The World Health Organization (WHO) has released new guidance on the pharmacological treatment of hypertension in adults.
Background Information:
Blood pressure is the force exerted by circulating blood against the walls of the body’s arteries, the major blood vessels in the body. Hypertension is when blood pressure is too high.
Blood pressure is written as two numbers. The first (systolic) number represents the pressure in blood vessels when the heart contracts or beats. The second (diastolic) number represents the pressure in the vessels when the heart rests between beats.
Hypertension is diagnosed if, when it is measured on two different days, the systolic blood pressure readings on both days is ≥140 mmHg and/or the diastolic blood pressure readings on both days is ≥90 mmHg.
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.
Key Messages:
An estimated 1.28 billion adults aged 30-79 years worldwide have hypertension, most (two-thirds) living in low- and middle-income countries.
An estimated 46% of adults with hypertension are unaware that they have the condition.
Less than half of adults (42%) with hypertension are diagnosed and treated.
Approximately 1 in 5 adults (21%) with hypertension have it under control.
Hypertension is a major cause of premature death worldwide.
One of the global targets for noncommunicable diseases is to reduce the prevalence of hypertension by 33% between 2010 and 2030.
Recommendations
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 mm Hg OR diastolic blood pressure of >= 90 mm Hg.
- with existing cardiovascular disease AND systolic blood pressure of 130-139 mm Hg
- without cardiovascular disease but with high cardiovascular risk, diabetes mellitus, or chronic kidney disease, AND systolic blood pressure of 130-139 mm Hg
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.
Recommendation on Cardiovascular disease risk assessment
WHO suggests cardiovascular disease risk assessment at or after the initiation of pharmacological treatment for hypertension, but only when this is feasible and does not delay treatment.
Recommendations 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:
- thiazide and thiazide-like agents
- angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs)
- long-acting dihydropyridine calcium channel blockers (CCBs)
Recommendations 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:
- thiazide and thiazide-like agents
- angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs)
- long-acting dihydropyridine calcium channel blockers (CCBs)
Recommendations on Target Blood Pressure
- WHO recommends a target blood pressure treatment goal of <140/90 mm Hg in all patients with hypertension without comorbidities.
- WHO recommends a target systolic blood pressure treatment goal of <130 mm Hg in patients with hypertension and known cardiovascular disease (CVD).
- WHO suggests a target systolic blood pressure treatment goal of <130 mm Hg in high-risk patients with hypertension (those with high CVD risk, diabetes mellitus, chronic kidney disease).
Recommendations on Frequency of assessment
WHO suggests a monthly follow up after initiation or a change in antihypertensive medications until patients reach target.
WHO suggests a follow up every 3-6 months for patients whose blood pressure is under control.
Recommendation on Treatment by non-physician professionals
WHO suggests that pharmacological treatment of hypertension can be provided by non-physician professionals such as pharmacists and nurses as long as the following conditions are met:
- proper training
- prescribing authority
- specific management protocols
- physician oversight
Useful Links:
Link to the related WHO news release:
https://www.who.int/news/item/25-08-2021-more-than-700-million-people-with-untreated-hypertension
Link to the WHO Guideline document:
https://apps.who.int/iris/bitstream/handle/10665/344424/9789240033986-eng.pdf
Link to the related article in The Lancet:
https://www.thelancet.com/journals/lancet/article/piiS0140-6736(21)01330-1/fulltext
Link to the updated WHO factsheet on hypertension:
https://www.who.int/news-room/fact-sheets/detail/hypertension
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