Following the announcement of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)[1] results at the end of 2002, the US hypertension guidelines were completely revised and reissued as the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and the Treatment of High Blood Pressure (JNC 7)[2] in the Spring of 2003. This was soon followed by guideline updates jointly issued from the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC).[3] The wave of updates continued at the 2004 meeting of International Society of Hypertension (ISH), in Sao Paulo, Brazil, where there was discussion of the recently updated World Health Organization (WHO)/ISH guidelines for the management of hypertension.
Ascertainment of overall cardiovascular risk to establish thresholds of and goals for treatment.
Treatment strategies
Cost-effectiveness
The 1999 guidelines remain current in other areas. Unlike the current US hypertension guidelines (JNC 7) and European guidelines, the WHO/ISH guidelines are aimed at a global audience and are intended to serve as a template for the development of national, regional, and local guidelines. However, they resemble the European guidelines more closely than they do JNC 7.
The WHO/ISH blood pressure classification includes 3 grades of hypertension (Table 1).
Blood Pressure Grade 1 Grade 2 Grade 3
SBP (mm Hg) 140-159 160-179 ≥ 180
DBP (mm Hg) 90-99 100-109 ≥ 110
DBP, diastolic blood pressure; SBP, systolic blood pressure
Unlike JNC 7, in the WHO/ISH statement, there is no “prehypertension” classification. According to WHO/ISH Writing Group member Judith A Whitworth, DSc, MD, PhD (The Australian National University, Canberra, ACT, Australia), who presented the guidelines in São Paulo, the guideline authors were concerned about the implications of such a label.
In the new set of WHO/ISH guidelines, factors influencing prognosis have not changed in essence from the 1999 guidelines, ie:
Levels of SBP and DBP (grades 1-3)
Males aged > 55 years
Females ages > 65 years
Smoking
Total cholesterol > 61 mmol/L (240 mg/dL) or LDL-cholesterol > 4.0 mmol/L (160 mg/dL)
HDL-cholesterol < 1.0 mmol/L (< 40 mg/dL) in men, < 1.2 mmol/L (< 45 mg/dL) in women
History of cardiovascular disease in first-degree relatives before age 50 years
Obesity, physical inactivity
Target organ damage (left ventricular hypertrophy, microalbuminuria [20-300 mg/day], radiologic or ultrasound evidence of extensive atherosclerotic plaque, hypertensive renopathy grade III or IV)
Associated clinical conditions (diabetes, cardiovascular disease, heart disease, renal disease, peripheral vascular disease)