Hypertension Clinical Practice Guidelines (ISH, 2020)

International Society of Hypertension

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

May 29, 2020

The International Society of Hypertension (ISH) released their global recommendations on the management of hypertension in adults aged 18 years and older in June 2020.[1] Where possible, the ISH differentiated between "optimal care" (evidence-based standard of care) and "essential care" (minimum standards of care in low-resource settings). Selected recommendations are outlined below.

Hypertension Classification

Office blood pressure (BP) measurement

  • Normal BP: <130 mmHg (systolic [SBP]) and <85 mmHg (diastolic [DBP])

  • High-normal: 130-139 mmHg SBP and/or 85-89 mmHg DBP

  • Grade 1 hypertension: 140-159 mmHg SBP and/or 90-99 mmHg DBP

  • Grade 2 hypertension: ≥160 mmHg SBP and/or ≥100 mmHg DBP

Hypertension Criteria

Office, ambulatory (ABPM), and home based (HBPM) (SBP/DBP [mmHg])

  • Office BP: ≥140 and/or ≥90 mmHg

  • ABPM: 24-Hour average of ≥130 and/or ≥80 mmHg; daytime/awake average of ≥135 and/or ≥85 mmHg; nighttime/sleep ≥120 and/or ≥70 mmHg

  • HBPM: ≥135 and/or ≥85 mmHg

Hypertension Diagnosis

Office and out-of-office BP measurements and plans

  • At the first office visit, concurrently measure BP in both arms. If a >10 mmHg difference is consistent between the arms on repeated measurements, use the arm with the higher BP. If a >20 mmHg difference is found, consider further evaluation.

  • Office BP <130/85 mmHg: Remeasure in 3 years (after 1 year if other risk factors exist)

  • Office BP 130-159/85-99 mmHg: Confirm with ABPM or HBPM measurement, or confirm with repeated office visits. If HBPM <135/85 mmHg or 24-hour ABPM <130/80 mmHg, remeasure after 1 year; If HBPM ≥135/85 mmHg or 24-hour ABPM ≥130/80 mmHg, then hypertension is diagnosed.

  • Office BP >160/100 mmHg: Confirm within a few days or weeks.

Diagnostic Studies

Laboratory, electrocardiography (ECG), and imaging

  • Levels of sodium, potassium, serum creatinine, fasting glucose; estimated glomerular filtration rate; lipid profile

  • Urine dipstick

  • 12-Lead ECG to detect atrial fibrillation, left ventricular hypertrophy, ischemic heart disease

  • Other tests as needed if organ damage or secondary hypertension is suspected

Treatment for Hypertension

Grade 1 hypertension (140-159/90-99 mmHg)

  • Start lifestyle interventions (smoking cessation, exercise, weight loss, salt and alcohol reduction, healthy diet)

  • Initiate pharmacotherapy in high-risk patients (cardiovascular disease, chronic kidney disease, diabetes, or organ damage) and those with persistent high BP after 3-6 months of lifestyle intervention

Grade 2 hypertension (≥160/100 mmHg)

  • Immediately initiate pharmacotherapy

  • Start lifestyle interventions

BP control targets

  • Aim for BP control within 3 months

  • Aim for at least a 20/10 mmHg BP reduction, ideally to <140/90 mmHg

  • <65 years: Target BP <130/80 mmHg if tolerated (but >120/70 mmHg)

  • ≥65 years: Target BP <140/90 mmHg if tolerated; individualizing target BPs may be considered in those who are frail, independent, and likely to tolerate therapy

Pharmacotherapy (if BP uncontrolled after 3-6 months of lifestyle intervention)

Consider monotherapy in low-risk grade 1 hypertension and elderly (>80 years) or frail patients. A simplified regimen with once-daily dosing and single pill combinations is ideal.

For non-black patients who are not pregnant or not planning pregnancy:

  • Step 1: Use a dual low-dose drug combination (angiotensin-converting enzyme inhibitor [ACEI] or angiotensin-receptor blocker [ARB] + dihydropyridine-calcium channel blocker [DHP-CCB])

  • Step 2: Increase the regimen to the dual full-dose combination

  • Step 3 (triple combination): Add a thiazide or thiazide-like diuretic

  • Step 4 (resistant hypertension): Triple combination plus spironolactone or, alternatively, amiloride doxazosin, eplerenone, clonidine, or a beta-blocker

For black patients who are not pregnant or not planning pregnancy:

  • Step 1: Use a dual low-dose drug combination (eg, ARB + DHP-CCB or DHP-CCB + thiazide/thiazide-like diuretic)

  • Step 2: Increase the regimen to the dual full-dose combination

  • Step 3 (triple combination): Add a diuretic or ARB or ACEI

  • Step 4 (resistant hypertension): Triple combination plus spironolactone or, alternatively, amiloride doxazosin, eplerenone, clonidine, or a beta-blocker

For more information, please go to Hypertension.

For more Clinical Practice Guidelines, please go to Guidelines.

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