2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

HomeCirculationVol. 138, No. 172017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUB2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Paul K. Whelton, MB, MD, MSc, FAHA, Robert M. Carey, MD, FAHA, Wilbert S. Aronow, MD, FACC, FAHA, Donald E. CaseyJr, MD, MPH, MBA, FAHA, Karen J. Collins, MBA, Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA, Sondra M. DePalma, MHS, PA-C, CLS, AACC, Samuel Gidding, MD, FAHA, Kenneth A. Jamerson, MD, Daniel W. Jones, MD, FAHA, Eric J. MacLaughlin, PharmD, Paul Muntner, PhD, FAHA, Bruce Ovbiagele, MD, MSc, MAS, MBA, FAHA, Sidney C. SmithJr, MD, MACC, FAHA, Crystal C. Spencer, JD, Randall S. Stafford, MD, PhD, Sandra J. Taler, MD, FAHA, Randal J. Thomas, MD, MS, FACC, FAHA, Kim A. WilliamsSr, MD, MACC, FAHA, Jeff D. Williamson, MD, MHS and Jackson T. WrightJr, MD, PhD, FAHA Paul K. WheltonPaul K. Whelton , Robert M. CareyRobert M. Carey , Wilbert S. AronowWilbert S. Aronow , Donald E. CaseyJrDonald E. CaseyJr , Karen J. CollinsKaren J. Collins , Cheryl Dennison HimmelfarbCheryl Dennison Himmelfarb , Sondra M. DePalmaSondra M. DePalma , Samuel GiddingSamuel Gidding , Kenneth A. JamersonKenneth A. Jamerson , Daniel W. JonesDaniel W. Jones , Eric J. MacLaughlinEric J. MacLaughlin , Paul MuntnerPaul Muntner , Bruce OvbiageleBruce Ovbiagele , Sidney C. SmithJrSidney C. SmithJr , Crystal C. SpencerCrystal C. Spencer , Randall S. StaffordRandall S. Stafford , Sandra J. TalerSandra J. Taler , Randal J. ThomasRandal J. Thomas , Kim A. WilliamsSrKim A. WilliamsSr , Jeff D. WilliamsonJeff D. Williamson and Jackson T. WrightJrJackson T. WrightJr Originally published22 Oct 2018https://doi.org/10.1161/CIR.0000000000000597Circulation. 2018;138:e426–e483Table of ContentsPreamble e4281. Introduction e4291.1. Methodology and Evidence Review e4301.2. Organization of the Writing Committee e4311.3. Document Review and Approval e4311.4. Scope of the Guideline e4311.5. Abbreviations and Acronyms e4332. BP and CVD Risk e4332.1. Observational Relationship e4332.2. BP Components e4332.3. Population Risk e4332.4. Coexistence of Hypertension and Related Chronic Conditions e4343. Classification of BP e4343.1. Definition of High BP e4343.2. Lifetime Risk of Hypertension e4343.3. Prevalence of High BP e4344. Measurement of BP e4354.1. Accurate Measurement of BP in the Office e4354.2. Out-of-Office and Self-Monitoring of BP e4354.3. Masked and White Coat Hypertension e4365. Causes of Hypertension e4385.1. Secondary Forms of Hypertension e4385.1.1. Drugs and Other Substances With Potential to Impair BP Control e4405.1.2. Primary Aldosteronism e4405.1.3. Renal Artery Stenosis e4405.1.4. Obstructive Sleep Apnea e4416. Nonpharmacological Interventions e4417. Patient Evaluation e4437.1. Laboratory Tests and Other Diagnostic Procedures e4438. Treatment of High BP e4438.1. Pharmacological Treatment e4438.1.1. Initiation of Pharmacological BP Treatment in the Context of Overall CVD Risk e4438.1.2. BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension e4438.1.3. Follow-Up After Initial BP Evaluation e4448.1.4. General Principles of Drug Therapy e4458.1.5. BP Goal for Patients With Hypertension e4478.1.6. Choice of Initial Medication e4478.2. Follow-Up of BP During Antihypertensive Drug Therapy e4478.2.1. Follow-Up After Initiating Antihypertensive Drug Therapy e4478.2.2. Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP e4489. Hypertension in Patients With Comorbidities e4489.1. Stable Ischemic Heart Disease e4489.2. Heart Failure e4499.2.1. Heart Failure With Reduced Ejection Fraction e4499.2.2. Heart Failure With Preserved Ejection Fraction e4499.3. Chronic Kidney Disease e4499.3.1. Hypertension After Renal Transplantation e4499.4. Cerebrovascular Disease e4509.4.1. Acute Intracerebral Hemorrhage e4509.4.2. Acute Ischemic Stroke e4509.4.3. Secondary Stroke Prevention e4519.5. Peripheral Artery Disease e4529.6. Diabetes Mellitus e4529.7. Metabolic Syndrome e4529.8. Atrial Fibrillation e4539.9. Valvular Heart Disease e4539.10. Aortic Disease e45310. Special Patient Groups e45310.1.1. Racial and Ethnic Differences in Treatment e45310.2. Sex-Related Issues e45310.2.1. Women e45410.2.2. Pregnancy e45410.3. Age-Related Issues e45410.3.1. Older Persons e45411. Other Considerations e45511.1. Resistant Hypertension e45511.2. Hypertensive Crises—Emergencies and Urgencies e45511.3. Cognitive Decline and Dementia e45811.4. Patients Undergoing Surgical Procedures e45812. Strategies to Improve Hypertension Treatment and Control e45812.1. Adherence Strategies for Treatment of Hypertension e45812.1.1. Antihypertensive Medication Adherence Strategies e45812.1.2. Strategies to Promote Lifestyle Modification e45812.2. Structured, Team-Based Care Interventions for Hypertension Control e45812.3. Health Information Technology–Based Strategies to Promote Hypertension Control e45912.3.1. EHR and Patient Registries e45912.3.2. Telehealth Interventions to Improve Hypertension Control e45912.4. Improving Quality of Care for Patients With Hypertension e45912.4.1. Performance Measures e45912.4.2. Quality Improvement Strategies e45912.5. Financial Incentives e45913. The Plan of Care for Hypertension e45913.1. Health Literacy e46013.2. Access to Health Insurance and Medication Assistance Plans e46013.3. Social and Community Services e46014. Summary of BP Thresholds and Goals for Pharmacological Therapy e461References e462Appendix 1. Author Relationships With Industry and Other Entities (Relevant) e475Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) e477PreambleSince 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines (guidelines) with recommendations to improve cardiovascular health. In 2013, the National Heart, Lung, and Blood Institute (NHLBI) Advisory Council recommended that the NHLBI focus specifically on reviewing the highest-quality evidence and partner with other organizations to develop recommendations.P-1,P-2 Accordingly, the ACC and AHA collaborated with the NHLBI and stakeholder and professional organizations to complete and publish 4 guidelines (on assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults) to make them available to the widest possible constituency. In 2014, the ACC and AHA, in partnership with several other professional societies, initiated a guideline on the prevention, detection, evaluation, and management of high blood pressure (BP) in adults. Under the management of the ACC/AHA Task Force, a Prevention Subcommittee was appointed to help guide development of the suite of guidelines on prevention of cardiovascular disease (CVD). These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA.Intended UsePractice guidelines provide recommendations applicable to patients with or at risk of developing CVD. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations can have a global impact. Although guidelines may be used to inform regulatory or payer decisions, they are intended to improve patients’ quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.Clinical ImplementationManagement in accordance with guideline recommendations is effective only when followed by both practitioners and patients. Adherence to recommendations can be enhanced by shared decision making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities.Methodology and ModernizationThe ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations, including the Institute of Medicine,P-3,P-4 and on the basis of internal reevaluation. Similarly, the presentation and delivery of guidelines are reevaluated and modified on the basis of evolving technologies and other factors to facilitate optimal dissemination of information to healthcare professionals at the point of care.Toward this goal, this guideline continues the introduction of an evolved format of presenting guideline recommendations and associated text called the “modular knowledge chunk format.” Each modular “chunk” includes a table of related recommendations, a brief synopsis, recommendation-specific supportive text, and when appropriate, flow diagrams or additional tables. References are provided within the modular chunk itself to facilitate quick review. Additionally, this format will facilitate seamless updating of guidelines with focused updates as new evidence is published, as well as content tagging for rapid electronic retrieval of related recommendations on a topic of interest. This evolved approach format was instituted when this guideline was near completion; therefore, the present document represents a transitional format that best suits the text as written. Future guidelines will fully implement this format, including provisions for limiting the amount of text in a guideline.Recognizing the importance of cost–value considerations in certain guidelines, when appropriate and feasible, an analysis of the value of a drug, device, or intervention may be performed in accordance with the ACC/AHA methodology.P-5To ensure that guideline recommendations remain current, new data are reviewed on an ongoing basis, with full guideline revisions commissioned in approximately 6-year cycles. Publication of new, potentially practice-changing study results that are relevant to an existing or new drug, device, or management strategy will prompt evaluation by the Task Force, in consultation with the relevant guideline writing committee, to determine whether a focused update should be commissioned. For additional information and policies regarding guideline development, we encourage readers to consult the ACC/AHA guideline methodology manualP-6 and other methodology articles.P-7–P-10Selection of Writing Committee MembersThe Task Force strives to avoid bias by selecting experts from a broad array of backgrounds. Writing committee members represent different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice. The Task Force may also invite organizations and professional societies with related interests and expertise to participate as partners, collaborators, or endorsers.Relationships With Industry and Other EntitiesThe ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without bias or improper influence. The complete relationships with industry and other entities (RWI) policy can be found online. Appendix 1 of the present document lists writing committee members’ relevant RWI. For the purposes of full transparency, writing committee members’ comprehensive disclosure information is available online. Comprehensive disclosure information for the Task Force is available online.Evidence Review and Evidence Review CommitteesIn developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data.P-6–P-9 Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited.An independent evidence review committee (ERC) is commissioned when there are 1 or more questions deemed of utmost clinical importance that merit formal systematic review. The systematic review will determine which patients are most likely to benefit from a drug, device, or treatment strategy and to what degree. Criteria for commissioning an ERC and formal systematic review include: a) the absence of a current authoritative systematic review, b) the feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline, c) the relevance to a substantial number of patients, and d) the likelihood that the findings can be translated into actionable recommendations. ERC members may include methodologists, epidemiologists, healthcare providers, and biostatisticians. The recommendations developed by the writing committee on the basis of the systematic review are marked with “SR.”Guideline-Directed Management and TherapyThe term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm the dosage by reviewing product insert material and evaluate the treatment regimen for contraindications and interactions. The recommendations are limited to drugs, devices, and treatments approved for clinical use in the United States.Class of Recommendation and Level of EvidenceThe Class of Recommendation (COR) indicates the strength of the recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence that supports the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1).P-6–P-8Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)The reader is encouraged to consult the full-text guidelineP-11 for additional guidance and details about hypertension, since the executive summary contains mainly the recommendations.Glenn N. Levine, MD, FACC, FAHAChair, ACC/AHA Task Force on Clinical Practice Guidelines1. IntroductionIn 2013, the National Heart, Lung, and Blood Institute (NHLBI) Advisory Council recommended that the NHLBI focus specifically on reviewing the highest-quality evidence and partner with other organizations to develop recommendations.S1-1,S1-2 Accordingly, the ACC and AHA collaborated with the NHLBI and stakeholder and professional organizations to complete and publish 4 guidelines (on assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults) to make them available to the widest possible constituency. In 2014, the ACC and AHA in partnership with several other professional societies initiated a guideline on the prevention, detection, evaluation and management of high blood pressure in adults. Under the management of the ACC/AHA Task Force, a Prevention Subcommittee was appointed to help guide development of the suite of guidelines on prevention of cardiovascular disease.As early as the 1920s, and subsequently in the 1959 Build and Blood Pressure StudyS1-3 of almost 5 million adults insured between 1934 and 1954, a strong direct relationship was noted between level of BP and risk of clinical complications and death. In the 1960s, these findings were confirmed in a series of reports from the Framingham Heart Study.S1-4 The 1967 and 1970 Veterans Administration Cooperative Study Group reports ushered in the era of effective treatment for high BP.S1-5,S1-6 The first comprehensive guideline for detection, evaluation, and management of high BP was published in 1977, under the sponsorship of the NHLBI.S1-7 In subsequent years, a series of Joint National Committee (JNC) BP guidelines were published to assist the practice community and improve prevention, awareness, treatment, and control of high BP.S1-7–S1-9 The present guideline updates prior JNC reports.1.1. Methodology and Evidence ReviewAn extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted between February and August 2015. Key search words included but were not limited to the following: adherence; aerobic; alcohol intake; ambulatory care; antihypertensive: agents, drug, medication, therapy; beta adrenergic blockers; blood pressure: arterial, control, determination, devices, goal, high, improve, measurement, monitoring, ambulatory; calcium channel blockers; diet; diuretic agent; drug therapy; heart failure: diastolic, systolic; hypertension: white coat, masked, ambulatory, isolated ambulatory, isolated clinic, diagnosis, reverse white coat, prevention, therapy, treatment, control; intervention; lifestyle: measures, modification; office visits; patient outcome; performance measures; physical activity; potassium intake; protein intake; renin inhibitor; risk reduction: behavior, counseling; screening; sphygmomanometers; spironolactone; therapy; treatment: adherence, compliance, efficacy, outcome, protocol, regimen; weight. Additional relevant studies published through June 2016, during the guideline writing process, were also considered by the writing committee and added to the evidence tables when appropriate. The final evidence tables included in the Online Data Supplement summarize the evidence used by the writing committee to formulate recommendations.As noted in the preamble, an independent ERC was commissioned to perform a formal systematic review of 4 critical clinical questions related to hypertension (Table 2), the results of which were considered by the writing committee for incorporation into this guideline. Concurrent with this process, writing committee members evaluated other published data relevant to the guideline. The findings of the ERC and the writing committee members were formally presented and discussed, and then guideline recommendations were developed. The systematic review report, “Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults,” is published in conjunction with this guideline,S1-10 and its respective data supplements are available online. No writing committee member reported a RWI. Drs. Whelton, Wright and Williamson had leadership roles in SPRINT (Systolic Blood Pressure Intervention Trial). Dr. Carey chaired committee discussions in which the SPRINT results were considered.Table 2. Systematic Review Questions on High BP in AdultsQuestion NumberQuestionSection Number1Is there evidence that self-directed monitoring of BP and/or ambulatory BP monitoring are superior to office-based measurement of BP by a healthcare worker for 1) preventing adverse outcomes for which high BP is a risk factor and 2) achieving better BP control?4.22What is the optimal target for BP lowering during antihypertensive therapy in adults?8.1.59.39.63In adults with hypertension, do various antihypertensive drug classes differ in their comparative benefits and harms?8.1.68.24In adults with hypertension, does initiating treatment with antihypertensive pharmacological monotherapy versus initiating treatment with 2 drugs (including fixed-dose combination therapy), either of which may be followed by the addition of sequential drugs, differ in comparative benefits and/or harms on specific health outcomes?8.1.6.1BP indicates blood pressure.1.2. Organization of the Writing CommitteeThe writing committee consisted of clinicians, cardiologists, epidemiologists, internists, an endocrinologist, a geriatrician, a nephrologist, a neurologist, a nurse, a pharmacist, a physician assistant, and 2 lay/patient representatives. It included representatives from the ACC, AHA, American Academy of Physician Assistants (AAPA), Association of Black Cardiologists (ABC), American College of Preventive Medicine (ACPM), American Geriatrics Society (AGS), American Pharmacists Association (APhA), American Society of Hypertension (ASH), American Society for Preventive Cardiology (ASPC), National Medical Association (NMA), and Preventive Cardiovascular Nurses Association (PCNA).1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers nominated by the ACC and AHA; 1 reviewer each from the AAPA, ABC, ACPM, AGS, APhA, ASH, ASPC NMA, and PCNA; and 38 individual content reviewers. Reviewers’ RWI information was distributed to the writing committee and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC, AHA, AAPA, ABC, ACPM, AGS, APhA, ASH, ASPC, NMA, and PCNA.1.4. Scope of the GuidelineThe present guideline is intended to be a resource for the clinical and public health practice communities. It is designed to be comprehensive but succinct and practical in providing guidance for prevention, detection, evaluation, and management of high BP. It is an update of the NHLBI publication, “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7).S1-9 It incorporates new information from studies of office-based BP-related risk of CVD, ambulatory blood pressure monitoring (ABPM), home blood pressure monitoring (HBPM), telemedicine, and various other areas. This guideline does not address the use of BP-lowering medications for the purposes of prevention of recurrent CVD events in patients with stable ischemic heart disease (SIHD) or chronic heart failure (HF) in the absence of hypertension; these topics are the focus of other ACC/AHA guidelines.S1-11,S1-12 In developing the present guideline, the writing committee reviewed prior published guidelines, evidence reviews, and related statements. Table 3 contains a list of publications and statements deemed pertinent to this writing effort and is intended for use as a resource, thus obviating the need to repeat existing guideline recommendations.Table 3. Associated Guidelines and StatementsTitleOrganizationPublication YearGuidelines Lower-extremity peripheral artery diseaseAHA/ACC2016S1-13 Management of primary aldosteronism: case detection, diagnosis, and treatmentEndocrine Society2016S1-14 Stable ischemic heart diseaseACC/AHA/AATS/PCNA/SCAI/STS2014S1-15* 2012S1-11 Pheochromocytoma and paragangliomaEndocrine Society2014S1-16 Atrial fibrillationAHA/ACC/HRS2014S1-17 Valvular heart diseaseACC/AHA2017S1-18 Assessment of cardiovascular riskACC/AHA2013S1-19 Hypertension in pregnancyACOG2013S1-20 Heart failureACC/AHA2017S1-212013S1-12 Lifestyle management to reduce cardiovascular riskAHA/ACC2013S1-22 Management of arterial hypertensionESH/ESC2013S1-23 Management of overweight and obesity in adultsAHA/ACC/TOS2013S1-24 ST-elevation myocardial infarctionACC/AHA2013S1-25 Treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adultsACC/AHA2013S1-26 Cardiovascular diseases during pregnancyESC2011S1-27 Effectiveness-based guidelines for the prevention of cardiovascular disease in womenAHA/ACC2011S1-28 Secondary prevention and risk-reduction therapy for patients with coronary and other atherosclerotic vascular diseaseAHA/ACC2011S1-29 Assessment of cardiovascular risk in asymptomatic adultsACC/AHA2010S1-30 Thoracic aortic diseaseACC/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM2010S1-31 Diagnosis, evaluation, and treatment of high blood pressure in children and adolescentsNHLBI2004S1-32Statements Salt sensitivity of blood pressureAHA2016S1-33 Cardiovascular team-based care and the role of advanced practice providersACC2015S1-34 Treatment of hypertension in patients with coronary artery diseaseAHA/ACC/ASH2015S1-35 Ambulatory blood pressure monitoring in children and adolescentsAHA2014S1-36 An effective approach to high blood pressure controlAHA/ACC/CDC2014S1-37 Ambulatory blood pressure monitoringESH2013 S1-38 Performance measures for adults with coronary artery disease and hypertensionACC/AHA/AMA-PCPI2011S1-39 Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adultsAHA2010S1-40 Resistant hypertension: diagnosis, evaluation, and treatmentAHA2008S1-41*The full-text SIHD guideline is from 2012.S1-11 A focused update was published in 2014.S1-15AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ACOG, American College of Obstetricians and Gynecologists; ACR, American College of Radiology; AHA, American Heart Association; AMA, American Medical Association; ASA, American Stroke Association; ASH, American Society of Hypertension; CDC, Centers for Disease Control and Prevention; ESC, European Society of Cardiology; ESH, European Society of Hypertension; HRS, Heart Rhythm Society; NHLBI, National Heart, Lung, and Blood Institute; PCNA, Preventive Cardiovascular Nurses Association; PCPI, Physician Consortium for Performance Improvement; SCA, Society of Cardiovascular Anesthesiologists; SCAI, Society for Cardiovascular Angiography and Interventions; SIHD, stable ischemic heart disease; SIR, Society of Interventional Radiology; STS, Society of Thoracic Surgeons; SVM, Society for Vascular Medicine; and TOS, The Obesity Society.1.5. Abbreviations and AcronymsAbbreviation/AcronymMeaning/PhraseABPMambulatory blood pressure monitoringACEangiotensin-converting enzymeAFatrial fibrillationARBangiotensin receptor blockerBPblood pressureCCBcalcium channel blockerCHDcoronary heart diseaseCKDchronic kidney diseaseCPAPcontinuous positive airway pressureCVDcardiovascular diseaseDBPdiastolic blood pressureDMdiabetes mellitusECGelectrocardiogramESRDend-stage renal diseaseGDMTguideline-directed management and therapyGFRglomerular filtration rateHBPMhome blood pressure monitoringEHRelectronic health recordHFheart failureHFpEFheart failure with preserved ejection fractionHFrEFheart failure with reduced ejection fractionICHintracerebral hemorrhageJNCJoint National CommissionLVleft ventricularLVHleft ventricular hypertrophyMImyocardial infarctionMRImagnetic resonance imagingPADperipheral artery diseaseRASrenin-angiotensin systemRCTrandomized controlled trialSBPsystolic blood pressureSIHDstable ischemic heart diseaseTIAtransient ischemic attack2. BP and CVD Risk2.1. Observational RelationshipObservational studies have demonstrated graded associations between higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) and increased CVD risk.S2.1-1,S2.1-2 In a meta-analysis of 61 prospective studies, the risk of CVD increased in a log-linear fashion from SBP levels <115 mm Hg to >180 mm Hg and from DBP levels <75 mm Hg to >105 mm Hg.S2.1-1 In that analysis, 20 mm Hg higher SBP and 10 mm Hg higher DBP were each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. In a separate observational study including >1 million adult patients ≥30 years of age, higher SBP and DBP were associated with increased risk of CVD incidence and angina, myocardial infarction (MI), HF, stroke, peripheral artery disease (PAD), and abdominal aortic aneurysm, each evaluated separately.S2.1-2 An increased risk of CVD associated with higher SBP and DBP has been reported across a broad age spectrum, from 30 years to >80 years of age. Although the relative risk of incident CVD associated with higher SBP and DBP is smaller at older ages, the corresponding high BP–related increase in absolute risk is larger in older persons (≥65 years) given the higher absolute risk of CVD at an older age.S2.1-12.2. BP ComponentsEpidemiological studies have evaluated associations of SBP and DBP, as well as derived components of BP measurements (including pulse pressure, mean BP, and mid-BP), with CVD outcomes (Table 4). When considered separately, higher levels of both SBP and DBP have been associated with increased CVD risk.S2.2-1,S2.2-2 Higher SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, DBP.S2.2-3–S2.2-5 In contrast, after consideration of SBP through adjustment or stratification, DBP has not been consistently associated with CVD risk.S2.2-6,S2.2-7 Although pulse pressure and mid-BP have been associated with increased CVD risk independent of SBP and DBP in some studies, SBP (especially) and DBP are prioritized in the present document because of the robust evidence base for these measures in both observational studies and clinical trials and because