Level of evidence and classes of recommendations
Criteria | Definition |
---|---|
Level of evidence | |
A | Data derived from multiple randomized controlled trials or meta-analyses. |
B | Data derived from a single randomized controlled trial or nonrandomized clinical trials. |
C | Experts’ opinion or data derived from limited evidence. |
Class of recommendation | |
I | Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, and effective. Therefore, it is recommended. |
IIa | Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure exists. However, in general, weight of evidence/opinion is in favor of usefulness/efficacy. Therefore, it is reasonable to be performed. |
IIb | Usefulness/efficacy less well established by evidence/opinion. Therefore, it may be considered. |
III | Evidence or general agreement that a given treatment or procedure is not beneficial and may be harmful in some case. Therefore, it is not recommended. |
Clinical evaluation of hypertension
Blood pressure measurement
Process | Recommendation |
---|---|
Proper preparation | Resting for 5 min in a quiet room. |
No smoking, alcohol, or caffeine for 30 min before measurement. | |
No talking by individual or observer during measurement or between measurements. | |
Emptying bladder before measurement. | |
Proper posture | Sitting in a chair with back support. |
Legs uncrossed and feet kept flat on the floor. | |
Bare upper arm or upper arm with light clothes resting on the table. | |
Proper technique | |
Use of validated device | Auscultatory device or automated device. |
Use the correct cuff size | |
Auscultatory device | Inflatable bladder length which is 75–100% of an individual’s middle upper-arm circumference and width 37–50% of the arm circumference. |
Automated device | Select cuff size according to the device’s instructions. |
Placement of cuff at the heart level | The middle portion of the cuff on the individual’s upper arm at the mid-sternal level (lower end of the cuff 2–3 cm above the antecubital fossa) |
Measurement with auscultatory device | Estimate radial pulse obliteration pressure and inflate the cuff 20–30 mmHg above this level for auscultatory determination of the BP level. |
Place the stethoscope (bell side) on the brachial artery at the point of maximal pulsation. | |
For auscultatory readings, deflate the cuff pressure 2 mmHg per beat or second and listen to Korotkoff sounds. | |
Document accurate BP readings properly: Record SBP as the onset of first Korotkoff sound (K1) and diastolic DBP as disappearance of all Korotkoff sound (K5). Record as DBP at the fourth Korotkoff sound (K4) in pregnancy, arteriovenous shunt, and chronic aortic insufficiency. | |
Repeated measurements | Separate repeated measurements in intervals of 1–2 min. |
BP measurement in both arms | Measure BP in both arms at the first visit and then the arm with the higher BP should be used at subsequent visits. |
Positional BP measurement | Measure BP 1 and 3 minutes after standing from a seated position in older people, people with diabetes, and people with suspected orthostatic hypotension. |
BP measurement in arrhythmia | Take triplicate BP measurements and use their average. |
Pulse measurement | Record heart rate and use pulse palpation at rest to exclude arrhythmia. |
BP measurement in the leg | Measure leg BP in suspected peripheral arterial disease if the lower extremity pulse is weak. |
Measure ankle BP, in the supine position using a validated automated device with the cuff placed around the ankle/lower calf. |
Office blood pressure measurement
Out-of-office blood pressure measurement
Confirm the diagnosis of hypertension. | |
Detect the white coat hypertension. | |
Detect the masked hypertension in individuals with high-normal OBP or normal BP with target organ damage or high cardiovascular risk. | |
Detect the hypertension in cases of marked BP discrepancy between OBP and home BP. | |
Assess the dipping patterns (dipper, nondipper, reverse dipper, and extreme dipper), nocturnal hypertension, morning hypertension, and morning surge. | |
Assess the cause of secondary hypertension (e.g., sleep apnea). | |
Assess labile hypertension or hypotension (postural, postprandial, and drug-induced hypotension). | |
Assess the BP caused by autonomic dysfunction. | |
Assess the short-term BP variability. | |
Monitoring the efficacy of antihypertensive medications in treated patients. | |
Assess the white coat effect and masked uncontrolled hypertension. | |
Assess symptomatic hypotension due to excessive treatment. | |
Ensure 24-hour BP control (particularly in high-risk individuals and pregnant women). | |
Confirm the diagnosis of resistant hypertension. | |
Assess accurate BP measurement for risk assessment. |
Category | Systolic BP (mmHg) | Diastolic BP (mmHg) |
---|---|---|
Office BP | ≥140 | ≥90 |
Ambulatory BP | ||
24 Hours | ≥130 | ≥80 |
Daytime | ≥135 | ≥85 |
Nighttime | ≥120 | ≥70 |
Home BP | ≥135 | ≥85 |
Process | Recommendation |
---|---|
Preparation | Resting for 5 min in a quiet room with comfortable temperature. |
No smoking, alcohol or caffeine, exercise, and bathing 30 min before measurement. | |
No talking during measurement and between measurements. | |
Position | Sitting in a chair with back support. |
Legs uncrossed and feet kept flat on the floor. | |
Upper arm resting on the table with wearing light clothes. | |
Technique | |
Device | Validated automated upper-arm device. |
Cuff | Select proper cuff size according to the device’s instructions |
Proper placement of cuff at the heart level | Placement of cuff on the mid-arm with the lower edge of the cuff 2–3 cm above the antecubital fossa. |
Measurement time | |
Morning | Before a meal and after urination, and before drug intake if treated. |
Evening | 1 Hr before sleep. |
Measurement frequency | Two measurements with 1-min intervals. |
Measurement schedule | Measurement for at least 5 day, especially for 7 day for first diagnosing hypertension (discard 1st day readings and use their average values) |
Recording | Record all readings in BP log accurately All BP recordings in the built-in memory of device should be brought to clinic appointments BP values should not be selectively recorded by individual. |
White coat hypertension and masked hypertension
Recommendation | Class | Level | Reference |
---|---|---|---|
Out-of-office BP with either ABPM or HBPM is recommended to detect WCH. | I | A | |
In individuals with WCH, regular BP monitoring with either ABPM or HBPM is reasonable to detect transition to sustained hypertension. | IIa | B | |
In treated individuals with uncontrolled OBP, out-of-office BP with either ABPM, or HBPM is reasonable to detect white coat effect (WCE). | IIa | C | |
In individuals with high-normal OBP or normal OBP accompanying target organ damage, screening for MH with ABPM or HBPM may be considered. | IIb | B | |
In individuals with high-normal OBP or normal OBP accompanying target organ damage, screening for masked uncontrolled hypertension (MUCH) with ABPM or HBPM may be considered. | IIb | C | [21] |
Unattended automated office blood pressure measurement
Blood pressure measurement using cuffless wearable devices
Central blood pressure measurement
Hypertension screening
Recommendation | Class | Level | Reference |
---|---|---|---|
Hypertension screening using standard BP measurements is recommended for all adults aged ≥20 years. | I | B |
Corresponding blood pressure
Office BP | Ambulatory BP (24 hours) | Ambulatory BP (daytime) | Home BP | |
---|---|---|---|---|
Systolic BP (mmHg) | 140 | 130 | 135 | 135 |
Systolic BP (mmHg) | 130 | 125 | 130 | 130 |
Laboratory examination
Recommendation | Class | Level | Reference |
---|---|---|---|
It is reasonable that the routine laboratory tests should be evaluated at the first visit and annually. | IIa | C |
Test | Examination |
---|---|
Routine test | 12-Lead electrocardiogram |
Urinalysis (proteinuria, hematuria, and glucosuria) | |
Hemoglobin, hematocrit | |
K+, creatinine, eGFRa), and uric acid | |
Fasting glucose, lipids (total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, and triglyceride) | |
Chest X-ray | |
Microalbuminuriab) (albumin/creatinine [a random urine sample]) | |
Recommended test | 75 g oral glucose tolerance test or hemoglobin A1c (if fasting glucose ≥100 mg/dL) |
Transthoracic echocardiography | |
Carotid ultrasound (plaque) | |
Ankle-brachial blood pressure index | |
Pulse wave velocity | |
Fundoscopy (mandatory in diabetes) | |
24-hr urine protein excretion | |
Cystatin Cc) | |
Extended test | Search for subclinical organ damage (brain, heart, kidney, and vessels) |
Search for secondary causes of hypertension |
Treatment of hypertension
Cardiovascular risk and treatment plan
Target blood pressure
Recommendation | Class | Level | Reference |
---|---|---|---|
It is recommended to control BP to less than 140/90 mmHg in low-risk and intermediate-risk groups. | I | A | |
It is reasonable to reduce BP below 130/80 mmHg in patients with coronary artery disease (CAD), peripheral artery disease, abdominal aortic aneurysm, heart failure, and left ventricular hypertrophy. | IIa | B | [58] |
It is reasonable to reduce BP below 130/80 mmHg in individuals with high CV risk.a) | IIa | B |
Clinical situation | SBP (mmHg) | DBP (mmHg) | COR | LOE |
---|---|---|---|---|
Hypertension without complications | ||||
Low to intermediate cardiovascular risk | <140 | < 90 | I | A |
Elderly | <140 | < 90 | I | A |
High cardiovascular riska) | < 130 | < 80 | IIa | B |
Diabetes mellitus | < 130 | < 80 | IIa | B |
Low to intermediate risk | < 140 | < 90 | I | A |
High riskb) | < 130 | < 80 | IIa | B |
Hypertension with complications | ||||
Cardiovascular diseasec) | < 130 | < 80 | IIa | B |
Chronic kidney disease | ||||
Without albuminuriad) | <140 | < 90 | I | A |
With albuminuria | < 130 | < 80 | IIa | B |
With diabetes mellitus | < 130 | < 80 | IIa | B |
Stroke | <140 | < 90 | I | B |
Lacunar stroke | < 130 | < 80 | IIa | B |
Antiplatelet therapy
Recommendation | Class | Level | Reference |
---|---|---|---|
It is recommended to use aspirin in hypertensive patients with CVD. | I | A | [93] |
Low-dose aspirin for primary prevention may be considered in high-risk hypertensive individuals aged 40 to 70 years without CVD. | IIb | B | |
The use of aspirin for primary prevention is not recommended in hypertensive patients over 70 years of age with low or intermediate CV risk. | III | A |
Antidyslipidemic therapy
Recommendation | Class | Level | Reference |
---|---|---|---|
In hypertensive patients with intermediate or high CV risk, statin is recommended. | I | A | |
In hypertensive patients with CVD, statin is recommended. | I | A | [99] |
It is recommended that low-density lipoprotein (LDL) cholesterol level should be reduced to < 70 mg/dL in hypertensive patients with CVD. | I | A | [99] |
Blood glucose control
Recommendation | Class | Level | Reference |
---|---|---|---|
If there is no risk of hypoglycemia in diabetic patients with hypertension, it is recommended to lower glycated hemoglobin to < 6.5%. | I | A | [100] |
Patient monitoring and follow-up
Adherence
Recommendation | Class | Level | Reference |
---|---|---|---|
As reduced dosing frequency is associated with better adherence, antihypertensive drugs are recommended to be administered once a day unless there are special situations such as resistant hypertension, morning hypertension, medication adjustment. | I | A | |
In stable patients with the same drug and dosage during a long period of time, it is reasonable to use fixed-dose combination drugs because their drug adherence is better than that of free combination drugs. | IIa | B | |
The use of the fixed-dose combination of antihypertensive drugs and statins to increase adherence to drug therapy may be considered. | IIb | B | [112] |
Hypertension in special situations
Diabetes mellitus
Recommendation | Class | Level | Reference |
---|---|---|---|
In diabetic patients without CV risk factors, clinical CVD, stages 3, 4, or 5 CKD, and subclinical organ damage, it is recommended to control BP below 140/90 mmHg. | I | A | |
In diabetic patients with CV risk factors ≥1, CVD, stages 3, 4, or 5 CKD, and subclinical organ damage, it is reasonable to control BP below 130/80 mmHg. | IIa | B | |
In hypertensive patients with DM, all five classes of antihypertensive drugs can be recommended as first-line drugs. | I | A | |
Angiotensin converting enzyme (ACE) inhibitors or ARBs are recommended if microalbuminuria or proteinuria is present. | I | B |
Hypertension in the elderly
Cardiovascular disease
Coronary artery disease
Atrial fibrillation
Aortic disease
Chronic kidney disease
Recommendation | Class | Level | Reference |
---|---|---|---|
For CKD patients with hypertension, a target BP below 140/90 mmHg is recommended. | I | A | |
For CKD patients with hypertension and albuminuria, a target BP below 130/80 mmHg is reasonable. | IIa | B | |
In hypertensive patients with CKD, combination therapy with ACE inhibitors, ARBs, or direct renin inhibitors are not recommended. | III | B |
Cerebrovascular disease
Blood pressure control in acute ischemic stroke
Recommendation | Class | Level | Reference |
---|---|---|---|
In patients who are treated with intravenous recombinant tissue plasminogen activator (IV-TPA), in order to reduce the risk of intracerebral hemorrhage (ICH), it is reasonable to lower BP to < 185/100 mmHg before treatment and to maintain BP < 180/105 mmHg during the first 24 hours. | I | B | |
For patients undergoing endovascular recanalization therapy (ERT), it is reasonable to maintain preoperative BP < 185/110 mmHg to reduce the risk of cerebral hemorrhage. During the first 24 hours after ERT, the optimal BP level remains uncertain and should be individualized based on the patient’s clinical and imaging profiles. In general, maintaining BP < 180/105 mmHg may be considered. However, a lower BP level may be considered in patients who achieved successful reperfusion. | IIb | C | |
In patients with persistent high BP levels of > 140/90 mmHg and in a stable neurological condition without contraindications to BP lowering, it is reasonable to initiate antihypertensive therapy before or at discharge in order to improve long-term BP control. | IIa | B | |
The benefit of BP lowering within 48 to 72 hours after stroke onset is uncertain in acute ischemic stroke patients with BP ≥220/120 mmHg not receiving IV-TPA or ERT and having no comorbidities. If BP lowering is required based on clinical judgment, BP lowering by approximately 15% may be considered during the first 24 hours. | IIb | C | [7] |
In acute ischemic stroke patients with BP < 220/120 mmHg not receiving IV-TPA or ERT and having no comorbidities, initiating BP lowering within 48 to 72 hours after stroke onset is not recommended because it neither improves functional disabilities nor reduces major vascular events at 3 to 6 months. | III | A |
Acute parenchymal hemorrhage
Recommendation | Class | Level | Reference |
---|---|---|---|
In patients with acute ICH presenting within 6 hours of the onset who have an SBP level between 150 and 220 mmHg, rapid lowering of SBP to 140 mmHg may be considered. However, excessive BP lowering (SBP < 140 mmHg) is not usually recommended because it does not have additional benefit on functional outcome and potentially increases the risk of renal dysfunction. | IIb | A | |
In patients with acute ICH who have an elevated SBP > 220 mmHg, it is reasonable to reduce BP with intravenous antihypertensive agent infusion along with close BP monitoring. | IIa | C |
Secondary prevention
Recommendation | Class | Level | Reference |
---|---|---|---|
In patients with stroke or transient ischemic attack (TIA) who have previously or newly been diagnosed with hypertension of an established BP of ≥140/90 mmHg, antihypertensive treatment should be restarted or initiated several days after the stroke or TIA to reduce the risk of recurrent stroke and other CV events. | I | A | |
Treatment with thiazide diuretics, ACE inhibitors, or ARBs, or combination treatment consisting of thiazide diuretics plus ACE inhibitors, is recommended for adults who experience a stroke or TIA. | I | A | |
It is reasonable to consider using calcium blockers in order to control hypertension in patients with stroke or TIA. | IIa | C | [174] |
For adults with a lacunar stroke, a target SBP goal of less than 130 mmHg is reasonable. | IIa | B | [175] |