REVIEW ARTICLE Updated National and International Hypertension Guidelines: A Review of Current Recommendations Sverre Kjeldsen • Ross D. Feldman • Liu Lisheng • Jean-Jacques Mourad • Chern-En Chiang • Weizhong Zhang • Zhaosu Wu • Wei Li • Bryan Williams Published online: 15 October 2014 Ó The Author(s) 2014. This article is published with open access at Springerlink.com Abstract Despite the availability of effective pharmaco- logical treatments to aid the control of blood pressure, the global rate of uncontrolled blood pressure remains high. As such, further measures are required to improve blood pressure control. Recently, several national and international guidelines for the management of hypertension have been published. These aim to provide easily accessible information for healthcare professionals and patients to aid the diagnosis and treatment of hypertension. In this review, we have compared new and current guidelines from the American and Interna- tional Societies of Hypertension; the American Heart Asso- ciation, American College of Cardiology and the US Center for Disease Control and Prevention; the panel appointed to the Eighth Joint National Committee; the European Societies of Hypertension and Cardiology; the French Society of Hyper- tension; the Canadian Hypertension Education Program; the National Institute for Health and Clinical Excellence (UK); the Taiwan Society of Cardiology and the Chinese Hypertension League. We have identified consensus opinion regarding best practises for the management of hypertension and have highlighted any discrepancies between the recommendations. In general there is good agreement between the guidelines, however, in some areas, such as target blood pressure ranges for the elderly, further trials are required to provide sufficient high-quality evidence to form the basis of recommendations. Key Points 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. S. Kjeldsen (&) Department of Cardiology, Faculty of Medicine, Oslo University Hospital Ullevaal, University of Oslo, 0450 Oslo, Norway R. D. Feldman Departments of Medicine and of Physiology and Pharmacology, Sculich School of Medicine and Dentistry, Western University, London, Canada L. Lisheng Á W. Li Fu Wai Hospital, National Center for Cardiovascular Diseases, Beijing, China J.-J. Mourad Hypertension Excellence Centre-Avicenne University Hospital, AP-HP, Bobigny, France C.-E. Chiang Division of Cardiology and General Clinical Research Center, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan W. Zhang Shanghai Institute of Hypertension, Ruijin Hospital of Shanghai Jiaotong University, Shanghai, China Z. Wu An Zhen Hospital, Beijing, China B. Williams Institute of Cardiovascular Science, University College London, London, UK Drugs (2014) 74:2033–2051 DOI 10.1007/s40265-014-0306-5
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REVIEW ARTICLE
Updated National and International Hypertension Guidelines:A Review of Current Recommendations
Sverre Kjeldsen • Ross D. Feldman • Liu Lisheng •
Jean-Jacques Mourad • Chern-En Chiang •
Weizhong Zhang • Zhaosu Wu • Wei Li • Bryan Williams
Published online: 15 October 2014
� The Author(s) 2014. This article is published with open access at Springerlink.com
Abstract Despite the availability of effective pharmaco-
logical treatments to aid the control of blood pressure, the
global rate of uncontrolled blood pressure remains high. As
such, further measures are required to improve blood pressure
control. Recently, several national and international guidelines
for the management of hypertension have been published.
These aim to provide easily accessible information for
healthcare professionals and patients to aid the diagnosis and
treatment of hypertension. In this review, we have compared
new and current guidelines from the American and Interna-
tional Societies of Hypertension; the American Heart Asso-
ciation, American College of Cardiology and the US Center
for Disease Control and Prevention; the panel appointed to the
Eighth Joint National Committee; the European Societies of
Hypertension and Cardiology; the French Society of Hyper-
tension; the Canadian Hypertension Education Program; the
National Institute for Health and Clinical Excellence (UK); the
Taiwan Society of Cardiology and the Chinese Hypertension
League. We have identified consensus opinion regarding best
practises for the management of hypertension and have
highlighted any discrepancies between the recommendations.
In general there is good agreement between the guidelines,
however, in some areas, such as target blood pressure ranges
for the elderly, further trials are required to provide sufficient
high-quality evidence to form the basis of recommendations.
Key Points
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.
S. Kjeldsen (&)
Department of Cardiology, Faculty of Medicine,
Oslo University Hospital Ullevaal,
University of Oslo, 0450 Oslo, Norway
R. D. Feldman
Departments of Medicine and of Physiology and Pharmacology,
Sculich School of Medicine and Dentistry, Western University,
London, Canada
L. Lisheng � W. Li
Fu Wai Hospital, National Center for Cardiovascular Diseases,
Beijing, China
J.-J. Mourad
Hypertension Excellence Centre-Avicenne University Hospital,
AP-HP, Bobigny, France
C.-E. Chiang
Division of Cardiology and General Clinical Research Center,
Taipei Veterans General Hospital and National Yang-Ming
University, Taipei, Taiwan
W. Zhang
Shanghai Institute of Hypertension, Ruijin Hospital of Shanghai
Jiaotong University, Shanghai, China
Z. Wu
An Zhen Hospital, Beijing, China
B. Williams
Institute of Cardiovascular Science, University College London,
London, UK
Drugs (2014) 74:2033–2051
DOI 10.1007/s40265-014-0306-5
1 Introduction
The worldwide prevalence of hypertension is rising; the
number of cases rose from 600 million in 1980 to 1 billion
in 2008 [1]. Although hypertension itself is generally
asymptomatic, it is one of the key risk factors for cardio-
vascular disease (CVD). Hypertension accounts for
approximately 45 % of deaths due to heart disease and
51 % of deaths due to stroke [1]. Complications of
hypertension are thought to cause 9.4 million deaths each
year, and without further action the World Health Orga-
nization (WHO) has predicted this number will increase
[1]. It has been predicted that by 2030 nearly a quarter of
all deaths worldwide will be due to CVD [1]. However, if
hypertension was controlled in all patients, a substantial
decrease in CV events would be seen; for example, in the
UK it has been predicted that the incidence of stroke would
be reduced by 28–44 % and ischaemic heart disease by
20–35 % [2].
Effective treatments to control blood pressure (BP) are
available but measures need to be taken to ensure their use
is maximised in the required patient groups. To achieve
this, effective multifactorial programmes with strategies to
manage blood pressure are being sought. As part of this
programme, clear evidence-based guidelines that can be
readily implemented across diverse populations are
required. Indeed, clinical guidelines are considered the
intersection between evidence and clinical practice to
improve patients’ CV outcomes [3].
In 2013, a number of national and international hyper-
tension guidelines were updated. Although these guidelines
have evolved to reflect new evidence and best practice, the
objective remains unequivocal: to develop recommenda-
tions, based on clinical evidence, to aid the diagnosis,
treatment and management of hypertension. In light of the
recent updates, we felt it important to review and compare
the latest updates with currently utilised regional guide-
lines. The review will discuss hypertension guidelines from
the US including those from the Eighth Joint National
Committee (JNC 8) (updated 2013) [3–5], regularly
updated Canadian recommendations (annual non-radical
updates) [6], European (European Societies of Hyperten-
sion and Cardiology (ESH/ESC]) guidelines (updated in
2013) [7], UK (National Institute for Health and Clinical
Excellence [NICE); last updated in 2011) [8], France
(updated in 2013) [9], Taiwan (last updated in 2010
[pending update in 2014]) [10] and China (last updated in
2010) [11]. Table 1 [3–11] provides an overview of the
development and aims of these guidelines.
All the guidelines were produced by committees of
healthcare professionals and scientists with a broad range
of expertise in the field of hypertension and principally
used evidence from systematic reviews of randomised
control trials (RCT) [3–11]. Notably, NICE also has
patients on the panel to support the development and
updating of their clinical practice guidelines [8]. The
guidelines were developed as a means of improving and
standardising the management of hypertension within their
jurisdictions. It is important to note that all the guidelines
state that they are not mandatory, but aim to help facilitate
the physicians’ treatment decisions on a case by case basis.
By comparing these guidelines, we aim to identify the
major differences in recommendations and establish where
there is consensus on best practice for hypertension man-
agement (summarised in Table 2). Specifically, the review
will focus on recommendations for the utilisation of diag-
nostic tools, the BP levels defined for initiating treatment,
target BP levels, and the proposed non-pharmacological
and pharmacological interventions. Further to this analysis,
we will collectively provide our expert opinion on the
future development of guidelines and how best to imple-
ment these into clinical practice.
2 Tools for Diagnosing Hypertension and Monitoring
Blood Pressure
Accurate diagnosis of hypertension and the identification of
other CV risk factors is essential to identify patients that
will likely benefit from treatment to control BP [1]. Based
on office BP measurements, all the guidelines utilise a
common definition of stage 1 hypertension as clinic seated
systolic (SBP)/diastolic (DBP) C140/90 mmHg and stage 2
hypertension as C160/100 mmHg [3–11]. Where stated,
the guidelines are in agreement regarding the use of lower
BP measurements for defining hypertension based on
ambulatory (ABPM) or home blood pressure monitoring
(HBPM). With the exception of the American Heart Asso-
ciation (AHA), American College of Cardiology (ACC), the
Center for Disease Control and Prevention (CDC) and JNC
8 guidelines, all the guidelines discuss methods for diag-
nosing and monitoring BP [3, 4]. With the exception of the
NICE and Canadian Hypertension Education Program
(CHEP) guidelines, the consensus is that a diagnosis of
hypertension should be based on multiple office BP mea-
surements, taken on at least two separate visits, 1–4 weeks
apart [5, 7, 9–11]. The CHEP guidelines are more stringent
and suggest that if SBP is 140–160 mmHg or DBP
90–100 mmHg, then office BP should be measured on four
to five separate occasions, or self-monitoring/ABPM should
be used before diagnosis is made [6].
Although the use of both ABPM and HBPM are
recognised as effective diagnostic tools that are becoming
more widely used, only the CHEP and NICE guidelines
currently recommend that a diagnosis can be made based
on either of these measurements [6, 8]; for all other
2034 S. Kjeldsen et al.
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Updated National and International Hypertension Guidelines 2037
guidelines office BP is still regarded as the gold standard
for diagnosis [3–5, 7, 9–11]. Uniquely, the NICE guide-
lines recommend that office BP is used to initially screen
for hypertension, with ABPM (or HBPM if patients are
unable or unwilling to use ABPM) then used to confirm the
diagnosis [8]. French and Taiwan guidelines recommend
the use of self-monitoring to confirm office BP measure-
ments before diagnosis is made [9, 10], while other
guidelines (American and International Societies of
Hypertension [ASH/ISH] and ESH/ESC) recommend self-
monitoring for borderline cases, when variable office BP
measurements are recorded or when white-coat
hypertension is suspected [5, 7]. The ESH/ESC and NICE
guidelines state that ABPM is the preferred method of self-
monitoring for diagnosis [7, 8], although French and ESH/
ESC guidelines state that HBPM is more suitable than
ABPM for monitoring BP subsequent to diagnosis [7, 9]. In
Taiwan and Canada, the cost of ABPM is not reimbursed
by the National Health Insurance System, therefore its use
is limited and HBPM is more widely used [10]; this is an
example of how healthcare resource and financial con-
straints can enforce differences in recommendations. As
the cost of ABPM decreases its use is likely to become
more commonplace. Indeed, a UK-based study
Table 2 Summary highlighting the major consensus findings and discrepancies between guidelines
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 hypertensionSelf-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 treatmentFocus on the same factors e.g., diet and exercise
Pharmacological
treatment
Individualise treatment to meet patient needs b-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
b-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
–
AHA/ACC/CDC American Hypertension Association/American College of Cardiology/Centers for Disease Control and Prevention, ASH/ISH
American Society of Hypertension/International Society of Hypertension, CHEP Canadian hypertension education program, ESH/ESC European
Society of Hypertension/European Society of Cardiology, JNC 8 Eighth Joint National Committee, NICE National Institute for Clinical
blocker, BP blood pressure, CCB calcium channel blocker, CKD chronic kidney disease, SPC single pill combinationa Consensus recommendations are those that are presented in the majority of the guidelines, with no conflicting advice presented in the other
guidelines (although the subject may not be discussed)
2038 S. Kjeldsen et al.
investigating the cost effectiveness of using ABPM for
diagnosis concluded that the additional cost of imple-
menting ABPM outweighed the savings made by providing
more accurate diagnosis and treatment [12].
3 Blood Pressure Thresholds for Initiating Treatment
There is some disparity between the guidelines regarding
when drug treatment to control BP should be initiated
(Table 3 [3–11]). The Taiwan guidelines are the only guide-
lines to recommend treatment of patients with high-normal
BP (130–139/80–89 mmHg) if they have additional risk
factors [10]. Both the French and Taiwan guidelines recom-
mend commencing pharmacological treatment of stage 1
patients regardless of other risk factors, whereas the other
guidelines recommend a trial period of health behaviour
modifications to try and control BP without therapy. The
recommended duration of this period varies from several
months in the ESH/ESC guidelines [7], 3 months in the AHA/
ACC/CDC guidelines [4], to 6–12 months in the ASH/ISH
guidelines [5] (NICE guidelines do not specify a time period
[8]). In addition, the French guidelines recommend health
behaviour modifications commence prior to a confirmed
diagnosis of hypertension [9]. The NICE and Canadian rec-
ommendations note that for those at very low risk (the para-
digm being a pre-menopausal female with no other risk
factors, or younger people) with an SBP of \160 mmHg and
DBP \100 mmHg, initiation of antihypertensive therapy can
be deferred. This recommendation is in accordance with their
very low risk for CV complications, subsequent low proba-
bility of benefiting from therapy and that lack of evidence for
treatment in low-risk patients with stage 1 hypertension [6, 8].
With the exception of the ESH/ESC guidelines, all
guidelines recommend commencing pharmacological
treatment of stage 2 patients immediately following diag-
nosis. The ESH/ESC recommend that, even low-risk stage
2 patients undergo a phase of health modifications before
commencing treatment.
Some guidelines provide specific recommendations for
initiating treatment of the elderly. ESH/ESC, NICE and
CHEP suggest that for patients aged C80 years, an SBP
of [160 mmHg should be used as a threshold for initiating