The International Society of

Hypertension Guidelines

Directed by:
Rahmat Azimi (C014212141)

Supervisor :

dr. Aussie Fitriani Ghaznawie,Sp.JP (K) , FIHA

JOURNAL
 ABSTRAC
T
• Evaluation and Treatment of High Blood Pressure (JNC) began issuing
hypertension guidelines in 1977 and updated them regularly until the task was
taken over in 2017 by the American College of Cardiology (ACC) and the American
Heart Association (AHA), in partnership with several other professional societies.
 OVERVIEW

• Since the various hypertension guidelines generally refer to the same clinical trials and
observational studies as their evidence base, they might be expected to make similar treatment
recommendations. However, there are differences between guidelines regarding important
issues, e.g. the choice of first line treatment. The recommended treatment algorithm by
International Society of Hypertension is shown for the special this one use four step. consider
monotherapy in low risk grade 1 hypertension or in very old or frailer patients.
 GUIDELINES

Recommended treatment algorithm by ISH

Step one dual low dose combination :
ACEi or ARB + CCB or CCB+
thiazid-like diuretic in black patients
Step two dual full dose combination :
ACEi or ARB + CCB
Step three triple combination :
ACEi or ARB + CCB + thiazide-like
diuretic
Step four triple combination +
spironolactone or other drug :
Resistant hypertension add
spironolactone (12.5-50 mg OD) or
other drug
ISH GUIDELINES AND ESC GUIDELINES
STEP EXPLAIN TREATMENT FROM ISH GUIDELINES
For step one and step two include angiotensin converting enzyme inhibitors or angiotensin receptor
blockers in low dose and full dose combination. The decision to move thiazide or thiazide-like diuretics
such as chlortalidone to step 3 was based in part on results of the avoiding Cardiovascular Events through
Combination therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial in which the
ACE inhibitors plus CCB combination was also the most effective combination in the Anglo-
Scandinavian Cardiac Outcomes Trial (ASCOT) when compared plus bndroflumethiazide combination.
 WHICH IS CONSIDER TO USE?
Consider monotherapy in low risk grade 1 hypertension ( systolic BP <150 mmHg) or in very old (≥ 80
years) or frailer patients. Consider a thiazide-like diuretic in post stroke, very old, incipient heart failure or
CCB-intolerant patients and decision to move thiazid or thiazide-like diuretics such as chlorthalidone or
indapamide to step three was based in part on results of the Avoiding Cardiovascular Events through
combination Therapy.

How about resistant hypertension ?

We can use triple combination and we should add spironolactone 12.5-50 mg OD ; because for the other
coution with spironolactone/ potassium sparing diuretics like amiloride when eGFR <45 mL/min/1.73 or
K+ >4.5 mmol/L

When use Beta-blockers ?

Consider beta-blocker at any treatment step, when there is a specific indication for their use, e.g. heart
failure, angina post MI , atrial fibrillation, or younger women with or planning pregnancy.
 EVIDENCE BASE MEDICATION
It is peculiar that in the ISH Guidelines only two outcome trials performed in the Nordic Countries,
United Kingdom and the United States, most important recommendation, choice of first treatment, of
hypertension patients throughout the world. Numerous outcoe trials in hypertension have shown the
benefit of thiazide or thiazide-type diuretics in preventing cardiovascular disease outcomes . All
placebo controlled trials of antihypertensive medications have shown active treatment prevented
cardiovascular disease including stroke, heart failure, myocardial infarction, left ventricular
hypertrophy and aortic aneurysm. Numerous recent outcome trials have compared antihypertensive
drugs of different classes head-to-head and have shown no inferiority when a diuretic was administered as
the first or second line drug .
The only outcome trial that has shown a difference between first line grugs for the primary endpoint is the
Losartan Intervention for endpoint prevention in hypertension study ( LIFE). LIFE showed that
losartan was superior to atenolol for the composite outcome of stroke, myocardial infarcyion and
cardiovascular death, but hydrochlorothiazide was given approximately 90% of study participants
to ensure blood pressure control. Amlodipine was equally effective as valsartan in the Valsartan Long-
term use for endpoint Evaluation study (VALUE), but hydroclorothizide was given as the number 2 drug
in both arms to ensure blood pressure control .
Many outcome trials of cardiovascular disease prevention in hypertension have included a diuretic
as a first or second step, clearly supporting the role of diuretics as a first line antihypertensive
treatment, as recommended in the 2017 American and European 2018 hypertensiom guidelines.
Importantly, several frequently occurring hypertension-related conditions including aging, obesity,
diabetes and renal function impairment are associated with salt sensitivity, which favours diuretics
treatment .Furthermore, Insufficient diuretics is one of the most frequent reasons of not achieving blood
pressure targets.Finally, there is now increasing evidence that all diuretics are not equal in terms of
efficacy and tolerability as well as clinical evidence.
PLOT FROM JNC 8 GUIDELINES
PLOT FROM JNC 7 GUIDELINES
JOINT NATIONAL COMMITTEE 8 REPORT: HOW IT DIFFER
FROM JNC 7
 CONCLUSION
• From the ISH hypertension guidelines diverge from the American and European
hypertension gudelines chice of initial drug treatment. We are concerned that
this could be a step in the wrong direction because a thiazide type diuretic, e.g.
chlorthalidone or indapamide, is a top of the list of evidence based first line
anthypertensive drugs for avoiding cardiovascular events.
• From JNC 7 guidelines Thiazide type diuretics should be used as initial therapy
for most patients with hypertension, either alone or in combination with one of
the other classes (ACEi,ARB,BBs,CCBs) demonstrated to be beeficial in
randomized controlled outcome trials for high coronary disease risk and heart
failure.
• From JNC 8 guidelines use to thiazide type diuretic alone or combination for
black and non black races.
 Referens
i
• Sverre E. Kjeldsen, et.al . 2020 . The International Society of Hypertension Guidelines 2020 – a new
drug treatment recommendation in the wrong direction? . Departement of Cardiology, University of
Oslo, Ullevaal Hospital, Oslo Norway . Doi : https://doi.org/10.1080/08037051.2020.1806494

• Rajiv Mahajan. 2014 . Joint National Committee 8 report: How it iffer from JNC 7 . Int J Apple Basic
Med Res. 2014 Jul-Dec; 4(2): 61-62 . Doi: https://10.4103/2229-516X.136773
THANK
YOU