Table 7.

Summary of Major Findings (January, 2018-March, 2021) and Relevance to the Management of Hypertension

• BP control rates increased steadily until 2013-14 after which they have declined. Adherence to 2017 ACC/AHA BP Guideline recommendations has the potential to reverse this alarming trend.

• Out-of-office BP readings (ABPM or HBPM) continue to be recommended to detect WCH and MH, with ABPM more sensitive to detect MH.

• HBPM is the most practical method to document BP for medication titration towards the achievement and maintenance of BP goal.

• Autonomous aldosterone production may play a role in the pathogenesis of Stages 1 and 2 hypertension and resistant hypertension. All adults with difficult to control or resistant hypertension should be screened for primary aldosteronism. If aldosterone to renin ratio is low but plasma renin is low, consider 24 hour urine aldosterone measurement during salt loading (high sodium diet) conditions.

• Young adults with hypertension have earlier onset of CVD events compared with those with normal BP. Thus, it may be inappropriate to delay treatment, even though RCT evidence is lacking. The evidence supports initial management in young adults with evidence of TOD with lifestyle modification for 6-12 months followed by antihypertensive drug therapy if BP remains above goal.

• Lifestyle modification continues to be the cornerstone of antihypertensive therapy. Each nonpharmacological intervention is effective in lowering BP, and concurrent use of 2 or more interventions results in additive effects. Lifestyle modification improves the effectiveness of pharmacologic therapy.

• Intensive BP control is not associated with increased hospitalization and does not increase the risk of orthostatic hypotension. Asymptomatic orthostatic hypotension in hypertensive adults is not associated with higher rates of CVD events, syncope, injurious falls or acute renal failure and should not be a reason to withdraw or down-titrate treatment.

• For older adults with hypertension, intensive BP lowering may prevent or at least partially arrest cognitive decline.

• The definition of resistant hypertension is BP ≥130/80 mm Hg in adults on ≥3 antihypertensive medications of different classes, prescribed at maximum or maximally tolerated doses, or BP <130/80 mm Hg but requiring ≥4 antihypertensive drugs after exclusion of pseudo-resistance (inaccurate BP measurement, the white coat effect and/or suboptimal drug adherence).

• Multilevel, multicomponent implementation strategies, including team-based care, are the most effective methods of BP control in hypertensive patients.

• Home BP self-monitoring and telemonitoring are effective in facilitating antihypertensive drug titration leading to achievement and maintenance of BP goal.

ABPM, ambulatory blood pressure monitoring; ACC, American College of Cardiology; AHA, American Heart Association; BP, blood pressure; HBPM, home blood pressure monitoring; MH, masked hypertension; TOD, target organ damage; WCH, white coat hypertension.