medication adherence and the most successful interventions. The creation of an encouraging, blame-free environment in which patients are recognized for achieving treatment goals and given permission to answer questions related to their treatment honestly is essential to identify and address nonad- herence. Patient medication adherence assessment toolsS12.1.1-17 are presented in Online Data Supplement A. Members of the hypertension care team may use these self-report tools in a nonthreatening fashion to identify barriers and facilitate behaviors associated with improved adherence to antihyper- tensive medications. Use of more objective methods (eg, pill counts, data on medication refills) to assess adherence along with self-report methods is optimal. Recommendation-Specific Supportive Text 1. Remembering to take medication is often challenging, particularly for regimens that must be dosed several times daily. Taking medications several times through- out the day requires greater attention to scheduling, as well as additional issues such as transportation or stor- age, which can be challenging for some patients. The impact of once-daily dosing of antihypertensive drugs versus dosing multiple times daily has been evaluated in several meta-analyses.S12.1.1-1 S12.1.1-3 Medication ad- herence was greatest with once-daily dosing (range 71% to 94%) and declined as dosing frequency 2. Assessment and possible modification of drug therapy regimens can improve suboptimal adherence. Simplifying medication regimens, either by less frequent dosing (ie, once daily versus multiple times daily) or use of com- bination drug therapy, improves adherence. Available fixed-dose combination drug therapy is listed in Online Data Supplement D. 12.1.2. Strategies to Promote Lifestyle Modification Recommendation for Strategies to Promote Lifestyle Modification References that support the recommendation are summarized in Online Data Supplement 61. COR LOE Recommendation I C-EO 1. Effective behavioral and motivational strategies to achieve a healthy lifestyle (ie, tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with Synopsis The primary lifestyle modification interventions that can help reduce high BP are outlined in Section 6 (healthy diet, weight loss, exercise and moderate alcohol intake). In addi- tion, tobacco cessation is crucial for CVD risk reduction. These modifications are central to good health and require specific motivational and cognitive intervention strategies designed to promote adherence to these healthy behaviors. High-quality evidence supporting some of these strategies is provided in Online Data Supplement G. Additionally, interventions such as goal setting, provision of feedback, self-monitoring, follow-up, motivational interviewing, and promotion of self-sufficiency are most effective when com- bined. Most individuals have clear expectations about what a new lifestyle will provide; if their experiences do not match these expectations, they will be dissatisfied and less moti- vated to maintain a lifestyle change, particularly in envi- ronments that do not support healthy choices. Other factors that may influence adoption and maintenance of new physi- cal activity or dietary behaviors include age, sex, baseline health status, and body mass index, as well as the presence of comorbid conditions and depression, which negatively affect adherence to most lifestyle change regimens.S12.1.2-1 Primary strategies include cognitive-behavioral strategies for pro- moting behavior change, intervention processes and delivery strategies, and addressing cultural and social context vari- ables that influence behavioral change. Recommendation-Specific Supportive Text 1. It is crucial to translate and implement into practice the most effective evidence-based strategies for ad- herence to nonpharmacological treatment for hyper- tension. Both adoption and maintenance of new CVD risk-reducing behaviors pose challenges for many in- dividuals. Success requires consideration of race, eth- nicity, and socioeconomic status, as well as individual, provider, and environmental factors that may influence the design of such interventions.S12.1.2-1 High-quality evi- dence has shown that even modest sustained lifestyle changes can substantially reduce CVD morbidity and Because many beneficial effects of lifestyle changes accrue over time, long-term adher- ence maximizes individual and population benefits. Interventions targeting sodium restriction, other dietary patterns, weight reduction, and new physical activity habits often result in impressive rates of initial behavior changes but frequently are not translated into long-term behavioral maintenance. 12.1.3. Improving Quality of Care for Resource-Constrained Populations The availability of financial, informational, and instrumental support resources can be important though not sole determi- nants of hypertension control.S12.1.3-1,S12.1.3-2 The management of hypertension in resource-constrained populations poses a challenge that will require the implementation of all recom- mendations discussed in Section 13 (Table 21), with specific sensitivity to challenges posed by limited financial resources, including those related to health literacy, alignment of and potential need to realign healthcare priorities by patients, the convenience and complexity of the management strategy, accessibility to health care, and health-related costs (includ- ing medications). Resource-constrained populations are also populations with high representation of groups most likely to manifest health disparities, including racial and ethnic minorities (see Section 10.1), residents located in rural areas, and older adults. The more comprehensive BP targets pro- posed in the present guideline will present added challenges in these populations. It is crucial to invest in measures to enhance health lit- eracy and reinforce the importance of adhering to treatment strategies, while paying attention to cultural sensitivities. These measures may include identification of and partner- ing with community resources and organizations devoted to hypertension control and cardiovascular health. Although comparative-effectiveness data documenting efficacy of various interventions are limited, multidisciplinary team based approaches and the use of community health work- ers (see Sections 12.1.1 and 12.2) have shown some utility, as has the use of out-of-office BP monitoring (or no-cost BP control visits), particularly among resource-constrained Long-acting once-daily medica- tions (eg, chlorthalidone, amlodipine) that are now avail- able generically and often on discount formularies can often be used to reduce complexity of the regimen and promote adherence by decreasing the effect of missed medication dosages. When possible, prescriptions requiring longer than 30-day refills should be considered, especially once a Table 21. Clinician s Sequential Flow Chart for the Management of Hypertension Clinician s Sequential Flow Chart for the Management of Hypertension Measure office BP accurately Section 4 Detect white coat hypertension or masked hypertension by using ABPM and HBPM Evaluate for secondary hypertension Section 5 Identify target organ damage Sections 5 and 7 Introduce lifestyle interventions Section 6 Identify and discuss treatment goals Sections 7 and 8 Use ASCVD risk estimation to guide BP threshold for drug therapy Align treatment options with comorbidities Section 9 Account for age, race, ethnicity, sex, and special circumstances in antihypertensive treatment Initiate antihypertensive pharmacological therapy Insure appropriate follow-up Section 8 Use team-based care Section 12 Connect patient to clinician via telehealth Section 12 Detect and reverse nonadherence Section 12 Detect white coat effect or masked uncontrolled hypertension Use health information technology for remote monitoring and self-monitoring of BP ABPM indicates ambulatory blood pressure monitoring; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; and HBPM, home blood pressure monitoring. Whelton et al 2017 High Blood Pressure Clinical Practice Guideline e73 stable regimen is achieved. Where appropriate, using scored tablets and pill cutters can decrease the cost of medication for patients. 12.2. Structured, Team-Based Care Interventions for Hypertension Control Recommendation for Structured, Team-Based Care Interventions for Hypertension Control References that support the recommendation are summarized in Online Data Supplement 62. COR LOE Recommendation I A 1. A team-based care approach is recommended for adults with Synopsis Team-based care to improve BP control is a health sys- tems level, organizational intervention that incorporates a multidisciplinary team to improve the quality of hyperten- sion care for patients.S12.2-8 S12.2-10 Various team-based hyper- tension care models have been demonstrated to increase the proportion of individuals with controlled BP and to reduce both SBP and DBP.S12.2-1 S12.2-7,S12.2-11,S12.2-12 A team-based care approach is patient centered and is frequently implemented as part of a multifaceted approach, with systems support for clinical decision making (ie, treatment algorithms), collabo- ration, adherence to prescribed regimen, BP monitoring, and patient self-management. Team-based care for hypertension includes the patient, the patient s primary care provider, and other professionals, such as cardiologists, nurses, pharma- cists, physician assistants, dietitians, social workers, and community health workers. These professionals complement the activities of the primary care provider by providing pro- cess support and sharing the responsibilities of hypertension care. Section 13 contains a comprehensive, patient-centered plan of care that should be the basis of all team-based care for hypertension. Team-based care aims to achieve effective control of hypertension by application of the strategies outlined in Online Data Supplement H.S12.2-3 Delineation of individual team member roles on the basis of knowledge, skill set, and availability, as well as the patient s needs, allows the pri- mary care provider to delegate routine matters to the team, thereby permitting more time to manage complex and criti- cal patient-care issues. Important implementation aspects, such as type of team member added, role of team members related to medication management, and number of team members, influence BP outcomes.S12.2-3,S12.2-13 Team member roles should be clear to all team members and to patients and families. Team-based care often requires organizational change and reallocation of resources.S12.2-14,S12.2-15 Systems-level sup- port, such as use of electronic health records (EHR) (see Section 12.3.1), clinical decision support (ie, treatment algo- rithms), technology-based remote monitoring (see Section 12.3.2), self-management support tools, and monitoring of performance, are likely to augment and intensify team-based care efforts to reduce high BP. Recommendation-Specific Supportive Text 1. RCTs and meta-analyses of RCTs of team-based hyper- tension care involving nurse or pharmacist intervention demonstrated reductions in SBP and DBP and/or greater achievement of BP goals when compared with usual Similarly, systematic reviews of team-based care, including a review of studies that in- cluded community health workers, for patients with pri- mary hypertension showed reductions in SBP and DBP and improvements in BP control, appointment keeping, and hypertension medication adherence as compared with usual care.S12.2-3,S12.2-12 12.3. Health Information Technology Based Strategies to Promote Hypertension Control 12.3.1. EHR and Patient Registries Recommendations for EHR and Patient Registries References that support recommendations are summarized in Online Data Supplement 63. COR LOE Recommendations I B-NR 1. Use of the EHR and patient registries is beneficial for identification of patients with undiagnosed or undertreated I B-NR 2. Use of the EHR and patient registries is beneficial for guiding quality improvement efforts designed to improve hypertension control.S12.3.1-1 S12.3.1-3 Synopsis A growing number of health systems are developing or using registries and EHR that permit large-scale queries to sup- port population health management strategies to identify undiagnosed or undertreated hypertension. Such innovations are implemented as ongoing quality improvement initia- tives in clinical practice. To reduce undiagnosed hyperten- sion and improve hypertension management, a multipronged approach may include 1) application of hypertension screen- ing algorithms to EHR databases to identify at-risk patients, 2) contacting at-risk patients to schedule BP measurements, 3) monthly written feedback to clinicians about at-risk patients who have yet to complete a BP measurement, and 4) electronic prompts for BP measurements whenever at-risk patients visit Recommendation-Specific Supportive Text 1. A growing number of health systems have implemented secure EHR and are developing databases that permit large-scale queries to support population health manage- ment strategies for more effective and accurate identifica- tion of patients with hypertension.S12.3.1-1 S12.3.1-3 2. A growing number of health systems have implemented secure EHR and are developing databases that permit large-scale quality improvement initiative designed queries to support population health management strategies for more effective management and control 12.3.2. Telehealth Interventions to Improve Hypertension Control Recommendation for Telehealth Interventions to Improve Hypertension Control References that support the recommendation are summarized in Online Data Supplement 64. COR LOE Recommendation IIa A 1. Telehealth strategies can be useful adjuncts to interventions shown to reduce BP for adults with Synopsis Telehealth strategies, such as telemedicine, digital health ( eHealth ), and use of mobile computing and communica- tion technologies ( mHealth ), are new and innovative tools to facilitate improvements in managing patients with hyperten- sion. mHealth interventions show promise in reducing SBP in patients with hypertension but with large variability in behav- ioral targets, intervention components, delivery modalities, and patient engagement.S12.3.2-5 In addition, there are important implications for the role of social networks, social media, and electronic technology as viable components of weight man- agement and other lifestyle modification and disease manage- Commonly used telehealth interventions for hyperten- sion management are listed in Online Data Supplement I. Wireless technologies (Online Data Supplement I) allow link- ing BP devices and other measurement devices to telephone- or Internet-based transmission systems or to Wi-Fi access points available in users homes and in communities. Some systems require patients to manually enter data, which is then forwarded to a remote computer or the mobile device of the telehealth provider through a telephone line or the Internet.S12.3.2-7 When data are received, they are stored and analyzed, and reports are generated, including variations and averages in BP and other parameters over the recording period. Recommendation-Specific Supportive Text 1. Meta-analyses of RCTs of different telehealth inter- ventions have demonstrated greater SBP and DBP and a larger proportion of patients achieving BP controlS12.3.2-2 than those achieved with usual care without telehealth. The effect of various telehealth interventions on BP lowering was signifi- cantly greater than that of BP self-monitoring without transmission of BP data, which suggests a possible add- ed value of the teletransmission approach.S12.3.2-1,S12.3.2-3 Although mHealth interventions in general showed promise in reducing SBP in patients with hyperten- sion, results were inconsistent.S12.3.2-5 It is unclear which combination of telehealth intervention features is most effective, and telehealth has not been demonstrated to be effective as a standalone strategy for improving hypertension control. 12.4. Improving Quality of Care for Patients With Hypertension 12.4.1. Performance Measures Recommendation for Performance Measures References that support the recommendation are summarized in Online Data Supplement 65. COR LOE Recommendation IIa B-NR 1. Use of performance measures in combination with other quality improvement strategies at patient-, provider-, and system- based levels is reasonable to facilitate optimal hypertension control.S12.4.1-1 S12.4.1-3 Synopsis Efforts to improve suboptimal medical care include the use of performance measures, which are defined as standardized, vali- dated approaches to assess whether correct healthcare processes are being performed and that desired patient outcomes are being Performance measures are often combined with other quality improvement strategies, such as certification or financial incentives tied to higher-quality care.S12.4.1-5 Guidelines help define clinical care standards that can be used to develop per- formance measures.As guidelines evolve over time to incorporate new evidence, related performance measures may also evolve. Because identification, treatment, and control of hyperten- sion are suboptimal, performance measures for hypertension control have been developed and recommended for use in qual- ity improvement projects aimed at improving hypertension control and related outcomes in clinical practice.S12.4.1-6 S12.4.1-8 Because the specific methods used in performance measures can have an impact on their accuracy and ultimate impact (eg, the method of BP measurement used in the assessment), they should be developed, tested, and implemented according to See Online Data Supplement J for publicly available performance measures to assess the quality of hypertension care (generally using JNC 7 criteria). Recommendation-Specific Supportive Text 1. RCTs on the impact of performance measures on hyper- tension control are lacking; RCTs of quality improve- ment protocols have shown improvements in hypertension Furthermore, a large observational study showed that a systematic approach to hypertension control, including the use of performance measures, was associated with significant improvement in hypertension control compared with historical control groups.S12.4.1-3 12.4.2. Quality Improvement Strategies Recommendation for Quality Improvement Strategies References that support the recommendation are summarized in Online Data Supplements 66 and 67. COR LOE Recommendation IIa B-R 1. Use of quality improvement strategies at the health system, provider, and patient levels to improve identification and control of hypertension can be effective.S12.4.2-1 S12.4.2-8 Whelton et al 2017 High Blood Pressure Clinical Practice Guideline e75 Synopsis High-quality BP management is multifactorial and requires the engagement of patients, families, providers, and healthcare The difference between patient out- comes achieved with current hypertension treatment methods and patient outcomes thought to be possible with best-practice treatment methods is known as a quality gap, and such gaps are at least partly responsible for the loss of thousands of lives This includes expanding patient and healthcare provider awareness, appropriate lifestyle modifications, access to care, evidence-based treatment, a high level of medication adherence, and adequate follow-up.S12.4.2-9 Quality improvement strategies or interventions aimed at reducing the quality gap for a group of patients who are representative of those encoun- tered in routine practice have been effective in improving the hypertension care and outcomes across a wide variety of clinic and community settings.S12.4.2-1 S12.4.2-4,S12.4.2-6,S12.4.2-8,S12.4.2-10 Hypertension quality improvement strategies, with exam- ples of substrategies that have been demonstrated to reduce BP and improve BP, are provided in Online Data Supplement E. Because the effects of the different quality improvement strategies varied across trials, and most trials included >1 qual- ity improvement strategy, it is not possible to discern which specific quality improvement strategies have the greatest effects. Team-based care (see Section 12.4) and an organized system of regular review, with antihypertensive drug therapy implemented via a stepped-care protocol, had a clinically sig- nificant effect on reducing SBP and DBP and improving BP control. The assessed strategies in Online Data Supplement E may be beneficial under some circumstances and in varying National initiatives such as Million Hearts Make Control Your Goal Blood Pressure Toolkit and Team Up Pressure Down provide quality improvement tools to support hypertension care in communities and clinical For other national and regional initiatives to improve hypertension, see Online Data Supplement G. Recommendation-Specific Supportive Text 1. Systematic review and meta-analyses of trials of quality improvement interventions at health system, provider, and patient levels have demonstrated greater SBP and DBP re- ductions and a larger proportion of patients achieving BP control than those observed with no intervention or usual care. Multicomponent and multilevel strategies at the lo- cal community and healthcare delivery system levels have been shown to improve BP control.S12.4.2-6,S12.4.2-7 12.5. Financial Incentives Recommendations for Financial Incentives References that support recommendations are summarized in Online Data Supplement 68. COR LOE Recommendations IIa B-R 1. Financial incentives paid to providers can be useful in achieving improvements in treatment and management of patient populations with hypertension.S12.5-1 S12.5-3 IIa B-NR 2. Health system financing strategies (eg, insurance coverage and copayment benefit design) can be useful in facilitating improved medication adherence and BP control in patients with hypertension.S12.5-4 Synopsis With the evolution of the US health system to reward value over volume, payment systems have focused on financial incentives to improve quality of care. Use of performance measures promulgated by national organizations, govern- mental payers, and commercial payers have fostered greater attention to control of high BP among healthcare providers and their patients. These performance measures have formed the basis for determining financial incentives for pay for performance initiatives, commercial insurer pay-for-value contracts, and the Medicare Shared Savings Programs devel- oped by the Centers for Medicare & Medicaid Services Innovation for Accountable Care Organizations. In addi- tion, the Centers for Medicare and Medicaid Services has developed The Million Hearts: Cardiovascular Disease Risk Reduction Model, which is an RCT designed to iden- tify and test scalable models of care delivery that reduce Greater attention is being paid to the influence of health insurance coverage and benefit designs focused on reducing patient copayments for antihypertensive medications. Recommendation-Specific Supportive Text 1. Moderate-quality evidence with mixed results sug- gests that population-based payment incentive pro- grams can play an important role in achieving better BP 2. Reduced copayments for health care, including for medi- cations, and improved outcomes of hypertension care have been identified in several US studies and in single studies in Finland, Israel, and Brazil.S12.5-4 This is con- sistent with other evidence on how copayments reduce uptake of care and has implications for policy makers, particularly because the balance of evidence does not suggest that reducing medication copayments leads to an increase in overall healthcare expenditure. 13. The Plan of Care for Hypertension Recommendation for the Plan of Care for Hypertension COR LOE Recommendation I C-EO 1. Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals, encourages effective management of comorbid conditions, prompts timely follow- up with the healthcare team, and adheres to CVD GDMT (Table 22). Recommendations for Financial Incentives (Continued) COR LOE Recommendations Synopsis A specific plan of care for hypertension is essential and should reflect understanding of the modifiable and nonmodifiable determinants of health behaviors, including the social deter- minants of risk and outcomes. A clinician s sequential flow chart for management of hypertension is presented in Table 21. Detailed evidence-based elements of the plan of care are listed in Table 22. The determinants will vary among demographic subgroups (see Section 10 for additional information). Recommendation-Specific Supportive Text 1. Studies demonstrate that implementation of a plan of care for hypertension can lead to sustained reduction of BP and attainment of BP targets over several years.S13-1 S13-6 Meta-analysis of RCTs shows reductions in BP of pa- tients with hypertension and achievement of BP goals at 6 months and 1 year when compared with usual care. 13.1. Health Literacy Communicating alternative behaviors that support self- management of healthy BP in addition to medication adher- ence is important. This should be done both verbally and in writing. Today, mobile phones have a recording option. For patients with mobile phones, the phone can be used to inform patients and family members of medical instructions after the doctor s visit as an additional level of communication. Inclusion of a family member or friend that can help interpret and encourage self-management treatment goals is suggested when appropriate. Examples of needed communication for alternative behaviors include a specific regimen relating to physical activity; a specific sodium-reduced meal plan indi- cating selections for breakfast, lunch, and dinner; lifestyle recommendations relating to sleep, rest, and relaxation; and finally, suggestions and alternatives to environmental barri- ers, such as barriers that prevent healthy food shopping or limit reliable transportation to and from appointments with health providers and pharmacy visits. 13.2. Access to Health Insurance and Medication Assistance Plans Health insurance and medication plan assistance for patients is especially important to improving access to and affordability of medical care and BP medications. Learning how the patient financially supports and budgets for his or her medical care and medications offers the opportunity to share additional insight relating to cost reductions, including restructured payment plans. Ideally, this would improve the patient s compliance with medication adherence and treatment goals. 13.3. Social and Community Services Health care can be strengthened through local partner- ships. Hypertensive patients, particularly patients with lower incomes, have more opportunity to achieve treatment goals with the assistance of strong local partnerships. In patients with low socioeconomic status or patients who are challenged by social situations, integration of social and community services offers complementary reinforcement of clinically identified treatment goals. Social and community services are helpful when explicitly related to medical care. However, additional Table 22. Evidence-Based Elements of the Plan of Care for Patients With Hypertension Plan of Care Associated Section(s) of Guideline and Other Reference(s) Pharmacological and nonpharmacological treatments Medication selection (initial and ongoing) Monitoring for adverse effects and adherence Nonpharmacological interventions Diet Exercise Weight loss if overweight Moderate alcohol consumption Management of common comorbidities and conditions Ischemic heart disease Section 9.1S13.1-3,S13.1-4 Heart failure Reduced ejection fraction Preserved ejection fraction Diabetes mellitus Section 9.6S13.1-6 Chronic kidney disease Section 9.3 Cerebrovascular disease Section 9.4 Peripheral artery disease Section 9.5 Atrial fibrillation Section 9.8 Valvular heart disease Section 9.9 Left ventricular hypertrophy Section 7.3 Thoracic aortic disease Section 9.10 Patient and family education Achieving BP control and self-monitoring Sections 4.2, 8.2 Risk assessment and prognosis Section 8.1.2 Sexual activity and dysfunction Section 11.4 Special patient groups Pregnancy Section 10.2.2 Older persons Section 10.3.1 Children and adolescents Section 10.3.2 Metabolic syndrome Section 9.7 Possible secondary causes of hypertension Resistant hypertension Section 11.1 Patients with hypertension undergoing surgery Renal transplantation Section 9.3.1 Psychosocial factors Sex-specific issues Section 10.2 Culturally sensitive issues (race and ethnicity) Resource constraints Section 12.5 (Continued) Whelton et al 2017 High Blood Pressure Clinical Practice Guideline e77 financial support and financial services are incredibly benefi- cial to patients, some of whom may choose to skip a doctor s appointment to pay a residential utility bill. 14. Summary of BP Thresholds and Goals for Pharmacological Therapy Several different BP thresholds and goals for the long-term treatment of hypertension with pharmacological therapy are recommended in this guideline. To provide a quick reference for practicing clinicians, these are summarized for hyperten- sive patients in general and for those with specific comorbidi- ties in Table 23. 15. Evidence Gaps and Future Directions In the present guideline, the writing committee was able to call on the large body of literature on BP and hypertension to make strong recommendations across a broad range of medical con- ditions. Nonetheless, significant gaps in knowledge exist. Importantly, there are areas where epidemiological and natural history studies suggest that hypertension prevention or earlier treatment of hypertension might substantially improve outcomes, but clinical trials are lacking to provide guidance. The combination of epidemiological data showing a graded relationship between BP and outcomes, particularly above a BP of 120/80 mm Hg, and the results of the SPRINT trial showing benefit of more comprehensive treatment to a target BP of <120/80 mm Hg, suggests that a lifelong BP below that level will substantially lower CVD and CKD incidence. This is especially the case for younger individuals, those with DM, and those with high lifetime CVD risk based on the presence of multiple risk factors, including high BP. If hard, cardiovascular outcome clinical trials remain the sole driver of evidence-based guidelines, then determining the full benefit of earlier interven- tion may not be possible because of the cost and length of time needed for intervention. Outcomes may be different if antihy- pertensive treatment is initiated earlier in the natural history of CVD. DM may provide a population in whom to test this hypothesis. Composite outcomes that include both prevention of events and surrogates, such as prevention of decline in renal function or amelioration of measures of subclinical atheroscle- rosis, vascular stiffness, or LV structure and function, should be considered. Otherwise, these younger individuals may be undertreated and experience mortality or CVD events before being old enough to enter hard outcome driven trials such as SPRINT. Replication of SPRINT, especially in younger patients with DM and in countries where nonischemic stroke is the predominant cause of CVD, is highly desirable. Likewise, implementation studies that demonstrate the practicality of SPRINT-like interventions in resource-constrained practice settings are needed. More information is urgently needed relating hypertensive target organ damage to CVD risk and outcomes. Should the identification of target organ damage and hypertensive heart disease prompt more aggressive BP management (ie, increase the rationale for instituting pharmacological therapy earlier or more intensively? Should all patients with hypertension be screened with echocardiogram for LVH? Should echocardiog- raphy be repeated once LVH is noted? Is it important to docu- ment LVH regression? At present, there are no RCT data to inform guideline recommendations. ABPM and HBPM provide enhanced ability to both diag- nose hypertension and monitor treatment. Although evidence is sufficient to recommend incorporating these tools into clini- cal practice, more knowledge about them is required. Areas of inquiry include closer mapping of the relationship of out- comes to ambulatory and home BP measurements, so that definitions of hypertension and hypertension severity based on Clinician follow-up, monitoring, and care coordination Follow-up visits Sections 8.1.3, Team-based care Section 12.2 Electronic health record Section 12.3.1 Health information technology tools for remote and self-monitoring Socioeconomic and cultural factors Health literacy Section 13.1.3 Access to health insurance and medication assistance plans Social services Section 13.1.3 Community services Section 13.1.3 BP indicates blood pressure. Table 22. Continued Plan of Care Associated Section(s) of Guideline and Other Reference(s) Table 23. BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions Clinical Condition(s) BP Threshold, mm Hg BP Goal, mm Hg General Clinical CVD or 10-year ASCVD No clinical CVD and 10-year ASCVD risk <10% Older persons ( 65 years of age; noninstitutionalized, ambulatory, community-living adults) Specific comorbidities Chronic kidney disease 130/80 <130/80 Chronic kidney disease after renal transplantation Stable ischemic heart disease 130/80 <130/80 Secondary stroke prevention 140/90 <130/80 Peripheral artery disease 130/80 <130/80 ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure. these measures can be developed, including the importance of masked hypertension, white coat hypertension, and nocturnal hypertension. Reproducibility of ambulatory and home BPs must be studied, and cohorts should include a broader range of ethnicities. Trials with entry criteria and treatment goals based on ambulatory or home BP measures should be con- ducted, including studies of masked and white coat hyperten- sion. The practicality and cost of incorporating ABPM into EHR and routine care should be assessed. The existence of these techniques should not hamper efforts to investigate ways to improve accuracy in the measurement of clinic BP. Further research on improving accuracy of office BP measurements, including number of measurements, training of personnel mea- suring BP, and device comparisons, will help standardize care and thus improve outcomes. Technology for measurement of BP continues to evolve with the emergence of cuffless devices and other strategies that provide the opportunity for continuous noninvasive assessment of BP. The accuracy, cost, and useful- ness of these new technologies will need to be assessed. The contemporary healthcare environment is dramatically different from the era in which awareness of hypertension as a risk factor and benefits of treatment were discovered. With the advent of the EHR, complex calculations of CVD risk and renal function can be incorporated into routine reports, and many new avenues to support intervention strategies are avail- able to clinicians. Optimizing these approaches will require continued focused research. Recognition that simply applying what we know about BP control would have a large impact on population health, observations on inefficiencies and excessive cost in the US healthcare system, and the growth of information technology have led to promising studies of ways to improve and monitor hypertension care. Results of this research are reflected in this guideline, but further work is required. Examples for study include the effectiveness of mul- tidisciplinary healthcare teams to achieve BP treatment goals at lower cost, social media to maintain contact with patients, information technology to monitor outcomes and decrease practice variability, and incentives to providers to achieve bet- ter outcomes for patients. A key goal of these efforts should be to demonstrate reduction in healthcare disparities across ethnicity, sex, social and economic class, and age barriers. More research on the prevention of the development of hypertension and the benefit of lifetime low BP should be conducted. In this regard, elucidation of genetic expression, epigenetic effects, transcriptomics, and proteomics that link genotypes with longitudinal databases may add consider- able knowledge about beneficial outcomes of lifelong lower BP, determinants of rise in BP over time, and identification of new treatment targets through understanding the under- lying pathophysiological mechanisms. Research should be directed toward the development of therapies that directly counteract the mechanisms accounting for the development of hypertension and disease progression. Additional research aimed at development of practical approaches to implemen- tation of clinical and population-based strategies to prevent obesity, increase physical fitness, and control excess salt and sugar intake could have significant public health impact. In addition, there are minimal, if any, data on whether treatment of hypertension during pregnancy mitigates risk; thus, there is a need for further research in this area, considering both proximate (during the pregnancy and postpartum period) and distant (CVD prevention) outcomes.S15-1 In the very old, frailty and higher risk of medication side effects complicate treatment. Additional knowledge of the effects of antihypertensive treatment for patients with demen- tia and patients who reside in long-term-care facility settings is needed. The best approach to older persons who have supine hypertension but postural hypotension needs to be clarified. Further research related to shared decision-making with patients and their families is needed. Examples include areas where evidence does not clearly identify one treatment or goal as substantially better than another, where improved patient knowledge (or improved provider knowledge of the patient s circumstances) might improve compliance, where reliance on patient collaboration improves achievement of outcomes (eg, HBPM, use of social media), and where there are competing health concerns (eg, older individuals with frailty). Finally, clinical guidelines are increasingly required to man- age the large body of accumulated knowledge related to diag- nosis and management of high BP. However, guidelines often cause controversy and confusion when competing recommen- dations are made by different expert groups or when changes in definitions, treatments, or treatment goals are introduced. Now may be the time to begin the investigation of the impact of guidelines on clinical practice, costs, and patient outcomes, as well as ways to facilitate communication and collaboration between different guideline-developing organizations. This document is, as its name implies, a guide. In managing patients, the responsible clinician s judgment remains paramount. Presidents and Staff American College of Cardiology Mary Norine Walsh, MD, MACC, President Shalom Jacobovitz, Chief Executive Officer William J. 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