The recently published updates to European, American, Canadian, French, UK, Chinese and Taiwanese guidelines for hypertension broadly provide a consensus on the best practise for diagnosing and management of hypertension. |
There are some areas, such as treatment goals for the elderly and for patients with diabetes, where there are discrepancies in the recommendations due to a lack of consistent and high-quality evidence to form the basis of recommendations. |
1 Introduction
Guidelines | Developers | Aims | Evidence used | Format |
---|---|---|---|---|
2013 ESH/ESC Guidelines for the management of arterial hypertension [7] (ESH/ESC) | Task force of European scientists and physicians appointed by the ESH and ESC. Appointed based on their recognised expertise and absence of major conflict of interest | Update of the 2003 and 2007 guidelines | Highest priority RCTs and their meta-analyses Observational and other studies of an appropriate scientific calibre | Provides tables and concise recommendations that can easily be consulted by physicians The strength of the recommendations and the level of evidence are ranked Contains explanations of the supporting evidence |
2013 French Society of hypertension guidelines [9] | A small working group (seven members) of academic volunteers from the French Society of Hypertension and a larger reading group of hypertension specialists and general practitioners | To produce a set of guidelines with the following characteristics: usefulness for clinical practise, short, easy-to-read format, comprehensive writing for non-physicians, wide dissemination among healthcare professionals and the hypertensive population, assessment of their impact among healthcare professionals and with regard to public health goals Designed to be an operational tool and call-to-action To improve hypertension control in the individual patient and the French population as a whole from 50 to 70 % by 2015 | Literature analyses performed for previous hypertension recommendations and systematic reviews, consensus conferences, meta-analyses and national or international guidelines published in recent years | Fifteen recommendations divided into three sections (prior to treatment initiation, initial treatment plan and long-term care plan) |
National Institute for Health and Clinical Excellence 2011 Hypertension guidelines [8] (NICE) | A UK-based guideline development group consisting of professional group members and patient representatives | Update previous guidelines (2004 and 2006) Develop standards and provide recommendations for healthcare professionals for the diagnosis, treatment and management of hypertension | Systematic literature search of studies published up until November 2010 focused around specific questions, accompanied by formal cost-effectiveness analyses to support recommendations. The data analysis is completely independent. Guideline draft is subject to national open consultation by registered stakeholder groups, before completing the final draft | A quick reference guide with lists of recommendations and algorithms for diagnosis and treatment A full guide containing detailed evidence to support each of the recommendations A patient specific guide |
2014 Canadian hypertension education program recommendations [6] (CHEP) | Expert subgroups made up of volunteer members of the CHEP committee who are fully independent and free from external influence. The guidelines are developed independently from the government | Annually updated evidence based recommendations for healthcare providers To improve hypertension prevention, detection and management in Canada | An annual systematic literature search was used to identify: RCTs and systematic reviews of RCTs for treatment recommendations Cross-sectional and cohort studies for assessing diagnosis and prognosis | Complete recommendations: a book containing extensive lists and tables of recommendations and a diagnosis algorithm Increasingly sophisticated web-based approaches for more effective dissemination and implementation (www.hypertension.ca) |
2013 Clinical practise guidelines for the management of hypertension in the community. A statement by the American Society of Hypertension and the International Society of Hypertension (ASH/ISH) [5] | Developed by members of ASH and ISH on a volunteer basis. The societies sponsored the guidelines and no additional external funding was used Endorsed by the Asia Pacific Society of Hypertension | Provide a straightforward set of recommendations for healthcare workers to care for people with hypertension | Based on current guidelines Considered costs of diagnosis, monitoring and treatment | Lists of recommendations Tables detailing recommended drugs Treatment algorithm |
An effective approach to high blood pressure control: a science advisory from the American Heart Association, American College of Cardiology and the Centers for Disease Control and Prevention (AHA/ACC/CDC) [4] | A writing group composed of members of the societies | Develop a hypertension treatment algorithm to be implemented as part of a systematic approach to control hypertension Designed to complement clinical guidelines | Not specified | Treatment algorithm Description of how and why the algorithm was developed |
2014 Evidence-based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the Eighth Joint National Committee (JNC 8) [3] | A panel of around 50 healthcare professionals (appointed from >400 nominees) with a range of expertise It is important to note that although the committee was originally formed by the National Heart, Lung and Blood Institute (NHLBI), the guidelines were subsequently developed and published independently and are not endorsed by the NHBLI | Provide clinicians with evidence based recommendations for the management of high BP Update JNC 7 guidelines (published in 2003) | Systematic review of RCTs published between January 1996 and August 2013, containing more than 100 people with a follow-up period of at least 1 year | Nine treatment recommendations Treatment algorithm Presents evidence for the recommendations The strength of the recommendations and the level of evidence are ranked |
2010 Guidelines of the Taiwan Society of Cardiology for the management of hypertension [10] | Hypertension Committee of the Taiwan Society of Cardiology | Provide physicians with the most up to date information and guidelines for hypertension management An update is due to be published in 2014 | Highest priority: primary endpoints in RCTs Second priority: secondary endpoints, subgroup analyses, and post hoc analyses of RCTs, or meta-analyses Epidemiological data: Taiwanese cohort studies | Fifteen key messages regarding the management of hypertension Treatment algorithm Tables detailing recommended health behaviour and drug interventions Information explaining the evidence supporting the recommendations |
2010 Chinese guidelines for the management of hypertension [11] | A guideline committee of nearly 100 members (including hypertension experts, cardiologists, nephrologists, endocrinologists, epidemiologists, gynaecologists, neurologists and gerontologists) appointed by the CHL and the CCD | Update the 1999 and 2005 guidelines Provide guidelines that are suitable for both economically advantaged and disadvantaged regions | Highest priority RCTs, meta-analyses, observational and other studies Where possible, Chinese studies were used | Tables and concise recommendations for primary healthcare unit to use in daily practise |
Consensus opiniona
| Discrepancies | |
---|---|---|
Measuring BP | Multiple office BP measurements are the gold standard for diagnosis | NICE states that ABPM is the gold standard for diagnosis before initiating therapy—daytime average BP >135/85 defined as hypertension |
Self-monitoring can aid diagnosis and long-term BP monitoring | ||
Target office BP | <140/90 mmHg for general population | Differing targets for elderly |
CHEP, Taiwan and EHC/ESC recommend lower target for patients with diabetes or CKD | ||
Health behaviour modifications | Important role in combination with pharmacological treatment | Initiation before (ASH/ISH, AHA/ACC/CDC, ESH/ESC, NICE, France) or in conjunction (China, Taiwan), with pharmacological treatment |
Focus on the same factors e.g., diet and exercise | ||
Pharmacological treatment | Individualise treatment to meet patient needs | β-Blockers are not advised for treatment of general population in the JNC 8, ASH/ISH. AHA/ACC/CDC, NICE, Taiwan guidelines and are restricted to those <60 years of age in CHEP guidelines |
Principally use 4 classes of drugs, diuretics, CCB, ACEI and ARB | ||
Simplify drug regimens by using long-acting drugs and SPCs | ||
Gaining BP control as soon as possible improves persistence | ||
Patient education improves persistence | ||
Regular monitoring is required | ||
Drug combinations | Multiple drugs are required in most cases SPCs can be used when available ACEI and ARB should not be used in combination CCB + thiazide + ACEI/ARB is the preferred 3-drug combination | SPCs recommended by China and Taiwan guidelines for initial treatment if more than one drug is required No consensus on drug class to be used for initial treatment No consensus on most effective 2-drug combinations |
Treatment recommendations for specific patient groups | Specific treatment recommendations are required for patients with associated comorbidities | – |
Treatment of black patients should be initiated with CCB or thiazide diuretic | ||
β-Blockers should be prescribed for patients with a history of myocardial infarction, heart failure or angina pectoris | ||
Treatment algorithms | A useful tool for providing simplified treatment advice | – |
2 Tools for Diagnosing Hypertension and Monitoring Blood Pressure
3 Blood Pressure Thresholds for Initiating Treatment
Patient group | Recommendation | ASH/ISH | AHA/ACC/CDC | ESH/ESC | NICE | France | Taiwan | CHEP | China |
---|---|---|---|---|---|---|---|---|---|
High normal BP, high risk | Health behaviour modifications and pharmacological treatment | ✓ | |||||||
Stage 1, low risk | Health behaviour modifications and monitoring before initiating pharmacological treatment | ✓ | ✓ | ✓ | ✓ | ||||
Health behaviour modifications and pharmacological treatment | ✓ | ✓ | ✓ | ||||||
Stage 1, high risk | Health behaviour modifications and pharmacological treatment | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Stage 2, low risk | Health behaviour modifications and monitoring before initiating pharmacological treatment | ✓ | |||||||
Health behaviour modifications and pharmacological treatment | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
Stage 2, high risk | Health behaviour modifications and pharmacological treatment | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Elderly, >80 years | Health behaviour modifications and pharmacological treatment | Not specified | Not specified | ✓ (SBP ≥160 mmHg only) | Not specified | ✓ | Not specified | ✓ (SBP ≥160 mmHg only) | Not specified |
4 Target Blood Pressure Levels
4.1 Elderly Patients
Population | Target BP (SBP/DBP mmHg) | Guidelines |
---|---|---|
General | <140/90 | Alla
|
Elderly | ||
≥60 years | <150/90 | JNC 8 |
≥65 years | <150/90 | China |
≥80 years | <150/90 | ASH/ISH, ESH/ESC, France, NICE, CHEP |
Diabetes | <130/80 | CHEP, China, Taiwan |
<140/85 | ESH/ESC | |
CKD | <130/80 | China, Taiwan, ESH/ESCb
|
Other high-risk patients e.g., with coronary disease, history of stroke | <130/80 | Taiwan, Chinac
|
4.2 Patients with Diabetes or Chronic Kidney Disease
5 Health Behaviour Intervention Strategies
Guidelines | What is recommended? |
---|---|
JNC 8 | Not specifically addressed, but supports the recommendations of the 2013 Lifestyle Work Group, a set of diet and activity guidelines to reduce CV disease risk [26] |
ASH/ISH | Weight loss in patients who are overweight or obese |
Reduce salt intake | |
Regular exercise as part of the daily routine | |
Reduce alcohol consumption—Up to 2 drinks a day for men and 1 for women | |
Stopping smoking | |
AHA/ACC/CDC | Maintain BMI 18.5–24.9 kg/m2
|
Consume a diet rich in fruits, vegetables and low-fat dairy products with a reduced content of saturated and total fat | |
Consume no more than 2,400 mg sodium/day. Further reduction of sodium intake to 1,500 mg/day is desirable since it is associated with even greater reduction in BP. Reduce intake by at least 1,000 mg/day since that will lower BP, even if the desired daily sodium intake is not achieved | |
Engage in regular aerobic physical activity such as brisk walking at least 30 min per day, most days of the week | |
Limit alcohol consumption to no more than 2 drinks per day in most men, and no more than 1 drink per day in women and lighter weight persons | |
CHEP | Physical exercise: 30–60 min moderate intensity dynamic exercise 4–7 days a week |
Weight reduction: target BMI 18.5–24.9 kg/m2 and waist circumference <102 cm for men and <88 cm for women | |
Alcohol consumption: two drinks or less per day, with consumption not exceeding 14 or 9 standard drinks per week for men and women, respectively (standard drink is considered 17.2 ml ethanol) | |
Diet: consume a diet that emphasises fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources that is reduced in saturated fat and cholesterol | |
Reduce sodium intake towards 5 g of salt daily | |
Supplementation of potassium, calcium and magnesium is not recommended | |
Stress management | |
ESH/ESC | Salt reduction |
Moderation of alcohol consumption, no more than 20–30 g ethanol per day in men and 10–20 g in women | |
Consume a diet of vegetables, fruits and low-fat dairy products, dietary and soluble fibre, whole grains and proteins from plant sources | |
Reduce consumption of saturated fat and cholesterol | |
Weight reduction for overweight or obese patients | |
Regular physical exercise, 30–60 min moderate intensity dynamic exercise 5–7 days a week | |
Cessation of smoking | |
France | Reduce excessive salt consumption |
Regular physical activity | |
Reduce weight if overweight | |
Reduce excessive consumption of alcohol | |
Adopt a diet rich in fruit and vegetables | |
Cease smoking | |
NICE | Provide diet and exercise advice |
Reduce alcohol consumption | |
Reduce consumption of coffee and caffeine-rich products | |
Reduce salt intake | |
Cease smoking | |
Calcium, magnesium and potassium supplements are not recommended | |
Relaxation therapies | |
Taiwan | S-ABCDE: |
Salt restriction | |
Alcohol limitation | |
Body weight reduction | |
Cessation of smoking | |
Diet adaption | |
Exercise adoption | |
China | Sodium reduction |
Smoking cessation | |
Reduction of body weight | |
Reduction in alcohol consumption | |
Increase dietary potassium | |
Increase physical activity |
6 Pharmacological Treatment Recommendations
6.1 Treatment Algorithms
Guidelines | Patient characteristics | Treatment recommendations |
---|---|---|
JNC 8 | Patients categorised based on age, goal BP, race and patients with diabetes/CKD | Specifies drug classes to be used as first-line treatment and longer-term follow-up treatment options if BP remains uncontrolled |
ASH/ISH | Patients categorised based on BP and other factors e.g., age, race, comorbidities | Specifies drug class to be used as first-line treatment and longer-term follow-up treatment options if BP remains uncontrolled |
AHA/ACC/CDC | Patients categorised based on stage of hypertension | Suggests drug classes to be used, monitoring and follow-up options |
CHEP | Provides algorithms for diagnosis and treatment | Specifies drug classes to be used as first-line treatment and longer-term follow-up treatment options if BP remains uncontrolled |
ESH/ESC | Patients categorised based on low or high risk | Describes steps to be taken in moving to a more intensive therapy through dose titration or adding more drugs No recommendations on drug classes or doses |
France | No algorithm provided | n/a |
NICE | Diagnosis and treatment algorithms. Treatment algorithm categorised based on age and race | Recommends drug classes to be used for initial therapy and drug combinations to be considered if BP remains uncontrolled |
Taiwan | Patients categorised based on BP and non-high risk or high risk | Specifies the number of drugs to be prescribed but not specific drug classes or doses |
China | Patients categorised based on BP and risk assessment | Specifies drug classes to be used as first-line treatment and longer-term follow-up treatment options if BP remains uncontrolled |
7 Treatment Regimens for the General Population
Guidelines | Initial treatment | Two-drug combinations | Three-drug combinations |
---|---|---|---|
JNC 8 | Thiazide diuretic, CCB, ACEI or ARB | Add a drug from another class: thiazide diuretic, CCB, ACEI or ARB | CCB + thiazide + ACEI or ARB |
Alone or in combination | |||
ASH/ISH | Stage 1: ACEI or ARB | CCB or thiazide + ACEI or ARB | CCB + thiazide + ACEI or ARB |
Stage 2: 2 drugs | |||
AHA/ACC/CDC | Stage 1: Thiazide for most patients or ACEI, ARB, CCB | Add a drug from another class, either, thiazide diuretic, CCB, ACEI or ARB | Not specified |
Stage 2: Thiazide + ACEI, ARB or CCB OR ACEI + CCB | |||
CHEP | Thiazide, β-blocker, ACEI, ARB, CCB | Add a drug from another class, either, thiazide, β-blocker, CCB, ACEI or ARB | Not specified |
Consider combination if SBP ≥20 mmHg or DBP ≥10 mmHg above target | |||
ESH/ESC | Stage 1: Diuretics, ACEI, ARB, CCB or β-blocker | Preferred combinations: Thiazide + ARB or ACEI Thiazide + CCB CCB + ARB or ACEI | Add a drug from another class: thiazide diuretic, CCB, ACEI, ARB or β-blocker |
Stage 2: 2 drugs | |||
France | Initiating treatment with ARB or ACEI (better persistence versus diuretic or β-blocker) | Add a drug from another class: thiazide, β-blocker, CCB, ACEI or ARB. | CCB + thiazide + ACEI or ARB |
CCB (for adherence) is preferred versus diuretic or β-blocker | |||
NICE | <55 years, ACEI or ARB | CCB + ACEI or ARB | CCB + thiazide + ACEI or ARB |
>55 years CCB | |||
Taiwan | Stage 1: Thiazide diuretic, CCB, ARB or ACEI | ACEI or ARB + CCB or thiazide | CCB + thiazide + ACEI or ARB |
Stage 2: 2 drugs | |||
China | Stage 1: Thiazide diuretic, CCB, ARB, ACEI or β-blocker Stage 2: SPCs of 2 drugs | CCB + ACEI or ARB
OR ACEI or ARB + thiazide
OR CCB + thiazide.
OR CCB + β-blocker | CCB + ACEI or ARB + thiazide
OR CCB + ACEI or ARB + β-blocker
OR ACEI or ARB + thiazide + α- blocker |