2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice GuidelinesFree Access

Intended Use

Practice guidelines provide recommendations applicable to patients with or at risk of developing CVD. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations can have a global impact. Although guidelines may be used to inform regulatory or payer decisions, they are intended to improve patients’ quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.

Clinical Implementation

Management in accordance with guideline recommendations is effective only when followed by both practitioners and patients. Adherence to recommendations can be enhanced by shared decision making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities.

Methodology and Modernization

The ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations, including the Institute of Medicine (P-3,P-4), and on the basis of internal reevaluation. Similarly, the presentation and delivery of guidelines are reevaluated and modified on the basis of evolving technologies and other factors to facilitate optimal dissemination of information to healthcare professionals at the point of care.

Toward this goal, this guideline continues the introduction of an evolved format of presenting guideline recommendations and associated text called the “modular knowledge chunk format.” Each modular “chunk” includes a table of related recommendations, a brief synopsis, recommendation-specific supportive text, and when appropriate, flow diagrams or additional tables. References are provided within the modular chunk itself to facilitate quick review. Additionally, this format will facilitate seamless updating of guidelines with focused updates as new evidence is published, as well as content tagging for rapid electronic retrieval of related recommendations on a topic of interest. This evolved approach format was instituted when this guideline was near completion; therefore, the present document represents a transitional format that best suits the text as written. Future guidelines will fully implement this format, including provisions for limiting the amount of text in a guideline.

Recognizing the importance of cost–value considerations in certain guidelines, when appropriate and feasible, an analysis of the value of a drug, device, or intervention may be performed in accordance with the ACC/AHA methodology (P-5).

To ensure that guideline recommendations remain current, new data are reviewed on an ongoing basis, with full guideline revisions commissioned in approximately 6-year cycles. Publication of new, potentially practice-changing study results that are relevant to an existing or new drug, device, or management strategy will prompt evaluation by the Task Force, in consultation with the relevant guideline writing committee, to determine whether a focused update should be commissioned. For additional information and policies regarding guideline development, we encourage readers to consult the ACC/AHA guideline methodology manual (P-6) and other methodology articles (P-7—P-10).

Selection of Writing Committee Members

The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds. Writing committee members represent different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice. The Task Force may also invite organizations and professional societies with related interests and expertise to participate as partners, collaborators, or endorsers.

Relationships With Industry and Other Entities

The ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without bias or improper influence. The complete relationships with industry and other entities (RWI) policy can be found online. Appendix 1 of the present document lists writing committee members’ relevant RWI. For the purposes of full transparency, writing committee members’ comprehensive disclosure information is available online. Comprehensive disclosure information for the Task Force is available online.

Evidence Review and Evidence Review Committees

In developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data (P-6—P-9). Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited.

An independent evidence review committee (ERC) is commissioned when there are 1 or more questions deemed of utmost clinical importance that merit formal systematic review. The systematic review will determine which patients are most likely to benefit from a drug, device, or treatment strategy and to what degree. Criteria for commissioning an ERC and formal systematic review include: a) the absence of a current authoritative systematic review, b) the feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline, c) the relevance to a substantial number of patients, and d) the likelihood that the findings can be translated into actionable recommendations. ERC members may include methodologists, epidemiologists, healthcare providers, and biostatisticians. The recommendations developed by the writing committee on the basis of the systematic review are marked with “SR”.

Guideline-Directed Management and Therapy

The term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm the dosage by reviewing product insert material and evaluate the treatment regimen for contraindications and interactions. The recommendations are limited to drugs, devices, and treatments approved for clinical use in the United States.

Class of Recommendation and Level of Evidence

The Class of Recommendation (COR) indicates the strength of the recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence that supports the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1) (P-6—P-8).

Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)

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The reader is encouraged to consult the full-text guideline (P-11) for additional guidance and details about hypertension, since the executive summary contains mainly the recommendations.

Glenn N. Levine, MD, FACC, FAHA

Chair, ACC/AHA Task Force on Clinical Practice Guidelines

1.1 Methodology and Evidence Review

An extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted between February and August 2015. Key search words included but were not limited to the following: adherence; aerobic; alcohol intake; ambulatory care; antihypertensive: agents, drug, medication, therapy; beta adrenergic blockers; blood pressure: arterial, control, determination, devices, goal, high, improve, measurement, monitoring, ambulatory; calcium channel blockers; diet; diuretic agent; drug therapy; heart failure: diastolic, systolic; hypertension: white coat, masked, ambulatory, isolated ambulatory, isolated clinic, diagnosis, reverse white coat, prevention, therapy, treatment, control; intervention; lifestyle: measures, modification; office visits; patient outcome; performance measures; physical activity; potassium intake; protein intake; renin inhibitor; risk reduction: behavior, counseling; screening; sphygmomanometers; spironolactone; therapy; treatment: adherence, compliance, efficacy, outcome, protocol, regimen; weight. Additional relevant studies published through June 2016, during the guideline writing process, were also considered by the writing committee and added to the evidence tables when appropriate. The final evidence tables included in the Online Data Supplement summarize the evidence used by the writing committee to formulate recommendations.

As noted in the preamble, an independent ERC was commissioned to perform a formal systematic review of 4 critical clinical questions related to hypertension (Table 2), the results of which were considered by the writing committee for incorporation into this guideline. Concurrent with this process, writing committee members evaluated other published data relevant to the guideline. The findings of the ERC and the writing committee members were formally presented and discussed, and then guideline recommendations were developed. The systematic review report, “Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults,” is published in conjunction with this guideline (S1-10), and its respective data supplements are available online. No writing committee member reported a RWI. Drs. Whelton, Wright and Williamson had leadership roles in SPRINT (Systolic Blood Pressure Intervention Trial). Dr. Carey chaired committee discussions in which the SPRINT results were considered.

1.2 Organization of the Writing Committee

The writing committee consisted of clinicians, cardiologists, epidemiologists, internists, an endocrinologist, a geriatrician, a nephrologist, a neurologist, a nurse, a pharmacist, a physician assistant, and 2 lay/patient representatives. It included representatives from the ACC, AHA, American Academy of Physician Assistants (AAPA), Association of Black Cardiologists (ABC), American College of Preventive Medicine (ACPM), American Geriatrics Society (AGS), American Pharmacists Association (APhA), American Society of Hypertension (ASH), American Society for Preventive Cardiology (ASPC), National Medical Association (NMA), and Preventive Cardiovascular Nurses Association (PCNA).

1.3 Document Review and Approval

This document was reviewed by 2 official reviewers nominated by the ACC and AHA; 1 reviewer each from the AAPA, ABC, ACPM, AGS, APhA, ASH, ASPC NMA, and PCNA; and 38 individual content reviewers. Reviewers’ RWI information was distributed to the writing committee and is published in this document (Appendix 2).

This document was approved for publication by the governing bodies of the ACC, AHA, AAPA, ABC, ACPM, AGS, APhA, ASH, ASPC, NMA, and PCNA.

1.4 Scope of the Guideline

The present guideline is intended to be a resource for the clinical and public health practice communities. It is designed to be comprehensive but succinct and practical in providing guidance for prevention, detection, evaluation, and management of high BP. It is an update of the NHLBI publication, “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7) (S1-9). It incorporates new information from studies of office-based BP-related risk of CVD, ambulatory blood pressure monitoring (ABPM), home blood pressure monitoring (HBPM), telemedicine, and various other areas. This guideline does not address the use of BP-lowering medications for the purposes of prevention of recurrent CVD events in patients with stable ischemic heart disease (SIHD) or chronic heart failure (HF) in the absence of hypertension; these topics are the focus of other ACC/AHA guidelines (S1-11,S1-12). In developing the present guideline, the writing committee reviewed prior published guidelines, evidence reviews, and related statements. Table 3 contains a list of publications and statements deemed pertinent to this writing effort and is intended for use as a resource, thus obviating the need to repeat existing guideline recommendations.

1.5 Abbreviations and Acronyms

2.1 Observational Relationship

Observational studies have demonstrated graded associations between higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) and increased CVD risk (S2.1-1,S2.1-2). In a meta-analysis of 61 prospective studies, the risk of CVD increased in a log-linear fashion from SBP levels <115 mm Hg to >180 mm Hg and from DBP levels <75 mm Hg to >105 mm Hg (S2.1-1). 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. In a separate observational study including >1 million adult patients ≥30 years of age, higher SBP and DBP were associated with increased risk of CVD incidence and angina, myocardial infarction (MI), HF, stroke, peripheral artery disease (PAD), and abdominal aortic aneurysm, each evaluated separately (S2.1-2). An increased risk of CVD associated with higher SBP and DBP has been reported across a broad age spectrum, from 30 years 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 (S2.1-1).

2.2 BP Components

Epidemiological studies have evaluated associations of SBP and DBP, as well as derived components of BP measurements (including pulse pressure, mean BP, and mid-BP), with CVD outcomes (Table 4). When considered separately, higher levels of both SBP and DBP have been associated with increased CVD risk (S2.2-1,S2.2-2). Higher SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, DBP (S2.2-3—S2.2-5). In contrast, after consideration of SBP through adjustment or stratification, DBP has not been consistently associated with CVD risk (S2.2-6,S2.2-7). Although pulse pressure and mid-BP have been associated with increased CVD risk independent of SBP and DBP in some studies, SBP (especially) and DBP are prioritized in the present document because of the robust evidence base for these measures in both observational studies and clinical trials and because of their ease of measurement in practice settings (S2.2-8—S2.2-11).

2.3 Population Risk

In 2010, high BP was the leading cause of death and disability-adjusted life years worldwide (S2.3-1,S2.3-2). In the United States, hypertension (see Section 3.1 for definition) accounted for more CVD deaths than any other modifiable CVD risk factor and was second only to cigarette smoking as a preventable cause of death for any reason (S2.3-3). In a follow-up study of 23,272 U.S. NHANES (National Health and Nutrition Examination Survey) participants, >50% of deaths from coronary heart disease (CHD) and stroke occurred among individuals with hypertension (S2.3-4). Because of the high prevalence of hypertension and its associated increased risk of CHD, stroke, and end-stage renal disease (ESRD), the population-attributable risk of these outcomes associated with hypertension is high (S2.3-4,S2.3-5). In the population-based ARIC (Atherosclerosis Risk in Communities) study, 25% of the cardiovascular events (CHD, coronary revascularization, stroke, or HF) were attributable to hypertension. In the Northern Manhattan study, the percentage of events attributable to hypertension was higher in women (32%) than in men (19%) and higher in blacks (36%) than in whites (21%) (S2.3-6). In 2012, hypertension was the second leading assigned cause of ESRD, behind diabetes mellitus (DM), and accounted for 34% of incident ESRD cases in the U.S. population (S2.3-7).

2.4 Coexistence of Hypertension and Related Chronic Conditions

3.1 Definition of High BP

3.2 Lifetime Risk of Hypertension

Observational studies have documented a relatively high incidence of hypertension over periods of 5 to 10 years of follow-up (S3.2-1,S3.2-2). Thus, there is a much higher long-term population burden of hypertension as BP progressively increases with age. Several studies have estimated the long-term cumulative incidence of developing hypertension (S3.2-3,S3.2-4). In an analysis of 1132 white male medical students (mean age: approximately 23 years at baseline) in the Johns Hopkins Precursors study, 0.3%, 6.5%, and 37% developed hypertension at age 25, 45, and 65 years, respectively (S3.2-5). In MESA (Multi-Ethnic Study of Atherosclerosis), the percentage of the population developing hypertension over their lifetimes was higher for African Americans and Hispanics than for whites and Asians (S3.2-3). For adults 45 years of age without hypertension, the 40-year risk of developing hypertension was 93% for African-American, 92% for Hispanic, 86% for white, and 84% for Chinese adults (S3.2-3). In the Framingham Heart Study, approximately 90% of adults free of hypertension at age 55 or 65 years developed hypertension during their lifetimes (S3.2-4). All of these estimates were based on use of the 140/90–mm Hg cutpoint for recognition of hypertension and would have been higher had the 130/80–mm Hg cutpoint been used.

3.3 Prevalence of High BP

4.1 Accurate Measurement of BP in the Office

4.2 Out-of-Office and Self-Monitoring of BP

4.3 Masked and White Coat Hypertension

5.1 Secondary Forms of Hypertension

7.1 Laboratory Tests and Other Diagnostic Procedures

8.1 Pharmacological Treatment

8.1.2 BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension

Recommendations for BP Treatment Threshold and Use of Risk Estimation^∗ to Guide Drug Treatment of Hypertension

References that support recommendations are summarized in Online Data Supplement 23.

COR	LOE	Recommendations
I	SBP: A	1. Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher, and for primary prevention in adults with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average SBP 130 mm Hg or higher or an average DBP 80 mm Hg or higher (S8.1.2-1—S8.1.2-9).
	DBP: C-EO
I	C-LD	2. Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and 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 (S8.1.2-3,S8.1.2-10—S8.1.2-13).

∗ ACC/AHA Pooled Cohort Equations ( http://tools.acc.org/ASCVD-Risk-Estimator/) (S8.1.2-13a) to estimate 10-year risk of atherosclerotic CVD. ASCVD was defined as a first CHD death, non-fatal MI or fatal or non-fatal stroke.

8.2 Follow-Up of BP During Antihypertensive Drug Therapy

Appropriate follow-up and monitoring enable assessment of adherence (see Section 12.1) and response to therapy, help identify adverse responses to therapy and target organ damage, and allow assessment of progress toward treatment goals. High-quality RCTs have successfully and safely developed strategies for follow-up, monitoring, and reassessment from which recommendations can be made (Figure 4) (S8.2-1,S8.2-2). A systematic approach to out-of-office BP assessment is an essential part of follow-up and monitoring of BP, to assess response to therapy; check for evidence of white coat hypertension, white coat effect, masked hypertension, or masked uncontrolled hypertension; and help achieve BP targets (see Sections 4 and 12).

9.1 Stable Ischemic Heart Disease

Figure 5 is an algorithm on management of hypertension in patients with SIHD.

9.2 Heart Failure

9.3 Chronic Kidney Disease

Figure 6 is an algorithm on management of hypertension in patients with CKD.

9.4 Cerebrovascular Disease

9.4.1 Acute Intracerebral Hemorrhage

Recommendations for Management of Hypertension in Patients With Acute Intracerebral Hemorrhage (ICH)

References that support recommendations are summarized in Online Data Supplement 41.

COR	LOE	Recommendations
IIa	C-EO	1. In adults with ICH who present with SBP greater than 220 mm Hg, it is reasonable to use continuous intravenous drug infusion (Table 19) and close BP monitoring to lower SBP.
III: Harm	A	2. Immediate lowering of SBP (Table 19) to less than 140 mm Hg in adults with spontaneous ICH who present within 6 hours of the acute event and have an SBP between 150 mm Hg and 220 mm Hg is not of benefit to reduce death or severe disability and can be potentially harmful (S9.4.1-1,S9.4.1-2).

9.4.2 Acute Ischemic Stroke

Recommendations for Management of Hypertension in Patients With Acute Ischemic Stroke

References that support recommendations are summarized in Online Data Supplement 42.

COR	LOE	Recommendations
I	B-NR	1. Adults with acute ischemic stroke and elevated BP who are eligible for treatment with intravenous tissue plasminogen activator should have their BP slowly lowered to less than 185/110 mm Hg before thrombolytic therapy is initiated (S9.4.2-1,S9.4.2-2).
I	B-NR	2. In adults with an acute ischemic stroke, BP should be less than 185/110 mm Hg before administration of intravenous tissue plasminogen activator and should be maintained below 180/105 mm Hg for at least the first 24 hours after initiating drug therapy (S9.4.2-3).
IIa	B-NR	3. Starting or restarting antihypertensive therapy during hospitalization in patients with BP greater than 140/90 mm Hg who are neurologically stable is safe and reasonable to improve long-term BP control, unless contraindicated (S9.4.2-4,S9.4.2-5).
IIb	C-EO	4. In patients with BP of 220/120 mm Hg or higher who did not receive intravenous alteplase or endovascular treatment and have no comorbid conditions requiring acute antihypertensive treatment, the benefit of initiating or reinitiating treatment of hypertension within the first 48 to 72 hours is uncertain. It might be reasonable to lower BP by 15% during the first 24 hours after onset of stroke.
III: No Benefit	A	5. In patients with BP less than 220/120 mm Hg who did not receive intravenous thrombolysis or endovascular treatment and do not have a comorbid condition requiring acute antihypertensive treatment, initiating or reinitiating treatment of hypertension within the first 48 to 72 hours after an acute ischemic stroke is not effective to prevent death or dependency (S9.4.2-4—S9.4.2-9).

9.4.3 Secondary Stroke Prevention

Recommendations for Treatment of Hypertension for Secondary Stroke Prevention

References that support recommendations are summarized in Online Data Supplements 43 and 44.

COR	LOE	Recommendations
I	A	1. Adults with previously treated hypertension who experience a stroke or transient ischemic attack (TIA) should be restarted on antihypertensive treatment after the first few days of the index event to reduce the risk of recurrent stroke and other vascular events (S9.4.3-1—S9.4.3-3).
I	A	2. For adults who experience a stroke or TIA, treatment with a thiazide diuretic, ACE inhibitor, or ARB, or combination treatment consisting of a thiazide diuretic plus ACE inhibitor, is useful (S9.4.3-1,S9.4.3-3—S9.4.3-5).
I	B-R	3. Adults not previously treated for hypertension who experience a stroke or TIA and have an established BP of 140/90 mm Hg or higher should be prescribed antihypertensive treatment a few days after the index event to reduce the risk of recurrent stroke and other vascular events (S9.4.3-1—S9.4.3-3).
I	B-NR	4. For adults who experience a stroke or TIA, selection of specific drugs should be individualized on the basis of patient comorbidities and agent pharmacological class (S9.4.3-6).
IIb	B-R	5. For adults who experience a stroke or TIA, a BP goal of less than 130/80 mm Hg may be reasonable (S9.4.3-6,S9.4.3-7).
IIb	B-R	6. For adults with a lacunar stroke, a target SBP goal of less than 130 mm Hg may be reasonable (S9.4.3-8).
IIb	C-LD	7. In adults previously untreated for hypertension who experience an ischemic stroke or TIA and have a SBP less than 140 mm Hg and a DBP less than 90 mm Hg, the usefulness of initiating antihypertensive treatment is not well established (S9.4.3-9).

Figure 9 is an algorithm on management of hypertension in patients with a previous history of stroke (secondary stroke prevention).

9.5 Peripheral Artery Disease

9.6 Diabetes Mellitus

9.7 Metabolic Syndrome

Metabolic syndrome is a state of metabolic dysregulation characterized by visceral fat accumulation, insulin resistance, hyperinsulinemia, and hyperlipidemia, as well as predisposition to type 2 DM, hypertension, and atherosclerotic CVD (S9.7-1—S9.7-3). According to data from the NHANES III and NHANES 1999–2006 (S9.7-1,S9.7-4), the prevalence of metabolic syndrome in the United States was 34.2% in 2006 and has likely increased substantially since that time. The metabolic syndrome is linked to several other disorders, including nonalcoholic steatohepatitis, polycystic ovary syndrome, certain cancers, CKD, Alzheimer’s disease, Cushing’s syndrome, lipodystrophy, and hyperalimentation (S9.7-5,S9.7-6).

Lifestyle modification, with an emphasis on improving insulin sensitivity by means of dietary modification, weight reduction, and exercise, is the foundation of treatment of the metabolic syndrome. The optimal antihypertensive drug therapy for patients with hypertension in the setting of the metabolic syndrome has not been clearly defined (S9.7-1). Although caution exists with regard to the use of thiazide diuretics in this population because of their ability to increase insulin resistance, dyslipidemia, and hyperuricemia and to accelerate conversion to overt DM, no data are currently available demonstrating deterioration in cardiovascular or renal outcomes in patients treated with these agents (S9.7-1). Indeed, as shown in follow-up of ALLHAT, chlorthalidone use was associated with only a small increase in fasting glucose levels (1.5–4.0 mg/dL), and this increase did not translate into increased CVD risk at a later date (S9.7-7—S9.7-10). In addition, in post hoc analysis of the nearly two thirds of participants in ALLHAT that met criteria for the metabolic syndrome, chlorthalidone was unsurpassed in reducing CVD and renal outcomes compared with lisinopril, amlodipine, or doxazosin (S9.7-9,S9.7-11). Similarly, high-dose ARB therapy reduces arterial stiffness in patients with hypertension with the metabolic syndrome, but no outcomes data are available from patients in which this form of treatment was used (S9.7-12). Use of traditional beta blockers may lead to dyslipidemia or deterioration of glucose tolerance, and ability to lose weight (S9.7-2). In several large clinical trials, the risk of developing DM as a result of traditional beta-blocker therapy was 15% to 29% (S9.7-2). However, the newer vasodilating beta blockers (e.g., labetalol, carvedilol, nebivolol) have shown neutral or favorable effects on metabolic profiles compared with the traditional beta blockers (S9.7-13). Trials using vasodilator beta blockers have not been performed to demonstrate effects on CVD outcomes.

9.8 Atrial Fibrillation

9.9 Valvular Heart Disease

9.10 Aortic Disease

10.1.1 Racial and Ethnic Differences in Treatment

10.2 Sex-Related Issues

The prevalence of hypertension is lower in women than in men until about the fifth decade but is higher later in life (S10.2-1). Other than special recommendations for management of hypertension during pregnancy, there is no evidence that the BP threshold for initiating drug treatment, the treatment target, the choice of initial antihypertensive medication, or the combination of medications for lowering BP differs for women versus men (S10.2-2,S10.2-3).

10.3 Age-Related Issues

11.1 Resistant Hypertension

11.2 Hypertensive Crises—Emergencies and Urgencies

11.3 Cognitive Decline and Dementia

11.4 Patients Undergoing Surgical Procedures

12.1 Adherence Strategies for Treatment of Hypertension

12.2 Structured, Team-Based Care Interventions for Hypertension Control

12.3 Health Information Technology–Based Strategies to Promote Hypertension Control

12.4 Improving Quality of Care for Patients With Hypertension

12.5 Financial Incentives

13.1 Health Literacy

Communicating alternative behaviors that support self-management of healthy BP in addition to medication adherence is important. This should be done both verbally and in writing. Today, mobile phones have a recording option. For patients with mobile phones, the phone can be used to inform patients and family members of medical instructions after the doctor’s visit as an additional level of communication. Inclusion of a family member or friend that can help interpret and encourage self-management treatment goals is suggested when appropriate. Examples of needed communication for alternative behaviors include a specific regimen relating to physical activity; a specific sodium-reduced meal plan indicating selections for breakfast, lunch, and dinner; lifestyle recommendations relating to sleep, rest, and relaxation; and finally, suggestions and alternatives to environmental barriers, such as barriers that prevent healthy food shopping or limit reliable transportation to and from appointments with health providers and pharmacy visits.

13.2 Access to Health Insurance and Medication Assistance Plans

Health insurance and medication plan assistance for patients is especially important to improving access to and affordability of medical care and BP medications. Learning how the patient financially supports and budgets for his or her medical care and medications offers the opportunity to share additional insight relating to cost reductions, including restructured payment plans. Ideally, this would improve the patient’s compliance with medication adherence and treatment goals.

13.3 Social and Community Services

Health care can be strengthened through local partnerships. Hypertensive patients, particularly patients with lower incomes, have more opportunity to achieve treatment goals with the assistance of strong local partnerships. In patients with low socioeconomic status or patients who are challenged by social situations, integration of social and community services offers complementary reinforcement of clinically identified treatment goals. Social and community services are helpful when explicitly related to medical care. However, additional financial support and financial services are incredibly beneficial to patients, some of whom may choose to skip a doctor’s appointment to pay a residential utility bill.