The International Society of Hypertension (ISH) recently released their global recommendations on the management of hypertension in adults, aged 18 years and older. The treatment approach is categorised based on the grades of hypertension. ISH recommends following a step-wise strategy when deciding the drug treatment.

Hypertension affects more than 1.4 billion people worldwide and is the leading cause of death in the world. There has been a drastic shift of the highest blood pressure (BP) from high-income regions countries (HIC) to low- and middle-income countries (LMIC). As per recent reports, there are around 1.04 billion people with high BP in low- and middle-income countries (LMIC) compared to 349 million with hypertension in high-income countries (HIC). The International Society of Hypertension (ISH) recently released their global recommendations on the management of hypertension in adults, aged 18 years and older. Here we list few important recommendations from the ISH guidelines.

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Definition of Hypertension

It is recommended that hypertension be diagnosed when a person’s systolic blood pressure (SBP) in the office or clinic is ≥140 mmHg and/or their diastolic blood pressure (DBP) is ≥90 mmHg following repeated examination. Below is a classification of BP based on office BP measurements; these BP categories may help to align therapeutic approaches with BP levels.

Office 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

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Hypertension Diagnosis: Office and out-of-office BP measurements and plans

The measurement of office BP is most commonly the basis for hypertension diagnosis and follow-up. In the initial office visit, BP should be measured in both arms (preferably simultaneously). If a >10 mmHg difference is consistent between the arms on repeated measurements, the arm with the higher BP should be used; however, if a >20 mmHg difference is found, further evaluation should be considered.

As per the measured office blood pressure levels, the following blood pressure measurement plan is recommended:

• If the office BP is <130/85 mmHg: Remeasure in 3 years (after 1 year if other risk factors exist)
• If the office BP is 130-159/85-99 mmHg: Confirm with out-of-office blood pressure measurement (ABPM or HBPM), or confirm with repeated office visits:
  • Average home blood pressure after excluding readings of the first day ≥ 135 or 85 mmHg indicates hypertension.
  • 24-hour ambulatory blood pressure ≥ 130/80 mmHg indicates hypertension (primary criterion).
  • Daytime (awake) ambulatory blood pressure ≥ 135/85 mmHg and night time (asleep) ≥ 120/70 mmHg indicates hypertension
• Office BP >160/100 mmHg: Confirm within a few days or weeks.

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Diagnostic studies

Patients with hypertension are usually asymptomatic; hence assessment of medical and family history is essential to identify specific symptoms that can detect secondary hypertension or hypertensive complications that require further investigation. A complete medical and family history should include following:

• Evaluation of blood pressure
• Risk factors
• Assessment of overall cardiovascular risk
• Symptoms/signs of hypertension/coexistent illnesses
• Symptoms suggestive of secondary hypertension

Apart from history, a complete physical examination with assessment of heart, circulation and other reacted organ systems should be carried out.

Laboratory, electrocardiography (ECG), and imaging should include the following:

• 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 – echocardiography, carotid ultrasound, kidneys/renal artery and adrenal imaging, fundoscopy, brain CT/MRI etc.

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Treatment for hypertension

The treatment approach is categorised based on the grades of hypertension:

Grade 1 hypertension - For grade 1 hypertension (140-159/90-99 mmHg), lifestyle interventions such as smoking cessation, exercise, weight loss, salt and alcohol reduction, healthy diet are recommended.

• Drug therapy should be initiated in low to moderate risk patients (without cardiovascular disease, chronic kidney disease, diabetes mellitus, or organ damage) if BP not controlled after 3-6 months of lifestyle intervention.
• Immediate drug therapy should be initiated in high-risk patients (cardiovascular disease, chronic kidney disease, diabetes mellitus, or hypertension mediated organ damage)
• If there is a problem with limited drug availability, such as in area with low resources, lifestyle intervention should be followed for 3-6 months; if BP is still not controlled, drug treatment should be initiated in patients aged 50-80 years.

Grade 2 hypertension - For grade 2 hypertension (≥160/100 mmHg), drug therapy along with lifestyle interventions should be initiated immediately.

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Office blood pressure targets for treated hypertension

• Target for BP control within 3 months
• Target for at least a 20/10 mmHg BP reduction, ideally to <140/90 mmHg
• Patients <65 years: Target BP <130/80 mmHg if tolerated (but >120/70 mmHg)
• Patients ≥65 years: Target BP <140/90 mmHg if tolerated; individualising target BPs may be considered in those who are frail, independent, and likely to tolerate therapy

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ISH core drug-treatment step-wise strategy

A simplified regimen with once-daily dosing and single pill combinations is ideal.

Step 1: Dual low-dose (half of the maximum recommended dose) combination

ACE-inhibitor (angiotensin-converting enzyme inhibitors) or ARB (angiotensin receptor blocker) + DHP-CCB (dihydropyridine-calcium channel blocker)

• Consider monotherapy in low risk grade 1 hypertension or in very old (≥ 80 yrs) or frailer patients.
• Consider ACE-Inhibitor or ARB + Thiazide-like diuretic in post-stroke, very elderly, incipient heart failure or CCB intolerance.

Step 2: Dual full-dose combination

ACE-inhibitor or ARB + DHP-CCB

• Consider monotherapy in low risk grade 1 hypertension or in very old (≥ 80 yrs) or frailer patients.
• Consider ACE-Inhibitor or ARB + thiazide-like diuretic in post-stroke, very elderly, incipient heart failure or CCB intolerance.

Step 3: Triple combination

ACE-Inhibitor or ARB + DHP-CCB + thiazide-like diuretic

Step 4 (Resistant Hypertension): Triple combination + spironolactone or other alternative drug

ACE-Inhibitor or ARB + DHP-CCB + thiazide-like diuretic + spironolactone (12.5 – 50 mg o.d.) or other drug (alternatives include amiloride, doxazosin, eplerenone, clonidine or beta-blocker)

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Points to consider while following the step-wise strategy

• Consider beta-blockers at any treatment step when there is an indication for their use, e.g. heart failure, angina, post-MI, atrial or younger women with, or planning pregnancy
• Spironolactone or other potassium sparing diuretics should be used with caution when estimated glomerular filtration rate (GFR) <45 ml/min/1.73m² or K+ >4.5 mmol/L