Comparison of international blood pressure guidelines

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Guidelines on the choice of agents and how best to step up treatment for various subgroups in hypertension (high blood pressure) have changed over time and differ between countries.

A Comparison of International Guidelines on Goal Blood Pressure and Initial Therapy for Adults With Hypertension (adapted from JNC 8 guidelines [1] )
GuidelinePopulationGoal blood pressure (mmHg)Initial treatment options
ESC 2024 [2] General120–129/70–79 BP >140/90: Two from different classes: preferably RAS-inhibitor (ACEI or ARB) with either thiazide diuretic/thiazide-like diuretic or dihydropyridine CCB.
ESH 2023 [3] General age <65

General age 65–79

General age ≥80

<130/80

<140 SBP

<150 SBP

BP <150/95: Lifestyle changes

BP ≥150/95 or has CVD risk factors or failed lifestyle changes: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB

AAFP 2022 [4] [5] General<140/90BP >140/90 and low-risk for CVD: Lifestyle changes

BP >140/90 and CVD risk factors or failed lifestyle changes: monotherapy with thiazide-type diuretic, ACEI/ARB, and/or CCB

BP >160/100: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB

WHO 2021 [6] General

High CVD risk, diabetes or CKD

Previous CVD

<140/90

<130 SBP

<130 SBP

BP ≥140/90 and low-risk for CVD: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB

SBP ≥130 and CVD risk factors, diabetes or CKD: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB

SBP ≥130 and previous CVD: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB

KDIGO 2021 [7] CKD

with kidney transplant

<120 SBP

<130/80

CKD: ACEI/ARB

Kidney transplant: ARB or CCB

ISH 2020 [8] General

Age <65

Age ≥65

<140/90 (reduction by at least 20/10)

<130/80

<140/90

BP >140/90 and low-risk for CVD: Lifestyle changes

BP >140/90 and CVD risk factors or failed lifestyle changes: monotherapy with thiazide-type diuretic, ACEI/ARB, and/or CCB

BP >160/100: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB

VA/DoD 2020 [9] General

Age ≥60

Age ≥60 with diabetes

<130/90

<150/90

<140/90

Thiazide-type diuretic, ACEI/ARB, and/or CCB

Black: avoid monotherapy with ACEI/ARB

NICE 2019 [10] Age <80

Age ≥80

<140/90

<150/90

Age <55: ACEI/ARB

Age ≥55 or black: CCB

ADA 2018 [11] Diabetes

Diabetes with CVD risk

<140/90

<130/80

ACEI/ARB, thiazide-like diuretic, and/or dihydropyridine CCB
ESC/ESH 2018 [12] General age <65

General age ≥65

<130/80

<140/80

Thiazide-type diuretic, ACEI/ARB, and/or CCB

CAD: add beta-blocker

Resistant hypertension: add spironolactone

ACC/AHA 2017 [13] General<130/80BP > 130/80: Lifestyle changes and monotherapy with thiazide-type diuretic, ACEI/ARB, and/or CCB

BP >20/10 above target: Lifestyle changes and two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB

JNC 8 2013 [1] General age ≥60

General age <60

Diabetes

CKD

<150/90

<140/90

<140/90

<140/90

Non-black: thiazide-type diuretic, ACEI/ARB, and/or CCB

Black: thiazide-type diuretic, and/or CCB

Diabetes: thiazide-type diuretic, ACEI/ARB, and/or CCB

CKD: ACEI/ARB

CHEP 2013 [14] General <80 y

General ≥80 y

Diabetes

CKD

<140/90

<150/90

<130/80

<140/90

General: thiazide-type diuretic, beta-blocker (age, 60 y), ACEI (non-black) or ARB

Diabetes with additional risk : ACEI/ARB

Diabetes without additional risk : ACEI/ARB, thiazide, or DHPCCB

CKD: ACEI, or ARB

ISHIB 2010 [15] Black, lower risk

Target organ damage or CVD risk

<135/85

<130/80

Diuretic or CCB

Abbreviations:

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<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is the study of the heart. Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease, and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a sub-specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Blood pressure</span> Pressure exerted by circulating blood upon the walls of arteries

Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" refers to the pressure in a brachial artery, where it is most commonly measured. Blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure in the cardiac cycle. It is measured in millimeters of mercury (mmHg) above the surrounding atmospheric pressure, or in kilopascals (kPa). The difference between the systolic and diastolic pressures is known as pulse pressure, while the average pressure during a cardiac cycle is known as mean arterial pressure.

<span class="mw-page-title-main">Hypertension</span> Long-term high blood pressure in the arteries

Hypertension, also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms itself. It is, however, a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia. Hypertension is a major cause of premature death worldwide.

A hypertensive urgency is a clinical situation in which blood pressure is very high with minimal or no symptoms, and no signs or symptoms indicating acute organ damage. This contrasts with a hypertensive emergency where severely high blood pressure is accompanied by evidence of progressive organ or system damage.

<span class="mw-page-title-main">Heart failure</span> Failure of the heart to provide sufficient blood flow

Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome caused by an impairment in the heart's ability to fill with and pump blood.

Antihypertensives are a class of drugs that are used to treat hypertension. Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke, heart failure, kidney failure and myocardial infarction. Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21%, and can reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. There are many classes of antihypertensives, which lower blood pressure by different means. Among the most important and most widely used medications are thiazide diuretics, calcium channel blockers, ACE inhibitors, angiotensin II receptor antagonists (ARBs), and beta blockers.

<span class="mw-page-title-main">Pulmonary hypertension</span> Increased blood pressure in lung arteries

Pulmonary hypertension is a condition of increased blood pressure in the arteries of the lungs. Symptoms include shortness of breath, fainting, tiredness, chest pain, swelling of the legs, and a fast heartbeat. The condition may make it difficult to exercise. Onset is typically gradual. According to the definition at the 6th World Symposium of Pulmonary Hypertension in 2018, a patient is deemed to have pulmonary hypertension if the pulmonary mean arterial pressure is greater than 20mmHg at rest, revised down from a purely arbitrary 25mmHg, and pulmonary vascular resistance (PVR) greater than 3 Wood units.

Essential hypertension is a form of hypertension without an identifiable physiologic cause. It is the most common type affecting 85% of those with high blood pressure. The remaining 15% is accounted for by various causes of secondary hypertension. Essential hypertension tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors. Hypertension can increase the risk of cerebral, cardiac, and renal events.

<span class="mw-page-title-main">Valsartan</span> Angiotensin II receptor antagonist

Valsartan, sold under the brand name Diovan among others, is a medication used to treat high blood pressure, heart failure, and diabetic kidney disease. It belongs to a class of medications referred to as angiotensin II receptor blockers (ARBs). It is a reasonable initial treatment for high blood pressure. It is taken by mouth.

Secondary hypertension is a type of hypertension which has a specific and identifiable underlying primary cause. It is much less common than essential hypertension, affecting only 5-10% of hypertensive patients. It has many different causes including obstructive sleep apnea, kidney disease, endocrine diseases, and tumors. The cause of secondary hypertension varies significantly with age. It also can be a side effect of many medications.

<span class="mw-page-title-main">Hypertensive heart disease</span> Medical condition

Hypertensive heart disease includes a number of complications of high blood pressure that affect the heart. While there are several definitions of hypertensive heart disease in the medical literature, the term is most widely used in the context of the International Classification of Diseases (ICD) coding categories. The definition includes heart failure and other cardiac complications of hypertension when a causal relationship between the heart disease and hypertension is stated or implied on the death certificate. In 2013 hypertensive heart disease resulted in 1.07 million deaths as compared with 630,000 deaths in 1990.

The Dietary Approaches to Stop Hypertension or the DASH diet is a diet to control hypertension promoted by the U.S.-based National Heart, Lung, and Blood Institute, part of the National Institutes of Health (NIH), an agency of the United States Department of Health and Human Services. The DASH diet is rich in fruits, vegetables, whole grains, and low-fat dairy foods. It includes meat, fish, poultry, nuts, and beans, and is limited in sugar-sweetened foods and beverages, red meat, and added fats. In addition to its effect on blood pressure, it is designed to be a well-balanced approach to eating for the general public. DASH is recommended by the United States Department of Agriculture (USDA) as a healthy eating plan. The DASH diet is one of three healthy diets recommended in the 2015–20 U.S. Dietary Guidelines, which also include the Mediterranean diet and a vegetarian diet. The American Heart Association (AHA) considers the DASH diet "specific and well-documented across age, sex and ethnically diverse groups."

Arterial stiffness occurs as a consequence of biological aging and arteriosclerosis. Inflammation plays a major role in arteriosclerosis development, and consequently it is a major contributor in large arteries stiffening. Increased arterial stiffness is associated with an increased risk of cardiovascular events such as myocardial infarction, hypertension, heart failure and stroke, the two leading causes of death in the developed world. The World Health Organization predicts that in 2010, cardiovascular disease will also be the leading killer in the developing world and represents a major global health problem.

Prehypertension, also known as high normal blood pressure and borderline hypertensive (BH), is a medical classification for cases where a person's blood pressure is elevated above optimal or normal, but not to the level considered hypertension. Prehypertension is now referred to as "elevated blood pressure" by the American College of Cardiology (ACC) and the American Heart Association (AHA). The ACC/AHA define elevated blood pressure as readings with a systolic pressure from 120 to 129 mm Hg and a diastolic pressure under 80 mm Hg, Readings greater than or equal to 130/80 mm Hg are considered hypertension by ACC/AHA and if greater than or equal to 140/90 mm Hg by ESC/ESH. and the European Society of Hypertension defines "high normal blood pressure" as readings with a systolic pressure from 130 to 139 mm Hg and a diastolic pressure 85-89 mm Hg.

Central aortic blood pressure is the blood pressure at the root of aorta. Studies have shown the importance of central aortic pressure, especially as compared to peripheral blood pressure, and its implications in assessing the efficacy of antihypertensive treatment with respect to cardiovascular risk factors, kidney disease, and mortality. There is an emerging movement for clinicians to begin using central aortic blood pressure, instead of peripheral blood pressure, as a guide for clinical decisions.

<span class="mw-page-title-main">Orthostatic hypertension</span> Medical condition

Orthostatic hypertension is a medical condition consisting of a sudden and abrupt increase in blood pressure (BP) when a person stands up. Orthostatic hypertension is diagnosed by a rise in systolic BP of 20 mmHg or more when standing. Orthostatic diastolic hypertension is a condition in which the diastolic BP raises to 98 mmHg or over in response to standing, but this definition currently lacks clear medical consensus, so is subject to change. Orthostatic hypertension involving the systolic BP is known as systolic orthostatic hypertension.

<span class="mw-page-title-main">Blood pressure measurement</span> Techniques for determining blood pressure

Arterial blood pressure is most commonly measured via a sphygmomanometer, which historically used the height of a column of mercury to reflect the circulating pressure. Blood pressure values are generally reported in millimetres of mercury (mmHg), though modern aneroid and electronic devices do not contain mercury.

Hypertension is managed using lifestyle modification and antihypertensive medications. Hypertension is usually treated to achieve a blood pressure of below 140/90 mmHg to 160/100 mmHg. According to one 2003 review, reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21% and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease.

<span class="mw-page-title-main">Stefan D. Anker</span> German cardiologist

Stefan D. Anker is a German cariologist who is Head of Field “Tissue Homeostasis and Cachexia" at Charité University, Berlin, Germany. Previously, he was Professor of Innovative Clinical Trials at University Medical Center Göttingen in Germany. The main focus of the Innovative Clinical Trials department was research in the field of chronic heart failure, including the development and clinical testing of new therapies.

non-pharmacological intervention (NPI) is any type of healthcare intervention which is not primarily based on medication. Some examples include exercise, sleep improvement, and dietary habits.

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