Guideline for the Pharmacological Treatment of Hypertension in Adults

Overview

This concise Guidelines summary covers World Health Organization (WHO) recommendations on initiating treatment for hypertension in adults. For a complete set of recommendations, refer to the full guideline.

The guideline does not address measurement of blood pressure, diagnosis of hypertension, or hypertensive crisis. It addresses pharmacotherapy in individuals with a ‘confirmed’ diagnosis of hypertension, such as hypertension diagnosed when blood pressure is found to be elevated on 2 different days.

Strength of Recommendations

The strength of the recommendations reflects the degree of confidence of the guideline development group (GDG) that the desirable effects (for example, beneficial health outcomes) of the recommendations outweigh the undesirable effects (for example, adverse effects). The strength of recommendations in this guideline was graded into two categories:

• A strong recommendation is one for which the GDG was confident that the desirable effects of adhering to the recommendation outweigh the undesirable effects
• A weak or conditional recommendation is one for which the GDG concluded that the desirable effects of adhering to the recommendation probably outweigh the undesirable effects, but was not confident about these trade-offs.

Reflecting on your Learnings

Nonpharmacological Management

• Although this guideline does not address modifiable risk factors for hypertension such as unhealthy diet, physical inactivity, consumption of tobacco and alcohol, and being overweight or obese, a comprehensive treatment plan for hypertension must include addressing these risk factors through lifestyle modifications and other interventions
• Nonpharmacological approaches to treatment or prevention of hypertension include:
  • reducing salt intake (to less than 5 g daily)
  • eating more fruit and vegetables
  • being physically active on a regular basis
  • avoiding use of tobacco
  • reducing alcohol consumption
  • limiting the intake of foods high in saturated fats
  • eliminating/reducing trans fats in diet.

Blood Pressure Threshold for Initiation of Pharmacological Treatment

• WHO recommends initiation of pharmacological antihypertensive treatment of individuals with a confirmed diagnosis of hypertension and systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90 mmHg (strong recommendation, moderate- to high-certainty evidence)
• WHO recommends pharmacological antihypertensive treatment of individuals with existing cardiovascular disease (CVD) and systolic blood pressure of 130–139 mmHg (strong recommendation, moderate- to high-certainty evidence)
• WHO suggests pharmacological antihypertensive treatment of individuals without CVD but with high CVD risk, diabetes mellitus, or chronic kidney disease, and systolic blood pressure of 130–139 mmHg (conditional recommendation, moderate- to high-certainty evidence)
• Initiation of pharmacological hypertension treatment should start no later than 4 weeks following diagnosis of hypertension. If blood pressure level is high (for example, systolic ≥160 mmHg or diastolic ≥100 mmHg) or there is accompanying evidence of end organ damage, initiation of treatment should be started without delay.

For recommendations on laboratory testing before and during pharmacological treatment, refer to the full guideline.

CVD Risk Assessment

• WHO suggests CVD risk assessment at or after the initiation of pharmacological treatment for hypertension, but only where this is feasible and does not delay treatment (conditional recommendation, low-certainty evidence)
• Most patients with systolic blood pressure of ≥140 or diastolic blood pressure of ≥90 mmHg are high risk and indicated for pharmacological treatment; they do not require CVD risk assessment prior to initiating treatment. CVD risk assessment is most important for guiding decisions about initiating pharmacological treatment for hypertension in those with lower systolic blood pressure (130–139 mmHg). It is critical in those with hypertension that other risk factors must be identified and treated appropriately to lower total CVD risk
• Many CVD risk-assessment systems are available. In the absence of a calibrated equation for the local population, the choice should depend on resources available, acceptability, and feasibility of application
• Whenever risk assessment may threaten timely initiation of hypertension treatment and/or patient follow up, it should be postponed and included in the follow-up strategy, rather than taken as a first step to indicate treatment.

Drug Classes to be Used as First-Line Agents

• For adults with hypertension requiring pharmacological treatment, WHO recommends the use of drugs from any of the following three classes of pharmacological antihypertensive medications as an initial treatment (strong recommendation, high-certainty evidence):

  • thiazide and thiazide-like agents

  • angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs)

  • long-acting dihydropyridine calcium channel blockers (CCBs)

• Long-acting antihypertensives are preferred

• Examples of indications to consider specific agents include diuretics or CCBs in patients over 65 years or those of African descent, beta-blockers in ischaemic heart disease, ACEis/ARBs in patients with severe proteinuria, diabetes mellitus, heart failure, or kidney disease.

Combination Therapy

• For adults with hypertension requiring pharmacological treatment, WHO suggests combination therapy, preferably with a single-pill combination (to improve adherence and persistence), as an initial treatment. Antihypertensive medications used in combination therapy should be chosen from the following three drug classes: diuretics (thiazide or thiazide-like), ACEis/ARBs, and long-acting dihydropyridine CCBs (conditional recommendation, moderate-certainty evidence)
• Combination medication therapy may be especially valuable when the baseline blood pressure is ≥20/10 mmHg higher than the target blood pressure
• Single-pill combination therapy improves medication-taking adherence and persistence and blood pressure control.

Target Blood Pressure

• WHO recommends a target blood pressure treatment goal of <140/90 mmHg in all patients with hypertension without comorbidities (strong recommendation, moderate-certainty evidence)
• WHO recommends a target systolic blood pressure treatment goal of <130 mmHg in patients with hypertension and known CVD (strong recommendation, moderate-certainty evidence)
• WHO suggests a target systolic blood pressure treatment goal of <130 mmHg in high-risk patients with hypertension (those with high CVD risk, diabetes mellitus, chronic kidney disease; conditional recommendation, moderate-certainty evidence).

Frequency of Reassessment

• WHO suggests a monthly follow up after initiation or a change in antihypertensive medications until patients reach target (conditional recommendation, low-certainty evidence)
• WHO suggests a follow up every 3–6 months for patients whose blood pressure is under control (conditional recommendation, low-certainty evidence).

Administration of Treatment by Nonphysician Professionals

• WHO suggests that pharmacological treatment of hypertension can be provided by nonphysician professionals such as pharmacists and nurses, as long as the following conditions are met: proper training, prescribing authority, specific management protocols, and physician oversight (conditional recommendation, low-certainty evidence)
• Community healthcare workers (HCWs) may assist in tasks such as education, delivery of medications, and blood pressure measurement and monitoring through an established collaborative care model. The scope of hypertension care practised by community HCWs depends on local regulations and currently varies by country
• Telemonitoring and community or home-based self-care are encouraged to enhance the control of blood pressure as a part of an integrated management system, when deemed appropriate by the treating medical team and found feasible and affordable by patients
• Physician oversight can be done through innovative methods such as telemonitoring or similar to ensure access to treatment is not delayed.

For information on managing hypertension in special settings, refer to the full guideline.