Hypertensionaha 120 15026

Clinical Practice Guidelines
2020 International Society of Hypertension Global

Hypertension Practice Guidelines
Thomas Unger, Claudio Borghi, Fadi Charchar, Nadia A. Khan, Neil R. Poulter,
Dorairaj Prabhakaran, Agustin Ramirez, Markus Schlaich, George S. Stergiou,
Maciej Tomaszewski, Richard D. Wainford, Bryan Williams, Aletta E. Schutte
Table of Contents Section 1: Introduction

Section 1. Introduction.................................................. 1334 Context and Purpose of This Guideline
Section 2. Definition of Hypertension�� 1336
Section 3. Blood Pressure Measurement and Statement of Remit
Diagnosis of Hypertension.......................... 1336 To align with its mission to reduce the global burden of raised
Section 4. Diagnostic and Clinical Tests�� 1337 blood pressure (BP), the International Society of Hypertension
Section 5. Cardiovascular Risk Factors�� 1339 (ISH) has developed worldwide practice guidelines for the
Section 6. Hypertension-Mediated Organ Damage�� 1340 management of hypertension in adults, aged 18 years and
Section 7. Exacerbators and Inducers older.
of Hypertension�� 1341 The ISH Guidelines Committee extracted evidence-based
Section 8. Treatment of Hypertension�� 1341 content presented in recently published extensively reviewed
8.1 Lifestyle Modification�� 1341 guidelines and tailored and standards
8.2 Pharmacological Treatment�� 1341 of care in a practical format that is easy-to-use particularly
8.3 Adherence to Antihypertensive in low, but also in high resource settings – by clinicians, but
Treatment�� 1341 also nurses and community health workers, as appropriate.
Section 9. Common and Other Comorbidities
Although distinction between low and high resource settings
of Hypertension�� 1342
often refers to high (HIC) and low- and middle-income coun-
Section 10. Specific Circumstances�� 1346
tries (LMIC), it is well established that in HIC there are areas
10.1 Resistant Hypertension�� 1346
10.2 Secondary Hypertension�� 1346 with low resource settings, and vice versa.
10.3 Hypertension in Pregnancy�� 1347 Herein optimal care refers to evidence-based standard of
10.4 Hypertensive Emergencies�� 1348 care articulated in recent guidelines1,2 and summarized here,
10.5 Ethnicity, Race and whereas standards recognize that
Hypertension�� 1350 standards would not always be possible. Hence essential stan-
Section 11. Resources�� 1350 dards refer to minimum standards of care. To allow specifica-
Section 12. Hypertension Management at a Glance�� 1352 tion of essential standards of care for low resource settings,
Acknowledgments�� 1354 the Committee was often confronted with the limitation or
References�� 1354 absence in clinical evidence, and thus applied expert opinion.
Received March 6, 2020; first decision March 16, 2020; revision accepted March 27, 2020.
From the CARIM – School for Cardiovascular Diseases, Maastricht University, the Netherlands (T.U.); Department of Medical and Surgical Sciences,
University of Bologna, Italy (C.B.); Federation University Australia, School of Health and Life Sciences, Ballarat, Australia (F.C.); University of
Melbourne, Department of Physiology, Melbourne, Australia (F.C.); University of Leicester, Department of Cardiovascular Sciences, United Kingdom
(F.C.); University of British Columbia, Vancouver, Canada (N.A.K.); Center for Health Evaluation and Outcomes Sciences, Vancouver, Canada (N.A.K.);
Imperial Clinical Trials Unit, Imperial College London, United Kingdom (N.R.P.); Public Health Foundation of India, New Delhi, India (D.P.); Centre for
Chronic Disease Control, New Delhi, India (D.P.); London School of Hygiene and Tropical Medicine, United Kingdom (D.P.); Hypertension and Metabolic
Unit, University Hospital, Favaloro Foundation, Buenos Aires, Argentina (A.R.); Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital
Unit, University of Western Australia, Perth (M.S.); Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute,
Melbourne, Victoria, Australia (M.N.); Hypertension Center STRIDE‐7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National
and Kapodistrian University of Athens, Greece (G.S.S.); Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of
Manchester, United Kingdom (M.T.); Division of Medicine and Manchester Academic Health Science Centre, Manchester University NHS Foundation
Trust Manchester, United Kingdom (M.T.); Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, MA
(R.D.W.); The Whitaker Cardiovascular Institute, Boston University, MA (R.D.W.); Department of Health Sciences, Boston University Sargent College,
MA (R.D.W.); University College London, NIHR University College London, Hospitals Biomedical Research Centre, London, United Kingdom (B.W.);
Faculty of Medicine, University of New South Wales, Sydney, Australia (A.E.S.); The George Institute for Global Health, Sydney, Australia (A.E.S.);
and Hypertension in Africa Research Team (A.E.S.) and South African MRC Unit for Hypertension and Cardiovascular Disease (A.E.S.), North-West
University, Potchefstroom, South Africa.
This article has been copublished in the Journal of Hypertension.
Correspondence to Thomas Unger, CARIM-Maastricht University, P.O. Box 616, 6200 MD Maastricht, the Netherlands. Email thomas.unger@
maastrichtuniversity.nl
(Hypertension. 2020;75:00-00. DOI: 10.1161/HYPERTENSIONAHA.120.15026.)
© 2020 American Heart Association, Inc.
Hypertension is available at https://www.ahajournals.org/journal/hyp DOI: 10.1161/HYPERTENSIONAHA.120.15026
1
2 Hypertension June 2020
Abbreviations SRI serotonin reuptake inhibitors

ABI ankle-brachial index SSRI selective serotonin reuptake inhibitors
ABPM ambulatory blood pressure monitoring s-UA serum uric acid
ACE angiotensin converting enzyme T4 thyroxin 4
ARB angiotensin AT-1 receptor blocker TIA transient ischemic attack
ARNI angiotensin receptor-neprilysin inhibitors TMA thrombotic microangiopathy
BMI body mass index TSH thyroid stimulating hormone
BP blood pressure TTE two-dimensional transthoracic echocardiogram
CAD coronary artery disease UACR urinary albumin creatinine ratio
CCBs calcium channel blockers
CKD chronic kidney disease
In the Guidelines, differentiation between optimal and es-
COPD chronic obstructive pulmonary disease sential standards were not always possible, and were made
CVD cardiovascular disease in sections where it was most practical and sensible. The
DBP diastolic blood pressure Guidelines Committee is also aware that some recommended
DHP-CCB dihydropyridine calcium channel blocker essential standards may not be feasible in low resource set-
DM diabetes mellitus tings, for example, out-of-office BP measurements, the
DRI direct renin inhibitor requirement of multiple visits for the diagnosis of hyperten-
ECG electrocardiogram sion, or advising the use of single pill combination therapy.
Although challenging to implement, these guidelines may aid
eGFR estimated glomerular filtration rate
in local initiatives to motivate policy changes and serve as an
ESC-ESH European Society of Cardiology, European Society of
instrument to drive local improvements in standards of care.
Hypertension
Every effort should be made to achieve essential standards of
HBPM home blood pressure measurement care to reduce hypertension-induced cardiovascular morbidity
HDL high density lipoprotein and mortality.
HELLP hemolysis, elevated liver enzymes and low platelets
Motivation
HF heart failure
Raised BP remains the leading cause of death globally,
HFpEF heart failure with preserved ejection fraction
accounting for 10.4 million deaths per year.3 When reviewing
HFrEF heart failure with reduced ejection fraction global figures, an estimated 1.39 billion people had hyperten-
HIC high-income countries sion in 2010. 4 However, BP trends show a clear shift of the
HIIT high intensity interval training highest BPs from high-income to low-income regions,5 with
HIV human immunodeficiency virus an estimated 349 million with hypertension in HIC and 1.04
HMOD hypertension-mediated organ damage billion in LMICs.4
IMT intima media thickness The large disparities in the regional burden of hyperten-
IRD inflammatory rheumatic disease
sion are accompanied by low levels of awareness, treatment
and control rates in LMIC, when compared to HIC. In re-
ISH International Society of Hypertension
sponse to poor global awareness for hypertension (estimated
LDH lactate dehydrogenase
67% in HIC and 38% in LMIC),4 the ISH launched a global
LDL-C low-density lipoprotein cholesterol campaign to increase awareness of raised BP, namely the May
LMIC low- and middle-income countries Measurement Month initiative.6,7
LV left ventricular Despite several initiatives, the prevalence of raised BP
LVH left ventricular hypertrophy and adverse impact on cardiovascular morbidity and mor-
MAP mean arterial pressure tality are increasing globally, irrespective of income.4,5 It
MRI magnetic resonance imaging is therefore critical that population-based initiatives are
MS metabolic syndrome
applied to reduce the global burden of raised BP, such as salt-
reduction activities and improving the availability of fresh
NSAIDs nonsteroidal anti-inflammatory drugs
fruit and vegetables. To improve the management of hyper-
PWV pulse wave velocity
tension, the ISH has published in 2014 with the American
RAAS renin angiotensin aldosterone system Society of Hypertension, Clinical Practice Guidelines for the
RAS renin-angiotensin system Management of Hypertension in the Community (See Section
RCT randomized control trials 11: Resources). Recently, we have observed a recent flurry
SBP systolic blood pressure of updated evidence-based guidelines arising mainly from
SNRI selective norepinephrine and serotonin reuptake high-income regions and countries, including the United
inhibitors States of America,2 Europe,1 United Kingdom,8 Canada9 and
SPC single pill combination therapy Japan.10 New developments include redefining hypertension,2
initiating treatment with a single pill combination therapy,1
Unger et al 2020 ISH Global Hypertension Practice Guidelines 3
Table 1. Classification of Hypertension Based on Office Blood Pressure (BP) Table 2. Criteria for Hypertension Based on Office-, Ambulatory (ABPM)-, and
Measurement Home Blood Pressure (HBPM) Measurement
Category Systolic (mm Hg) Diastolic (mm Hg) SBP/DBP, mm Hg

Normal BP <130 and <85 Office BP ≥140 and/or ≥90
High-normal BP 130–139 and/or 85–89 ABPM
Grade 1 hypertension 140–159 and/or 90–99 24-h average ≥130 and/or ≥80
Grade 2 hypertension ≥160 and/or ≥100 Day time (or awake) average ≥135 and/or ≥85
Night time (or asleep) average ≥120 and/or ≥70
advising wider out-of-office BP measurement,2,10 and lower
BP targets.1,2,8,11,12 HBPM ≥135 and/or ≥85
Low- and middle-income regions often follow the re-
pressure (DBP) is ≥90 mm Hg following repeated
lease of guidelines from high-income regions closely, as
examination (see below, Section 3). Table 1 provides
their resources and health systems to develop and imple-
a classification of BP based on office BP measure-
ment local guidelines remain challenging. In Africa only
ment, Table 2 provides ambulatory and home BP
25% of countries have hypertension guidelines13 and in values used to define hypertension; these definitions
many instances these guidelines are adopted from those apply to all adults (>18 year old). These BP cate-
of high-income regions. However, the adoption of guide- gories are designed to align therapeutic approaches
lines from high-income regions are sometimes impractical with BP levels.
as low resource settings are confronted with a substantial • High-normal BP is intended to identify individuals
number of obstacles including severe lack of trained health- who could benefit from lifestyle interventions and who
care professionals, unreliable electricity in rural clinics, low would receive pharmacological treatment if compelling
access to basic office BP devices and limited ability to con- indications are present (see Section 9).
duct basic recommended diagnostic procedures and poor • Isolated systolic hypertension defined as elevated SBP
access to affordable high-quality medications. In both low (≥140 mm Hg) and low DBP (<90 mm Hg) is common
and high-income regions, the ambiguities of latest guide- in young and in elderly people. In young individuals,
lines are often met with confusion among healthcare pro- including children, adolescents and young adults, iso-
viders, anxiety among patients,14 and they resulted in a call lated systolic hypertension is the most common form of
for global harmonization.15 Guidelines from high-income essential hypertension. However, it is also particularly
regions may thus not fit global purpose.16 common in the elderly, in whom it reflects stiffening of
the large arteries with an increase in pulse pressure (dif-
Guideline Development Process ference between SBP and DBP).
The 2020 ISH Global Hypertension Practice Guidelines were • Individuals identified with confirmed hypertension
developed by the ISH Hypertension Guidelines Committee (grade 1 and grade 2) should receive appropriate phar-
based on evidence criteria, (1) to be used globally; (2) to be macological treatment.
fit for application in low and high resource settings by advis- • Details of home-, office- and ambulatory BP measure-
ing on essential and optimal standards; and (3) to be concise, ment techniques are addressed in Section 3.
simplified, and easy to use. They were critically reviewed and
evaluated by numerous external hypertension experts from Section 3: Blood Pressure Measurement and
HIC and LMIC with expertize in the optimal management of Diagnosis of Hypertension
hypertension and management in resource-constraint settings.
These Guidelines were developed without any support from
industry or other sources. Hypertension Diagnosis – Office BP Measurement
• The measurement of BP in the office or clinic is
Composition of the ISH Hypertension Guidelines
most commonly the basis for hypertension diagno-
Committee and Selection of External Reviewers
sis and follow-up. Office BP should be measured ac-
The ISH Hypertension Guidelines Committee was composed
cording to recommendations shown in Table 3 and
of members of the ISH Council; they were included on the Figure 1.1,2,17,18
basis of (1) specific expertize in different areas of hyperten- • Whenever possible, the diagnosis should not be made
sion; (2) previous experience with the generation of hyper- on a single office visit. Usually 2–3 office visits at
tension guidelines, as well as (3) representation of different 1–4-week intervals (depending on the BP level) are
regions of the world. A similar strategy was followed con- required to confirm the diagnosis of hypertension.
cerning the selection of external reviewers with particular The diagnosis might be made on a single visit, if BP
consideration of representatives from LMICs. is ≥180/110 mm Hg and there is evidence of cardio-
vascular disease (CVD).1,2,17,18
Section 2: Definition of Hypertension • The recommended patient management according to
• In accordance with most major guidelines it is rec- office BP levels is presented in Table 4.
ommended that hypertension be diagnosed when a • If possible and available, the diagnosis of hyperten-
person’s systolic blood pressure (SBP) in the office sion should be confirmed by out-of-office BP meas-
or clinic is ≥140 mm Hg and/or their diastolic blood urement (see below).1,2,19–21
Table 3. Recommendations for Office Blood Pressure Measurement
Conditions • Quiet room with comfortable temperature.

• Before measurements: Avoid smoking, caffeine and exercise for 30 min; empty bladder; remain seated and relaxed for 3–5 min.
• Neither patient nor staff should talk before, during and between measurements.
Positions • Sitting: Arm resting on table with mid-arm at heart level; back supported on chair; legs uncrossed and feet flat on floor (Figure 1).
Device • Validated electronic (oscillometric) upper-arm cuff device. Lists of accurate electronic devices for office, home and ambulatory BP
measurement in adults, children and pregnant women are available at www.stridebp.org.22 (see also Section 11: Resources)
• Alternatively use a calibrated auscultatory device, (aneroid, or hybrid as mercury sphygmomanometers are banned in most
countries) with 1st Korotkoff sound for systolic blood pressure and 5th for diastolic with a low deflation rate.22
Cuff • Size according to the individual’s arm circumference (smaller cuff overestimates and larger cuff underestimates blood pressure).
• For manual auscultatory devices the inflatable bladder of the cuff must cover 75%–100% of the individual’s arm circumference.
For electronic devices use cuffs according to device instructions.
Protocol • At each visit take 3 measurements with 1 min between them. Calculate the average of the last 2 measurements. If BP of first
reading is <130/85 mm Hg no further measurement is required.
Interpretation • Blood pressure of 2–3 office visits ≥140/90 mm Hg indicates hypertension.
use the arm with the higher BP. If the difference is

Hypertension Diagnosis – Office Blood Pressure >20 mm Hg consider further investigation.
Measurement • Standing blood pressure: Measure in treated hyper-
• Initial evaluation: Measure BP in both arms, prefer- tensives after 1 min and again after 3 min when there
ably simultaneously. If there is a consistent difference are symptoms suggesting postural hypotension and at
between arms >10 mm Hg in repeated measurements, the first visit in the elderly and people with diabetes.
Figure 1. How to measure blood pressure.

• Unattended office blood pressure: Multiple auto- Table 5. Clinical Use of Home and Ambulatory Blood Pressure (BP) Monitoring
mated BP measurements taken while the patient re- Home 24-Hour Ambulatory
mains alone in the office provide a more standardized Blood Pressure Blood Pressure
evaluation but also lower BP levels than usual office Monitoring Monitoring
measurements with uncertain threshold for hyperten-
Condition As for office blood Routine working day.
sion diagnosis.17,18,23,24 Confirmation with out-of-of-
pressure (see above).
fice BP is again needed for most treatment decisions.
Position As for office BP (see Avoid strenuous
Hypertension Diagnosis – Out-of-Office Blood above). activity. Arm still and
Pressure Measurement relaxed during each
• Out-of-office BP measurements (by patients at home measurement.
or with 24-hour ambulatory blood pressure moni- Device Validated electronic (oscillometric) upper-arm
toring [ABPM]) are more reproducible than office cuff device (www.stridebp.org, and Section 11:
measurements, more closely associated with hyper- Resources)
tension-induced organ damage and the risk of car-
Cuff Size according to the individual’s arm
diovascular events and identify the white coat and circumference
masked hypertension phenomena (see below).
• Out-of-office BP measurement is often necessary for Measurement Before each visit to the • 24-hour monitoring at
the accurate diagnosis of hypertension and for treat- protocol health professional: 15–30 min intervals
• 3–7-day monitoring during daytime and
ment decisions. In untreated or treated subjects with
in the morning (before nighttime.
office BP classified as high-normal BP or grade 1 hy- drug intake if treated) • At least 20 valid
pertension (systolic 130–159 mm Hg and/or diastolic and the evening. daytime and 7
85–99 mm Hg), the BP level needs to be confirmed us- • Two measurements nighttime BP readings
ing home or ambulatory BP monitoring (Table 5).1,2,17,21 on each occasion are required. If less,
• Recommendations for performing home and ambula- after 5 min sitting rest the test should be
tory BP measurement are presented in Table 5. and 1 min between repeated.
measurements.
White Coat and Masked Hypertension Long-term follow-up of
treated hypertension:
• The use of office and out-of-office (home or ambulatory)
• 1 –2 measurements
BP measurements identifies individuals with white coat per week or month.
hypertension, who have elevated BP only in the office
(nonelevated ambulatory or home BP), and those with Interpretation • A verage home • 24-hour ambulatory
masked hypertension, who have nonelevated BP in the blood pressure blood pressure
after excluding ≥130/80 mm Hg
office but elevated BP out of the office (ambulatory or
readings of the first indicates hypertension
home).1,2,17–21,25–27 These conditions are common among day ≥135 or 85 (primary criterion).
both untreated subjects and those treated for hyperten- mm Hg indicates • Daytime (awake)
sion. About 10%–30% of subjects attending clinics due hypertension. ambulatory blood
to high BP have white coat hypertension and 10%–15% pressure ≥135/85
have masked hypertension. mm Hg and nighttime
• White coat hypertension: These subjects are at inter- (asleep) ≥120/70
mediate cardiovascular risk between normotensives and mm Hg indicates
sustained hypertensives. The diagnosis needs confirma- hypertension
tion with repeated office and out-of-office BP measure-
ments. If their total cardiovascular risk is low and there may develop sustained hypertension requiring drug
is no hypertension-mediated organ damage (HMOD), treatment.1,2,17–21,25–27
drug treatment may not be prescribed. However, they • Masked hypertension: These patients are at similar risk
should be followed with lifestyle modification, as they of cardiovascular events as sustained hypertensives. The
diagnosis needs confirmation with repeated office and
Table 4. Blood Pressure Measurement Plan According to Office Blood Pressure out-of-office measurements. Masked hypertension may
Levels require drug treatment aiming to normalize out-of-office
BP.1,2,17–21,25–27
Office Blood Pressure Levels (mm Hg)
<130/85 130–159/85–99 >160/100 Section 4: Diagnostic / Clinical Tests
Remeasure within 3 If possible confirm with Confirm within a few
years (1 year in those out-of-office blood days or weeks
with other risk factors) pressure measurement Medical History
(high possibility of Patients with hypertension are often asymptomatic, how-
white coat or masked ever specific symptoms can suggest secondary hyperten-
hypertension).
sion or hypertensive complications that require further
Alternatively confirm
with repeated office
investigation. A complete medical and family history is
visits. recommended and should include1:
• Blood pressure: New onset hypertension, duration, • Carotid ultrasound: Plaques (atherosclerosis),
previous BP levels, current and previous antihyper- stenosis.
tensive medication, other medications/over-the coun- • Kidneys/renal artery and adrenal imaging:
ter medicines that can influence BP, history of intol- Ultrasound/renal artery Duplex; CT-/MR-angiography:
erance (side-effects) of antihypertensive medications, renal parenchymal disease, renal artery stenosis, adre-
adherence to antihypertensive treatment, previous hy- nal lesions, other abdominal pathology.
pertension with oral contraceptives or pregnancy. • Fundoscopy: Retinal changes, hemorrhages, papill-
• Risk factors: Personal history of CVD (myocardial edema, tortuosity, nipping.
infarction, heart failure [HF], stroke, transient ische- • Brain CT/MRI: Ischemic or hemorrhagic brain in-
mic attacks [TIA], diabetes, dyslipidemia, chronic jury due to hypertension.
kidney disease [CKD], smoking status, diet, alcohol
Functional Tests and Additional Laboratory
intake, physical activity, psychosocial aspects, his-
Investigations
tory of depression). Family history of hypertension,
premature CVD, (familial) hypercholesterolemia, • Ankle-brachial index: Peripheral (lower extremity)
diabetes. artery disease.
• Assessment of overall cardiovascular risk: In line • Further testing for secondary hypertension if sus-
with local guidelines/recommendations (see risk pected: Aldosterone-renin ratio, plasma free meta-
scores in Section 11 at the end of the document). nephrines, late-night salivary cortisol or other screen-
• Symptoms/signs of hypertension/coexistent ill- ing tests for cortisol excess.
nesses: Chest pain, shortness of breath, palpitations, • Urinary albumin/creatinine ratio
claudication, peripheral edema, headaches, blurred • Serum uric acid (s-UA) levels
vision, nocturia, hematuria, dizziness. • Liver function tests
• Symptoms suggestive of secondary hypertension:
Muscle weakness/tetany, cramps, arrhythmias (hy- Section 5: Cardiovascular Risk Factors
pokalemia/primary aldosteronism), flash pulmonary Diagnostic Approach
edema (renal artery stenosis), sweating, palpitations, • More than 50% of hypertensive patients have additional
frequent headaches (pheochromocytoma), snoring, cardiovascular risk factors.28,29
daytime sleepiness (obstructive sleep apnea), symp- • The most common additional risk factors are diabetes
toms suggestive of thyroid disease (see Section 10 for (15%–20%), lipid disorders (elevated low-density lipopro-
full list of symptoms). tein-cholesterol [LDL-C] and triglycerides [30%]), over-
Physical Examination weight-obesity (40%), hyperuricemia (25%) and metabolic
A thorough physical examination can assist with confirm- syndrome (40%), as well as unhealthy lifestyle habits (eg,
ing the diagnosis of hypertension and the identification smoking, high alcohol intake, sedentary lifestyle).28–30
of HMOD and/or secondary hypertension and should • The presence of one or more additional cardiovascular
include: risk factors proportionally increases the risk of coro-
• Circulation and heart: Pulse rate/rhythm/character, nary, cerebrovascular, and renal diseases in hypertensive
jugular venous pulse/pressure, apex beat, extra heart patients.1
sounds, basal crackles, peripheral edema, bruits (ca-
rotid, abdominal, femoral), radio-femoral delay.
• Other organs/systems: Enlarged kidneys, neck cir- • An evaluation of additional risk factors should be
cumference >40 cm (obstructive sleep apnea), en- part of the diagnostic workup in hypertensive pa-
larged thyroid, increased body mass index (BMI)/ tients particularly in the presence of a family history
waist circumference, fatty deposits and coloured of CVD.
striae (Cushing disease/syndrome). • Cardiovascular risk should be assessed in all hy-
Laboratory Investigations and ECG pertensive patients by easy-to-use scores based on
• Blood tests: Sodium, potassium, serum creatinine BP levels and additional risk factors according to a
and estimated glomerular filtration rate (eGFR). If a- simplified version of the approach proposed by ESC-
vailable, lipid profile and fasting glucose. ESH Guidelines (Table 6).1
• Urine test: Dipstick urine test. • A reliable estimate of cardiovascular risk can be ob-
• 12-lead ECG: Detection of atrial fibrillation, left ven- tained in daily practice by including:
tricular hypertrophy (LVH), ischemic heart disease. • Other Risk Factors: Age (>65 years), sex
(male>female), heart rate (>80 beats/min), increased
body weight, diabetes, high LDL-C/triglyceride, fam-
Additional Diagnostic Tests ily history of CVD, family history of hypertension,
early-onset menopause, smoking habits, psychosocial
Additional investigations when indicated can be undertaken
or socioeconomic factors. HMOD: LVH (LVH with
to assess and confirm suspicion of HMOD, coexistent dis-
ECG), moderate-severe CKD (CKD; eGFR <60 ml/
eases or/and secondary hypertension.
min/1.73m2), any other available measure of organ
Imaging Techniques damage. Disease: previous coronary heart disease
• Echocardiography: LVH, systolic/diastolic dysfunc- (CHD), HF, stroke, peripheral vascular disease, atrial
tion, atrial dilation, aortic coarctation. fibrillation, CKD stage 3+.
Table 6. Simplified Classification of Hypertension Risk according to additional Specific Aspects of HMOD and Assessment
Risk Factors, Hypertension-Mediated Organ Damage (HMOD), and Previous
Disease* • Brain: TIA or strokes are common manifestations of
elevated BP. Early subclinical changes can be detected
Other Risk most sensitively by magnetic resonance imaging (MRI)
Factors, High-Normal Grade 1 Grade 2 and include white matter lesions, silent microinfarcts,
HMOD, or SBP 130−139 SBP 140–159 SBP ≥160
microbleeds, and brain atrophy. Due to costs and limited
Disease DBP 85−89 DBP 90−99 DBP ≥100
availability brain MRI is not recommended for routine
No other risk practice but should be considered in patients with neuro-
Low Low Moderate High
factors logic disturbances, cognitive decline and memory loss.
1 or 2 risk • Heart: A 12-lead ECG is recommended for routine
Low Moderate High
factors workup of patients with hypertension and simple criteria
≥3 risk factors Low Moderate High High (Sokolow-Lyon index: SV1+RV5 ≥35 mm, Cornell in-
dex: SV3+RaVL >28 mm for men or >20 mm for women
HMOD, CKD
and Cornell voltage duration product: >2440 mm•ms)
grade 3,
diabetes
High High High are available to detect presence of LVH. Sensitivity of
mellitus, CVD ECG-LVH is very limited and a two-dimensional trans-
thoracic echocardiogram (TTE) is the method of choice
*Example based on a 60 year old male patient. Categories of risk will vary
to accurately assess LVH (left ventricular mass index
according to age and sex.
[LVMI]: men >115 g/m2; women >95 g/m2) and relevant
parameters including LV geometry, left atrial volume,
• The therapeutic strategy must include lifestyle changes, LV systolic and diastolic function and others.
BP control to target and the effective treatment of the • Kidneys: Kidney damage can be a cause and conse-
other risk factors to reduce the residual cardiovascular quence of hypertension and is best assessed routinely
risk. by simple renal function parameters (serum creatinine
• The combined treatment of hypertension and additional and eGFR) together with investigation for albuminuria
cardiovascular risk factors reduces the rate of CVD be- (dipstick or urinary albumin creatinine ratio [UACR]) in
yond BP control. early morning spot urine).
• Arteries: Three vascular beds are commonly assessed
Other Additional Risk Factors to detect arterial HMOD: (1) the carotid arteries through
• Elevated serum uric acid (s-UA) is common in patients carotid ultrasound to detect atherosclerotic plaque bur-
with hypertension and should be treated with diet, urate den/stenosis and intima media thickness (IMT); (2) the
influencing drugs (losartan, fibrates, atorvastatin) or u- aorta by carotid-femoral pulse wave velocity (PWV)
rate lowering drugs in symptomatic patients (gout with assessment to detect large artery stiffening; and (3) the
s-UA >6 mg/dl [0.357 mmol/L]). lower extremity arteries by assessment of the ankle-bra-
• An increase in cardiovascular risk must be considered chial index (ABI). Although there is evidence to indicate
in patients with hypertension and chronic inflamma- that all three provide added value beyond traditional risk
tory diseases, chronic obstructive pulmonary disease factors, their routine use is currently not recommended
(COPD), psychiatric disorders, psychosocial stressors unless clinically indicated, that is, in patients with neu-
where an effective BP control is warranted.1 rologic symptoms, isolated systolic hypertension, or
suspected peripheral artery disease, respectively.
• Eyes: Fundoscopy is a simple clinical bedside test to
Section 6: Hypertension-Mediated Organ screen for hypertensive retinopathy although interob-
Damage (HMOD) server and intraobserver reproducibility is limited.
Definition and Role of HMOD in Hypertension Fundoscopy is particularly important in hypertensive
Management urgencies and emergencies to detect retinal hemorrhage,
Hypertension-mediated organ damage (HMOD) is defined as microaneurysms, and papilledema in patients with ac-
the structural or functional alteration of the arterial vascula- celerated or malignant hypertension. Fundoscopy should
ture and/or the organs it supplies that is caused by elevated BP. be performed in patients with grade 2 hypertension, ide-
ally by experienced examiners or alternative techniques
End organs include the brain, the heart, the kidneys, central
to visualize the fundus (digital fundus cameras) where
and peripheral arteries, and the eyes.
available.
While assessment of overall cardiovascular risk is im-
portant for the management of hypertension, additional de-
tection of HMOD is unlikely to change the management of The following assessments to detect HMOD should be per-
those patients already identified as high risk (ie, those with formed routinely in all patients with hypertension:
established CVD, stroke, diabetes, CKD, or familial hyper- • Serum creatinine and eGFR
cholesterolemia). However, it can provide important thera- • Dipstick urine test
peutic guidance on (1) management for hypertensive patients • 12-lead ECG
with low or moderate overall risk through reclassification due
to presence of HMOD, and (2) preferential selection of drug All other techniques mentioned above can add value to op-
treatment based on the specific impact on HMOD.1 timize management of hypertension in affected individuals
Table 7. Drug/Substance Exacerbators and Inducers of Hypertension
Comments on Specific Drugs and

• Screen all patients (with hypertension and those at
Drug/Substance32-43 Substances* risk for hypertension) for substances that may in-
crease BP or interfere with the BP-lowering effect of
Nonsteroidal No difference or an increase of up to 3/1 antihypertensive medications.
anti-inflammatory mm Hg with celecoxib
• Where appropriate, consider reducing or eliminating
drugs (NSAIDs) 3/1 mm Hg increase with nonselective
NSAIDs
substances that raise BP. If these substances are re-
No increase in blood pressure with aspirin quired or preferred, then treat BP to target regardless.
NSAIDs can antagonize the effects of (See resource31 on possible antihypertensive therapies
RAAS-inhibitors and beta blockers that target mechanisms underlying the raised BP in-
Combined oral 6/3 mm Hg increase with high doses of
duced by these substances).
contraceptive pill estrogen (>50 mcg of estrogen and 1–4
mcg progestin) Section 8: Treatment of Hypertension
Antidepressants 2/1 mm Hg increase with SNRI (selective 8.1 Lifestyle Modifications
norepinephrine and serotonin reuptake
Healthy lifestyle choices can prevent or delay the onset of
inhibitors)
Increased odds ratio of 3.19 of high BP and can reduce cardiovascular risk.46 Lifestyle mod-
hypertension with tricyclic antidepressant ification is also the first line of antihypertensive treatment.
use Modifications in lifestyle can also enhance the effects of
No increases in blood pressure with SSRI antihypertensive treatment. Lifestyle modifications should in-
(selective serotonin reuptake inhibitors) clude the following (Table 8).47–64
Acetaminophen Increased relative risk of 1.34 of
Seasonal BP Variation65
hypertension with almost daily
acetaminophen use
BP exhibits seasonal variation with lower levels at higher temper-
atures and higher at lower temperatures. Similar changes occur
Other medications Steroids in people traveling from places with cold to hot temperature, or
Antiretroviral therapy: inconsistent study
the reverse. A meta-analysis showed average BP decline in sum-
findings for increased blood pressure
Sympathomimetics: pseudoephedrine, mer of 5/3 mm Hg (systolic/diastolic). BP changes are larger in
cocaine, amphetamines treated hypertensives and should be considered when symptoms
Antimigraine serotonergics suggesting over-treatment appear with temperature rise, or BP is
Recombinant human erythropoeitin increased during cold weather. BP below the recommended goal
Calcineurin inhibitors should be considered for possible downtitration, particularly if
Antiangiogenesis and kinase inhibitors
there are symptoms suggesting overtreatment.
11 ß-hydroxysteroid dehydrogenase type
2 inhibitors
8.2 Pharmacological Treatment
Herbal and other Alcohol, ma-huang, ginseng at high doses,
substances44-45 liquorice, St. John’s wort, yohimbine Contemporary data from over 100 countries66,67 suggest that
*Average increase in blood pressure or risk of hypertension. However, the
on average, less than 50% of adults with hypertension receive
effect of these medications/ substances on blood pressure may highly vary BP-lowering medication, with few countries performing bet-
between individuals. ter than this and many worse. This is despite the fact that a
difference in BP of 20/10 mm Hg is associated with a 50%
difference in cardiovascular risk.68
and should be considered where clinically indicated and a- The pharmacological treatment strategies recommended
vailable. Serial assessment of HMOD (LVH and albuminu- here (Figures 2–4) are largely compatible with those made
ria) to monitor regression with antihypertensive treatment in the most recent US2 and European guidelines.1,8
may be helpful to determine the efficacy of treatment in in-
dividual patients but this has not been sufficiently validated
8.3 Adherence to Antihypertensive Treatment
for most measures of HMOD.
Background
Adherence is defined as to the extent to which a person’s behav-
Section 7: Exacerbators and Inducers of iors such as taking a medication, following a diet or executing
Hypertension lifestyle changes corresponds with agreed recommendations
from a healthcare provider.74 Nonadherence to antihypertensive
Background treatment affects 10%–80% of hypertensive patients and is one
Several medications and substances may increase BP or an- of the key drivers of suboptimal BP control.75–77 Poor adherence
tagonize the BP-lowering effects of antihypertensive therapy to antihypertensive treatment correlates with the magnitude of
in individuals (Table 7). It is important to note that the indi- BP elevation and is an indicator of poor prognosis in hyperten-
vidual effect of these substances on BP can be highly vari- sive patients.78–81 The etiology of nonadherence to antihyperten-
able with greater increases noted in the elderly, those with sive treatment is multifactorial and includes causes associated
higher baseline BP, using antihypertensive therapy or with with the healthcare system, pharmacological therapy, the di-
kidney disease. sease, patients and their socioeconomic status.74
Table 8. Lifestyle Modifications
Salt reduction There is strong evidence for a relationship between high salt intake and increased blood pressure.47 Reduce salt added when preparing
foods, and at the table. Avoid or limit consumption of high salt foods such as soy sauce, fast foods and processed food including
breads and cereals high in salt.
Healthy diet Eating a diet that is rich in whole grains, fruits, vegetables, polyunsaturated fats and dairy products and reducing food high in sugar,
saturated fat and trans fats, such as the DASH diet (http://www.dashforhealth.com).48 Increase intake of vegetables high in nitrates known
to reduce BP, such as leafy vegetables and beetroot. Other beneficial foods and nutrients include those high in magnesium, calcium and
potassium such as avocados, nuts, seeds, legumes and tofu.49
Healthy drinks Moderate consumption of coffee, green and black tea.50 Other beverages that can be beneficial include karkadé (hibiscus) tea,
pomegranate juice, beetroot juice and cocoa.49
Moderation of alcohol Positive linear association exists between alcohol consumption, blood pressure, the prevalence of hypertension, and CVD risk.51 The
consumption recommended daily limit for alcohol consumptions is 2 standard drinks for men and 1.5 for women (10 g alcohol/standard drink). Avoid
binge drinking.
Weight reduction Body weight control is indicated to avoid obesity. Particularly abdominal obesity should be managed. Ethnic-specific cut-offs for BMI and waist
circumference should be used.52 Alternatively, a waist-to-height ratio <0.5 is recommended for all populations.53,54
Smoking cessation Smoking is a major risk factor for CVD, COPD and cancer. Smoking cessation and referral to smoking cessation programs are advised.55
Regular physical activity Studies suggest that regular aerobic and resistance exercise may be beneficial for both the prevention and treatment of
hypertension.56–58 Moderate intensity aerobic exercise (walking, jogging, cycling, yoga, or swimming) for 30 minutes on 5–7 days
per week or HIIT (high intensity interval training) which involves alternating short bursts of intense activity with subsequent recovery
periods of lighter activity. Strength training also can help reduce blood pressure. Performance of resistance/strength exercises on 2–3
days per week.
Reduce stress and induce Chronic stress has been associated to high blood pressure later in life.59 Although more research is needed to determine the effects of
mindfulness chronic stress on blood pressure, randomized clinical trials examining the effects of transcendental meditation/mindfulness on blood
pressure suggest that this practice lowers blood pressure.60 Stress should be reduced and mindfulness or meditation introduced into
the daily routine.
Complementary, alternative or Large proportions of hypertensive patients use complementary, alternative or traditional medicines (in regions such as Africa and
traditional medicines China)61,62 yet large-scale and appropriate clinical trials are required to evaluate the efficacy and safety of these medicines. Thus, use
of such treatment is not yet supported.
Reduce exposure to air pollution Evidence from studies support a negative effect of air pollution on blood pressure in the long-term.63,64
and cold temperature
Figure 2. Pharmacological treatment of hypertension: general scheme. See Table 2 (Section 2) for equivalent BP levels based on ambulatory or home BP recordings.
Figure 3. Office blood pressure targets for treated hypertension.
Figure 4. ISH core drug-treatment strategy. Data from references 69–73. Ideal characteristics of drug treatment (see Table 9).
Table 9. Ideal Characteristics of Drug Treatment
1. Treatments should be evidence-based in relation to morbidity/mortality prevention.

2. Use a once-daily regimen which provides 24-hour blood pressure control.
3. Treatment should be affordable and/or cost-effective relative to other agents.
4. Treatments should be well-tolerated.
5. Evidence of benefits of use of the medication in populations to which it is to be applied.
Recommendations: Adherence to Antihypertensive Therapy first-line drugs in hypertensive patients.1

• Lipid-lowering treatment with an LDL-C target <55 mg/
• Evaluate adherence to antihypertensive treatment as dL (1.4 mmol/L).89
appropriate at each visit and prior to escalation of an- • Antiplatelet treatment with acetyl salicylic acid is rou-
tihypertensive treatment. tinely recommended.1
• Consider the following strategies to improve medica-
Hypertension and Previous Stroke
tion adherence82-87
• Hypertension is the most important risk factor for ische-
a. reducing polypharmacy – use of single pill
mic or hemorrhagic stroke.90
combinations
• Stroke can be largely prevented by BP control.
b. once-daily dosing over multiple times per day dosing
• BP should be lowered if ≥140/90 mm Hg and treated to
c. linking adherence behavior with daily habits
a target <130/80 mm Hg (<140/80 in elderly patients).1
d. providing adherence feedback to patients
• RAS blockers, CCBs, and diuretics are first-line drugs.1
e. home BP monitoring
• Lipid-lowering treatment is mandatory with a LDL-C
f. reminder packaging of medications
target <70 mg/dL (1.8 mmol/L) in ischemic stroke.1
g. empowerment-based counseling for self-management
• Antiplatelet treatment is routinely recommended for is-
h. electronic adherence aids such as mobile phones or
chemic stroke, but not hemorrhagic stroke, and should
short messages services
be carefully considered in patients with hemorrhagic
i. multidisciplinary healthcare team approach (ie,
stroke only in the presence of a strong indication.1
pharmacists) to improve monitoring for adherence
Hypertension and Heart Failure (HF)
• Objective indirect (ie, review of pharmacy records, • Hypertension is a risk factor for the development of HF
pill counting, electronic monitoring devices) and di- with reduced ejection fraction (HFrEF), and with pre-
rect (ie, witnessed intake of medications, biochemical served ejection fraction (HFpEF). Clinical outcome is
detection of medications in urine or blood) are gen- worse and mortality is increased in hypertensive patients
erally preferred over subjective methods to diagnose with HF.2
nonadherence to antihypertensive treatment.80,85 • Lifestyle changes are recommended (diet and exercise).
• The most effective methods for management of non- • Treating hypertension has a major impact on reduc-
adherence require complex interventions that com- ing the risk of incident HF and HF hospitalization. BP
bine counseling, self-monitoring, reinforcements and should be lowered if ≥140/90 mm Hg and treated to a
supervision. target <130/80 mm Hg but >120/70 mm Hg.
• RAS blockers, beta-blockers, and mineralocorticoid re-
Section 9: Common and Other Comorbidities ceptor antagonists are all effective in improving clinical
and Complications of Hypertension outcome in patients with established HFrEF, whereas for
diuretics, evidence is limited to symptomatic improve-
Background
ment.1 CCBs are indicated on in case of poor BP control.
• Hypertensive patients have several common and other • Angiotensin receptor-neprilysin inhibitor (ARNI; sacu-
comorbidities that can affect cardiovascular risk and bitril-valsartan) is indicated for the treatment of HFrEF
treatment strategies. as an alternative to ACE inhibitors or ARBs also in hy-
• The number of comorbidities increases with age, with pertensive populations. The same treatment strategy can
the prevalence of hypertension and other diseases. be applied to patients with HFpEF even if the optimal
• Common comorbidities include coronary artery disease treatment strategy is not known.91
(CAD), stroke, CKD, HF, and COPD.
• Uncommon comorbidities include rheumatic diseases Hypertension and Chronic Kidney Disease (CKD)
and psychiatric diseases. • Hypertension is a major risk factor for the development
• Uncommon comorbidities are largely underestimated by and progression of albuminuria and any form of CKD.92
guidelines and frequently treated with drugs often self- • A lower eGFR is associated with resistant hyperten-
prescribed and possibly interfering with BP control. sion, masked hypertension, and elevated nighttime BP
• Common and uncommon comorbidities should be iden- values.92
tified and managed according to available evidence. • The effects of BP lowering on renal function (and al-
buminuria) are dissociated from cardiovascular benefit.1
Common Comorbidities and Complications • BP should be lowered if ≥140/90 mm Hg and treated to
a target <130/80 mm Hg (<140/80 in elderly patients).1
Hypertension and Coronary Artery Disease (CAD)
• RAS-inhibitors are first-line drugs because they reduce al-
• A strong epidemiological interaction exists between
buminuria in addition to BP control. CCBs and diuretics
CAD and hypertension that accounts for 25%–30% of
(loop-diuretics if eGFR <30 ml/min/1.73m2) can be added.1
acute myocardial infarctions.88
• eGFR, microalbuminuria and blood electrolytes should
• Lifestyle changes are recommended (smoking cessation,
be monitored.1
diet and exercise).
• BP should be lowered if ≥140/90 mm Hg and treated to Hypertension and Chronic Obstructive
a target <130/80 mm Hg (<140/80 in elderly patients). Pulmonary Disease (COPD)
• RAS blockers, beta-blockers irrespective of BP levels • Hypertension is the most frequent comorbidity in pa-
with or without calcium channel blockers (CCBs) are tients with COPD.
• BP should be lowered if ≥140/90 mm Hg and treat- • Serum triglyceride lowering should be considered if
ed to a target <130/80 mm Hg (<140/80 in elderly >200 mg/dL (2.3 mmol/L) particularly in patients with
patients). hypertension and DM. Possible additional benefits using
• Lifestyle changes (smoking cessation) are mandatory.93 fenofibrate in low HDL/high triglyceride subgroup.
• Environmental (air) pollution should be considered and
Metabolic Syndrome (MS)
avoided if possible.93
• Patients with hypertension and MS have a high-risk
• The treatment strategy should include an angiotensin
AT1-receptor blocker (ARB) and CCB and/or diuretic, profile.
while beta blockers (ß1-receptor selective) may be used • The diagnosis of MS should be made by separate evalu-
in selected patients (eg, CAD, HF). ation of single components.
• Additional cardiovascular risk factors should be man- • The treatment of MS is based on changes in lifestyle
aged according to cardiovascular risk profile. (diet and exercise).
• The treatment of hypertension and MS should include
HIV/AIDS BP control as in the general population and treatment of
• People living with HIV are at increased cardiovascular additional risk factors based on level and overall cardio-
risk.40 vascular risk (SCORE and/or ASCVD calculator).
• There may be a drug interaction with CCB under most
of the antiretroviral therapies. Other Comorbidities
• Hypertension management should be similar to the ge- (See Table 10).
neral hypertensive populations.
Hypertension and Inflammatory Rheumatic Diseases (IRD)
Management of Comorbidities • IRD (rheumatoid arthritis, psoriasis-arthritis, etc) are as-
sociated with an increased prevalence of hypertension
• In addition to BP control, the therapeutic strategy under diagnosed and poorly controlled.99,100
should include lifestyle changes, body weight control • IRD show an increase in cardiovascular risk only par-
and the effective treatment of the other risk factors to tially related to cardiovascular risk factors.99
reduce the residual cardiovascular risk.1 • Rheumatoid arthritis is predominant among IRD.
• Lifestyle changes as in Table 8. • The presence of IRD should increase 1 step of cardio-
• LDL-cholesterol should be reduced according to risk vascular risk.99
profile: (1) >50% and <70 mg/dL (1.8 mmol/L) in • BP should be lowered as in the general population, pref-
hypertension and CVD, CKD, DM or no CVD and erentially with RAS-inhibitors (evidence of an overac-
high risk; (2) >50% and <100 mg/dL (2.6 mmol/L) tive RAAS)100 and CCBs.
in high-risk patients; (3) <115 mg/dL (3 mmol/L) in • Underlying diseases should be effectively treated by
moderate-risk patients.1,89 reducing inflammation and by avoiding high doses of
• Fasting serum glucose levels should be reduced be- NSAIDs.
low 126 mg/dL (7 mmol/L) or HbA1c below 7% (53 • Lipid-lowering drugs should be used according to cardi-
mmol/mol).1 ovascular risk profile (SCORE/ASCVD calculator) also
• s-UA should be maintained below 6.5 mg/dL (0.387 considering the effects of biologic drugs.100
mmol/L), and <6 mg/dL (0.357 mmol/L) in patients
with gout.94 Hypertension and Psychiatric Diseases
• Antiplatelet therapy should be considered in patients • The prevalence of hypertension is increased in pa-
with CVD (secondary prevention only).95 tients with psychiatric disorders and in particular
depression.101,102
Diabetes • According to guidelines, psychosocial stress and major
• BP should be lowered if ≥140/90 mm Hg and treat- psychiatric disorders increase the cardiovascular risk.
ed to a target <130/80 mm Hg (<140/80 in elderly • Depression has been associated with cardiovascular
patients).96 morbidity and mortality, suggesting the importance of
• The treatment strategy should include an RAS inhibitor BP control.101
(and a CCB and/or thiazide-like diuretic). • BP should be lowered as in the general population,
• The treatment should include a statin in primary preven- preferentially with RAS-inhibitors and diuretics with a
tion if LDL-C >70 mg/dL (1.8 mmol/L) (diabetes with lesser rate of pharmacological interactions under anti-
target organ damage) or >100 mg/dL (2.6 mmol/L) (un-
depressants. CCBs and alpha1-blockers should be used
complicated diabetes).
with care in patients with orthostatic hypotension (eg,
• The treatment should include glucose and lipid lowering
SRIs).
as per current guidelines (see Section 11: Resources).
• The risk of pharmacologic interactions, ECG abnormali-
Lipid Disorders ties and postural BP changes must be considered.
• BP should be lowered as done in the general popula- • Beta-blockers (not metoprolol) should be used in pres-
tion, preferentially with RAS-inhibitors (ARB, ACE-I) ence of drug-induced tachycardia (antidepressant, anti-
and CCBs.97 psychotic drugs).103
• Statins are the lipid-lowering treatment of choice with • Additional risk factors should be managed according to
or without ezetimibe and/or PCSK9 inhibitor (in the op- cardiovascular risk profile (SCORE/ASCVD calculator,
timal setting).98 see Section 11: Resources).
Table 10. Outline of Evidence-Based Management of Other Comorbidities and tolerated, amiloride, doxazosin, eplerenone, cloni-
Hypertension
dine, and beta-blockers are alternatives, or any availa-
Additional ble antihypertensive class not already in use.1,111–114
Comorbidity Recommended Drugs Warning
• Resistant hypertension should be managed in spe-
Rheumatic • RAS-inhibitors and High doses of NSAIDs
disorders CCBs±diuretics
cialist centers with sufficient expertize, and resources
• Biologic drugs not necessary to diagnose and treat this condition.115
affecting blood pressure
should be preferred 10.2 Secondary Hypertension116-121
(where available)
Background
Psychiatric • RAS-inhibitors and Avoid CCBs A specific cause of secondary hypertension can be identified in
disorders diuretics if orthostatic 5%–10% of hypertensive patients (Table 11). Early diagnosis
• Beta-blockers (not hypotension (SRIs) of secondary hypertension and the institution of appropriate
metoprolol) if drug-
induced tachycardia
targeted treatment have the potential to cure hypertension in
(antidepressant, some patients or improve BP control/reduce the number of
antipsychotic drugs). prescribed antihypertensive medications in others. The most
• Lipid-lowering drugs/ common types of secondary hypertension in adults are renal
antidiabetic drugs parenchymal disease, renovascular hypertension, primary al-
according to risk profile dosteronism, chronic sleep apnea, and substance/drug-induced.
Recommendations
Section 10: Specific Circumstances
10.1 Resistant Hypertension • Consider screening for secondary hypertension in (1)
patients with early onset hypertension (<30 years of
Background age) in particular in the absence of hypertension risk
Resistant hypertension is defined as seated office BP >140/90 factors (obesity, metabolic syndrome, familial history
mm Hg in a patient treated with three or more antihyperten- etc.), (2) those with resistant hypertension, (3) indi-
sive medications at optimal (or maximally tolerated) doses in- viduals with sudden deterioration in BP control, (4)
cluding a diuretic and after excluding pseudoresistance (poor hypertensive urgency and emergency, (5) those pre-
BP measurement technique, white coat effect, nonadherence senting with high probability of secondary hyperten-
and suboptimal choices in antihypertensive therapy)104,105 as sion based on strong clinical clues.
well as the substance/drug-induced hypertension and sec- • In patients with resistant hypertension, investigations
ondary hypertension.79 Resistant hypertension affects around for secondary hypertension should generally be pre-
10% of hypertensive individuals, has a negative impact on ceded by exclusion of pseudoresistant hypertension
well-being106 and increases the risk of coronary artery disease, and drug/substance-induced hypertension.
chronic HF, stroke, end-stage renal disease, and all-cause • Basic screening for secondary hypertension should
mortality.107 Approximately 50% of patients diagnosed with include a thorough assessment of history, physical ex-
resistant hypertension have pseudoresistance rather than true amination (see clinical clues), basic blood biochem-
resistant hypertension.104,105,108 istry (including serum sodium, potassium, eGFR,
TSH), and dipstick urine analysis.
Recommendations
• Further investigations for secondary hypertension
• If seated office BP >140/90 mm Hg in patients man- (additional biochemistry/imaging/others) should be
aged with three or more antihypertensive medications carefully chosen based on information from history,
at optimal (or maximally tolerated) doses including a physical examination and basic clinical investigations.
diuretic, first exclude causes of pseudoresistance (poor • Consider referring for further investigation and man-
BP measurement technique, white coat effect, nonad- agement of suspected secondary hypertension to a
herence and suboptimal choices in antihypertensive specialist center with access to appropriate expertize
therapy), and substance-induced increases in BP. and resources.
• Consider screening patients for secondary causes as
appropriate (refer to Section 10.2). 10.3 Hypertension in Pregnancy122-126
• Optimize the current treatment regimen including Hypertension in pregnancy is a condition affecting 5%–10%
health behavior change and diuretic-based treatment of pregnancies worldwide. Maternal risks include placental
(maximally tolerated doses of diuretics, and optimal abruption, stroke, multiple organ failure (liver, kidney),
choice of diuretic: use of thiazide-like rather than thia- disseminated vascular coagulation. Fetal risks include in-
zide diuretics, and initiation of loop diuretics for eGFR trauterine growth retardation, preterm birth, intrauterine
<30 ml/min/1.73m2 or clinical volume overload).109
death. Hypertension in pregnancy includes the following
• Add a low dose of spironolactone as the 4th line agent
conditions:
in those whose serum potassium is <4.5 mmol/L and
• Preexisting hypertension: Starts before pregnancy or
whose eGFR is >45 ml/min/1.73m2 to achieve BP tar-
<20 weeks of gestation, and lasts >6 weeks postpartum
gets.8,71,110 If spironolactone is contraindicated or not
with proteinuria.
Table 11. Features of Secondary Hypertension
Secondary Clinical History and Physical Basic Biochemistry

Hypertension Examination and Urine Analysis Further Diagnostic Tests
Renal parenchymal disease • Personal/familial history of CKD • Proteinuria, hematuria, leukocyturia • Kidney ultrasound
on dipstick urine analysis
• Decreased estimated GFR
Primary aldosteronism • Symptoms of hypokalemia (muscle • Spontaneous hypokalemia or • Confirmatory testing (eg, intravenous
weakness, muscle cramps, tetany) diuretic-induced hypokalemia on saline suppression test)
blood biochemistry (50%–60% of • Imaging of adrenals (adrenal
patients are normokalemic). computed tomography)
• Elevated plasma aldosterone-renin • Adrenal vein sampling
activity ratio
Renal artery stenosis • Abdominal bruit • Decrease in estimated GFR • Imaging of renal arteries (duplex
• Bruits over other arteries (ie, carotid ultrasound, abdominal computed
and femoral arteries) tomography or magnetic resonance
• Drop in estimated GFR >30% after angiograms depending on
exposure to ACE-inhibitors/ARBs availability and patient’s level of
• For suspected atherosclerotic RAS, renal function)
history of flash pulmonary edema
or history of atherosclerotic disease
or presence of cardiovascular risk
factors
• For suspected fibromuscular
dysplasia, young women with onset
of hypertension <30 years
Pheochromocytoma • Headaches • Increased plasma levels of • Abdominal/pelvic computational
• Palpitations metanephrines tomography or MRI
• Perspiration • Increased 24-hour urinary fractional
• Pallor excretion of metanephrines and
• History of labile hypertension catecholamines
Cushing’s syndrome and disease • Central obesity • Hypokalemia • Dexamethasone suppression tests118
• Purple striae • Increased late-night salivary cortisol • 24 hour urinary free cortisol
• Facial rubor • Abdominal/ pituitary imaging
• Signs of skin atrophy
• Easy bruising
• Dorsal and supraclavicular fat pad
• Proximal muscle weakness
Coarctation of the aorta • Higher blood pressure in upper than • Echocardiogram
lower extremities • Computational tomography
• Delayed or absent femoral pulses angiogram
• Magnetic resonance angiogram
Obstructive sleep apnea • Increased BMI • Home sleep apnea testing (eg, level
• Snoring 3 sleep study)
• Daytime sleepiness • Overnight polysomnography testing
• Gasping or choking at night
• Witnessed apneas during sleep
• Nocturia
Thyroid disease • Symptoms of hyperthyroidism: heat • TSH, Free T4
intolerance, weight loss, tremor,
palpitations
• Symptoms of hypothyroidism: cold
intolerance, weight gain, dry brittle hair
• Gestational hypertension: Starts >20 weeks of gesta- autoimmune disease (SLE). Risks are fetal growth re-
tion, and lasts <6 weeks postpartum. striction, preterm birth.
• Preexisting hypertension plus superimposed gesta- • Eclampsia: Hypertension in pregnancy with seizures,
tional hypertension with proteinuria. severe headaches, visual disturbance, abdominal pain,
• Preeclampsia: Hypertension with proteinuria (>300 nausea and vomiting, low urinary output: Immediate
mg/24 h or ACR >30 mg/mmol [265 mg/g]). treatment and delivery required.
Predisposing factors are preexisting hypertension, • HELLP (hemolysis, elevated liver enzymes, low
hypertensive disease during previous pregnancy, di- platelets) syndrome: Immediate treatment and delivery
abetes, renal disease, first- or multiple pregnancy, required.
Blood Pressure Measurement in Pregnancy • Breastfeeding: All antihypertensives excreted into

Office BP measurement following general breast milk at low concentrations. Avoid atenolol, pro-
guidelines. Take office BP measurement using a manual pranolol, nifedipine (high concentration in milk). Prefer
auscultatory device, or an automated upper-arm cuff device long acting CCBs. Refer to prescribing information.
which has been validated specifically in pregnancy and pre- • Long-term consequences of gestational hyperten-
eclampsia (list of validated devices at www.stridebp.org). sion: Increased risk of hypertension and CVD (stroke,
ABPM or home BP monitoring using devices ischemic heart disease) in later life.
validated specifically in pregnancy and preeclampsia to e-
valuate white coat hypertension, DM, nephropathy. Lifestyle adjustment
Lifestyle adjustment and annual checkups (BP,
Investigation of Hypertension in Pregnancy metabolic factors)
Urine analysis, full blood count, liver en-
zymes, hematocrit, serum creatinine and s-UA. Test for 10.4 Hypertensive Emergencies
proteinuria in early pregnancy (preexisting renal disease)
and second half of pregnancy (preeclampsia). A dipstick Definition of Hypertensive Emergencies
test >1+ should be followed up with UACR in a single spot and Their Clinical Presentation
urine; UACR <30 mg/mmol excludes proteinuria. A hypertensive emergency is the association of substantially
Ultrasound of kidneys and adrenals, free plasma elevated BP with acute HMOD. Target organs include the
metanephrines (if clinical features of pheochromocytoma); retina, brain, heart, large arteries, and the kidneys.127 This
Doppler ultrasound of uterine arteries (after 20 weeks of situation requires rapid diagnostic workup and immediate
gestation is useful to detect those at higher risk of gesta- BP reduction to avoid progressive organ failure. Intravenous
tional hypertension, preeclampsia, and intrauterine growth therapy is usually required. The choice of antihypertensive
retardation). treatment is predominantly determined by the type of organ
damage. Specific clinical presentations of hypertensive emer-
Prevention of Preeclampsia
gencies include:
Women at high risk (hypertension in previous pregnancy,
• Malignant hypertension: Severe BP elevation (com-
CKD, autoimmune disease, diabetes, chronic hypertension),
monly >200/120 mm Hg) associated with advanced
or moderate risk (first pregnancy in a woman >40 years,
bilateral retinopathy (hemorrhages, cotton wool spots,
pregnancy interval >10 years, BMI >35 kg/m2, family his- papilledema).
tory of preeclampsia, multiple pregnancies): 75–162 mg • Hypertensive encephalopathy: Severe BP elevation
aspirin at weeks 12–36. Oral calcium supplementation of associated with lethargy, seizures, cortical blindness and
1.5–2 g/day is recommended in women with low dietary in- coma in the absence of other explanations.
take (<600 mg/day). • Hypertensive thrombotic microangiopathy: Severe
Management of Hypertension in Pregnancy BP elevation associated with hemolysis and thrombocy-
• Mild hypertension: Drug treatment at persistent BP topenia in the absence of other causes and improvement
>150/95 mm Hg in all women. Drug treatment at per- with BP-lowering therapy.
sistent BP >140/90 mm Hg in gestational hypertension, • Other presentations of hypertensive emergencies in-
preexisting hypertension with superimposed gestational clude severe BP elevation associated with cerebral hem-
hypertension; hypertension with subclinical HMOD at orrhage, acute stroke, acute coronary syndrome, cardio-
any time during pregnancy. First choices: methyldopa, genic pulmonary edema, aortic aneurysm/dissection,
beta-blockers (labetalol), and dihydropyridine-calcium and severe preeclampsia and eclampsia.
channel blockers (DHP-CCBs) (nifedipine [not cap- Patients with substantially elevated BP who lack acute
sular], nicardipine). Contraindicated: RAS blockers HMOD are not considered a hypertensive emergency and can
(ACE-I, ARB, direct renin inhibitors [DRI]) due to ad- typically be treated with oral antihypertensive therapy.128
verse fetal and neonatal outcomes. Clinical Presentation and Diagnostic Workup
• Severe hypertension: At BP >170 mm Hg systolic and/
The clinical presentation of a hypertensive emergency can
or >110 mm Hg diastolic: immediate hospitalization is
vary and is mainly determined by the organ(s) acutely af-
indicated (emergency). Treatment with intravenous la-
fected. There is no specific BP threshold to define a hyperten-
betalol (alternative intravenous nicardipine, esmolol,
hydralazine, urapidil), oral methyldopa or DHP-CCBs sive emergency.
(nifedipine [not capsular] nicardipine). Add magnesium Symptoms include headaches, visual disturbances, chest
(hypertensive crisis to prevent eclampsia). In pulmonary pain, dyspnea, neurologic symptoms, dizziness, and more un-
edema: nitroglycerin intravenous infusion. Sodium- specific presentations.
nitroprusside should be avoided due to the danger of fe- Medical history: preexisting hypertension, onset and du-
tal cyanide poisoning with prolonged treatment. ration of symptoms, potential causes (nonadherence with
• Delivery in gestational hypertension or preeclampsia: prescribed antihypertensive drugs, lifestyle changes, concom-
At week 37 in asymptomatic women. Expedite delivery itant use of BP elevating drugs [NSAIDS, steroids, immune-
in women with visual disturbances, hemostatic disorders. suppressants, sympathomimetics, cocaine, antiangiogenic
• Blood pressure postpartum: If hypertension persists, therapy]).
any of recommended drugs except methyldopa (postpar- Thorough physical examination: Cardiovascular
tum depression). and neurologic assessment. Laboratory analysis: hemoglobin,
Table 12. Hypertensive Emergencies Requiring Immediate BP Lowering
Clinical Presentation Timeline and Target BP First Line Treatment Alternative

Malignant hypertension with or without Several hours, MAP −20% to −25% Labetalol Nitroprusside
TMA or acute renal failure Nicardipine Urapidil
Hypertensive encephalopathy Immediate, MAP −20% to −25% Labetalol Nitroprusside
Nicardipine
Acute ischaemic stroke and SBP >220 1 h, MAP −15% Labetalol Nitroprusside
mm Hg or DBP >120 mm Hg Nicardipine
Acute ischaemic stroke with indication 1 h, MAP −15% Labetalol Nitroprusside
for thrombolytic therapy and SBP >185 Nicardipine
mm Hg or DBP >110 mm Hg
Acute hemorrhagic stroke and SBP >180 Immediate, 130<SBP<180 mm Hg Labetalol Urapidil
mm Hg Nicardipine
Acute coronary event Immediate, SBP <140 mm Hg Nitroglycerine Urapidil
Labetalol
Acute cardiogenic pulmonary edema Immediate, SBP <140 mm Hg Nitroprusside or nitroglycerine Urapidil (with loop diuretic)
(with loop diuretic)
Acute aortic disease Immediate, SBP <120 mm Hg and heart Esmolol and nitroprusside or nitroglycerine Labetalol or metoprolol
rate <60 bpm or nicardipine
Eclampsia and severe preeclampsia/ Immediate, SBP <160 mm Hg and Labetalol or nicardipine and magnesium
HELLP DBP <105 mm Hg sulphate
Adapted from van den Born et al.127
platelets, creatinine, sodium, potassium, lactate dehydrogen- are generally safe to use in all hypertensive emergencies and
ase (LDH), haptoglobin, urinalysis for protein, urine sedi- should be available wherever hypertensive emergencies are
ment. Examinations: Fundoscopy, ECG. being managed. Nitroglycerin and nitroprusside are specifi-
Additional investigations may be required cally useful in hypertensive emergencies including the heart
and indicated depending on presentation and clinical and the aorta.
findings and may be essential in the context: troponins
(chest pain), chest x-ray (congestion/fluid overload), Specific Situations
transthoracic echocardiogram (cardiac structure and • Sympathetic hyperreactivity: If intoxication with am-
function), CT/MRI brain (cerebral hemorrhage/stroke), phetamines, sympathomimetics or cocain is suspected as
CT-angiography thorax/abdomen (acute aortic disease). cause of presentation with a hypertensive emergency use
Secondary causes can be found in 20%–40% of patients of benzodiazepines should be considered prior to spe-
presenting with malignant hypertension118 and appropri- cific antihypertensive treatment. Phentolamine, a com-
ate diagnostic workup to confirm or exclude secondary petitive alpha-receptor blocking agent and clonidine, a
forms is indicated. centrally sympatholytic agent with additional sedative
properties are useful if additional BP-lowering therapy
Diagnostic Tests and Acute Therapeutic Management
is required. Nicardipine and nitroprusside are suitable
The overall therapeutic goal in patients presenting with hy-
alternatives.
pertensive emergencies is a controlled BP reduction to safer
• Pheochromocytoma: The adrenergic drive associated
levels to prevent or limit further hypertensive damage while
with pheochromocytoma responds well to phentola-
avoiding hypotension and related complications. There is a
mine. Beta-blockers should only be used once alpha-
lack of randomized controlled trial data to provide clear cut
blockers have been introduced to avoid acceleration of
guidance on BP targets and times within which these should hypertension. Urapidil and nitroprusside are additional
be achieved. Most recommendations are based on expert con- suitable options.
sensus. The type of acute HMOD is the main determinant of • Preeclampsia/eclampsia: See Section 10.3: Hypertension
the preferred treatment choice. The timeline and magnitude of in Pregnancy.
BP reduction is strongly dependent on the clinical context. For
example, acute pulmonary edema and aortic dissection require Follow-Up
rapid BP reduction, whereas BP levels not exceeding 220/120 Patients who experienced a hypertensive emergency are
mm Hg are generally tolerated in acute ischemic stroke for at increased risk of cardiovascular and renal disease. 129,130
certain periods. Table 12 provides a general overview of time- Thorough investigation of potential underlying causes
lines and BP targets as well as preferred antihypertensive drug and assessment of HMOD is mandatory to avoid re-
choices with most common clinical presentations. Availability current presentations with hypertensive emergencies.
of drugs and local experience with individual drugs are likely Similarly, adjustment and simplification of antihyperten-
to influence the choice of drugs. Labetalol and nicardipine sive therapy paired with advice for lifestyle modification
will assist to improve adherence and long-term BP con- Section 11: Resources
trol. Regular and frequent follow-up (monthly) is recom- • 2018 European Society of Cardiology/European
mended until target BP and ideally regression of HMOD Society of Hypertension Guidelines [Williams
has been achieved. B, Mancia G, Spiering W, et al. 2018 ESC/ESH
Guidelines for the management of arterial hyperten-
10.5 Ethnicity, Race and Hypertension sion: The Task Force for the management of arterial
Hypertension prevalence, treatment and control rates hypertension of the European Society of Cardiology
vary significantly according to ethnicity. Such differences and the European Society of Hypertension: The
are mainly attributed to genetic differences, but lifestyle Task Force for the management of arterial hyper-
and socioeconomic status possibly filters through into tension of the European Society of Cardiology and
health behaviors such as diet – which appear to be major the European Society of Hypertension. J Hypertens
contributors. 2018; 36(10): 1953–2041.]: These comprehensive
and evidence-based guidelines form a complete de-
Populations From African Descent tailed resource.
• Black populations, whether residing in Africa, the • 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/AphA/ASH/
Caribbean, United States, or Europe, develop hy- ASPC/NMA/PCNA Guidelines [Whelton PK, Carey
pertension and associated organ damage at younger RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/
ages, have a higher frequency of resistant and night- ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA
time hypertension, and a higher risk of kidney di- Guideline for the Prevention, Detection, Evaluation,
sease, 131 stroke, HF, and mortality, 132 than other eth- and Management of High blood pressure in Adults:
nic groups. A Report of the American College of Cardiology/
• This increased cardiovascular risk may be due to physi- American Heart Association Task Force on Clinical
ological differences including a suppressed RAAS,133,134 Practice Guidelines. Hypertension 2017; 71(6):e13–
altered renal sodium handling,135 increased cardiovas- e115.]: The Guidelines from the United States of
cular reactivity,136 and early vascular aging (large artery America, which attracted much comment on rede-
stiffness).137 fining hypertension, is very comprehensive and evi-
• Management of hypertension: dence-based, and largely in agreement with the 2018
– Wherever possible, annual screening for hypertension European guidelines.
is advised for adults 18 years and older. • Weber MA, Poulter NR, Schutte AE, et al. Is it time
– Lifestyle modification should place additional focus to reappraise blood pressure thresholds and tar-
on salt restriction, increased intake of vegetables and gets? Statement from the International Society of
fruits (potassium intake), weight management, and re- Hypertension–a global perspective. Hypertension 2016;
ducing alcohol intake. 68:266–268.
– First-line pharmacological therapy is recommended • Clinical Practice Guidelines for the Management
as a single pill combination including a thiazide-like of Hypertension in the Community A Statement
diuretic plus CCB or CCB plus ARB (see Sections 8 by the American Society of Hypertension and the
and 12).71,138 International Society of Hypertension. [Weber MA,
– Among RAS-inhibitors, ARBs maybe preferred as Schiffrin EL,White WB et al. The Journal of Clinical
angioedema is about 3 times more likely to occur with Hypertension 2014; 16(1):14–26].
ACE inhibitors among black patients.139 • NICE Guideline: Hypertension in adults: diagnosis and
Populations From Asia management. Published: 28 August 2019 www.nice.org.
• Ethnic-specific characteristics are recognized for East uk/guidance/ng136.
Asian populations. Hypertensive patients have a greater • The Japanese Society of Hypertension Guidelines for the
likelihood of salt-sensitivity accompanied with mild o- Management of Hypertension (JSH 2019). Hypertens
besity. When compared to Western populations, East Res 2019; 42:1235–1481 https://doi.org/10.1038/
Asian people present a higher prevalence of stroke (par- s41440-019-0284-9.
ticularly hemorrhagic stroke) and nonischemic HF.1 • 2018 Chinese Guidelines for Prevention and Treatment
• Morning hypertension and nighttime hypertension140 are of Hypertension – A report of the Revision Committee
also more common in Asia, compared with European of Chinese Guidelines for Prevention and Treatment of
populations. Hypertension. Liu LS, Wu ZS, Wang JG, Wang W. J
• South Asian populations originating from the Indian Geriatr Cardiol (2019) 16: 182–241.
subcontinent have a particularly high risk for cardi- • Guidelines on the management of arterial hyperten-
ovascular and metabolic diseases, including CAD sion and related comorbidities in Latin America. Task
and type 2 DM. With large hypertensive populations Force of the Latin American Society of Hypertension. J
residing in India and China, clinical trials in these Hypertens 2017, 35:1529–1545.
populations are required to advise whether current • 2019 ESC/EAS Guidelines for the management of dys-
treatment approaches are ideal.141,142 lipidaemias: lipid modification to reduce cardiovascular
• Management of hypertension: risk. [Mach F, Baigent C, Catapano AL et al. Eur Heart J
– South East Asia: Standard treatment as indicated in 2020;41:111–188. doi:10.1093/eurheartj/ehz455].
these guidelines is advised, until more evidence be- • 2019 ESC Guidelines on diabetes, prediabetes, and car-
comes available.138 diovascular diseases developed in collaboration with
the EASD: The Task Force for diabetes, prediabetes, – Based on this Roadmap, an Africa-specific roadmap
and cardiovascular diseases of the European Society of was also developed: [Dzudie A, Rayner B, Ojji D,
Cardiology (ESC) and the European Association for the Schutte AE, et al. Roadmap to achieve 25% hyper-
Study of Diabetes (EASD). [Cosentino F, Peter J, Grant tension control in Africa by 2025. Global Heart 2018;
PJ, Aboyans V et al. Eur Heart J 2020; 41:255–323, 13:45–59].
https://doi.org/10.1093/eurheartj/ehz486].
• The HOPE Asia Network contributes largely to evidence Listings of Validated Electronic Blood Pressure
for this region: [Kario K et al. HOPE Asia (Hypertension Devices That Were Independently Assessed for
Cardiovascular Outcome Prevention and Evidence in Accuracy
Asia) Network. The HOPE Asia Network for “zero” • STRIDE BP: https://stridebp.org/
cardiovascular events in Asia. J Clin Hypertens 2018; • British and Irish Hypertension Society: https://bihsoc.
20:212–214]. org/bp-monitors/
• World Health Organization, HEARTS Technical • German Hypertension Society: https://www.hochdruck-
Package: [https://www.who.int/cardiovascular_diseases/ liga.de/messgeraete-mit-pruefsiegel.html
hearts/en/]: The HEARTS package contains free mod-
• Hypertension Canada: https://hypertension.ca/hyperten
ules (in English, French, Spanish, and Russian) on,
sion-and-you/managing-hypertension/measuring
for example, healthy-lifestyle counseling; Risk based
-blood-pressure/devices/
charts, but particularly for Team-based care which is
• Japanese Society of Hypertension: http://www.jpnsh.jp/
particularly relevant in low resource settings where task-
com_ac_wg1.html.
sharing is highly relevant: https://apps.who.int/iris/
bitstream/handle/10665/260424/WHO-NMH-NVI-
Blood Pressure Management in Pediatric
18.4-eng.pdf;jsessionid=7AC6EC215FEB390CBD93
898B69C4705C?sequence=1. Populations
• Cardiovascular Risk Scores: Several scoring systems • Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical
are available. Some are based only on European popula- practice guideline for screening and management of high
tions, for example, SCORE. blood pressure in children and adolescents. Pediatrics
– SCORE: http://www.heartscore.org/en_GB/access 2017; 140: e20171904.
The following scores also take ethnicity into • Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016
account. European Society of Hypertension guidelines for the
– QRISK2: https://qrisk.org/2017/index.php management of high blood pressure in children and ado-
– ASCVD: https://tools.acc.org/ldl/ascvd_risk_estima- lescents. J Hypertens 2016; 34:1887–1920.
tor/index.html#!/calulate/estimator/ • Xi B, Zong X, Kelishadi R, Hong YM, et al. Establishing
• World Heart Federation Roadmap to the Management international blood pressure references among nonover-
and Control of Raised Blood Pressure provides guid- weight children and adolescents aged 6 to 17 years.
ance on achieving the target of a relative reduction Circulation 2016; 133:398–408.
of the prevalence of raised blood pressure by 25% • Dong Y, Ma J, Song Y, Dong B, et al. National blood pres-
by 2025: https://www.world-heart-federation.org/ sure reference for Chinese Han children and adolescents
cvd-roadmaps/whf-global-roadmaps/hypertension/ aged 7 to 17 years. Hypertension 2017; 70:897–890.
Section 12: Hypertension Management at a Glance
Figure 5. ISH 2020 recommendations (minimum standards of care).

Figure 6. ISH 2020 recommendations (evidence-based standards of care).

Document Reviewers 10. Umemura S, Arima H, Arima S, Asayama K, Dohi Y, Hirooka Y,

Horio T, Hoshide S, Ikeda S, Ishimitsu T, et al. The Japanese Society
Hind Beheiry (Sudan), Irina Chazova (Russia), Albertino Damasceno of Hypertension Guidelines for the management of hypertension (JSH
(Mozambique), Anna Dominiczak (United Kingdom), Anastase Dzudie 2019). Hypertens Res. 2019;42:1235–1481.
(Cameroon), Stephen Harrap (Australia), Hiroshi Itoh (Japan), Tazeen 11. Nakagawa N, Hasebe N. Impact of the 2017 American College of
Jafar (Singapore), Marc Jaffe (United States), Patricio Jaramillo- Cardiology/American Heart Association blood pressure guidelines on the
Lopez (Colombia), Kazuomi Kario (Japan), Giuseppe Mancia (Italy), next blood pressure guidelines in Asia. Curr Hypertens Rep. 2019;21:2.
Ana Mocumbi (Mozambique), Sanjeevi N.Narasingan (India), Elijah 12. Kario K, Wang JG. Could 130/80 mm Hg Be Adopted as the diagnostic
Ogola (Kenya), Srinath Reddy (India), Ernesto Schiffrin (Canada), Ann threshold and management goal of hypertension in consideration of the
Soenarta (Indonesia), Rhian Touyz (United Kingdom), Yudah Turana characteristics of Asian populations? Hypertension. 2018;71:979–984.
(Indonesia), Michael Weber (United States), Paul Whelton (United 13. Dzudie A, Rayner B, Ojji D, Schutte AE, Twagirumukiza M, Damasceno A,
States), Xin Hua Zhang, (Australia), Yuqing Zhang (China). Ba SA, Kane A, Kramoh E, Anzouan Kacou JB, et al. Roadmap to achieve
25% hypertension control in Africa by 2025. Glob Heart. 2018;13:45–59.
14. Messerli FH, Bangalore S. The blood pressure landscape: Schism among
Acknowledgements guidelines, confusion among physicians, and anxiety among patients. J
The authors are grateful to Elena Kaschina and Michél Strauss- Am Coll Cardiol. 2018;72:1313–1316.
Kruger for their help in preparing and editing this article. 15. Rehan HS, Grover A, Hungin AP. Ambiguities in the guidelines for the
management of arterial hypertension: Indian perspective with a call for
global harmonization. Curr Hypertens Rep. 2017;19:17.
Disclosures 16. Poulter NR, Castillo R, Charchar FJ, Schlaich MP, Schutte AE,
The authors have no conflict of interest to declare, but declare lec- Tomaszewski M, Touyz RM, Wang JG. Are the American Heart Association/
ture honoraria or consulting fees as follows: T.U., Bayer, Boehringer American College of Cardiology high blood pressure guidelines fit for
Ingelheim, Hexal, Vifor Pharma; C.B., Servier, Menarini, Merck global purpose?: Thoughts from the International Society of Hypertension.
Pharma, Novartis, Egis, Daichy Sankyo, Gilead; N.R.P., Servier, Hypertension. 2018;72:260–262.
Pfizer, Sanofi, Eva Pharma; D.P., Torrent Pharmaceuticals; M.S., 17. Stergiou GS, Palatini P, Asmar R, Bilo G, de la Sierra A, Head G, Kario K,
Medtronic, Abbott, Novartis, Servier, Pfizer, Boehringer-Ingelheim; Mihailidou A, Wang J, Mancia G, O’Brien E, Parati G. Blood pressure
G.S.S., AstraZeneca, Menarini, Pfizer, Servier; B.W., Vascular monitoring: theory and practice. European Society of Hypertension
Dynamics USA, Inc, Relypsa, Inc, USA; Daiichi Sankyo, Pfizer, Working Group on blood pressure monitoring and cardiovascular varia-
Servier, Novartis, Menarini, Omron; A.E.S., Omron, Novartis, bility teaching course proceedings. Blood Press Monit. 2018;23:1–8.
18. Muntner P, Einhorn PT, Cushman WC, Whelton PK, Bello NA, Drawz PE,
Takeda, Servier, Abbott.
Green BB, Jones DW, Juraschek SP, Margolis KL, et al. Blood pressure
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Clinical Practice Guidelines

2020 International Society of Hypertension Global

Table of Contents Section 1: Introduction

Abbreviations SRI serotonin reuptake inhibitors

Category Systolic (mm Hg) Diastolic (mm Hg) SBP/DBP, mm Hg

Table 3. Recommendations for Office Blood Pressure Measurement

Conditions • Quiet room with comfortable temperature.

use the arm with the higher BP. If the difference is

Figure 1. How to measure blood pressure.

Table 7. Drug/Substance Exacerbators and Inducers of Hypertension

Comments on Specific Drugs and

Table 8. Lifestyle Modifications

Figure 3. Office blood pressure targets for treated hypertension.

Table 9. Ideal Characteristics of Drug Treatment

1. Treatments should be evidence-based in relation to morbidity/mortality prevention.

Recommendations: Adherence to Antihypertensive Therapy first-line drugs in hypertensive patients.1

Table 11. Features of Secondary Hypertension

Secondary Clinical History and Physical Basic Biochemistry

Blood Pressure Measurement in Pregnancy • Breastfeeding: All antihypertensives excreted into

Table 12. Hypertensive Emergencies Requiring Immediate BP Lowering

Clinical Presentation Timeline and Target BP First Line Treatment Alternative

Section 12: Hypertension Management at a Glance

Figure 5. ISH 2020 recommendations (minimum standards of care).

Figure 6. ISH 2020 recommendations (evidence-based standards of care).

Document Reviewers 10. Umemura S, Arima H, Arima S, Asayama K, Dohi Y, Hirooka Y,

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Conditions • Quiet room with comfortable temperature.