AHA guidelines causing controversy

New Blood Pressure Guidelines Raise Concerns for Patients & Healthcare Providers

For the first time in more than a decade, officials with the American Heart Association (AHA) have reclassified how they recommend healthcare providers evaluate and treat high blood pressure. With the new set of guidelines, which were established in conjunction with 10 other organizations and now define high blood pressure as a reading of 130 mm Hg and higher for systolic blood pressure measurement or 80 mm Hg and higher for diastolic measurement, nearly half of all Americans will be considered to be living with hypertension. That means the prevalence of high blood pressure is expected to triple among men under age 45 and double among women under 45.

Additionally, the new guidelines eliminate the category of “prehypertension,” which was used for blood pressures with a systolic between 120-139 mm Hg or diastolic between 80-89 mm Hg. These readings will now be categorized as a patient having either “elevated’ (120-129 and less than 80) or “Stage I hypertension” (130-139 or 80-89). The previous standard for identifying Stage I hypertension (140/90 mm) is now considered to be “Stage II hypertension.”

While this may seem to be a path toward a healthier population in the treatment of the “silent killer” and potential prevention of heart disease, not everyone is embracing the new suggested standards which recommend that antihypertensive medication targeting below 130/80 mm Hg for nearly everyone ages 79 years or older based on history of cardiovascular disease, or a 10-year risk for cardiovascular events of 10% or greater.

Of particular concern among officials with the American College of Physicians (ACP), a group that publicly reported its opposition through an op-ed in the Annals of Internal Medicine after publication of the new guidelines, is that certain folks may be exposed to taking a daily medication at an earlier age than their risk factors would normally indicate, creating a scenario, where adverse events could outweigh the benefit of treatment. Inherent in the new guidelines, antihypertensive drug therapy is recommended for 36.2% of adults in the United States (81.9 million adults) and increases the number of U.S. adults recommended for drug therapy by 4.2 million.

According to researchers from the University of Alabama at Birmingham, the prevalence of hypertension in this country following the new guidelines would increase to 45.6% from 31.9%, per the number of adults said to be living with hypertension as of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, which was released in 2003.

The new guidelines also suggest that nonpharmacologic therapy be considered for 21.4 million Americans and advise that healthcare providers employ the use of automated measurement systems in their office as a means to gather more accurate readings. They also endorse that blood pressure measurements be taken by patients at home when possible to help rule out those folks who experience “white-coat” hypertension while identifying those who experience “masked hypertension,” described by the ADA as pressure that is normal in a medical setting but elevated at home.

Other concerns raised by the ACP related to the new guidelines include costs, potential lack of individualized care planning to treat varying levels of hypertension, and a general overburdening on healthcare providers due to the time-consuming nature of helping patients to manage and treat high blood pressure.

To counter however, Paul K. Whelton, MB, MD, MSc, a clinical professor at Tulane University and the lead author of the guidelines, stresses the dangers of blood pressure levels between 130-139/80-89 mm Hg in support of providers following the guidelines. “You’ve already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure [at those levels],” Whelton said in a statement to the press. “We want to be straight with people – if you already have a doubling of risk, you need to know about it. It doesn’t mean you need medication, but it’s a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches.”

“People with ‘white-coat’ hypertension do not seem to have the same elevation in risk as someone with true sustained high blood pressure,” Whelton continued. ‘‘Masked hypertension’ is more sinister and very important to recognize because these people seem to have a similar risk as those with sustained high blood pressure.”

As it pertains to pharmacology, ACA officials said the new guidelines only call for the prescribing of medication for Stage I hypertension if the patient has already experienced a cardiovascular event, such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age or the presence of diabetes, chronic kidney disease, or atherosclerotic risk based on high cholesterol. ADA officials also ask healthcare providers to recognize that many people will need two or more types of medications to control their blood pressure, and that people may take their pills more consistently if multiple medications are combined into a single pill.

Identifying socioeconomic status and psychosocial stress as risk factors for high blood pressure that should be considered in a patient’s plan of care is also advised by the ADA. The guideline authors have recently gone public in support of their recommendations despite the critical reception that some have showcased. “Yes, we will label more people hypertensive and give more medication, but we will save lives and money by preventing more strokes, cardiovascular events, and kidney failure,” said Kenneth Jamerson, MD, PhD, a professor of internal medicine and hypertension specialist at the University of Michigan Health System who is among the guideline writing committee. “If you are going to put money into the healthcare system, it’s to everyone’s advantage if we treat and prevent on this side of it, in early treatment.”


  1. New Guidelines Announcement: http://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017
  2. Young People: http://wwlp.com/2018/02/08/new-guidelines-put-younger-people-in-range-of-having-high-blood-pressure/
  3. Large Numbers of People: https://www.greenvilleonline.com/story/news/2018/01/28/half-all-americans-have-high-blood-pressure-new-guidelines-say-yes/1063255001/
  4. Controversy: https://www.medpagetoday.com/cardiology/hypertension/70677

About The Author