Hypertension: Highlights from the 2020 ISH guidelines

Dr Giuseppe Mancia, past president of the International Society of Hypertension and the European Society of Hypertension and author of over 1000 papers in peer-reviewed journals, offers a brief review of the new guidelines from the International Society of Hypertension.

Roman Jaeschke, MD, MSc: The International Society of Hypertension (ISH) recently published clinical practice guidelines, which I found very interesting. You provided an editorial to these guidelines. Could you share your thoughts about it with us?

Giuseppe Mancia, MD, PhD: Yes, we published the guidelines in the Journal of Hypertension. They were also simultaneously published in Hypertension and I wrote an editorial with Professor Anna Dominiczak, the editor in chief of Hypertension.

I like these guidelines very much. First of all, they were meant to be written in a plain and simple style, which was achieved. I think it’s a very pleasant and easy reading. This is important, because too much detail and too much complexity doesn’t help the implementation of guidelines.

I think the guidelines corrected an error of the European guidelines, I am sorry to say this. The European guidelines recommended to use a combination treatment with 2 drugs as a first-step treatment in most patients, and there were very good reasons for this. Then, they recommended to go to a triple therapy if blood pressure control was not achieved. What was missed was that if blood pressure is not controlled by giving 2 drugs, as an intermediate step we should still go for a 2-drug treatment, but increase the dose of either both drugs or just 1 of the 2-drug combination components. This of course was taken into account by the ISH guidelines.

What I also like very much in these guidelines is that this is the first time guidelines include in the lifestyle changes maneuvers that reduce stress. These ways of reducing blood pressure had never been considered in guidelines before because there is no chance to do studies with a placebo group, so they were considered second-rate research. But in fact this is quite important in clinical practice, and physicians and patients always ask to do something about this important factor, which certainly is involved in blood pressure elevation. The ISH guidelines did not forget it this time.

The third point I like is they paid a lot of attention to adherence. We know that it’s very difficult to measure adherence, but this is not a justification for forgetting, because it is an extremely important factor in guaranteeing protection by treatment. If patients do not take drugs, drugs do nothing.

The ISH guidelines devote quite a large space to tell patients and, primarily, doctors that although it is difficult to guess adherence in an individual patient, if you are careful in your questioning and if you pay attention to a number of details, including what the patient’s relatives say, you may have a pretty good idea of whether the patient will be adherent or not. And this makes a big difference in terms of blood pressure control and cardiovascular protection.

Finally, you alluded to the question of target blood pressure. It is true that the ISH guidelines take a conservative position on the issue, because rather than going to more demanding, SPRINT-like targets of <130/80 mm Hg or even <120/70 mm Hg, they stick with the old targets of going to <140/90 mm Hg. The European guidelines are somewhere in between: <140/90 mm Hg in the elderly and <130/80 mm Hg in younger people. I think the position of the ISH guidelines is very reasonable, because most of the benefit of antihypertensive treatment is achieved by going <140/90 mm Hg or <140/80 mm Hg. Below that the relationship between events and blood pressure values flattens. A lot of work and many difficulties for a limited benefit, in a way.

Also, what is probably wise is not to pay too much attention to what should be the value to reach but just try to go below a certain value, because this makes the task of the physician easier. And this is not a minor issue for guidelines.

Roman Jaeschke: I am very pleased with your summary of those guidelines. It’s true they read much easier than a lot of others, and listening to you and following your advice is probably even easier. They clearly are more practical and more achievable, and maybe the issue would be compliance of not only patients with medications but also of physicians with practice guidelines. Thank you for writing the editorial and publishing it in your journal.

I truly hope—as you presented current views on hypertension during the 5th McMaster International Review Course in Internal Medicine in Kraków—that we will be able to see you there next year as well.

Thank you very much, Professor Mancia.

Giuseppe Mancia: Thank you.