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Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease September 10, 2019 Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 e616 CLINICAL STATEMENTS AND GUIDELINES 4.4 Adults With High Blood Pressure or Hypertension Recommendations from the 2017 Hypertension Clinical Practice GuidelinesS4.4-1 are adapted below. Recommendations for Adults With High Blood Pressure or Hypertension Referenced studies that support recommendations are summarized in Online Data Supplements 13 and 14. COR LOE Recommendations I A 1. In adults with elevated blood pressure (BP) or hypertension, including those requiring antihypertensive medications nonpharmacological interventions are recommended to reduce BP. These include: weight lossS4.4-2–S4.4-5; a heart-healthy dietary patternS4.4-6–S4.4-8; sodium reductionS4.4-9–S4.4-13; dietary potassium supplementationS4.4-14–S4.4-18; increased physical activity with a structured exercise programS4.4-3,S4.4-5,S4.4-11, S4.4-19–S4.4-23; and limited alcohol.S4.4-24–S4.4-29 Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 I SBP:A 2. In adults with an estimated 10-year ASCVD risk* of 10% or higher and an average systolic BP (SBP) of 130 mm Hg or higher or an average diastolic BP (DBP) of 80 mm Hg or higher, use of BP-lowering medications is recommended for primary prevention of CVD.S4.4-30–S4.4-38 Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I SBP:B-RSR 3. In adults with confirmed hypertension and a 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mm Hg is recommended.S4.4-33,S4.4-39–S4.4-42 Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I SBP:B-RSR 4. In adults with hypertension and chronic kidney disease, treatment to a BP goal of less than 130/80 mm Hg is recommended.S4.4-43–S4.4-48 Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I SBP:B-RSR 5. In adults with T2DM and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mm Hg or higher, with a treatment goal of less than 130/80 mm Hg.S4.4-33,S4.4-47,S4.4-49–S4.4-54 Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I C-LD 6. In adults with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher, initiation and use of BP-lowering medication are recommended.S4.4-36,S4.4-55–S4.4-58 Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 IIb SBP:B-NR 7. In adults with confirmed hypertension without additional markers of increased ASCVD risk, a BP target of less than 130/80 mm Hg may be reasonable.S4.4-59–S4.4-62 Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO *ACC/AHA pooled cohort equations to estimate 10-year risk of ASCVD. Synopsis In the United States, hypertension accounts for more ASCVD deaths than any other modifiable ASCVD risk factor.S4.4-63 The prevalence of hypertension (defined as systolic blood pressure [SBP] ≥130 mm Hg or diastolic blood pressure [DBP] ≥80 mm Hg) among US adults is 46%; is higher in blacks than in whites, Asians, and Hispanic Americans; and increases dramatically with increasing age.S4.4-64 In a meta-analysis of 61 prospective studies, a log-linear association was observed between SBP levels <115 to >180 mm Hg and DBP levels <75 to 105 mm Hg and risk of ASCVD.S4.4-55 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. An increased risk of ASCVD associated with higher SBP and DBP has been reported across a broad age spectrum, from 30 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.S4.4-55 See Figure 4 for the BP thresholds and treatment recommendations algorithm and refer to the 2017 Hypertension Clinical Practice Guidelines for comprehensive details.S4.4-1 Recommendation-Specific Supportive Text 1 Nonpharmacological interventions are effective in lowering BP and may be sufficient to prevent hypertension and to achieve goal BP in some individuals with hypertension, and they are integral in the management of those on anti hypertensive medication.S4.4-2,S4.4-3,S4.4-6,S4.4-7,S4.4-9–S4.4-11, S4.4-14,S4.4-15,S4.4-19,S4.4-20,S4.4-24 Furthermore, combining recommended nonpharmacological interventions has been shown to increase impact on BP reduction.S4.4-65 Nonpharmacological intervention is the preferred therapy for adults with elevated BP and an appropriate first-line therapy for adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of <10%. Adherence to and impact of nonpharmacological therapy should be assessed within 3 to 6 months. See Table 7 for recommended goals and approximate impact on SBP. 2. Meta-analyses and RCTs provide evidence for the benefit of BP-lowering medications on ASCVD prevention in adults with moderate to high ASCVD risk and SBP ≥130 mm Hg or DBP ≥80 mm Hg,S4.4-32,S4.4-33,S4.4-36,S4.4-37,S4.4-66 with significant outcome reductions demonstrated in stroke, heart failure, coronary events, and death. Significant reductions Downloaded from http://ahajournals.org by on October 7, 2026