Are the American Heart Association/American College of Cardiology High Blood Pressure Guidelines Fit for Global Purpose?: Thoughts From the International Society of Hypertension

In 2017, the American College of Cardiology (ACC), the American Heart Association (AHA), and 9 other American societies released guidelines for the prevention, detection, evaluation, and management of high blood pressure (BP) in adults.1 These guidelines are perhaps the most controversial set of US guidelines—even more so than those attributed to some of the committee set up to produce the guidelines of the Eighth Joint National Committee in 2014.2 Before discussing the various controversial aspects of the ACC/AHA guidelines, the International Society of Hypertension would like to congratulate the authors on 3 counts. First, emphasis was placed on the appropriate technique of BP measurements and the increased need for out-of-office BP measurement. Second, the value of risk assessment was recognized and introduced for the first time in US guidelines and finally, perhaps in part because of the controversial nature of the document, awareness of the importance of BP as a global cause of morbidity and mortality has been raised. The central controversy around which several others arise is the redefining of hypertension—as a systolic BP ≥130 mm Hg or a diastolic BP ≥80 mm Hg. Although there is a clear dose-response relationship between increasing BP levels and adverse cardiovascular outcomes,3 this preempts the ability, based on predicting cardiovascular events, of precisely defining hypertension. However, the pragmatic definition proposed by Geoffrey Rose decades ago should perhaps be considered—viz: “that level of BP above which investigation and management does more good than harm.”4 Does the new BP level proposed in the ACC/AHA guidelines fully satisfy that criterion? Perhaps not. To date, the relevant data are inconsistent and hence controversial. The problem arises because the definition of hypertension, treatment thresholds, and BP targets should …