Helping patients stress out less: Updated practice guidelines for dealing with hypertension

Nearly half of adults in the U.S. have hypertension…and that was even before the current pandemic and its effects on our physical, emotional and financial health! Looking globally, high blood pressure remains the leading cause of mortality, accounting for 10.4 million deaths each year.

To provide you with the latest resources, the International Society of Hypertension (ISH) has released updated hypertension guidelines. These can be a valuable support tool as you create care plans and manage the health of your patients with hypertension. While we’ve embedded the link to the full guidelines, the following blog is meant to provide highlights of these evidence-based recommendations, both involving pharmacology and lifestyle changes.

Pharmacological treatment

ISH notes that a difference in BP of 20/10 mmHg is associated with a 50% difference in cardiovascular risk. This of course is why it’s so important to suggest adding medication if lifestyle changes aren’t working to achieve the target BP for most people of <140/90 mmHg. (That stat differing slightly from the American College of Cardiology and American Heart Association’s joint hypertension clinical practice guideline from 2017 of 130/80 mmHg.)

ISH core drug-treatment strategy is detailed in the chart at right.

Ideal characteristics of drug treatment include:

  • Evidence-based treatments in relation to morbidity/mortality prevention
  • A once-daily regimen that provides 24-hour BP control
  • Treatment that’s affordable and/or cost-effective relative to other agents
  • Treatment that’s well-tolerated
  • Evidence of benefits of use of the medication in populations to which it’s to be applied

Lifestyle modifications

While lifestyle changes should, of course, be the first line of antihypertensive treatment (healthy diet, salt reduction, smoking cessation, etc.), we know that controlling patient adherence is often extremely difficult. So most often, you and your team will be prescribing one or more medications in addition to suggesting lifestyle modifications.

How to encourage antihypertensive therapy adherence

Since patient non-adherence is such a huge barrier to improving health, that’s why RxLive clinical pharmacists use motivational interviewing in our medication-management consults…to get to the why behind the patient’s nonadherence. Here are some recommendations we use to help you help your patients improve adherence to antihypertensive therapy:

  • Reducing polypharmacy — Encouraging cost-effective use of single-pill combinations to simplify medication regimes
  • Once-daily dosing vs. multiple times per day dosing
  • Linking adherence behavior with daily habits
  • Providing adherence feedback to patients
  • Home BP monitoring
  • Reminder packaging of medications
  • Empowerment-based counseling for self-management
  • Electronic adherence aids such as mobile phones or short messages services

Common and other comorbidities, complications of hypertension

Hypertensive patients have several common and other comorbidities that can affect cardiovascular risk and treatment strategies. Following are some of the most-common comorbidities and complications:

Coronary artery disease (CAD)

  • RAS blockers, beta-blockers irrespective of BP levels with or without calcium channel blockers are first-line drugs in hypertensive patients
  • Lipid-lowering treatment with an LDL-C target <55 mg/dL
  • Antiplatelet treatment with aspirin is routinely recommended

Previous stroke

  • RAS blockers, CCBs, and diuretics are first-line drugs
  • Lipid-lowering treatment is mandatory with a LDL-C target <70 mg/dL (1.8 mmol/L) in ischemic stroke
  • Antiplatelet treatment is routinely recommended for ischemic stroke, but not hemorrhagic stroke, and should be carefully considered in patients with hemorrhagic stroke only in the presence of a strong indication

Heart failure

  • RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists are all effective in improving clinical outcome in patients with established HFrEF; for diuretics, evidence is limited to symptomatic improvement. CCBs are indicated in case of poor BP control.
  • Angiotensin receptor-neprilysin inhibitor (ARNI; sacubitril-valsartan) is indicated for the treatment of HFrEF as an alternative to ACE inhibitors or ARBs also in hypertensive populations. The same treatment strategy can be applied to patients with HFpEF, even if the optimal treatment strategy is not known.

Chronic kidney disease (CKD)

  • RAS-inhibitors are first-line drugs because they reduce albuminuria in addition to BP control. CCBs and diuretics (loop-diuretics if eGFR <30 ml/min/1.73m2) can be added
  • eGFR, microalbuminuria and blood electrolytes should be monitored


  • The treatment strategy should include an RAS inhibitor (and a CCB and/or thiazide-like diuretic)
  • The treatment should include a statin in primary prevention if LDL-C >70 mg/dL (1.8 mmol/L) (diabetes with target organ damage) or >100 mg/dL (2.6 mmol/L) (uncomplicated diabetes)
  • The treatment should include glucose and lipid lowering as per current guidelines

Lipid disorders

  • BP should be lowered as done in the general population, preferentially with RAS-inhibitors (ARB, ACE-I) and CCBs
  • Statins are the lipid-lowering treatment of choice with or without ezetimibe and/or PCSK9 inhibitor (in the optimal setting)
  • Serum triglyceride lowering should be considered if >200 mg/dL (2.3 mmol/L), particularly in patients with hypertension and DM. Possible additional benefits using fenofibrate in low HDL/high triglyceride subgroup.

Awareness, guidance key to reducing impact

Hypertension is a condition that can be controlled with a combination of awareness and treatment. Due to its wide-reaching impact on good health due to the comorbidities that too often come with it, it’s an important conversation to have. And with the likelihood of the need for medication, it’s one where pharmacists on your care team can have an impact; we’re committed to reinforcing your guidance to date and perhaps being able to provide additional insights regarding the latest pharmacological research and treatment options.


ISH 2020 updated hypertension guidelines

Observing World Hypertension Day (“Measure Your Blood Pressure, Control It, Live Longer,” World Hypertension League, Oct. 17)

AHA High Blood Pressure Toolkit

Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.