Hypertension (especially systolic) is an important risk factor for ischemic and hemorrhagic stroke in male and female individuals at all ages. For adults aged 45 years 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. This is the single most important risk factor for stroke accounting for almost 60% of the global stroke burden. Based on two or more readings/occasions to estimate an individual’s level of blood pressure (BP), the latest American College of Cardiology/American Heart Association high BP guidelines define normal BP as <120/<80 mm Hg; elevated BP as 120 to 129/<80 mm Hg; hypertension stage 1 as 130 to 139 or 80 to 89 mm Hg; hypertension stage 2 as ≥140 or ≥90 mm Hg. Applying these new criteria to practice would mean that over half of the population aged 45 to 75 years (e.g., in the United States and China) would be classified as hypertensive and require antihypertensive treatment.

The risk for cardiovascular diseases (CVD, including stroke) increases in a log-linear fashion: from systolic BP (SBP) levels <115 to >180 mm Hg and from diastolic BP (DBP) levels <75 to >105 mm Hg. A 20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. The guidelines recommend greater use of out-of-office BP measurements to detect white coat hypertension (high office but normal out-of-office BP), which carries approximately the same risk of CVD as that of normal BP. Screening for the detection of secondary hypertension (about 10% of all cases of hypertension) is recommended for new onset or uncontrolled hypertension, presence of drug-resistant or drug-induced hypertension, abrupt onset of hypertension, onset in young persons (age <30 years), exacerbation of previously controlled hypertension, disproportioned target-organ damage for the degree of hypertension, accelerated or malignant hypertension, onset of diastolic hypertension in older adults (aged ≥65 years), or unprovoked or excessive hypokalemia.

Atherosclerosis occurs with increased frequency and severity in patients with chronic hypertension. However, the more specific nonatherosclerotic cerebrovascular abnormality in patients with sustained hypertension consists of lipohyalinosis and fibrinoid necrosis with microaneurysm formation in penetrating arterioles. Such lesions may lead to lacunar infarction or intracerebral hemorrhage. It is important to recognize that several modifiable lifestyle components can affect BP favorably, including diet (low sodium, low fat, low cholesterol, low calorie, high intake of fruits and vegetables), weight/body mass index (obesity is a risk factor), exercise (particularly aerobic exercise), limited alcohol intake (≤2 oz per day), and stress reduction. These components should be a staple of hypertension treatment even if medication is required.

The key aspects of this report are as follows. Prehypertensive individuals (SBP 120-129/<80 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in BP and CVD. Lifestyle changes alone (weight loss, healthy diet, sodium reduction, potassium supplementation, increased physical activity, and abstinence from or moderation in alcohol consumption) are also recommended for most adults newly classified as having stage 1 hypertension (130-139/80-89 mm Hg), and lifestyle changes plus drug therapy are recommended for those with existing CVD or increased CVD risk. For high-risk adults with stage 1 hypertension who have preexisting CVD, diabetes mellitus, chronic kidney disease, or an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk (ASCVD Risk Estimator Plus can be found on http://tools.ACC.org/ASCVD-Risk-Estimator) of at least 10%, the guideline recommends initiating drug treatment for those with an average BP of 130/80 mm Hg or higher. For lower risk adults without preexisting CVD and an estimated 10-year ASCVD risk less than 10%, the BP threshold for drug treatment is 140/90 mm Hg or higher. After initiation of antihypertensive drug therapy, regardless of ASCVD risk, the recommended BP target is less than 130/80 mm Hg. For adults without a compelling indication for use of a specific drug, clinicians should initiate therapy with thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACE-I), or angiotensin-receptor blockers. For patients with stage 2 hypertension, initiation of two antihypertensive agents from different classes is recommended when the average SBP and DBP are more than 20 and 10 mm Hg above target, respectively. Patients with stage 2 hypertension and an average BP of 160/100 mm Hg or higher should be treated promptly, should be carefully monitored, and should have prompt adjustment of their regimen until control is achieved. After initiation of drug therapy, management should include monthly evaluation of adherence and therapeutic response until control is achieved. Interventions to promote control, such as home-based BP measurement, team-based care, and telehealth, are useful in improving BP control.

Adults aged 65 years or older with hypertension have a 10-year ASCVD risk of at least 10%, placing them in the high-risk category that requires initiation of drug therapy at an SBP of 130 mm Hg or higher. Treatment of hypertension with an SBP goal of less than 130 mm Hg is recommended for noninstitutionalized, ambulatory, community-dwelling adults aged 65 years or older with an average SBP of 130 mm Hg or higher. Careful titration of BP-lowering medications and close monitoring are especially important in older adults with significant comorbidities because large trials have excluded many such persons. For older adults (aged ≥65 years) with hypertension, comorbidities, and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess the risk-benefit trade-offs of treatment are reasonable for decisions about the choice of drug and intensity of BP control. Regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. In more than two thirds of individuals, hypertension cannot be controlled on one drug and will require two or more antihypertensive agents selected from different drug classes; therefore, a combination therapy of two or three drugs (one of which usually will be a thiazide diuretic) is commonly needed to achieve optimal BP levels. There is evidence that lowering BP to optimal goal levels may be more important than specific drug selection. For most people, a reasonable goal of treatment to lower BP involves stabilization of SBP at or below 120 mm Hg and DBP at or below 80 mm Hg.