2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension

TLDR

Hypertension accounts for 4.5 % of global disease burden, is widespread worldwide, and its cardiovascular risk increases continuously with blood pressure, yet most diagnosed patients remain inadequately controlled and lifestyle modification is recommended for all. The statement aims to define cardiovascular risk thresholds for initiating treatment, set therapeutic goals, recommend non‑drug and drug strategies, and evaluate cost‑effectiveness, supporting a 140 mmHg systolic threshold even for low‑risk patients. The guideline recommends starting with a low‑dose diuretic—typically a thiazide—when no compelling indication exists, while acknowledging that in high‑risk patients expensive drugs can be cost‑effective, but in low‑risk patients only inexpensive options are justified. Evidence shows that high‑risk patients benefit from lower blood‑pressure thresholds and that expensive drugs can be cost‑effective for them, whereas low‑risk patients require cheaper therapies to achieve cost‑effectiveness.

Abstract

Hypertension is estimated to cause 4.5% of current global disease burden and is as prevalent in many developing countries, as in the developed world. Blood pressure-induced cardiovascular risk rises continuously across the whole blood pressure range. Countries vary widely in capacity for management of hypertension, but worldwide the majority of diagnosed hypertensives are inadequately controlled. This statement addresses the ascertainment of overall cardiovascular risk to establish thresholds for initiation and goals of treatment, appropriate treatment strategies for non-drug and drug therapies, and cost-effectiveness of treatment.Since publication of the WHO/ISH Guidelines for the Management of Hypertension in 1999, more evidence has become available to support a systolic blood pressure threshold of 140 mmHg for even 'low-risk' patients. In high-risk patients there is evidence for lower thresholds. Lifestyle modification is recommended for all individuals. There is evidence that specific agents have benefits for patients with particular compelling indications, and that monotherapy is inadequate for the majority of patients. For patients without a compelling indication for a particular drug class, on the basis of comparative trial data, availability, and cost, a low dose of diuretic should be considered for initiation of therapy. In most places a thiazide diuretic is the cheapest option and thus most cost effective, but for compelling indications where other classes provide additional benefits, even if more expensive, they may be more cost effective. In high-risk patients who attain large benefits from treatment, expensive drugs may be cost effective, but in low-risk patients treatment may not be cost-effective unless the drugs are cheap.