Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Appropriate arm cuff size according to subject’s upper arm circumference
| Arm cuff size | Upper arm circumference (cm) | Bladder size in the arm cuff (cm) |
|---|---|---|
| Small | 22–26 | 12 × 22 |
| Medium (regular adult size) | 27–34 | 16 × 30 |
| Large | 35–44 | 16 × 36 |
| Extra-large | 45–52 | 16 × 42 |
Recommendations to improve hypertension treatment and control
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Always use standardized BP measurements both in the diagnosis of hypertension and during follow-up. | I | A |
| Provide enough time for explaining and answering questions from the patients, especially when the first diagnosis of hypertension is made. | I | C |
| Use HBPM whenever possible. | I | B |
| HBPM is recommended to prevent inertia in the starting and adjustment of antihypertensive medication. | I | B |
Recommendations for management of white-coat hypertension
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Diagnosis of white-coat hypertension should be made and confirmed by out-of-office BP measurements, particularly in individuals with office BP in grade 1 hypertension. | I | B |
| Assessment of CV risk factors and HMOD is recommended in individuals with white-coat hypertension. | I | B |
| Patients with white-coat hypertension should be advised to change their improper lifestyle and reduce CV risk. | I | B |
| Patients with white-coat hypertension should be follow-up to screen for new HMOD. | I | B |
| Out-of-office BP measurements should be repeated from time to time, during follow-up, to timely identify sustained hypertension. | I | B |
| Patients with white-coat-hypertension with HMOD and/or high CV risks can be considered for antihypertensive drug therapy. | IIa | C |
Office BP targets for patients with hypertension
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Patients 18–64 years old | ||
| Office BP should be lower to <130/80 mmHg. | I | A |
| Patients 65–79 years old | ||
| Office BP should be initially lower to <140/90 mmHg. | I | A |
| Further office BP lowering to <130/80 mmHg should be considered if treatment is well tolerated. | I | B |
| Patients 65–79 years old with ISH | ||
| Office SBP should be initially lowered in the 140–150 mmHg range. | I | A |
| Further reduction of office SBP in the 130–139 mmHg range may be considered if well tolerated, albeit cautiously if office DBP is already below 70 mmHg. | IIb | B |
| Patients ≥80 years old | ||
| Office SBP should be lowered in the 140-150 mmHg range and DBP to <80 mmHg. | I | A |
| Further reduction of office SBP in the 130-139 mmHg range may be considered if well tolerated, albeit cautiously if office DBP is already below 70 mmHg. | IIb | B |
| General Recommendations | ||
| In frail patients, the treatment office BP target should be individualized. | I | C |
| Do not aim office SBP target below 120 mmHg or an office DBP target below 70 mmHg. | III | C |
Diurnal BP patterns as identified by ABPM and related CV risk
| BP patterns | Nighttime BP lowering as compared with daytime BP (%) | CV risk |
|---|---|---|
| Normal dipping | >10–20 | Notincreased |
| Extreme dipping | >20 | Debatable risk |
| Reduced dipping | 1–10 | Increased risk |
| Rising | Nighttime BP increases | Increased risk |
Recommendations for patients with stable CAD
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| In patients with stable CAD, antihypertensive drug treatment should be initiated in the office, with BP at risk range of 130–139 mmHg and/or 85–89 mmHg. | I | A |
| In patients with stable CAD, the treatment targets should be the same as in the general hypertensive population. | I | A |
| In patients with stable CAD and low office DBP (<70 mmHg), if office SBP is still well above the target values, the office SBP can be cautiously lowered. | IIa | C |
| In patients with CAD and low office DBP, office SBP lowering can be considered while monitoring tolerability, such as symptoms and signs of organ ischemia, especially in elderly patients. | IIa | C |
| ACEi and/or beta-blocker is recommended in patients with stable CAD and high BP. However, ARB can replace ACEi if not tolerated. | I | A |
| In symptomatic CAD patients with angina, beta-blockers, both DHP-CCB and non-DHP CCB, are recommended for the treatment of hypertension. | I | A |
| Lowering heart rate of CAD patients with hypertension to between 60 bpm and 80 bpm can be useful, for which a beta-blocker or a non-DHP-CCB should be prescribed | I | B |
Home BP targets for patients with hypertension
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Average home BP should be lower to <130/80 mmHg. | I | B |
| Further home SBP lowering to <125/75 mmHg can be considered in patients 18–65 years old, patients with DM, with CVD or with high CV risk. | IIa | B |
| Average home BP of patients 65–79 years old and patients with history of stroke should be <135/85 mmHg. | I | C |
| Average home BP below 140/80 mmHg is acceptable for patients 80 years or older. | IIb | C |
Criteria of hypertension diagnosis in different measurement methods
| Measurement method | SBP (mmHg) | DBP (mmHg) | |
|---|---|---|---|
| Office BP measurement | ≥140 | and/or | ≥90 |
| HBPM | ≥135 | and/or | ≥85 |
| ABPM | |||
| Average of daytime BP | ≥135 | and/or | ≥85 |
| Average of nighttime BP | ≥120 | and/or | ≥70 |
| Average of 24-h BP | ≥130 | and/or | ≥80 |
Recommended frequency for HBPM
| Conditions | Frequency of measurements |
|---|---|
| For hypertension diagnosis | Measure BP for 7 consecutive days |
| In urgent conditions, it can be done for at least 3 consecutive days. | |
| For treatment monitoring during antihypertensive medication adjustment | Measure BP for 7 consecutive days beginning 2 weeks after initiation or after changes in the treatment regimen and Measure BP at least 3 consecutive days during the week before a clinic visit. |
| For long-term follow-up in stable cases | Measure BP once or twice per week or Measure BP 7 d before each clinic visit, and at least over 1 week within 3 months of visit intervals. |
The acute phase treatment in patients with hypertensive emergencies based on organ damage
| End-organ damage | Target BP (mmHg) | Time frame | Recommended treatment | Note |
|---|---|---|---|---|
| Acute coronary syndromes | SBP <140 | Immediate | Nitroglycerine, labetalol* | Avoid over-BP reduction, SBP <110 mm Hg, or DBP <60 mm Hg. |
| Acute decompensated heart failure (cardiogenic pulmonary edema) | SBP <140 | Immediate | Nitroglycerine, nitroprusside | Add on loop diuretics as needed. |
| Malignant hypertension | Decrease MAP by 20%–25% | A few hours | Nicardipine, labetalol | Nitroprusside can be used as a second line treatment. |
| Acute ischemic stroke | Adhere to established guidelines for acute stroke management. | |||
| Acute hemorrhagic stroke | ||||
| Hypertensive encephalopathy | Decrease MAP by 20%–25% | Immediate | Nicardipine, labetalol | Nitroprusside can be used as a second line treatment. |
| Acute aortic diseases | SBP <120, and HR <60 bpm | Immediate | Esmolol, labetalol, nicardipine, and nitroglycerine | Combination therapy of 2 antihy-pertensive classes may be needed to control both SBP and HR. |
Recommendations for BP measurement
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| All types of BP measurement, including office, home, and ambulatory BP measurement, are recommended for the diagnosis and treatment of hypertension. | I | A |
| Only validated BP measuring devices with an appropriate size of upper arm cuff should be used. | I | A |
| Standardized procedure for BP measurement must be followed to obtain reliable BP records. | I | A |
| In the first visit, BP should be measured simultaneously in both arms. If an interarm SBP difference >10 mmHg is detected and confirmed with repeated measurements, the arm with the higher BP should be used for subsequent evaluation. | I | A |
| If interarm SBP difference >15–20 mmHg is detected and confirmed, further investigations to diagnose arterial disease of the upper extremities are recommended. | I | A |
| Orthostatic hypotension should be screened in subjects with DM, elderly, or with orthostatic symptoms. | IIa | C |
| BP measurement with the auscultatory technique is preferred in subjects with cardiac arrhythmia, and it is recommended to use the average BP from multiple BP records. | IIa | C |
| HBPM is advised in all treated hypertensive cases because it will enhance medication adherence, reduce white-coat effect, and detect masked uncontrolled hypertension. Upper arm devices are recommended, but wrist devices may be allowed in markedly obese subjects. | I | A |
| Cuffless devices are not recommended for clinical use. | III | C |
| ABPM should be used to determine specific diurnal BP patterns, nocturnal hypertension, morning BP surge, and BP variability. | I | A |
Recommendations for the treatment of hypertension in patients with obesity
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| In individuals with obesity, weight reduction is fundamental to reduce BP and improve CV outcomes. | I | A |
| Associated comorbidities that can elevate BP, e.g. OSA, should be aware and appropriately managed. | I | A |
| All major classes of antihypertensive agents can be used in individuals with obesity or metabolic syndrome. | I | B |
| Effective medications that do not worsen obesity or metabolic profiles should be selected. | I | A |
Diagnostic criteria of preeclampsia-eclampsia
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| High BP | ||
| After 20 weeks of gestation, pregnant woman with a previously normal BP, who has SBP ≥140 mm Hg and/or DBP ≥90 mm Hg on two occasions at least 4 h apart should be diagnosed as having high BP. | I | A |
| In a pregnant woman of any gestational weeks with unknown previous BP, SBP ≥160 mm Hg and/or DBP ≥110 mm Hg measured on two occasions within minutes (short interval), should be diagnosed as having high BP, to facilitate timely antihypertensive therapy for hypertensive crisis. | I | A |
| Proteinuria | ||
| Quantitative protein leakage ≥300 mg/24-h urine collection (or this amount extrapolated from other collection methods) should be diagnosed as proteinuria. | I | A |
| Quantitative urine protein/creatinine ratio ≥0.3 should be diagnosed as proteinuria. | I | A |
| Qualitative (only when quantitative methods are not immediately available), urine dipstick reading ≥2+ should be diagnosed as proteinuria. | I | A |
| End-organ involvement | ||
| Thrombocytopenia: platelet count <100,000/μL | I | A |
| Renal insufficiency: serum creatinine >1.1 mg/dL or doubling from the previous serum creatinine. | I | A |
| Impaired liver function: elevated serum liver transaminases to twice-normal concentration. | I | A |
| Pulmonary edema | I | A |
| Headache unresponsive to medication | I | A |
| Visual disturbances | I | A |
| Convulsion; generalized tonic-clonic seizure | I | A |
Etiology of secondary hypertension based on organ systems
| Endocrine causes | Primary aldosteronism
|
| Metabolic disease |
|
| Renal causes |
|
| CV causes |
|
Recommendations for HF prevention in hypertension
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Treatment of hypertension is recommended to effectively prevent HF | I | A |
| All major antihypertensive drug classes can be used in hypertension treatment for the prevention of HF | I | A |
Definition of BP and classification of the severity of hypertension in adults aged 18 years and older
| Category | SBP (mmHg) | DBP (mmHg) | |
|---|---|---|---|
| Optimal | <120 | and | <80 |
| Normal | 120–129 | and/or | <80 |
| BP at risk | 130–139 | and/or | 80–89 |
| Grade 1 hypertension | 140–159 | and/or | 90–99 |
| Grade 2 hypertension | 160–179 | and/or | 100–109 |
| Grade 3 hypertension | ≥180 | and/or | ≥110 |
| ISH | ≥140 | and | <90 |
| IDH | <140 | and | ≥90 |
Recommendations for pharmacological treatment of hypertension in HFrEF
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| In patients with HFrEF, it is recommended to combine drugs with proven HF outcome benefits, including ACEI or ARB or ARNI, beta-blocker, mineralocorticoid receptor antagonist, and SGLT2i, if not contraindicated and well tolerated | I | A |
| If patients remain with uncontrolled hypertension from the 4 major drug classes and a diuretic, a DHP-CCB should be added for BP control | I | B |
| Use of non-DHP-CCB is not recommended in HFrEF | III | C |
Aspirin prophylaxis and level of clinical risk for preeclampsia-eclampsia
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
Low dose aspirin is recommended in the presence of ≥1 of the followings
| I | A |
Low dose aspirin is recommended in the presence of ≥2 of the followings
| I | A |
Low dose aspirin is not recommended
| III | A |
Recommendations for hypertensive patients with AF
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Early detection and treatment of hypertension in patients at risk for AF is recommended. | I | C |
| Antihypertensive treatment is recommended to reduce the risk of incident and recurrent AF. The target for treatment is the same as for the general hypertensive population. | I | A |
| All major antihypertensive drug classes and combinations should be prescribed to control BP. | I | A |
| ACEis or ARBs and beta-blockers can be considered to prevent recurrent of AF. | IIa | B |
| At least 3 office BP measurements by auscultation can be recommended in AF to account for BP variability. | IIa | B |
| Automated oscillatory BP devices is an alternative for satisfactory SBP and modestly overestimated DBP measurement. | IIa | B |
| Beta-blockers are the preferred drug for heart rate control to be <110 bpm and targeting to <80 bpm in symptomatic patients. | I | B |
| Beta-blockers should not be combined with non-DHP CCBs. | III | C |
| Anticoagulants for stroke prevention can be considered in AF with BP ≥140/90 mmHg | IIa | B |
| If SBP is >160 mmHg, it is recommended to firstly reduce BP before initiation of anticoagulant in order to reduce risk of major bleeding and intracranial hemorrhage. | I | B |
| In AF patients with hypertension receiving anticoagulant, the treatment target and choice of agents are recommended the same as general hypertensive population. | I | B |
| Non-DHP CCBs for rate control should be used with caution because of drug interaction with oral anticoagulants and increased bleeding risk. | III | B |
Recommendations for the evaluation and management of patients presenting with hypertensive crises
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| General recommendations | ||
| Ensure the absence of acute organ damage through comprehensive physical examinations and necessary 1 laboratory tests. Assess for conditions such as ischemic and hemorrhagic stroke, acute HF, acute coronary 1 syndromes, acute aortic syndromes, and acute renal failure. | I | B |
| Hypertensive emergencies | ||
| It is critical to reduce BP immediately to prevent further organ damage. | I | A |
| Intravenous agents are preferred for initial management due to their rapid onset of action and ease of titration. The choice of agent may vary based on the type of organ damage present. | I | A |
| Continuous monitoring of BP and reassessment of organ function and damage is crucial to guide ongoing 1 management and adjust treatment as necessary during the initial treatment phase. | I | C |
| PSH | ||
| Identify triggers for accelerated BP increases, such as stress, anxiety, drug-induced hypertension, severe pain, withdrawal from antihypertensive medications, untreated hypertension, or severe white coat hyper-1 tension. | I | B |
| For individuals experiencing stress or anxiety, rest, breathing training, and anxiolytic medications can help alleviate symptoms and may assist in lowering BP. | IIb | B |
| For patients with moderate to severe pain, administer appropriate pain relief medication to improve symptoms and potentially aid in lowering BP. | IIa | B |
| Physicians should aim to lower BP gradually within 24–48 h instead of rapidly reducing BP to normal levels. | I | B |
| Upon discharge, ensure patients have been prescribed home medications. | I | B |
| For untreated hypertension, initiate antihypertensive therapy as per general treatment guidelines. | I | A |
| Schedule follow-up visits within 2–4 weeks for clinical evaluation and antihypertensive dose adjustments 1 to achieve target BP goals. | I | C |
| Patients discharged from the emergency department with PSH should be advised to subsequently monitor office or out-of-office BP measurements. | IIa | C |
Recommendations for management of masked hypertension
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Individuals with BP at risk should have out-of-office BP measurement by ABPM and/or HBPM, to identify masked hypertension | I | B |
| In patients with confirmed masked hypertension, stringent lifestyle interventions and close follow-up to timely identify sustained hypertension, and to detect new HMOD are recommended. | I | C |
| Antihypertensive drug therapy for individuals with confirmed masked hypertension can be considered if CV risk is high and/or having HMOD. | IIa | C |
Recommendations for lifestyle modifications to control and prevent hypertension
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Weight reduction in over-weight or obese individuals | I | A |
| Adopting a healthy eating pattern as a routine | I | A |
| Dietary sodium restriction | I | A |
| Regularly increasing physical activity and/or engaging in aerobic exercise | I | A |
| Smoking cessation and avoiding passive smoking | I | A |
| Limiting the quantity of alcoholic beverages | I | A |
| Avoid noise pollution and air pollution | IIa | C |
| Stress management | IIa | C |
Antihypertensive agents used for emergent BP control during pregnancy
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
Hydralazine 5 mg IV or IM bolus, then
| I | B |
Nifedipine 10–20 mg orally, repeat in 20 min if needed, then
| I | B |
Labetalol 10–20 mg IV bolus, then
| I | B |
Recommendations for hypertensive patients with OSA
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| OSA should be suspected in patients who have daytime sleepiness, loud snoring, choking, or interruptions in breathing while sleeping, especially in obese patients. | I | A |
| Polysomnography should be performed in patients who are suspected of OSA. | I | A |
| Primary aldosteronism can be screened in OSA patients. | IIa | B |
| Mineralocorticoid receptor antagonists, ACEis or ARBs should be used to lower BP in hypertensive patients with OSA. | I | A |
| CPAP can be considered in OSA patients with hypertension. | IIa | B |
Recommendations for reducing risk in hypertensive patients
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Patients should receive a risk assessment using Thai CV risk score. | I | C |
| Patients with ≥3 risk factors† should receive statin. | I | A |
| Patients who smoke should be advised or prescribed medication to quit smoking. | I | A |
| Patients with a calculated Thai CV risk score ≥10% (using blood results) can be considered to receive statin. | IIa | C |
| Hypertensive patients should avoid exposure to pollution, e.g., PM2.5•. | IIa | C |
| Aspirin should not be routinely used as primary prevention for every hypertensive patient. | III | A |
Recommendations for target BP in hypertensive patients with HF
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| In hypertensive patients at risk for HF, the recommended target BP is <130/80 mmHg | I | A |
| In patients with HFrEF and hypertension, the recommended target SBP is <130 mmHg | I | C |
| In patients with HFpEF and hypertension, the recommended target SBP is <130 mmHg | I | C |
| In stage D HF, GDMT should be maximized to improve hemodynamics, if not contraindicated and well tolerated | I | C |
Recommendations for patients with CKD, renovascular disease, and kidney transplantation
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| BP should be monitored at all stages of CKD, because hypertension is the most important risk factor for ESKD. | I | A |
| Immediate lifestyle interventions and antihypertensive drug treatment should be done in most patients with CKD, regardless of the CKD stage, if BP is ≥140/90 mmHg. | I | A |
| For CKD patients, especially those with albuminuria and high CV risk, the office target BP could be 120–130/70–79 mmHg. | IIa | A |
| CKD patients with an albumin-to-creatinine ratio ≥30 mg/g creatinine should be prescribed an ACEi or an ARB as the first-line medication. | I | A |
| CKD patients with albuminuria <30 mg/g creatinine should be prescribed all major antihypertensive drug classes, including an ACEi, an ARB, a beta-blocker, a CCB, and a thiazide/thiazide-like diuretic. | I | B |
| The combination of ACEi and ARB should not be prescribed for BP control. | III | B |
| The same office BP targets as in the hypertensive CKD population apply also to patients with renovascular disease. | IIa | B |
| ACEis or ARBs may be considered for the treatment of hypertension associated with renovascular disease if well-tolerated and under close monitoring. | IIb | B |
| The office BP may be lowered to <130/80 mmHg in kidney transplant patients. | IIb | B |
| ACEi/ARB or DHP-CCB should be used as the first-line antihypertensive agent in adult kidney transplant patients. | I | A |
Recommendations for management of IDH
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Lifestyle modification is recommended for all patients with IDH. | I | C |
| Recommendations for pharmacological interventions in general hypertensive patients should be applied to patients with IDH. | I | C |
Recommendations for management of hypertension in the elderly and ISH
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| 60–79 years old individuals | ||
| The office threshold for drug treatment is ≥140/90 mmHg. | I | A |
| The primary target BP is SBP 130–140 mmHg and DBP 70–79 mmHg. | I | A |
| The secondary target BP is SBP 120–129 mmHg and DBP 70–79 mmHg if well tolerated to treatment. | I | B |
| Individuals ≥80 years old | ||
| The frailty/functionality assessment should be done before initiation of treatment and repeated annually for monitoring. | I | C |
| The office SBP threshold for initiation of drug treatment is 160 mmHg | I | A |
| A lower SBP threshold in the 140–159 mmHg range may be considered in some selected persons. | IIb | C |
| The target office SBP 140–150 mmHg and DBP <80 mmHg is recommended. | I | A |
| The optional target SBP 130–139 mmHg may be considered if well tolerated and DBP is not too low. | IIb | B |
| In older persons, treatment should start with lower doses and titrate up slowly. | I | C |
| The search for orthostatic hypotension should be done systematically. | I | C |
| Do not aim to target office SBP <120 mmHg or DBP <70 mmHg. | III | C |
| Medication reduction or discontinuation can be considered in very elderly persons with a low SBP <120 mmHg or severe orthostatic hypotension or a high frailty level. | IIa | C |
| The treatment should be individualized in persons with moderate to severe level of frailty/functionality and/or dementia. | I | C |
| ISH in the elderly persons | ||
| Due to SBP variability, repeatedly averaged office BP and HBPM may help in the diagnosis of ISH. | I | C |
| The primary target office SBP is 140–150 mmHg. | I | A |
| A reduction of office SBP target to 130–139 mmHg may be considered if well tolerated, and DBP is not too low. | IIb | B |
| CCBs and thiazide/thiazide-like diuretics are the drugs of choice. However, all other major drug classes can be used for compelling indications and combination therapy. | I | A |
| Initiation of 2-drug combination therapy is recommended in most ISH in elderly persons who are not frail. | I | C |
Recommendations for additional investigations on patients with hypertension
| Recommendations | Strength of recommendation | Quality of evidence |
|---|---|---|
| Heart investigations | ||
| 12-lead electrocardiography should be done in every patient with hypertension. | I | B |
| Transthoracic echocardiography should be done in patients whose ECG is abnormal or in cases with suspected heart disease. | I | B |
| Transthoracic Echocardiography may be considered in patients suspected of having left ventricular hypertrophy. | IIb | B |
| Vascular investigations | ||
| Carotid artery ultrasound may be considered in patients with carotid bruit, those with cerebrovascular disease, or patients with artery diseases in other parts of the body. | IIb | B |
| Coronary calcium scan may be considered in patients with intermediate CV risk. | IIb | C |
| Abdominal aorta ultrasound should be performed in suspected aortic aneurysm. | I | C |
| PWV may be considered. | IIb | B |
| ABI may be considered. | IIb | B |
| Kidney investigations | ||
| Serum creatinine and eGFR should be tested in every patient with hypertension. | I | B |
| Measurement of urine albumin should be done in every patient with hypertension. | I | B |
| Urine microalbumin should be tested in every patient with hypertension and DM. | I | A |
| Kidney ultrasound and Doppler can be done in patients with CKD, with albuminuria or suspected of secondary hypertension from renal artery stenosis. | IIa | C |
| Eyes investigations | ||
| Retinal examination should be performed in every patients with very high BP (grade 3 HT) or patients with DM. | I | C |
| Brain Investigations | ||
| CT scan or MRI of the brain can be done for patients with neurological symptoms or cognitive disorders. | IIa | B |
Recommendations for hypertensive patients with PAD
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| In patients with PAD, maintaining BP within the normal range (SBP 120–129 mm Hg) is part of a general strategy for reducing CV risk and may reduce the risk of PAD-related adverse outcomes. | I | B |
| All major BP-lowering medications, such as diuretics, CCBs, RAS blockers, and beta-blockers are equally recommended. | I | B |
| For patients with both PAD and hypertension, lifestyle changes especially smoking cessation, and addressing atherosclerotic risk factors are recommended. | I | C |
BP treatment threshold and use of risk estimation to guide pharmacological treatment of hypertension
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Use of antihypertensive medication(s) is recommended in patients with clinical CVD, patients with DM, individuals with an estimated 10-year | I | A for SBP |
| CVD risk of 10% or higher, and an average office SBP of 130 mmHg or higher and/or an average office DBP of 80 mmHg or higher | C for DBP | |
| Use of antihypertensive medication(s) is recommended in adults with office SBP of 140 mmHg or higher and/or office DBP of 90 mmHg or higher | I | C |
Suggestions for appropriate timing of antihypertensive drug administration
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Patients can choose as to when to take their antihypertensive medication, in the morning or before bedtime. | I | C |
| Physicians may advise bedtime dosing in patients with documented high nocturnal BP | IIb | C |
| In general, THS recommend taking antihypertensive medication in the morning, as adherence to medication is better than at nighttime. | I | C |
Recommendations for hypertensive patients with diabetes
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Individuals with diabetes found to have office BP ≥130/80 mmHg should have BP confirmed on a different visit, to diagnose hypertension. | I | A |
| Hypertension is defined as an office SBP ≥130 mmHg and/or an office DBP ≥80 mmHg based on an average of at least two measurements on at least two occasions. | I | A |
| Individuals with office SBP ≥180 mmHg and/or DBP ≥110 mmHg, with repeat measurement, should be diagnosed with hypertension at a single visit. | I | B |
| Individuals with diabetes and hypertension should have HBPM. | I | A |
| Office BP targets for individuals with diabetes and hypertension should be ≤130/80 mmHg. | I | B |
| For individuals with BP 130–139/80–89 mmHg, lifestyle intervention such as body weight reduction in overweight or obese individuals, reducing sodium intake, moderation of alcohol intake, and increased physical activity is indicated. | I | A |
| Pharmacological intervention is indicated for individuals with office BP ≥140/90 mmHg or those who have persistently elevated office BP ≥130/80 mmHg despite lifestyle intervention for at least 3 months. | I | A |
| Individuals with confirmed office BP ≥150/90 mmHg should have prompt initiation of 2 drugs or a SPC of 2 antihypertensive drugs. | I | A |
| All first-line classes of antihypertensive agents should be selected to treat hypertension in diabetes. | I | A |
| In individuals with diabetes and hypertension, ACEis or ARBs are recommended for patients with albuminuria (UACR ≥30 mg/g creatinine). | I | A |
| Combination of ACEis and ARBs is not recommended. | III | A |
| SGLT2is or GLP1-RAs are recommended for diabetes individuals with ASCVD and hypertension. | I | A |
| SGLT2is are recommended for individuals with HF or CKD (eGFR <60 mL/min/1.73 m2 or presence of albuminuria) and hypertension. | I | A |
| GLP1-RAs can be prescribed for individuals with diabetes and HF or CKD and hypertension. | IIa | A |
Recommendations for BP management in patients with stroke
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| BP management in patients with acute ischemic stroke | ||
| In patients with BP >185/110 mmHg, urgent BP reduction should be initiated before starting intravenous thrombolysis. | I | B |
| In patients with BP >185/110 mmHg, urgent BP reduction can be initiated before mechanical thrombectomy. | IIa | B |
| Maintaining BP below 180/105 mmHg in the first 24 h after treatment (thrombolysis or mechanical thrombectomy) is recommended. | I | C |
| It is not recommended to use short-acting nifedipine due to the risk of causing excessive BP reduction, especially in the setting of acute ischemic stroke. | III | C |
| Patients who are not candidates for intravenous thrombolysis or mechanical thrombectomy | ||
| If BP remains >220/120 mmHg, treatment can be initiated to control SBP to be <220 mmHg and DBP <120 mmHg. | IIa | C |
| BP in patients with acute sICH | ||
| SBP >180 mmHg can be reduced by administering antihypertensive medication intravenously. | IIa | B |
| In patients with sICH with mild to moderate severity, acute lowering of SBP to the target of 140 mmHg is safe and may be considered. | IIb | B |
| BP control after acute phase of stroke | ||
| Patients previously treated for hypertension before the onset of stroke. In this group, resumption 1 of oral antihypertensive medications is recommended. | I | A |
| Patients were previously treated for hypertension before the onset of stroke. The resumption of oral antihypertensive medications should be initiated before the patient is discharged from the hospital. | IIa | B |
| Patients who have not been treated for hypertension before the onset of stroke. Oral antihypertensive medications are recommended when BP is >140/90 mmHg | IIa | B |
| BP control for secondary stroke prevention | ||
| After ischemic stroke, oral antihypertensive medication may be administered when BP exceeds 140/90 mmHg, with a target BP range of 120–130/70–80 mmHg. | IIb | B |
| Patients with intracranial artery stenosis may experience transient ischemic attacks or ischemic strokes associated with a decrease in BP. Lowering BP in this patient group requires special caution, and the appropriate target BP level should be carefully considered on an individual basis | IIb | C |
| In patients with sICH, it is reasonable to lower BP to 130/80 mmHg for long-term management to prevent recurrence. | IIa | B |
| It is important to choose an antihypertensive medication that can effectively reach the target BP, 1 as the extent of BP reduction is more significant than the specific type of medication. | I | A |
Recommendations for antihypertensive drug treatment
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Medications to start treatment of hypertension should be selected from 5 major drug classes, which include ACEis, ARBs, beta-blockers, CCBs, and diuretics (thiazides and thiazide-like diuretics). These drugs and their combinations are recommended as the basis of antihypertensive treatment. | I | A |
| A two-drug combination should be started for most patients. Preferred combinations are RAS blockers (ACEI or ARB) with a CCB or thiazide/thiazide-like diuretic. Other combinations of the 5 major drug classes can also be used as appropriate. | I | A |
Initiation with 1 drug should be considered in patients with:
| I | C |
| If BP cannot be controlled with the initial 2-drug combination using the best tolerated dose of the respective components, treatment should be increased to a 3-drug combination, usually a RAS blocker + CCB + thiazide/thiazide-like diuretic. However, 1 of the 3 components should be a diuretic and preferably a thiazide-like diuretic. | I | A |
| If BP cannot be controlled with a 3-drug combination by using the maximum recommended and/or tolerated dose of the respective components, which 1 component should be a diuretic, it is recommended to treat the patient as resistant hypertension. | I | A |
| The use of medication that is a combination of 2–3 different drug classes in a single pill should be preferred at any treatment step. | I | A |
| The combination of 2 RAS blockers is not recommended, due to increased risk of adverse events, especially AKI, hyperkalemia. | III | A |
| ARNI may be an appropriate choice, instead of a RAS blocker, in patients with resistant hypertension. | IIb | B |
| Selective SGLT2is or GLP1-RAs can be used as an ancillary treatment in hypertensive patients with comorbidities that indicate their use. | IIa | A |
| SGLT2is and/or GLP1-RAs are not recommended solely for the purpose of BP reduction | III | C |
Recommendations for pharmacological treatment of hypertension in HFpEF
| Recommendations | Strength of recommendations | Quality of evidence |
|---|---|---|
| Treatment of hypertension is recommended in patients with HFpEF | I | A |
| Substitution of a RAS-blocker by an ARNI can be considered, particularly in those with apparent resistant hypertension | IIb | B |
| Treatment with spironolactone can be considered regardless of diagnosed resistant hypertension, particularly in patients with low LVEF on the lower end of the spectrum | IIb | B |