Review Article| Volume 82, P1-6, December 2020

The 2020 International Society of Hypertension global hypertension practice guidelines - key messages and clinical considerations

Published:September 22, 2020DOI:


      The International Society of Hypertension (ISH) has recently developed practice guidelines for the management of hypertension in adults aged ≥18 years. Conceptually, the 2020 ISH Guidelines are closer to the 2018 ESC/ESH Guidelines rather than to the 2017 ACC/AHA Guidelines. The ISH Guidelines have two distinctive features when compared with the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines and the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines. First, they are written in a concise and easy-to-read style; second, they focuses on practical issues related to the management of hypertension in ‘high-income’ as well as in ‘low-income’ countries, where there is limited access to resources for the diagnosis and treatment of hypertension. In our opinion, the 2020 ISH Guidelines share with the 2018 ESC/ESH Guidelines an important limitation which may impair the retention of these key aspects of Guidelines by physicians, with consequent difficult adoption in clinical practice. It consists in the definition of several blood pressure targets in relation to age, target organ damage and concomitant disease. We believe that results of randomized clinical trials and meta-analysis do not support the recommendation of differential BP targets, as well as of rigid ‘safety boundaries’. This review critically examines similarities and differences across the three major Hypertension Guidelines, which include the definition of hypertension, drug treatment, and blood pressure targets, with emphasis on key messages relevant for clinical practice.


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        • Unger T.
        • Borghi C.
        • Charchar F.
        • Khan N.A.
        • Poulter N.R.
        • Prabhakaran D.
        • Ramirez A.
        • Schlaich M.
        • Stergiou G.S.
        • Tomaszewski M.
        • Wainford R.D.
        • Williams B.
        • Schutte A.E
        International Society of Hypertension global hypertension practice guidelines.
        J Hypertens. 2020; 38 (2020): 982-1004
        • Unger T.
        • Borghi C.
        • Charchar F.
        • Khan N.A.
        • Poulter N.R.
        • Prabhakaran D.
        • et al.
        International Society of Hypertension Global Hypertension Practice Guidelines.
        Hypertension. 2020; 75 (2020): 1334-1357
        • Williams B.
        • Mancia G.
        • Spiering W.
        • Agabiti Rosei E.
        • Azizi M.
        • Burnier M.
        • et al.
        ESC/ESH Guidelines for the management of arterial hypertension.
        Eur Heart J. 2018; (ehy339)
        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • Casey Jr., D.E.
        • Collins K.J.
        • Dennison Himmelfarb C.
        • et al.
        ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        J Am Coll Cardiol. 2017; 71 (2018): e127-e248
        • Bakris G.
        • Ali W.
        • Parati G
        ACC/AHA Versus ESC/ESH on Hypertension Guidelines: JACC Guideline Comparison.
        J Am Coll Cardiol. 2019; 73: 3018-3026
        • Muntner P.
        • Carey R.M.
        • Gidding S.
        • Jones D.W.
        • Taler S.J.
        • Wright Jr., J.T.
        • et al.
        Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline.
        Circulation. 2018; 137: 109-118
        • Khera R.
        • Lu Y.
        • Lu J.
        • Saxena A.
        • Nasir K.
        • Jiang L.
        • Krumholz H.M
        Impact of 2017 ACC/AHA guidelines on prevalence of hypertension and eligibility for antihypertensive treatment in United States and China: nationally representative cross sectional study.
        BMJ. 2018; 362: k2357
        • Lewington S.
        • Clarke R.
        • Qizilbash N.
        • Peto R.
        • Collins R.
        • Prospective Studies C
        Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.
        Lancet. 2002; 360: 1903-1913
        • de Boer I.H.
        • Bakris G.
        • Cannon C.P
        Individualizing Blood Pressure Targets for People With Diabetes and Hypertension: comparing the ADA and the ACC/AHA Recommendations.
        JAMA. 2018; 319: 1319-1320
        • Verdecchia P.
        • Angeli F.
        • Cavallini C.
        • Reboldi G
        Keep Blood Pressure Low, but Not Too Much.
        Circ Res. 2018; 123: 1205-1207
        • Angeli F.
        • Reboldi G.
        • Trapasso M.
        • Aita A.
        • Verdecchia P
        Managing hypertension in 2018: which guideline to follow.
        Heart Asia. 2019; 11e011127
        • Wright Jr., J.T.
        • Whelton P.K.
        • Reboussin D.M
        A Randomized Trial of Intensive versus Standard Blood-Pressure Control.
        N Engl J Med. 2016; 374: 2294
        • Verdecchia P.
        • Gentile G.
        • Angeli F.
        • Mazzotta G.
        • Mancia G.
        • Reboldi G
        Influence of blood pressure reduction on composite cardiovascular endpoints in clinical trials.
        J Hypertens. 2010; 28: 1356-1365
        • Bohm M.
        • Schumacher H.
        • Teo K.K.
        • Lonn E.M.
        • Mahfoud F.
        • Mann J.F.E.
        • Mancia G.
        • Redon J.
        • Schmieder R.E.
        • Sliwa K.
        • Weber M.A.
        • Williams B.
        • Yusuf S
        Achieved blood pressure and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials.
        Lancet. 2017; 389: 2226-2237
        • Verdecchia P.
        • Reboldi G.
        • Angeli F.
        • Trimarco B.
        • Mancia G.
        • Pogue J.
        • et al.
        Systolic and diastolic blood pressure changes in relation with myocardial infarction and stroke in patients with coronary artery disease.
        Hypertension. 2015; 65: 108-114
        • Ettehad D.
        • Emdin C.A.
        • Kiran A.
        • Anderson S.G.
        • Callender T.
        • Emberson J.
        • Chalmers J.
        • Rodgers A.
        • Rahimi K
        Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis.
        Lancet. 2016; 387: 957-967
        • Bundy J.D.
        • Li C.
        • Stuchlik P.
        • Bu X.
        • Kelly T.N.
        • Mills K.T.
        • et al.
        Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis.
        JAMA Cardiol. 2017; 2: 775-781
        • Bangalore S.
        • Toklu B.
        • Gianos E.
        • Schwartzbard A.
        • Weintraub H.
        • Ogedegbe G.
        • et al.
        Optimal Systolic Blood Pressure Target After SPRINT: insights from a Network Meta-Analysis of Randomized Trials.
        Am J Med. 2017; 130 (e708): 707-719
        • Angeli F.
        • Reboldi G.
        • Verdecchia P
        Masked hypertension: evaluation, prognosis, and treatment.
        Am J Hypertens. 2010; 23: 941-948
        • Parati G.
        • Stergiou G.
        • O'Brien E.
        • Asmar R.
        • Beilin L.
        • Bilo G.
        • Clement D.
        • de la Sierra A.
        • de Leeuw P.
        • Dolan E.
        • Fagard R.
        • Graves J.
        • Head G.A.
        • Imai Y.
        • Kario K.
        • Lurbe E.
        • Mallion J.M.
        • Mancia G.
        • Mengden T.
        • Myers M.
        • Ogedegbe G.
        • Ohkubo T.
        • Omboni S.
        • Palatini P.
        • Redon J.
        • Ruilope L.M.
        • Shennan A.
        • Staessen J.A.
        • vanMontfrans G.
        • Verdecchia P.
        • Waeber B.
        • Wang J.
        • Zanchetti A.
        • Zhang Y.
        European Society of Hypertension Working Group on Blood Pressure M, Cardiovascular V. European Society of Hypertension practice guidelines for ambulatory blood pressure monitoring.
        J Hypertens. 2014; 32: 1359-1366
        • Verdecchia P.
        • Schillaci G.
        • Borgioni C.
        • Ciucci A.
        • Porcellati C
        White-coat hypertension.
        Lancet. 1996; 348 (author reply 1445-1446): 1444-1445