2022 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension

Abstract

Hypertension is the most important modifiable cause of cardiovascular (CV) disease and all-cause mortality worldwide. Despite the positive correlations between blood pressure (BP) levels and later CV events since BP levels as low as 100/60 mmHg have been reported in numerous epidemiological studies, the diagnostic criteria of hypertension and BP thresholds and targets of antihypertensive therapy have largely remained at the level of 140/90 mmHg in the past 30 years. The publication of both the SPRINT and STEP trials (comprising > 8,500 Caucasian/African and Chinese participants, respectively) provided evidence to shake this 140/90 mmHg dogma. Another dogma regarding hypertension management is the dependence on office (or clinic) BP measurements. Although standardized office BP measurements have been widely recommended and adopted in large-scale CV outcome trials, the practice of office BP measurements has never been ideal in real-world practice. Home BP monitoring (HBPM) is easy to perform, more likely to be free of environmental and/or emotional stress, feasible to document long-term BP variations, of good reproducibility and reliability, and more correlated with hypertension-mediated organ damage (HMOD) and CV events, compared to routine office BP measurements. In the 2022 Taiwan Hypertension Guidelines of the Taiwan Society of Cardiology (TSOC) and the Taiwan Hypertension Society (THS), we break these two dogmas by recommending the definition of hypertension as ≥ 130/80 mmHg and a universal BP target of < 130/80 mmHg, based on standardized HBPM obtained according to the 722 protocol. The 722 protocol refers to duplicate BP readings taken per occasion ("2"), twice daily ("2"), over seven consecutive days ("7"). To facilitate implementation of the guidelines, a series of flowcharts encompassing assessment, adjustment, and HBPM-guided hypertension management are provided. Other key messages include that: 1) lifestyle modification, summarized as the mnemonic S-ABCDE, should be applied to people with elevated BP and hypertensive patients to reduce life-time BP burden; 2) all 5 major antihypertensive drugs (angiotensin-converting enzyme inhibitors [A], angiotensin receptor blockers [A], β-blockers [B], calcium-channel blockers [C], and thiazide diuretics [D]) are recommended as first-line antihypertensive drugs; 3) initial combination therapy, preferably in a single-pill combination, is recommended for patients with BP ≥ 20/10 mmHg above targets; 4) a target hierarchy (HBPM-HMOD- ambulatory BP monitoring [ABPM]) should be considered to optimize hypertension management, which indicates reaching the HBPM target first and then keeping HMOD stable or regressed, otherwise ABPM can be arranged to guide treatment adjustment; and 5) renal denervation can be considered as an alternative BP-lowering strategy after careful clinical and imaging evaluation.

Keywords: Blood pressure; Diagnosis; Drug; Guidelines; Hypertension; Treatment.

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Figure 1

Standardized blood pressure measurement. BP, blood pressure; THS, Taiwan Hypertension Society.

Figure 2

Algorithm of screening for secondary hypertension. BP, blood pressure; HMOD, hypertension-mediated organ damage; HTN, hypertension.

Figure 3

Diagnosis and treatment flowchart for primary aldosteronism. * Patients < 35 years of age with adrenal lesions < 1 cm can also undergo adrenal vein sampling if clinically indicated. APA, aldosterone-producing adenoma; ARR, aldosterone-to-renin ratio; AVS, adrenal venous sampling; CT, computed tomography; NP-59-SPECT, I-131-6-beta-iodomethyl-19-norcholesterol single-photon emission computed tomography.

Figure 4

Risk chart-based blood pressure thresholds and targets for the initiation of pharmacological treatment of hypertension. ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CKD, chronic kidney disease; DBP, diastolic blood pressure; DM, diabetes mellitus; HBPM, home blood pressure monitoring; HMOD, hypertension-mediated organ damage; SBP, systolic blood pressure.

Figure 5

Assessment flowchart for the initiation of hypertension management. BP, blood pressure; HBPM, home blood pressure monitoring; SPC, single-pill combination.

Figure 6

Adjustment flowchart for the pharmacological treatment of hypertension. ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; BP, blood pressure; CCB, calcium channel blocker; MRA, mineralocorticoid receptor antagonist; RAS, renin angiotensin system; SGLT-2i, sodium glucose cotransporter-2 inhibitor; SPC, single-pill combination.

Figure 7

Home blood pressure monitoring-guided hypertension management flowchart. ABPM, ambulatory blood pressure monitoring; HBP, home blood pressure; HBPM, home blood pressure monitoring; HMOD, hypertension-mediated organ damage; HTN, hypertension; OD, organ damage.

Figure 8

Components of the structured shared decision-making process for renal denervation. AF, atrial fibrillation; ASCVD, atherosclerotic cardiovascular disease; HCVD, hypertensive cardiovascular disease; HTN, hypertension.