In the Multi-Ethnic Study of Atherosclerosis (MESA), the cumulative incidence of HTN between ages 45 to 85 years ranged from 84 to 93%. In the Coronary Artery Risk Development in Young Adults (CARDIA) study, the incidence of hypertension from ages 18 to 55 years ranged from 40 to 76%. However, the cumulative lifetime incidence of HTN (and the associated CVD morbidity and mortality) can be substantial. Even with the presence of stage 1 HTN, younger adults will frequently have low 10-year atherosclerotic cardiovascular disease (ASCVD) risk scores, and even relatively low lifetime risk estimates. 5–8 Current tools to estimate 10-year risk do not effectively estimate long-term risk of CVD, especially in younger healthier populations. This new addition to the guidelines reflects the growing appreciation that while short- and intermediate-term risk of HTN and CVD morbidity and mortality may be low, the 20+ year risk can be quite high. This applies especially, though not exclusively, to those patients with additional CVD risk factors such as family history of premature CVD, personal history of HTN during pregnancy, or personal history of premature birth.
The AHA Scientific Statement includes a distinct new recommendation: all patients with stage 1 HTN not meeting blood pressure targets after 6 months of lifestyle modification should be considered for antihypertensive pharmacologic therapy. The authors of the recent AHA statement seek to address this gap. They recommend repeat interval blood pressure measurement every 3 to 6 months, but do not provide guidance for intervention if blood pressure remains above target (<130/<80 mm Hg). The 2017 AHA/ACC guidelines recommend lifestyle modification for adults with stage 1 HTN and low 10-year cardiovascular risk. This dearth of RCT data has left a gap in guideline recommendations until now. Because of the number of participants and the extended length of follow-up that would be required in this subgroup to accumulate events and examine risk, the RCTs needed to answer this clinical question would be prohibitively resource-intensive and are unlikely to be performed.
2017 ACC CONFERENCE TRIAL
There are currently no randomized controlled trial (RCT) data examining the relationship between blood pressure and cardiovascular risk in younger, "low-risk" patients. Importantly, this landmark study focused on subjects with elevated baseline cardiovascular risk. Investigators also found lower all-cause mortality with intensive targets (1.1% per year vs. 2.4% per year hazard ratio 0.73 95% confidence interval, 0.63 to 0.86). 3,4Īt 3.3 years of follow-up, they found that the lower SBP target resulted in a significantly lower rate of the composite outcome of myocardial infarction, acute coronary syndrome, stroke, acute decompensated heart failure, or cardiovascular death (1.8% per year vs. The Systolic Blood Pressure Intervention Trial ( SPRINT) first published in 2015 (with follow-data published in 2021) randomized 9361 patients with HTN and elevated cardiovascular risk to either an intensive systolic blood pressure (SBP) target (<120 mm Hg) or a standard SBP target (<140 mm Hg). This change was prompted by a growing body of evidence showing a linear relationship between blood pressure and cardiovascular risk, namely that more intensive blood pressure control improves cardiovascular outcomes and survival. 2 It also re-classified "pre-HTN" as elevated blood pressure (120-129/<80 mmHg).
2017 ACC CONFERENCE UPDATE
The last update was in 2017 and the major change at that time was lowering the definition of HTN from ≥140/≥90 mmHg to ≥130/≥80 mmHg. The AHA/ACC started synthesizing evidence and publishing guidelines specifically for HTN in 2014. 1 This is a welcome addition to the guidelines as it fills an important gap in the most recent AHA/American College of Cardiology (ACC) recommendations. The American Heart Association (AHA) has recently released a new Scientific Statement regarding management of stage 1 HTN in adults with a low 10-year risk for CVD. In recent years, the incidence and prevalence of HTN have increased while rates of HTN control have declined. More cardiovascular disease (CVD) events are attributable to hypertension (HTN) than any other modifiable CVD risk factor. If blood pressure remains uncontrolled at 3-6 months, consider starting pharmacologic therapy. Among low-risk adults (no ASCVD or 10-year CVD risk The AHA/ACC has released a scientific statement in 2021 offering new guidance for management of stage 1 hypertension among patients with low ASCVD risk.
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