Hypertension Clinical Practice Guidelines

Key points

• In May 2020 the International Society of Hypertension (ISH) published practice guidelines designed for global use, for low-middle-income and high-income settings, and to be concise and easy to use by clinicians, nurses and community health workers.
• Hypertension is defined by office blood pressure of 140/90 mm Hg or higher; grade 2 hypertension is systolic pressure of 160 mm Hg or higher and/or diastolic pressure of 100 mm Hg or higher.
• ISH separates essential care (minimum standards in low-resource settings) from optimal care (evidence-based standard of care).
• As first-line treatment ISH 2020 recommends combination therapy in a single combination tablet, whereas the Japanese guideline (JSH) recommends monotherapy.
• New elements include attention to medication adherence, stress-reducing measures such as meditation and yoga, and a flexible stepwise move from low-dose to high-dose dual combination therapy.

Overview

This review summarises the ISH 2020 hypertension guidelines and compares them with the ESC/ESH 2018, ACC/AHA, Latin American (LASH) and Japanese (JSH 2018) guidelines. The ISH diagnostic and treatment strategies largely reflect those of European, American and other major societies, with some differences. The authors conclude that the guidelines are practical, physician friendly and especially helpful for low-resource countries without national hypertension guidelines.

Purpose of the ISH 2020 guidelines

The aim was not to revisit the evidence but to adhere to current evidence, based on the ACC/AHA and ESC/ESH recommendations, and to offer a balanced proposal for global use in line with the ISH mission. To achieve this, the guidelines define essential and optimal criteria for diagnosis and treatment according to the resources available.

Diagnosis

As in ESC/ESH 2018, hypertension is based on office blood pressure of at least 140/90 mm Hg. In optimal care, screening uses office measurement and confirmation uses ambulatory, home or repeated office measurement; in essential care, office measurement is used and confirmed with ambulatory or home measurement if possible. If home blood pressure is below 135/85 mm Hg or 24-hour ambulatory pressure is below 130/80 mm Hg, measurement is repeated after 1 year; values at or above these levels confirm hypertension.

What is new

The guidelines emphasise collecting patient data on medication adherence, which is notoriously difficult to obtain. They include stress-reducing measures such as meditation and yoga among lifestyle changes, which other guidelines usually do not mention. They also favour a stratified approach from low-dose to high-dose dual combination therapy, in contrast to the ESC/ESH approach of immediate escalation from dual to triple therapy. For high-normal blood pressure, both ISH 2020 and ESC/ESH 2018 indicate that drug treatment should be considered if cardiovascular risk is very high. Compared with the 2017 Latin American guidelines, there is more agreement than disagreement.

Frequently asked questions

What blood pressure defines hypertension in ISH 2020?

An office blood pressure of 140/90 mm Hg or higher, as in the ESC/ESH 2018 guidelines.

How does ISH 2020 differ from ESC/ESH on escalating drug treatment?

ISH moves flexibly from low-dose to high-dose dual combination therapy, whereas ESC/ESH escalates immediately from dual to triple therapy.

Why are these guidelines useful in low-resource settings?

They define essential, minimum standards of care alongside optimal care, so they can be applied where resources are limited and no national guideline exists.

Source

Chakraborty DS, Lahiry S, Choudhury S. Hypertension Clinical Practice Guidelines (ISH, 2020): What Is New? Med Princ Pract 2021;30(6):579-584. doi:10.1159/000518812. Open access under CC BY-NC 4.0. This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.