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New ISH 2020 Blood Pressure Guidelines

Recently, the International Society of Hypertension released its 2020 blood pressure guidelines. Their guidelines do vary a little bit from the 2017 ACC/AHA guidelines that were put out a few years ago. Here are a few of the important highlights from the ISH 2020 blood pressure guidelines.

Blood Pressure Classification

  • Classification of hypertension based on office blood pressure measurement
    • Normal BP: SBP < 130 mmHg and DBP < 85 mmHg
    • High-normal BP: SBP 130-139 mmHg and/or DBP 85-89 mmHg
    • Grade 1 hypertension: SBP 140-159 mmHg and/or DBP 90-99 mmHg
    • Grade 2 hypertension: SBP > 160 mmHg and/or DBP > 100 mmHg

Essential and Optimal Blood Pressure

The ISH guidelines designate different categories of blood pressure control.

  • Essential
    • Target BP reduction by at least 20/10 mmHg, ideally to < 140/90 mmHg
    • Aim for BP control within 3 months
  • Optimal
    • < 65 years: BP target < 130/80 mmHg if tolerated
    • > 65 years: BP target < 140/90 mmHg if tolerated, but consider and individualized BP target depending on frailty, independence, and tolerability of medication

Drug Treatment

  • ISH core drug-treatment strategy
    • Essential recommendations:
      • Use drugs with the ideal characteristics for each patient
      • Use free combinations if single pill combinations (SPC) are not available
      • Use thiazide diuretics if thiazide-like diuretics are not available
      • Use alternative to DHP-CCB if these are not available (non-DHP-CCB)
      • Consider beta-blockers at any treatment step when there is a specific indication for their use (heart failure, angina, post-MI, AFib, pregnancy)

My Take

In general, I don’t think these guidelines really dramatically change my mindset about hypertension management. The ACC/AHA guidelines have some subtle variations from these guidelines in that the goals with the ACC/AHA are considered a little more strict than these guidelines.

In my geriatric population, the ISH 2020 blood pressure guidelines probably don’t have much of an impact compared to my current practice. As patients age, we need to continually reassess the risk versus benefit of aggressive treatment to prevent complications from hypertension compared to the risk for hypotension.

Written by Baley Pederson, PharmD Candidate in collaboration with Eric Christianson, PharmD, BCPS, BCGP

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