International Society of Hypertension
The International Society of Hypertension (ISH) released their global recommendations on the management of hypertension in adults aged 18 years and older in June 2020.[1] Where possible, the ISH differentiated between "optimal care" (evidence-based standard of care) and "essential care" (minimum standards of care in low-resource settings). Selected recommendations are outlined below.
Hypertension Classification
Office blood pressure (BP) measurement
-Normal BP: <130 mmHg (systolic [SBP]) and <85 mmHg (diastolic [DBP])
-High-normal: 130-139 mmHg SBP and/or 85-89 mmHg DBP
-Grade 1 hypertension: 140-159 mmHg SBP and/or 90-99 mmHg DBP
-Grade 2 hypertension: ≥160 mmHg SBP and/or ≥100 mmHg DBP
Hypertension Criteria
Office, ambulatory (ABPM), and home based (HBPM) (SBP/DBP [mmHg])
Office BP: ≥140 and/or ≥90 mmHg
ABPM: 24-Hour average of ≥130 and/or ≥80 mmHg; daytime/awake average of ≥135 and/or ≥85 mmHg; nighttime/sleep ≥120 and/or ≥70 mmHg
HBPM: ≥135 and/or ≥85 mmHg
Hypertension Diagnosis
Office and out-of-office BP measurements and plans
At the first office visit, concurrently measure BP in both arms. If a >10 mmHg difference is consistent between the arms on repeated measurements, use the arm with the higher BP. If a >20 mmHg difference is found, consider further evaluation.
Office BP <130/85 mmHg: Remeasure in 3 years (after 1 year if other risk factors exist)
Office BP 130-159/85-99 mmHg: Confirm with ABPM or HBPM measurement, or confirm with repeated office visits. If HBPM <135/85 mmHg or 24-hour ABPM <130/80 mmHg, remeasure after 1 year; If HBPM ≥135/85 mmHg or 24-hour ABPM ≥130/80 mmHg, then hypertension is diagnosed.
Office BP >160/100 mmHg: Confirm within a few days or weeks.
Diagnostic Studies
Laboratory, electrocardiography (ECG), and imaging
Levels of sodium, potassium, serum creatinine, fasting glucose; estimated glomerular filtration rate; lipid profile
Urine dipstick
12-Lead ECG to detect atrial fibrillation, left ventricular hypertrophy, ischemic heart disease
Other tests as needed if organ damage or secondary hypertension is suspected
Treatment for Hypertension
Grade 1 hypertension (140-159/90-99 mmHg)
Start lifestyle interventions (smoking cessation, exercise, weight loss, salt and alcohol reduction, healthy diet)
Initiate pharmacotherapy in high-risk patients (cardiovascular disease, chronic kidney disease, diabetes, or organ damage) and those with persistent high BP after 3-6 months of lifestyle intervention
Grade 2 hypertension (≥160/100 mmHg)
Immediately initiate pharmacotherapy
Start lifestyle interventions
BP control targets
Aim for BP control within 3 months
Aim for at least a 20/10 mmHg BP reduction, ideally to <140/90 mmHg
<65 years: Target BP <130/80 mmHg if tolerated (but >120/70 mmHg)
≥65 years: Target BP <140/90 mmHg if tolerated; individualizing target BPs may be considered in those who are frail, independent, and likely to tolerate therapy
Pharmacotherapy (if BP uncontrolled after 3-6 months of lifestyle intervention)
Consider monotherapy in low-risk grade 1 hypertension and elderly (>80 years) or frail patients. A simplified regimen with once-daily dosing and single pill combinations is ideal.
For non-black patients who are not pregnant or not planning pregnancy:
Step 1: Use a dual low-dose drug combination (angiotensin-converting enzyme inhibitor [ACEI] or angiotensin-receptor blocker [ARB] + dihydropyridine-calcium channel blocker [DHP-CCB])
Step 2: Increase the regimen to the dual full-dose combination
Step 3 (triple combination): Add a thiazide or thiazide-like diuretic
Step 4 (resistant hypertension): Triple combination plus spironolactone or, alternatively, amiloride doxazosin, eplerenone, clonidine, or a beta-blocker
For black patients who are not pregnant or not planning pregnancy:
Step 1: Use a dual low-dose drug combination (eg, ARB + DHP-CCB or DHP-CCB + thiazide/thiazide-like diuretic)
Step 2: Increase the regimen to the dual full-dose combination
Step 3 (triple combination): Add a diuretic or ARB or ACEI
Step 4 (resistant hypertension): Triple combination plus spironolactone or, alternatively, amiloride doxazosin, eplerenone, clonidine, or a beta-blocker
For more information, please go to Hypertension.
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