Dentistry and Health Care Lowering the Bar: New Hypertension Guidelines

TO GET C.E. CREDITS FOR THIS ARTICLE
PLEASE LOGIN OR REGISTER

Dentistry and Health Care Lowering the Bar: New Hypertension Guidelines

Hypertension (HTN), also referred to as high blood pressure, exists when the pressure exerted on the walls of blood vessel by the circulating blood is greater than normal. Blood pressure (BP) is measured in millimeters of mercury (mm Hg). Traditionally, this is performed by measuring the arterial pressure when the heart beats and between beats, known respectively as the systolic blood pressure (SBP) and diastolic blood pressure (DBP). In 2010, HTN was reported to be the leading worldwide cause of disability-adjusted life years (DALY), defined as the total of the years of productivity lost due to disability and premature death.1Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C, et al. 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: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol 2017.,2World Health Organization. DALYs / YLDs definition. Available at: http://www.who.int/mental_health/management/depression/daly/en/. Identifying patients at risk for HTN and with HTN, followed by successful early intervention to prevent and treat this condition, is an important initiative to reduce mortality and morbidity globally.

In 2010, HTN was reported to be the leading worldwide cause of disability-adjusted life years

HTN as a risk factor for systemic disease

HTN is a major risk factor for cardiovascular disease (CVD), including coronary artery disease, myocardial infarction (MI), heart failure (HF) and peripheral artery disease (PAD), as well as stroke, end-stage renal disease, reduced cognitive function and loss of vision.1Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C, et al. 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: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol 2017.,3Berry JD, Dyer A, Cai X, Garside DB, Ning H, Thomas A, Greenland P, Van Horn L, Tracy RP, Lloyd-Jones DM. Lifetime risks of cardiovascular disease. N Engl J Med 2012;366:321-9.,4Siu AL; U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015;163(10):778-86.,5Crichton GE, Elias MF, Davey A, Alkerwi A. Cardiovascular health and cognitive function: the Maine-Syracuse Longitudinal Study. PLoS One 2014;9(3):e89317.,6American Heart Association. How high blood pressure can lead to vision loss. Available at: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/LearnHowHBPHarmsYourHealth/How-High-Blood-Pressure-Can-Lead-to-Vision-Loss_UCM_301826_Article.jsp#.WzlEztVKiDI. (Table 1) An association of HTN and the development of vascular dementia following stroke and Alzheimer’s disease has also been found.7Paglieri C, Bisbocci D, Caserta M, Rabbia F, Bertello C, Canadè A, Veglio F. Hypertension and cognitive function. Clin Exp Hypertens 2008;30(8):701-10. In addition, HTN is associated with diabetes mellitus (DM). An increased prevalence of HTN is found in individuals with DM, and HTN and DM are risk factors for CVD.8Govindarajan G, Sowers JR, Stump CS. Hypertension and diabetes mellitus. Eur Cardiovasc Dis 2006;1:1-7.

Table 1. HTN as a risk factor for systemic diseases and conditions
Other diseases and conditions
Coronary artery disease
Stroke
Myocardial infarction
End-stage renal disease
Heart failure
Reduced cognitive function
Peripheral artery disease
Loss of vision

Pre-hypertension (PHTN) is defined as a condition between normal BP and HTN. PHTN has a low range of 120-129 (SBP)/80-84 (DPB) and a high range of 130-139/85-89. In one meta-analysis with more than a million patients in 20 prospective cohort studies, PHTN was found to result in a 28%, 12% and 41% increased risk of death due to CVD, CHD and stroke, respectively.9Huang Y, Su L, Cai X, Mai W, Wang S, Hu Y, Wu Y, Tang H, Xu D. Association of all-cause and cardiovascular mortality with prehypertension: a meta-analysis. Am Heart J 2014;167:160-8. (Figure 1) High- and low-range PHTN, respectively, resulted in a 28% and 8% (nonsignificant) greater risk for CVD. Low- and high-range PHTN increased risk for CVD by 46% and 80% respectively in another meta-analysis with more than 460,000 individuals.10Huang Y, Wang S, Cai X, Mai W, Hu Y, Tang H, Xu D. Prehypertension and incidence of cardiovascular disease: a meta-analysis. BMC Med 2013;11:177. In a third meta-analysis with more than 750,000 participants, PHTN increased risk for stroke by 66%, low-range PHTN by 44% and high-range PHTN by 95%.11Huang Y, Cai X, Li Y, Su L, Mai W, Wang S, Hu Y, Wu Y, Xu D. Prehypertension and the risk of stroke: a meta-analysis. Neurology 2014;82(13):1153-61. However, in a further meta-analysis, PHTN was not a risk factor for all-cause mortality and only high-range PHTN increased risk for CVD.12Guo X, Zhang X, Zheng L, Guo L, Li Z, Yu S, Yang H, Zhou X, Zou L, Zhang X, Sun Z, Li J, Sun Y. Prehypertension is not associated with all-cause mortality: a systematic review and meta-analysis of prospective studies. PLoS One 2013;8(4):e61796. PHTN is also associated with decreased renal function, and in one systematic review increased the risk of ESRD by 59% overall, with low- and high-range PTHN increasing the risk by 44% and 100%, respectively (p<0.05).13Garofalo C, Borrelli S, Pacilio M, Minutolo R, Chiodini P, De Nicola L, Conte G. Hypertension and Prehypertension and Prediction of Development of Decreased Estimated GFR in the General Population: A meta-analysis of cohort studies. Am J Kidney Dis 2016 Jan;67(1):89-97.,14Huang Y, Cai X, Zhang J, Mai W, Wang S, Hu Y, Ren H, Xu D. Prehypertension and incidence of ESRD: a systematic review and meta-analysis. Am J Kidney Dis 2014;63(1):76-83.

Figure 1. PHTN and increased risk of death, by condition9Huang Y, Su L, Cai X, Mai W, Wang S, Hu Y, Wu Y, Tang H, Xu D. Association of all-cause and cardiovascular mortality with prehypertension: a meta-analysis. Am Heart J 2014;167:160-8.

New American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on HTN

Guidelines for medical providers are regularly reviewed and updated. A joint committee with ACC and AHA representation developed updated guidelines that were published in 2017. These new recommendations define 120-129/< 80 as elevated BP and 130-139/ 80-89 as stage 1 HTN. (Table 2) As a result, the percentage of the U.S. adult population classified as having HTN increases from 32% to 46% when using these guidelines instead of the Joint National Committee 7 (JNC7) guidelines. This translates to an increase of 31 million people.15Messerli FH, Rimoldi SF, Bangalore S. Changing definition of hypertension in guidelines: how innocent a number game? Eur Heart J 2018.,16Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT Jr, Whelton PK. Potential U.S. population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018;71(2):109-18. JNC8 recommendations were also published, although not endorsed, with HTN thresholds of <150/90 for individuals age 60 and over, and 140/90 for all younger adults and all adults with DM and renal disease.17James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the Eighth Joint National Committee (JNC 8). J Am Med Assoc 2014;311:507-20.
Modification of lifestyle remains the initial approach to treatment of people with a 10-year cardiovascular risk of less than 10%. Based on an analysis of almost 10,000 records in the 2011- 2014 NHANES database, the prevalence of HTN, recommendations for anti-HTN medication and the percentage of patients above the target BP increases by 44%, 6% and 36%, respectively, using the ACC/AHA Guideline definitions rather than those of the JNC7 Guidelines.17James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the Eighth Joint National Committee (JNC 8). J Am Med Assoc 2014;311:507-20.(Figure 2) Therefore, in addition to the increased number of people with HTN based on the ACC/AHA guidelines, the identification and management of these individuals have become more complex.18Miller CS, Glick M, Rhodus NL. 2017 Hypertension guidelines: New opportunities and challenges. J Am Dent Assoc 2018;149(4):229-31.
Table 2. ACC/AHA BP and HTN Categories (2017)
Normal
AND
<120 mm Hg systolic
<80 mm Hg diastolic
Elevated blood pressure
AND
120 - 129 mm Hg systolic
<80 mm Hg diastolic
Hypertension: Stage 1 HTN
OR
130 - 139 mm Hg systolic
80 - 89 mm Hg diastolic
Hypertension: Stage 2 HTN
OR
≥140 mm Hg systolic
≥90 mm Hg diastolic
Hypertensive crisis > 180 mm Hg systolic

Figure 2. Percentage increases associated with the new ACC/AHA guidelines and classification for HTN

Other Guidelines, Controversy and Concerns

A strong direct relationship between an individual’s typical BP and risk for all-cause and vascular mortality above a threshold of 115/75 has been found,19Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:1903-13. and the ACC/AHA Guidelines are intended to alert patients and to foster earlier intervention. However, these guidelines have not been universally accepted and differ significantly from other guidelines.16Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT Jr, Whelton PK. Potential U.S. population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018;71(2):109-18.,20Medscape Today. Europe Stands Pat on Hypertension Thresholds ̶ ESC doesn't follow ACC/AHA on diagnostic cutoff, focuses on control rates. June 8, 2018. Available at: https://www.medpagetoday.com/cardiology/hypertension/73384. The American Academy of Family Physicians (AAFP) did not endorse the guidelines and stated that while a small benefit may accrue for CVD events using these guidelines, no benefit was observed for all-cause or CVD mortality, or some other conditions, and there were inconsistent outcomes.21Nadar SK, Stowasser M. New guidelines with few takers: will the new American guidelines ever be accepted? J Human Hyperten 2018. Doi: 10.1038/s41371-018-0049-y.,22AAFP. Guidelines Developed by External Organizations Not Endorsed by the AAFP. Available at: https://www.aafp.org/patient-care/clinical-recommendations/non-endorsed.html.
One of the concerns cited included a disproportionate reliance on the SPRINT study in developing the guidelines.21Nadar SK, Stowasser M. New guidelines with few takers: will the new American guidelines ever be accepted? J Human Hyperten 2018. Doi: 10.1038/s41371-018-0049-y. The SPRINT study included more than 9,000 participants with a target SBP of <120 or <140.23The Sprint Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015;373:2103-16. DOI: 10.1056/NEJMoa1511939: All participants were at least 50 years-of-age and more than a quarter were at least 75 years-of-age (mean age 68 years). More adverse events were found for the more (versus less) intensive BP lowering group. The study itself reported on the inability to extrapolate the findings to individuals younger than 50 years-of-age, or who had DM or had experienced a stroke.
A strong direct relationship between typical BP and risk for all-cause and vascular mortality above a threshold of 115/75 has been found.

The American College of Physicians (ACP)/AAFP also published new guidelines in 2017, in this case for the treatment of adults 60 years-of-age and older, recommending intervention at or above an SBP of 150 to achieve a target SBP of <150 for individuals with no history of stroke or transient ischemic attacks.24Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA for the Clinical Guidelines Committee of the American College of Physicians and the Commission on Health of the Public and Science of the American Academy of Family Physicians. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017;166:430-7. In Europe, new guidelines issued in August 2018 by the European Society of Cardiology (ESC)/European Society of Hypertension (ESH) define a BP of 140/90 as the threshold for HTN and refer to 130/80 as high-normal.21Nadar SK, Stowasser M. New guidelines with few takers: will the new American guidelines ever be accepted? J Human Hyperten 2018. Doi: 10.1038/s41371-018-0049-y. Further, a HTN threshold of 140/90 is recommended in the United Kingdom, Australia and Ireland, and Canadian and Latin American guidelines also differ, as do protocols for confirming HTN and recommended interventions.25Blood Pressure UK. Available at: http://www.bloodpressureuk.org/BloodPressureandyou/Thebasics/Whatishigh.,26National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Clinical guideline [CG127] Published date: August 2011 Last updated: November 2016. Available at: https://www.nice.org.uk/guidance/cg127/chapter/Key-priorities-for-implementation,27Heart Foundation. Is my blood pressure normal. Available at: https://www.heartfoundation.org.au/your-heart/know-your-risks/blood-pressure/is-my-blood-pressure-normal.,28Nerenberg KA, Zarnke KB, Leung AA, Dasgupta K, Butalia S, McBrien K, Harris K, et al.; for Hypertension Canada. Hypertension Canada’s 2018 Guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol 2018;34(5):506-25.,29Ribeiro JM. New Hypertension Guidelines: A View from Latin America. J Clin Hyperten 2014;16(4):261-2.

In a review of 34 randomized controlled trials, greater reductions in BP were found to reduce stroke, CVD events and death, including below an SBP of 130.30Thomopoulos C, Parati G and Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels - updated overview and meta-analyses of randomized trials. J Hyperten 2016; 34:613-22. Similar conclusions were drawn in a separate systematic review of reductions in CVD.31Reboussin DM, Allen NB, Griswold ME, Guallar E, Hong Y, Lackland DT, Miller EPR 3rd, Polonsky T, Thompson-Paul AM, Vupputuri S. 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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018;71(6):e116-35. In contrast, two other systematic reviews found no direct benefit. In a meta-analysis with more than 300,000 individuals, it was concluded that lowering BP was not associated with any benefit for patients with an initial SBP of <140 and no prior history of CVD.32Brunström M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: A systematic review and meta-analysis. J Am Med Assoc Intern Med 2018;178(1):28-36. In the second review with 8,000 participants 65 years-of-age and older, lowering target SBP to <140 versus <150 or <160 did not result in differences in all-cause mortality, total serious CV adverse events or stroke.33Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database Syst Rev 2017;8:CD011575.

In a Cochrane review with patient-level data for 6775 participants with HTN and CVD, and with a mean follow-up of 3.7 years, small reductions in CV events were observed at a target BP of ≤ 135/85 compared to ≤ 140 to 160/90 to 100.34Saiz LC, Gorricho J, Garjón J, Celaya MC, Muruzábal L, Malón MDM, Montoya R, López A. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev 2017;10:CD010315. However, no differences in total mortality or CVD mortality, or serious adverse events, were found and more treatment withdrawals occurred in the group with the lower target BP.35Tsai WC, Wu HY, Peng YS, Yang JY, Chen HY, Chiu YL, Hsu SP, Ko MJ, Pai MF, Tu YK, Hung KY, Chien KL. Association of intensive blood pressure control and kidney disease progression in nondiabetic patients with chronic kidney disease: A systematic review and eta-analysis. J Am Med Assoc Intern Med 2017;177(6):792-9. In patients with chronic renal disease, no additional benefit in renal health outcomes was found when using a target BP of <130/80 compared with <140/90 across 9 trials with more than 8,000 patients.35Tsai WC, Wu HY, Peng YS, Yang JY, Chen HY, Chiu YL, Hsu SP, Ko MJ, Pai MF, Tu YK, Hung KY, Chien KL. Association of intensive blood pressure control and kidney disease progression in nondiabetic patients with chronic kidney disease: A systematic review and eta-analysis. J Am Med Assoc Intern Med 2017;177(6):792-9. In addition, a Cochrane review of 5 randomized clinical trials with more than 7,000 individuals with DM, and a mean follow-up of 4.5 years, concluded that the evidence did not support a lower BP target (SBP < 120) versus a 'standard' target (SBP < 140).36Arguedas JA, Leiva V, Wright JM. Blood pressure targets for hypertension in people with diabetes mellitus. Cochrane Database Syst Rev 2013;(10):CD008277.

In a Cochrane review with patient-level data for 6775 participants with HTN and CVD, and with a mean follow-up of 3.7 years, small reductions in CV events were observed at a target BP of ≤ 135/85 compared to ≤ 140 to 160/ 90 to 100.

Implications for Dental Professionals

In 2015, the U.S. Preventive Services Task Force (USPSTF) recommended that all adults 18 years-of-age and over without HTN (defined as <130/85 by USPSTF) or other risk factors be screened for BP every 3 to 5 years, and annually for individuals 40 years-of-age and over, as well as individuals at risk for HTN.4 Screening in the dental office has been advocated for many years. Even if guidelines do differ, a dental visit is an opportunity to perform BP screening for patients who may be unaware of their BP status. It is therefore possible to alert patients, and it is essential to know BP status and medications before performing dental treatment. Furthermore, several studies have reported favorable opinions by patients regarding dental office screening for medical conditions.37Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients’ attitudes toward screening for medical conditions in a dental setting. J Public Health Dent 2012; 72(1):28-35.

A dental visit is an opportunity to perform BP screening for patients who may be unaware of their BP status.

BP screening is recommended at least 5 minutes after the patient arrives, with the patient seated, and again at least 5 minutes later. BP is usually measured with manual or mechanical sphygmomanometers.4 (Table 3) Due to the risk of “white coat HTN” and inaccuracies in in-office BP screening, ambulatory or home BP measurements are recommended to confirm HTN.4Huang Y, Cai X, Zhang J, Mai W, Wang S, Hu Y, Ren H, Xu D. Prehypertension and incidence of ESRD: a systematic review and meta-analysis. Am J Kidney Dis 2014;63(1):76-83.,38Piper MA, Evans CV, Burda BU, Margolis KL, O'Connor E, Whitlock EP. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2015;162(3):192-204. Overweight/obesity, lack of/insufficient exercise, smoking tobacco, high alcohol consumption and an unhealthy diet are associated with HTN and are modifiable risk factors for CVD.1Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C, et al. 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: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol 2017. The dental visit is an opportunity to provide patients with advice on diet and exercise, tobacco cessation and alcohol consumption, and thereby potentially help patients improve their systemic and oral health.

Table 3. How to Perform BP Screening
With patient seated
After at least 5 minutes in the office
Repeat screening at least 5 minutes after the first test
Repeat screening at least 5 minutes after the first test
BP cuff of appropriate size
Patient's arm at the level of the right atrium during measurement

Conclusions

BP screening in the dental office will likely become more important, since populations are aging. This is one way by which oral health care providers may have a positive impact on patients’ general health.39Lamster IB, Myers-Wright N. Oral health care in the future: Expansion of the scope of dental practice to improve health. J Dent Educ 2017;81(9):eS83-90. At the current time, sphygmomanometers are used for BP screening. However, an automated wireless brachial BP monitor is now available that sends and stores measurements to a smart-phone, a desktop computer, or the cloud where it can be further analyzed. In the future, it can be anticipated that digital technology may replace current methods.40Myers MG, Tobe SW. A Canadian perspective on the eighth Joint National Committee (JNC 8) hypertension guidelines. J Clin Hypertens 2014;16(4):246-8. However, several systematic reviews have reported insufficient evidence to determine clinical outcomes for BP targets and interventions, as well as a risk of bias in studies.34Saiz LC, Gorricho J, Garjón J, Celaya MC, Muruzábal L, Malón MDM, Montoya R, López A. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev 2017;10:CD010315.,35Tsai WC, Wu HY, Peng YS, Yang JY, Chen HY, Chiu YL, Hsu SP, Ko MJ, Pai MF, Tu YK, Hung KY, Chien KL. Association of intensive blood pressure control and kidney disease progression in nondiabetic patients with chronic kidney disease: A systematic review and eta-analysis. J Am Med Assoc Intern Med 2017;177(6):792-9.,37Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients’ attitudes toward screening for medical conditions in a dental setting. J Public Health Dent 2012; 72(1):28-35. These reviews have highlighted the need for more research and additional randomized clinical trials.34Saiz LC, Gorricho J, Garjón J, Celaya MC, Muruzábal L, Malón MDM, Montoya R, López A. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev 2017;10:CD010315.,35Tsai WC, Wu HY, Peng YS, Yang JY, Chen HY, Chiu YL, Hsu SP, Ko MJ, Pai MF, Tu YK, Hung KY, Chien KL. Association of intensive blood pressure control and kidney disease progression in nondiabetic patients with chronic kidney disease: A systematic review and eta-analysis. J Am Med Assoc Intern Med 2017;177(6):792-9.,37Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients’ attitudes toward screening for medical conditions in a dental setting. J Public Health Dent 2012; 72(1):28-35. As more evidence becomes available, guidelines and recommendations may become more standardized.

References

  • 1.Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C, et al. 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: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol 2017.
  • 2.World Health Organization. DALYs / YLDs definition. Available at: http://www.who.int/mental_health/management/depression/daly/en/.
  • 3.Berry JD, Dyer A, Cai X, Garside DB, Ning H, Thomas A, Greenland P, Van Horn L, Tracy RP, Lloyd-Jones DM. Lifetime risks of cardiovascular disease. N Engl J Med 2012;366:321-9.
  • 4.Siu AL; U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015;163(10):778-86.
  • 5.Crichton GE, Elias MF, Davey A, Alkerwi A. Cardiovascular health and cognitive function: the Maine-Syracuse Longitudinal Study. PLoS One 2014;9(3):e89317.
  • 6.American Heart Association. How high blood pressure can lead to vision loss. Available at: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/LearnHowHBPHarmsYourHealth/How-High-Blood-Pressure-Can-Lead-to-Vision-Loss_UCM_301826_Article.jsp#.WzlEztVKiDI.
  • 7.Paglieri C, Bisbocci D, Caserta M, Rabbia F, Bertello C, Canadè A, Veglio F. Hypertension and cognitive function. Clin Exp Hypertens 2008;30(8):701-10.
  • 8.Govindarajan G, Sowers JR, Stump CS. Hypertension and diabetes mellitus. Eur Cardiovasc Dis 2006;1:1-7.
  • 9.Huang Y, Su L, Cai X, Mai W, Wang S, Hu Y, Wu Y, Tang H, Xu D. Association of all-cause and cardiovascular mortality with prehypertension: a meta-analysis. Am Heart J 2014;167:160-8.
  • 10.Huang Y, Wang S, Cai X, Mai W, Hu Y, Tang H, Xu D. Prehypertension and incidence of cardiovascular disease: a meta-analysis. BMC Med 2013;11:177.
  • 11.Huang Y, Cai X, Li Y, Su L, Mai W, Wang S, Hu Y, Wu Y, Xu D. Prehypertension and the risk of stroke: a meta-analysis. Neurology 2014;82(13):1153-61.
  • 12.Guo X, Zhang X, Zheng L, Guo L, Li Z, Yu S, Yang H, Zhou X, Zou L, Zhang X, Sun Z, Li J, Sun Y. Prehypertension is not associated with all-cause mortality: a systematic review and meta-analysis of prospective studies. PLoS One 2013;8(4):e61796.
  • 13.Garofalo C, Borrelli S, Pacilio M, Minutolo R, Chiodini P, De Nicola L, Conte G. Hypertension and Prehypertension and Prediction of Development of Decreased Estimated GFR in the General Population: A meta-analysis of cohort studies. Am J Kidney Dis 2016 Jan;67(1):89-97.
  • 14.Huang Y, Cai X, Zhang J, Mai W, Wang S, Hu Y, Ren H, Xu D. Prehypertension and incidence of ESRD: a systematic review and meta-analysis. Am J Kidney Dis 2014;63(1):76-83.
  • 15.Messerli FH, Rimoldi SF, Bangalore S. Changing definition of hypertension in guidelines: how innocent a number game? Eur Heart J 2018.
  • 16.Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT Jr, Whelton PK. Potential U.S. population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018;71(2):109-18.
  • 17.James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the Eighth Joint National Committee (JNC 8). J Am Med Assoc 2014;311:507-20.
  • 18.Miller CS, Glick M, Rhodus NL. 2017 Hypertension guidelines: New opportunities and challenges. J Am Dent Assoc 2018;149(4):229-31.
  • 19.Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:1903-13.
  • 20.Medscape Today. Europe Stands Pat on Hypertension Thresholds ̶ ESC doesn't follow ACC/AHA on diagnostic cutoff, focuses on control rates. June 8, 2018. Available at: https://www.medpagetoday.com/cardiology/hypertension/73384.
  • 21.Nadar SK, Stowasser M. New guidelines with few takers: will the new American guidelines ever be accepted? J Human Hyperten 2018. Doi: 10.1038/s41371-018-0049-y.
  • 22.AAFP. Guidelines Developed by External Organizations Not Endorsed by the AAFP. Available at: https://www.aafp.org/patient-care/clinical-recommendations/non-endorsed.html.
  • 23.The Sprint Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015;373:2103-16. DOI: 10.1056/NEJMoa1511939:
  • 24.Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA for the Clinical Guidelines Committee of the American College of Physicians and the Commission on Health of the Public and Science of the American Academy of Family Physicians. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017;166:430-7.
  • 25.Blood Pressure UK. Available at: http://www.bloodpressureuk.org/BloodPressureandyou/Thebasics/Whatishigh.
  • 26.National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Clinical guideline [CG127] Published date: August 2011 Last updated: November 2016. Available at: https://www.nice.org.uk/guidance/cg127/chapter/Key-priorities-for-implementation
  • 27.Heart Foundation. Is my blood pressure normal. Available at: https://www.heartfoundation.org.au/your-heart/know-your-risks/blood-pressure/is-my-blood-pressure-normal.
  • 28.Nerenberg KA, Zarnke KB, Leung AA, Dasgupta K, Butalia S, McBrien K, Harris K, et al.; for Hypertension Canada. Hypertension Canada’s 2018 Guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol 2018;34(5):506-25.
  • 29.Ribeiro JM. New Hypertension Guidelines: A View from Latin America. J Clin Hyperten 2014;16(4):261-2.
  • 30.Thomopoulos C, Parati G and Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels - updated overview and meta-analyses of randomized trials. J Hyperten 2016; 34:613-22.
  • 31.Reboussin DM, Allen NB, Griswold ME, Guallar E, Hong Y, Lackland DT, Miller EPR 3rd, Polonsky T, Thompson-Paul AM, Vupputuri S. 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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018;71(6):e116-35.
  • 32.Brunström M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: A systematic review and meta-analysis. J Am Med Assoc Intern Med 2018;178(1):28-36.
  • 33.Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Blood pressure targets for hypertension in older adults. Cochrane Database Syst Rev 2017;8:CD011575.
  • 34.Saiz LC, Gorricho J, Garjón J, Celaya MC, Muruzábal L, Malón MDM, Montoya R, López A. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev 2017;10:CD010315.
  • 35.Tsai WC, Wu HY, Peng YS, Yang JY, Chen HY, Chiu YL, Hsu SP, Ko MJ, Pai MF, Tu YK, Hung KY, Chien KL. Association of intensive blood pressure control and kidney disease progression in nondiabetic patients with chronic kidney disease: A systematic review and eta-analysis. J Am Med Assoc Intern Med 2017;177(6):792-9.
  • 36.Arguedas JA, Leiva V, Wright JM. Blood pressure targets for hypertension in people with diabetes mellitus. Cochrane Database Syst Rev 2013;(10):CD008277.
  • 37.Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients’ attitudes toward screening for medical conditions in a dental setting. J Public Health Dent 2012; 72(1):28-35.
  • 38.Piper MA, Evans CV, Burda BU, Margolis KL, O'Connor E, Whitlock EP. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2015;162(3):192-204.
  • 39.Lamster IB, Myers-Wright N. Oral health care in the future: Expansion of the scope of dental practice to improve health. J Dent Educ 2017;81(9):eS83-90.
  • 40.Myers MG, Tobe SW. A Canadian perspective on the eighth Joint National Committee (JNC 8) hypertension guidelines. J Clin Hypertens 2014;16(4):246-8.