Combining home blood pressure monitoring with remote or telephone physician monitoring of results (i.e., self-measured blood pressure with clinician support) is a strategy recommended by the Centers for Disease Control and Prevention Community Preventive Services Task Force.7. This is a corrected version of the article that appeared in print. MICHAEL LEFEVRE, MD, MSPH, University of Missouri School of Medicine, Columbia, Missouri. ED Facility Level Coding Guidelines | ACEP As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. Secondary causes should be considered in patients 30 years or younger, especially without comorbidities, and any patient with resistant hypertension, sudden deterioration in control, severe BP elevations, or clinical signs of a cause for the secondary hypertension. Musculoskeletal. Also in 2017, the American Heart Association, the American College of Cardiology and nine partnering organizations released a guideline on the prevention, detection, evaluation and management of hypertension in adults, but the AAFP chose not to endorse it, opting instead to continue endorsing the JNC8 guidelines. Blood Family by Anne Fine | Goodreads All Rights Reserved. All Rights Reserved. The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) have collaborated on a clinical guideline for the treatment of hypertension in adults 60 years and . When BP is measured at home, hypertension is diagnosed if readings are consistently 135/85 mm Hg or greater. Until October 3, 1971, it was known as the American Academy of General Practice. Evidence-based decision-making tools for managing common pediatric conditions. Sports participation in children and adolescents: The - UpToDate The guideline authors also advised clinicians and policymakers to consider how social determinants of health can affect patient care, leading Coles to recommend another well-known Academy resource. Clinical Practice Guidelines and Recommendations | ACP First-line agents include thiazide diuretics, calcium channel blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. ABPM is generally accepted as the best out-of-office method, but HBPM is often a more practical approach. Coles said the AAFP has chosen not to endorse these guidelines due to concerns about methodological rigor, conflicts of interest and lack of consideration for harms, which has generated considerable uncertainty for family physicians and others who manage hypertension. There was no observed additional benefit in preventing stroke with the lower blood pressure target. No, Recommendations based on patient-oriented outcomes? Author disclosure: No relevant financial affiliations. Yes, Published source:J Am Coll Cardiol. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Adherence can be improved through strategies including combination pills, once-daily dosing, home BP monitoring, electronic reminders, and support from a multidisciplinary team. View all clinical practice guidelines. Treating to a target of less than 135/85 can further reduce the risk of MI by about four fewer MIs per 1,000 patients. The primary objective was to determine whether lower blood pressure targets were associated with lower morbidity and mortality compared with standard blood pressure targets. The American Academy of Family Physicians (AAFP) updated a recent systematic review with a literature review of subsequent studies to recommend blood pressure targets for primary care management . BP readings obtained with this method are 5 to 10 mm Hg lower than with techniques that involve a clinician, and they more closely reflect out-of-office readings. While treating to a lower blood pressure target of less than 135/85 mm Hg may be considered based on patient preferences and values, the lower target does not provide additional benefit at preventing mortality. Additional aspects of sports participation in children and adolescents are presented separately: However, the guideline states that in-office measurement is acceptable for diagnosis of hypertension if proper techniques are used.15 The ACC/AHA guideline provides a table that correlates blood pressure measured in the office with the generally lower readings using home blood pressure monitoring and ambulatory blood pressure monitoring (Table 1).15. Cardiovascular risk should be estimated using a calculator such as the Framingham Risk Score (https://www.mdcalc.com/framingham-risk-score-hard-coronary-heart-disease). The guideline is, however, vague about what to do for these patients when they return for follow-up in three to six months. The ISH guidelines, which were assembled using reviews of the ACC/AHA guidelines and six other international guidelines, overcome this conflict by providing separate diagnostic thresholds based on measurement techniques. This could increase cost, medication adverse effects and drug-drug interactions. On average, each patient would need to take one additional medication to get to the lower target. Intensify therapy for those already on medication. 2019 Feb;73 (2):327-334. doi: 10.1161/HYPERTENSIONAHA.118.12291. Evidence shows that home blood pressure measurements are generally lower than blood pressure measured in a clinician's office.1,2 The current expansion of telemedicine has increased the need to monitor blood pressure at home and decreased the number of in-office blood pressure measurements. Erectile dysfunction (ED) is when a man cannot get or keep an erection. lifestyle changes for blood pressure control. The ACC/AHA recommendations were based on a systematic review that addressed the following questions: Is there evidence that home BP monitoring (HBPM) and/or ambulatory BP monitoring (ABPM) are superior to office-based BP measurement by a health care professional for preventing adverse outcomes and achieving better BP control? When patients have grade 1 hypertension without cardiovascular disease, chronic kidney disease, diabetes, or signs of organ damage, lifestyle therapy for three to six months is recommended. June 2020;38(6):9821004, Available at:https://www.ahajournals.org/doi/epub/10.1161/HYPERTENSIONAHA.120.15026. Accurate measurement of blood pressure is essential to categorize blood pressure, stratify cardiovascular risk, and guide management. What Do We Do?. No, Recommendations based on patient-oriented outcomes? These recommendations are only one element in the complex process of improving the health of America. In adults with hypertension, do various antihypertensive drug classes differ in their comparative benefits and harms? ADA Diabetes Standards of Care 2023 Guideline Summary As such, they cannot substitute the individual judgment brought to each clinical situation by the patients family physician. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. American Academy of Family Physicians - Wikipedia No, Recommendations based on patient-oriented outcomes? The 2017 guideline is a comprehensive guideline incorporating new information from studies regarding blood pressure (BP)-related risk of cardiovascular disease (CVD), ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), BP thresholds to initiate antihypertensive drug treatment, BP goals of treatment, strategies to improve hypertension tre. (See "Guidelines for adolescent preventive services" .) American Academy of Family Physicians - Guideline Central Treatment of Hypertension in Adults Over Age 60 to Higher Vs Lower ). These four categories are based on average BP measurements in a health care setting. Secondary hypertension affects up to 10% of people with hypertension. Beta blockers are not recommended unless indicated for other medical conditions. To be effective, the guidelines must be implemented. The mission of the AAFP is to improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity. See permissionsforcopyrightquestions and/or permission requests. Erectile Dysfunction (ED) - familydoctor.org A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. To be effective, the recommendations must be implemented. Copyright 2021 by the American Academy of Family Physicians. They move us away from the 2017 American College of Cardiology/American Heart Association (ACC/AHA; https://www.aafp.org/afp/2018/0315/p413.html) guidelines, which recommended a diagnosis and treatment target of 130/80 mm Hg primarily based on a few large, well-controlled trials that are difficult to replicate in practice. Blood Pressure Targets in Adults With Hypertension: Guidelines - AAFP Other studies, such as echocardiography, renal artery evaluation, or brain imaging, are not routinely recommended. 15 The 2014 Eighth Joint National Committee guideline, which is endorsed by the American Academy of Family . Authors Use pharmacotherapy. Related Practice Guideline: High Blood Pressure: ACC/AHA Releases Updated Guideline. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. ), Initiating or intensifying pharmacologic treatment should be considered for certain adults 60 years and older with high cardiovascular risk, based on individualized assessment, to achieve a target systolic BP of less than 140 mm Hg. The guideline,Treatment of Hypertension in Adults Over Age 60 to Higher vs. Lower Targets, was developed by the American College of Physicians and the American Academy of Family Physicians. (Strong recommendation based on high-quality evidence. These recommendations are only one element in the complex process of improving the health of America. Home | AAFP The American Academy of Pediatrics has previously published a statement on the age limit of pediatrics in 1988, 3 which was reaffirmed in 2012 and identified the upper age limit as 21 years with a note that exceptions could be made when the pediatrician and family agree to an older age, particularly in the case of a child with special health car. Coles noted that the AAFP endorses a number of recommendations from the U.S. Preventive Services Task Force on the topic, including those on screening for hypertension in adults and the use of healthy diet and physical activity to prevent cardiovascular disease in individuals with CVD risk factors. SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF . Best practices for home blood pressure monitoring include using an appropriately fitting upper-arm cuff on a bare arm, emptying the bladder, avoiding caffeinated beverages for 30 minutes before taking the measurement, resting for five minutes before taking the measurement, keeping the feet on the floor uncrossed and the arm supported with the cuff at heart level, and not talking during the reading. Increasing to full-dose treatment should be considered before adding a third anti-hypertensive, usually a thiazide-like diuretic if not already selected. Hypertension - Clinical Preventive Service Recommendation | AAFP Guideline source: International Society of Hypertension, Systematic literature search described? Overall, the lower target group had an absolute risk increase of 3% for all other serious adverse events compared with the standard target group. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Even a properly obtained office BP measurement is suboptimal for the diagnosis or management of hypertension; out-of-office readings using 12- to 24-hour ambulatory or home BP monitoring provide the best guidance.2,4 Enthusiasm is increasing for automated office BP meaurement,5 which duplicates the process described in Table 1 but does so without a clinician in the examination room. Sodium intake should be reduced, and potassium should be supplemented unless contraindicated. ), Treatment is recommended for noninstitutionalized, ambulatory, community-dwelling adults 65 years and older with an average systolic BP of 130 mm Hg or above to achieve a target systolic BP of less than 130 mm Hg. It is one of the largest national medical organization. Access to safe environments to exercise, healthful foods and financial resources are important factors in blood pressure control, she added. Continue your education & view medical recommendations, clinical guidelines & more now. Copyright 2023 American Academy of Family Physicians. Related FPM article: Implementing Ambulatory Blood Pressure Monitoring in Primary Care Practice. This content is owned by the AAFP. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. Consider treating adults who have hypertension to a lower blood pressure target (less than 135/85 mm Hg) to reduce risk of myocardial infarction (weak recommendation; moderate-quality evidence). Dietary changes include salt reduction, moderation of alcohol consumption, and a diet high in vegetables and fruit that is low in added sugars and saturated fats (e.g., DASH diet). Because individual BP measurements tend to vary, a single reading is inadequate for clinical decision making. The 2022 Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP, was developed by the American Academy of Family Physicians and approved by the. The group also used a modified version of the Grading of Recommendations Assessment, Development and Evaluation system to rate the quality of evidence for each outcome and the overall strength of each recommendation. Weight loss is recommended to reduce BP in adults who are overweight or obese. The guideline applies to individuals with hypertension (with or without cardiovascular disease), and focuses on target blood pressure levels rather than specific treatments. CARRIE ARMSTRONG, AFP Senior Associate Editor. Blood pressure targets of 140 mm Hg systolic and 90 mm Hg diastolic offer similar reduction in cardiovascular and all-cause mortality as lower targets and have fewer adverse effects. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient's family physician. Pharmacotherapy should be started if BP remains uncontrolled, especially in patients 50 years or older. Patients should be instructed to record their readings for three (minimum) to seven (ideal) days leading up to their clinic appointment.912 Some guidelines recommend omitting the first day of readings because they tend to be more elevated than other readings.10,13 The recorded readings should be averaged. The American Academy of Family Physicians (AAFP) updated a recent systematic review with a literature review of subsequent studies to recommend blood pressure targets for primary care management of hypertension. Access a summary of the processes used by the AAFP to produce high-quality, evidence-based guidelines. All Rights Reserved. In health care settings that include the physician's office, hypertension is diagnosed when BP is 140/90 mm Hg or greater, ideally using an electronic device and following standard protocols for measurement, including repeat measurements. At first, the story was interesting to me, yet seemed to lose its spark and pick back up again in part 3 and beyond. Treat adults who have hypertension to a standard blood pressure target (less than 140/90 mm Hg) to reduce the risk of all-cause and cardiovascular mortality (strong recommendation; high-quality evidence). Although BP measurement in the office setting is relatively easy, errors are common and can result in a misleading estimation of a patient's true BP. Within the first three months of starting pharmacotherapy, the BP target should be less than 140/90 mm Hg. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. Much harm will come if this change is widely accepted and implemented, particularly if quality measures that echo this definition are put into place. Out-of-office readings can differentiate white coat hypertension, with elevated office measurements, and masked hypertension, where measurements are lower in the office. Adverse effects increase with more aggressive blood pressure targets. Home blood pressure readings can be used in hypertension quality measures. Primary literature based on randomized controlled trials, a cross-sectional study, and disease-oriented evidence, U.S. Preventive Services Task Force and American College of Cardiology/American Heart Association guidelines, and primary literature based on good-quality patient-oriented evidence and limited-quality patient-oriented evidence, Expert opinion based on American Heart Association guidelines and validation protocols, Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content, Immediate, unlimited access to just this article. Coles also served as the guideline panel chair. A target of less than 130/80 mm Hg may be reasonable for adults with confirmed hypertension but no additional markers of increased CVD risk. [published online ahead of print November 7, 2017], Available at:http://www.onlinejacc.org/content/early/2017/11/04/j.jacc.2017.11.006?_ga=2.22194297.316380784.1510771663-1271268032.1509237864. In constructing the guideline, the development group focused on patient-centered clinical outcomes such as total mortality, cardiovascular-related mortality, cardiovascular events such as stroke and myocardial infarction, and adverse events. (Moderate recommendation based on consensus opinion. Target BPs for adults with hypertension and comorbid conditions are shown in Table 1. Based on its review, the AAFP strongly recommends that clinicians treat adults who have hypertension to a standard blood pressure target of less than 140/90 mm Hg to reduce the risks of all-cause and cardiovascular mortality. The AAFP also supports its 2017 guideline, which was codeveloped with the American College of Physicians: Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets (https://www.aafp.org/patient-care/clinical-recommendations/all/hypertension-over-60.html). American Academy of Family Physicians represents 129,600 family physicians, residents, & students, providing advocacy, education, patient & practice resources. White coat hypertension is characterized by elevated BP measurements in the office setting but normal readings on ABPM or HBPM. A person's risk of hypertension is influenced by various genetic and environmental factors, such as being overweight or obese; diet; alcohol intake; and fitness level. ACP and AAFP release guideline for treatment of hypertension in adults Blood pressure control depends on accurate measurement. I encourage everyone to use resources from The EveryONE Project to screen for social determinants of health and connect people to community resources to address other factors that may contribute to health issues.. Primary Care Orgs Favor Looser BP Targets in Older Adults Editor's Note: The ISH guidelines are important because they successfully cut the Gordian knot of conflicting diagnosis thresholds and treatment targets in hypertension. Serious adverse events such as death, disability, and life-threatening complications are not increased with lower targets. Copyright 2022 by the American Academy of Family Physicians. High Blood Pressure: ACC/AHA Releases Updated Guideline, Instruct the patient to avoid caffeine, exercise, and smoking for at least 30 minutes before the visit, Have the patient relax, sitting in a chair (feet on floor with back supported) for at least five minutes, Ensure that the patient has emptied his/her bladder, Refrain from talking during the rest period and measurement, Remove all clothing covering the area where the cuff will be placed, Position the middle of the cuff on the patient's upper arm at the level of the right atrium (the midpoint of the sternum), Separate repeated measurements by one to two minutes, Take the average of at least two measurements, Treatment is recommended for adults 60 years and older with systolic BP persistently at or above 150 mm Hg to achieve a target systolic BP of less than 150 mm Hg to reduce the risk of stroke, cardiac events, and possibly mortality. Hypertension in Adults Over 60 | AAFP Although lower blood pressure targets do not improve mortality, they do appear to reduce cardiovascular events. Pressure Guidelines and Cardiovascular Risk - AHA/ASA Journals Editor's Note: The American Academy of Family Physicians (AAFP) does not endorse the 2017 ACC/AHA guideline on hypertension and continues to endorse the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. These summary guidelines include essential recommendations and suggestions for optimal care. The ACC/AHA guideline provides four categories of BP, ranging from normal to stage 2 hypertension, as shown below. Most persons who receive preventive medication will not benefit, and many will be harmed. These recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. ACC/AHA Hypertension Guideline: What Is New? What Do We Do? Coles also highlighted several resources on familydoctor.org, such as patient-centered articles on lifestyle changes for blood pressure control, blood pressure medications and ambulatory blood pressure monitoring. Our current approach to routine office BP measurement should not be used to implement the targets recommended in this guideline. A target BP of less than 130/80 mm Hg is recommended for adults with confirmed hypertension and CVD or a 10-year atherosclerotic CVD risk of 10% or more. The AAFP also recommends that clinicians consider treating adults who have hypertension to a blood pressure target of less than 135/85 mm Hg to reduce the risk of myocardial infarction, based on evidence showing a small additional benefit with this lower target. Guideline compares evidence for benefits and harms of higher vs. lower systolic blood pressure targets. Underpinning this guideline is the belief that achieving this target BP will lower a person's risk of CVD events, including the large group of adults younger than 75 years who are at low to moderate risk of CVD and who were not included in the trials. Therapy with a single agent is reasonable in adults with stage 1 hypertension and target BP less than 130/80 mm Hg. Our mission is simple: Strengthen family physicians and the communities they care for. Properly obtained measurements have been the standard in clinical trials, but require about 10 minutes and are not routinely obtained in the office setting (Table 1). Youll see a combination of AAFP-developed guidelines and recommendations from external organizations (e.g. The American College of Physicians and the American Academy of Family Physicians (AAFP) offer thoughtful and balanced guidance that incorporates the results of these trials for adults 60 years and . Clinical Practice Guidelines | AAFP These recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. Home blood pressure monitoring involves patients independently measuring their blood pressure with an electronic device, whereas ambulatory blood pressure monitoring involves patients wearing a portable monitor for 24 to 48 hours. Nine trials contributed to the ACC/AHA meta-analysis on which the guideline was based.7 Trials selectively enrolled persons at high risk of cardiovascular disease (CVD), with follow-up ranging from 2.0 to 5.7 years. American Board of Family Medicine - Wikipedia SEARCH BY SPECIALTY BY ORGANIZATION BY DATE Adults over age 60 with persistent systolic blood pressure 150 mm Hg should be treated to achieve a target systolic blood pressure of <150 mm Hg. Hypertension Clinical Guidance and Practice Resources webpage. APC's or "Ambulatory Payment Classifications" are the government's method of paying for facility outpatient services for the Medicare program. In the Systolic Blood Pressure Intervention Trial, patients were placed in a room where an automated device was used to take an average of several blood pressure measurements after a five-minute rest.3 However, out-of-office measurement of blood pressure (notably ambulatory blood pressure monitoring and home blood pressure monitoring) provide additional diagnostic information about blood pressure. Cardiovascular Disease and Mortality in Adults Aged 60 - PubMed The AAFP states that: "The American Academy of Family Physicians is the national association of family doctors. All Rights Reserved. Editor's Note: Dr. LeFevre was a member of the Eighth Joint National Committee panel that developed the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults, and currently serves on the Science Advisory Panel of the AAFP.