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Guideline for the pharmacological treatment of hypertension in adults [Internet]. Geneva: World Health Organization; 2021.

Cover of Guideline for the pharmacological treatment of hypertension in adults

Guideline for the pharmacological treatment of hypertension in adults [Internet].

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Executive summary

More people die each year from cardiovascular diseases than from any other cause. Over three quarters of heart disease and stroke-related deaths occur in low-income and middle-income countries. Hypertension – or elevated blood pressure – is a serious medical condition that significantly increases the risk of heart, brain, kidney and other diseases. Hypertension can be defined using specific systolic and diastolic blood pressure levels or reported use of antihypertensive medications. An estimated 1.4 billion people worldwide have high blood pressure, but just 14% have it under control. However, cost-effective treatment options do exist.

In this guideline, the World Health Organization (WHO) provides the most current and relevant evidence-based global public health guidance on the initiation of treatment with pharmacological agents for hypertension in adults. The recommendations target adult, non-pregnant patients who were appropriately diagnosed with hypertension and counselled about life-style modifications.

The guideline provides new recommendations on the threshold for the initiation of pharmacological treatment for hypertension, as well as recommendations on intervals for follow up, target blood pressure to be achieved for control, and the cadre of health care workers who may initiate treatment. The guideline provides the basis for deciding whether to initiate treatment with monotherapy, dual therapy or single-pill combinations, as well as guidance for countries selecting medicines and algorithms for hypertension control for their national guidelines for hypertension management.

The guideline was developed in accordance with the WHO Handbook for Guideline Development. In brief, the WHO Steering Group, in collaboration with the Guideline Development Group, developed key questions and rated outcomes to identify those critical for the development of the guideline. Conflicts of interest were handled in line with the current Compliance, Risk Management and Ethics (CRE) policy and all members of the GDG were asked to fill in the standard WHO Declaration of Interest (DOI) forms, which were reviewed. An overview of systematic reviews of the evidence was used to build summary of findings tables according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The Guideline Development Group developed recommendations, considering the certainty of the evidence; the balance between desirable and undesirable effects; resource requirements and cost-effectiveness; health equity; acceptability, patient values and preferences, and feasibility.

Recommendations

1. RECOMMENDATION ON 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 and systolic blood pressure of 130–139 mmHg.
Strong recommendation, moderate- to high-certainty evidence
WHO suggests pharmacological antihypertensive treatment of individuals without cardiovascular disease but with high cardiovascular risk, diabetes mellitus, or chronic kidney disease, and systolic blood pressure of 130–139 mmHg.
Conditional recommendation, moderate- to high-certainty evidence
2. RECOMMENDATION ON LABORATORY TESTING
When starting pharmacological therapy for hypertension, WHO suggests obtaining tests to screen for comorbidities and secondary hypertension, but only when testing does not delay or impede starting treatment.
Conditional recommendation, low-certainty evidence
3. RECOMMENDATION ON CARDIOVASCULAR DISEASE RISK ASSESSMENT
WHO suggests cardiovascular disease 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
4. RECOMMENDATION ON 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:
  1. thiazide and thiazide-like agents
  2. angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs)
  3. long-acting dihydropyridine calcium channel blockers (CCBs).
Strong recommendation, high-certainty evidence
5. RECOMMENDATION ON 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), angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs), and long-acting dihydropyridine calcium channel blockers (CCBs).
Conditional recommendation, moderate-certainty evidence
6. RECOMMENDATIONS ON 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 cardiovascular disease (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
7. RECOMMENDATIONS ON FREQUENCY OF ASSESSMENT
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
8. RECOMMENDATION ON 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
© World Health Organization 2021.

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Bookshelf ID: NBK573629
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