Perspective:

The following are 10 points to remember about this science advisory:

1. Hypertension currently affects nearly 78 million adults in the United States and is also a major modifiable risk factor for other cardiovascular diseases and stroke.

2. High-quality blood pressure management is multifactorial and requires engagement of patients, families, providers, and health care delivery systems and communities. This includes expanding patient and health care provider awareness, appropriate lifestyle modifications, access to care, evidence-based treatment, a high level of medication adherence, and adequate follow-up.

3. The identification of best practice, evidence-based management algorithms leading to standardization of treatment, is a critical element in helping to achieve national blood pressure control goals at a population level.

4. Developing, disseminating, and implementing an effective hypertension treatment algorithm is a critical part of a multipronged systematic approach to controlling hypertension, as it facilitates clinical decision making, provides a default approach with proven benefits, and engages multiple providers in a coordinated manner.

5. The blood pressure goal for an individual is set by utilizing a combination of factors including scientific evidence, clinical judgment, and patient tolerance. For most people, the goal is <140 and <90; however, lower targets may be appropriate for some populations such as African-Americans, the elderly, or patients with left ventricular hypertrophy, systolic or diastolic left ventricular dysfunction, diabetes mellitus, or chronic kidney disease.

6. Lifestyle modifications should be initiated in all patients with hypertension, and they should be assessed for target organ damage and existing cardiovascular disease.

7. Self-monitoring is encouraged for most patients throughout their care, and requesting and reviewing readings from home and community settings can help the provider assist the patient in achieving and maintaining good control.

8. Treatment guidelines serve to facilitate a systematic approach to the management of hypertension, but provide appropriate modifications based on specific patient characteristics, preferences, and other pragmatic factors (e.g., cost, pill burden, risks of certain side effects) to optimize a personalized approach to the care of individual patients. Consider thiazides as first-line therapy in most patients.

9. For patients with hypertension in combination with certain clinical conditions, specific medications should be considered first-line treatments. These include for:

• Coronary artery disease/post-myocardial infarction: beta-blocker (BB), angiotensin-converting enzyme inhibitor (ACEI);

• Systolic heart failure: ACEI or angiotensin-receptor blocker (ARB), BB, aldosterone antagonist, thiazide;

• Diastolic heart failure: ACEI or ARB, BB, thiazide;

• Diabetes: ACEI or ARB, thiazide, BB, calcium channel blocker;

• Kidney disease: ACEI or ARB; and

• Stroke or transient ischemic attack (TIA): thiazide, ACEI.

10. The prevention of heart disease and stroke mandates a greater emphasis on the population-wide improvement of blood pressure awareness, treatment, and control, together with other cardiovascular health factors.