Comparison of international blood pressure guidelines

Guidelines on the choice of agents and how best to step up treatment for various subgroups in hypertension (high blood pressure) have changed over time and differ between countries.

A Comparison of International Guidelines on Goal Blood Pressure and Initial Therapy for Adults With Hypertension (adapted from JNC 8 guidelines^[1])

Guideline	Population	Goal blood pressure (mmHg)	Initial treatment options
ESC 2024[2]	General	120–129/70–79	BP >140/90: Two from different classes: preferably RAS-inhibitor (ACEI or ARB) with either thiazide diuretic/thiazide-like diuretic or dihydropyridine CCB.
ESH 2023[3]	General age <65 General age 65–79 General age ≥80	<130/80 <140 SBP <150 SBP	BP <150/95: Lifestyle changes BP ≥150/95 or has CVD risk factors or failed lifestyle changes: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB
AAFP 2022[4][5]	General	<140/90	BP >140/90 and low-risk for CVD: Lifestyle changes BP >140/90 and CVD risk factors or failed lifestyle changes: monotherapy with thiazide-type diuretic, ACEI/ARB, and/or CCB BP >160/100: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB
WHO 2021[6]	General High CVD risk, diabetes or CKD Previous CVD	<140/90 <130 SBP <130 SBP	BP ≥140/90 and low-risk for CVD: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB SBP ≥130 and CVD risk factors, diabetes or CKD: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB SBP ≥130 and previous CVD: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB
KDIGO 2021[7]	CKD with kidney transplant	<120 SBP <130/80	CKD: ACEI/ARB Kidney transplant: ARB or CCB
ISH 2020[8]	General Age <65 Age ≥65	<140/90 (reduction by at least 20/10) <130/80 <140/90	BP >140/90 and low-risk for CVD: Lifestyle changes BP >140/90 and CVD risk factors or failed lifestyle changes: monotherapy with thiazide-type diuretic, ACEI/ARB, and/or CCB BP >160/100: Two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB
VA/DoD 2020[9]	General Age ≥60 Age ≥60 with diabetes	<130/90 <150/90 <140/90	Thiazide-type diuretic, ACEI/ARB, and/or CCB Black: avoid monotherapy with ACEI/ARB
NICE 2019[10]	Age <80 Age ≥80	<140/90 <150/90	Age <55: ACEI/ARB Age ≥55 or black: CCB
ADA 2018[11]	Diabetes Diabetes with CVD risk	<140/90 <130/80	ACEI/ARB, thiazide-like diuretic, and/or dihydropyridine CCB
ESC/ESH 2018[12]	General age <65 General age ≥65	<130/80 <140/80	Thiazide-type diuretic, ACEI/ARB, and/or CCB CAD: add beta-blocker Resistant hypertension: add spironolactone
ACC/AHA 2017[13]	General	<130/80	BP > 130/80: Lifestyle changes and monotherapy with thiazide-type diuretic, ACEI/ARB, and/or CCB BP >20/10 above target: Lifestyle changes and two from different classes: thiazide-type diuretic, ACEI/ARB, and/or CCB
JNC 8 2013[1]	General age ≥60 General age <60 Diabetes CKD	<150/90 <140/90 <140/90 <140/90	Non-black: thiazide-type diuretic, ACEI/ARB, and/or CCB Black: thiazide-type diuretic, and/or CCB Diabetes: thiazide-type diuretic, ACEI/ARB, and/or CCB CKD: ACEI/ARB
CHEP 2013[14]	General <80 y General ≥80 y Diabetes CKD	<140/90 <150/90 <130/80 <140/90	General: thiazide-type diuretic, beta-blocker (age, 60 y), ACEI (non-black) or ARB Diabetes with additional risk : ACEI/ARB Diabetes without additional risk : ACEI/ARB, thiazide, or DHPCCB CKD: ACEI, or ARB
ISHIB 2010[15]	Black, lower risk Target organ damage or CVD risk	<135/85 <130/80	Diuretic or CCB

Abbreviations:

• AAFP – American Academy of Family Physicians
• ACC – American College of Cardiology
• ACEI – angiotensin-converting enzyme inhibitor
• ADA – American Diabetes Association
• AHA – American Heart Association
• ARB – angiotensin receptor blocker
• CAD – coronary artery disease
• CCB – calcium channel blocker
• CHEP – Canadian Hypertension Education Program
• CKD – chronic kidney disease
• CVD – cardiovascular disease
• DHPCCB – dihydropyridine calcium channel blocker
• ESC – European Society of Cardiology
• ESH – European Society of Hypertension
• ISH – International Society for Hypertension
• ISHIB – International Society for Hypertension in Blacks
• JNC – Joint National Committee
• KDIGO – Kidney Disease: Improving Global Outcome
• NICE – National Institute for Health and Clinical Excellence (United Kingdom)
• SBP – systolic blood pressure
• WHO – World Health Organization