The document summarizes guidelines from the International Society of Hypertension (ISH), World Health Organization (WHO), American College of Cardiology/American Heart Association (ACC/AHA), and European Society of Cardiology/European Society of Hypertension (ESC/ESH) on the diagnosis and treatment of hypertension. It compares the guidelines on prevalence of hypertension, treatment thresholds and targets, drug choice and sequencing, and targets for specific patient groups. While the guidelines have some differences, they also have many similarities, including treatment targets of under 140/90 mmHg for most patients and under 130/80 mmHg for high-risk groups.

1. Hypertension Guidelines
Comparison
Dr Seebat Masrur
D-Card Student
Department of Cardiology
SZMCH

2. • Prevalence of Hypertension.
• Impact of Hypertension.
• Guidelines of hypertension
• Brief discussion of ISH guidelines
• Brief discussion of WHO guidelines
• Differences and similarities of different guidelines
• Summary

3. Global Burden Of Hypertension

4. Global Burden Of Hypertension
• 1.5 billion estimated with hypertension in 2020
• 9-10 million Death per year from Worldwide
• 13.5% Total mortality by HTN

5. Prevalence of Hypertension % in Bangladesh
Both Men Women Urban Rural
21.0 17.9 24.1 25.2 19.8

6. 1 out of 5 adults
are hypertensive
6
Ref: Journal ofHuman Hypertension(2018)32:668–680

7. 7
Ref: Journal ofHypertension,Issue 33, Volume 3, March 2015, p 465-472

8. Consequences of Hypertension
Myocardial infarction
Heart failure
End-stage heart disease
Plaque rupture
Risk Factors
Hypertension
Dyslipidemia
Diabetes
Atherosclerosis
Endothelial
dysfunction
Macrovascular disease
Dilatation/Remodeling
CVA
Renal
Failure
Microvascular
disease

10. Ref: Lancet. 2008;371(9623):1513
10

11. Average Percentage of Reduction
Stroke Incidence 35-40%
Myocardial Infraction 20-25%
Heart Failure 50%
Benefits of Lowering BP

12. 50%
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
20
mmHg
SBP
increase
Mortality from
IHD & Stroke
Prospective Studies Collaboration. Lancet. 2002;360:1903-1913
SBP versus Mortality

13. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
10%
2
mmHg
SBP
decrease
Mortality from
IHD & Stroke
Prospective Studies Collaboration. Lancet. 2002;360:1903-1913
Even a small decrease is
beneficial

14. Guideline for the pharmacological treatment of
hypertension in adults
• US guidelines-American Heart Association who were tasked with issuing an update to the
JNC VII in 2017. The US guidelines created a lot of controversies and discussions when
they lowered the threshold for the diagnosis of hypertension to a systolic BP (SBP) of
≥130 mmHg and/or a diastolic BP (DBP) ≥80 mmHg in 2017
• European guidelines-New updates were published in 2007, 2013, and the latest in August
2018.
• International guidelines-The International Society of Hypertension (ISH) published in 2014
with the American Society of Hypertension Clinical Practice Guidelines for the Management
of Hypertension in the Community. Subsequently, ISH developed and issued for the first
time in 2020 a worldwide practice guidelines.

15. 2020 ISH Hypertension Practice
Guidelines
15
ISH 2020 guidelines were
developed
To be used globally
To be fit for application
low and high resource
setting
To be concise,
simplified and easy to
use

16. Treatment of Hypertension
2
0
2
0
 Non-Pharmacological Treatment/ Lifestyle Modification
 Pharmacological Treatment/ Drug Treatment
2020 ISH Global
Hypertension Practice Guidelines

17. Treatment objective
 To control BP
BP <140/90 mmHG or
BP <130/80 mmHG
Diabetic/CKD Patients
 To Maintain BP control
 Over 24 Hours
 Over Long Time
To reduce
Cardiovascular,
Cerebrovascular and
Renal events.
Morbidity and
Mortality.
Prolong life span

18. Non-Pharmacological Treatment/
Lifestyle Modification
2
0
2
0
• Healthy lifestyle choices can prevent or delay the onset
of high BP and can reduce CV risk
• Lifestyle modification is often the first line of
antihypertensive treatment.
• Modifications in lifestyle can also enhance the effects
of antihypertensive treatment.

19. Non-Pharmacological Treatment/
Diet
2
0
2
0
• Reducing salt added when preparing foods and at the table. Avoid or limit consumption of
high salt foods.
• Eating a diet rich in whole grains, fruits, vegetables, poly-unsaturated fats and dairy
products, such as DASH diet.
• Reducing food high in sugar, saturated fat and trans fats.
• Increasing intake of vegetables high in nitrates (leafy vegetables and beetroot). Other
beneficial foods and nutrients include those high in magnesium, calcium and potassium
(avocados, nuts, seeds, legumes and tofu).

20. Non-Pharmacological Treatment/
Diet
2
0
2
0
• Moderate consumption of healthy drinks (coffee, green and black tea, Karkadé(Hibiscus)
tea, pomegranate juice, beetroot juice and cocoa.
• Moderation of alcohol consumption and avoidance of binge drinking.
• Reduce weight and avoid obesity.
• Be careful with complementary, alternative or traditional medicines –little/no evidence.

21. Non-Pharmacological Treatment/
Lifestyle
2
0
2
0
• Smoking cessation
• Engage in regular moderate intensity aerobic and resistance exercise, 30
minutes on 5 –7 days per week or HIIT (High Intensity Interval Training).
• Reduce stress and introduce mindfulness.
• Reduce exposure to air pollution and cold temperature.

22. Non-pharmacological Treatment - Lifestyle
Modification Approximately SBP reduction(range)
Weight Reduction 5-20 mmHg/10 kg weight loss
Adopt DASH eating plan 8-14 mmHg
Dietary sodium reduction 2-8 mmHg
Physical activity
4-9 mmHg
Moderation of alcohol consumption 2-4 mmHg

23. Pharmacological Treatment
Of Hypertension

24. ISH: Ideal Characteristics of Drug
Treatmentsshould be evidence-basedin
relation to morbidity/mortalityprevention.
Use a once-daily regimenwhich provides
24-hour blood pressurecontrol.
Evidence of benefitsof use of the
medication in populations to which it is to
be applied.
Treatmentsshould be well-
tolerated.

25. .
2
0
2
0

26. .
2
0
2
0

27. Classification Comparison
Ref-https://onlinelibrary.wiley.com/doi/full/10.1111/jch.14226

28. Drug Treatment Of
Hypertension:
Thresholds and Targets
NEW

29. Drug choice &
Sequencing

30. • WHO 2021
• An approach for
starting treatment with
a single-pill
combination

31. An approach for
starting
treatment not
using a single-pill
combination (i.e.
with
monotherapy or
free combination
therapy)

32. Initiation of treatment with
a single-pill combination
• Beginning treatment with two
antihypertensive drugs from different classes
is recommended when baseline BP is ≥20/10
mmHg above goal, and should be considered
when baseline BP is ≥140/90 mmHg.
• This protocol is contraindicated for women
who are or could become pregnant. Neither
an ACEI or ARB should be given to pregnant
women.
• Start two individual pills or, if available, both
in a single-pill combination (fixed-dose
combination).

33. Initiation of treatment not
using a single-pill
combination
• A CCB, rather than a thiazide-type diuretic or
ACEi/ARB, was selected as first-line medication if
one agent is used, to avoid the need for
electrolyte measurements or to alleviate
concerns regarding potential change in GFR.

34. WHO Vs ISH

35. Differences in the guidelines

36. Similarities between the guidelines

37. Comparison of the pharmacological approaches between WHO and ISH
guidelines

38. Similarities

39. Bp target and reassessment(WHO Vs ISH)
• Both the WHO and ISH recommend a target BP of <140/90 mmHg in patients without
comorbidities. The ISH further defines optimal BP targets for those aged <65 and
≥65 years.
• The ISH aims for BP control within 3 months of pharmacological initiation, while the WHO
does not define a target duration for achieving BP control.
• For patients with comorbidities and high CV risk, both guidelines suggest a target SBP of
<130 mmHg.

40. Bp target and reassessment (WHO Vs ISH)
• Another difference between these guidelines is the office BP targets. The WHO sets
targets based on comorbidities (<140/90 mmHg in all hypertensive patients without
comorbidities and <130 mmHg in hypertensive patients with known CVD or high-risk
populations).
• By contrast, the ISH uses a fixed number as the essential target (reduction by at least
20/10 mmHg or ideally to <140/90 mmHg).
• The WHO advises monthly reassessment of BP after starting BP-lowering therapy, with
follow-up every 3–6 months after BP is controlled.
• ISH does not provide recommendations on the follow-up frequency, although it does
provide a 3-month deadline for BP control.

41. ESCESH VS AHAACC

42. ACC Vs ESC

43. ACC/AHA BP 2017
1.Emphasis on absolute CV risk
computed through ASCVD risk
calculator with >10% 10-year risk
more aggressive.
2.Focus on prevention of
hypertension.
3.New definition of hypertension
>130/80 mm Hg for everyone,
with threshold and target the
same, regardless of age
ESC/ESH BP 2018
1.Emphasis on absolute CV risk
computed using SCORE system
coupled with risk modifiers and
assessment of HMOD, with >10%
10-year CV risk more aggressive.
2.No specific attention to
prevention as BP approaches
130/80 mm Hg.
3.Retained definition of
hypertension >140/90 mm Hg and
encouraged patient discussion
and education to
achieve <130/80 mm Hg in those
who require it by the evidence
(<140/90 mm Hg in older
persons) Limits on BP reduction,
not <120/70 mm Hg

44. ACC/AHA BP 2017
4. No discussion of isolated
systolic hypertension.
5. Concise mention of organ
damage assessment.
6. Similar SBP targets for all
patients.
7. No mention of environmental
and altitude effects on BP
ESC/ESH BP 2018
4. Detailed discussion of
isolated systolic hypertension.
5. Detailed description of
HMOD
6. Personalized approach to
definition of SBP targets.
7. Environmental and altitude
effects on BP mentioned

45. Summary of Guidelines

46. Initiation and choice of anti-
hypertension drugs
Indications AHA/ACC ESC/ESH ISH
BP ≥130/80 mmHg Treat if ASCVD+ve or
CV risk ≥10%
Consider treat in very
high risk with CVD
especially CAD
Consider treat if
ACVD+ve or DM, or
CKD or HMOD
BP 140–159/90–99 Drug treatment Immediate treatment
in high or very high
with CVD, CKD or
HMOD
Immediate treatment
in high risk or with
CVD or CKD or DM or
HMOD
BP ≥160/110 mmHg Drug treatment Immediate drug
treatment
Immediate treatment
in all patients

47. BP TARGET FOR CONTROL
AHA/ACC 2017 ESC/ESH
2018
ISH
2020
Target BP mmHg <130/80 SBP 130
DBP 70–79
<140/90
HTN+CAD <130/80 SBP 130
DBP 70–79
<130/80
HTN+CVA <130/80 SBP 130
DBP 70–79
<130/80
HTN+HF <130/80 SBP 130
DBP 70–79
<130/80 but not <120/70
HTN+UA <130/80 <130–139/70–79 <130/80

48. BP TARGET FOR CONTROL
AHA/ACC 2017 ESC/ESH
2018
ISH
2020
HTN+CKD <130/80 SBP <140 to 130 if
tolerated DBP 70–79
<130/80
HTN+DM <130/80 SBP 130
DBP 70–79
<130/80
HTN ≥65 years <130/80 130–139/70–79 <140/80
HTN ≥80 years NR 130–139/70–79 NR

49. Drug choice in special groups
AHA/ACC 2017 ESC/ESH
2018
ISH
2020
HTN+CAD BB RAS, CCB RAS+BB /CCB or DU^ RAS CCB DU
HTN+CVA DU^ RAS RAS+CCB/DU^
diuretic
RAS CCB DU
HTN+HF RAS BB DU MRA
(non-DHP CCB)
RAS, BB and MRAs RAS, BB and MRA
HTN+UA RAS RAS+CCB/DU^ RAS+CCB DU (Loop)

50. Drug choice in special groups
AHA/ACC 2017 ESC/ESH
2018
ISH
2020
HTN+DM DU, RAS CCB RAS+CCB/DU^c RAS ± CCB/DU
HTN ≥65 years DU CCB RAS NR NR
HTN ≥75 year NR DU CCB RAS DU CCB RAS

51. Thank You