Comparison between the world health organization (WHO) and international society of hypertension (ISH) guidelines for hypertension

Figures & data

Table 1. Fundamental differences in treatment and diagnostic methods.

Differences in the guidelines
Parameters	World Health Organisation (WHO)			International Society for Hypertension (ISH)
Office blood pressure (BP) defined as hypertensive	Systolic (mmHg)	and/or	Diastolic (mmHg)	Systolic (mmHg)	and/or	Diastolic (mmHg)
	Not mentioned			≥140		≥90
BP threshold for pharmacological treatment (General population)	Confirmed diagnosis of hypertension			Grade 2 hypertension*
	≥140		≥90	≥160		≥100
BP threshold for pharmacological treatment (High-risk population)**	130–139		any	Grade 1 hypertension*
				140–159		90–99
Comorbidity and secondary HT screening	Blood test, urine dipstick, and ECG are recommended if initiation of any pharmacological therapy is not postponed (especially in low-resource area)			CV medical and family history, CV physical examination, blood and urine tests, 12-lead ECG, and various imaging and functional tests
CV risk assessment	Only for patients with high-normal blood pressure (SBP 130–139)			Every hypertensive patient
Therapy follow-up	Monthly follow-up after initiation until controlled, followed by once every 3–6 months			Not mentioned
Similarities between the guidelines
	Recommends single-pill combination as initial therapy
	Does not address specific non-pharmacological interventions, but considers them as a part of a comprehensive treatment			Emphasizes and provides a specific target for each modifiable risk factor

BP: blood pressure; CV: Cardiovascular; ECG: electrocardiogram; ISH: International Society for Hypertension; HT: hypertension; SBP: systolic blood pressure; WHO: World Health Organisation.

*Based on the ISH grading of blood pressure.

**High-risk population as defined by the ISH (cardiovascular diseases, diabetes mellitus, chronic kidney disease, etc.).

Table 2. Comparison of the pharmacological approaches between WHO and ISH guidelines.

Differences
Characteristics	World Health Organisation (WHO)	International Society for Hypertension (ISH)
Single-pill combination therapy composition	Combination of ACEi/ARB or DHP-CCB or Thiazide/Thiazide-like diuretics	ACEi/ARB + DHP-CCB
Monotherapy consideration	Not mentioned	Low-risk grade 1 hypertension or in very old (≥80 years) patients
Resistant hypertension treatment strategy*	Refer to specialist	Adds spironolactone (12.5–50 mg once a day) or amiloride, doxazosin, clonidine, beta-blockers, etc. if spironolactone is contraindicated/unavailable
Similarities
	Considers beta-blockers in ischaemic heart disease or post myocardial infarction	Considers beta-blockers at any treatment step if specific indications are present, e.g. heart failure, ischaemic heart disease, atrial fibrillation
	Considers CCB in heart failure, chronic kidney disease, and diabetes mellitus
	Recommends triple-drug combinations when target BP is not achieved, despite having consumed dual drugs at maximum dose
	Suggests utilisation of CCB in black patients

ACEi: angiotensin-converting enzyme inhibitor; ARB: angiotensin II receptor blocker; BP: blood pressure; CCB: calcium channel blocker; DHP-CCB: dihydropyridine calcium channel blocker; ISH: International Society for Hypertension; WHO: World Health Organisation.

*seated office BP >140/90 mmHg in patients treated with ≥3 antihypertensives at optimal doses after excluding pseudoresistance.

Table 3. Comparison between the WHO and ISH guidelines.

World Health Organisation (WHO)	International Society for Hypertension (ISH)
Similarities
LMIC-oriented recommendations	Includes recommendations for LMICs and HICs
Provides detailed evidence and rationale for each recommendation along with evidence-to-decision considerations	Presents a short paragraph containing evidence and rationale before each recommendation
Differences
Breaks down recommendations into four levels of certainty (very low, low, moderate, and high)	Splits recommendation standards as “essential” and “optimal” based on current standards of care
Determines blood pressure targets based on known cardiovascular disease and patient’s risk	Determines blood pressure target based on patient’s age
Suggests nonphysician professionals to provide pharmacological therapy under some requirements	Discusses specific phenomena more commonly encountered in HICs such as white coat hypertension and masked hypertension
Discusses hypertension management in disasters and humanitarian crises	Pays more attention to ethnic and racial differences
Includes a section for hypertension in the context of Coronavirus disease

LMICs: low- and middle-income countries; HICs: high-income countries; ISH: International Society for Hypertension; WHO: World Health Organisation.

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article, reference number 1 and 2.