Hypertension Treatment & Drug Strategy (ISH 2026)
Aim: BP controlled to target within 3 months. Review monthly until controlled.
Step 1 — Thresholds and targets
| ESSENTIAL | OPTIMAL |
|---|
| BP used | Standardised office BP | Standardised office BP, confirmed with home or ambulatory BP |
| Treatment threshold | ≥140/90 | ≥130/80 (focus on systolic if DBP 80–89) |
| Target — office | <140/90 | <130/80 |
| Target — home | — | <130/80 |
| Target — ABPM | — | 24-h <125/75; daytime <130/80; night-time <110/65 |
Individualise threshold and target in age >85, frailty, symptomatic orthostatic hypotension, or limited life expectancy. Treating at ≥130/80 and targeting <130/80 is not appropriate for everyone.
Every 10 mmHg SBP fall ≈ 20% fewer major CV events, 30–40% less stroke and heart failure, 17% less CHD.
Step 2 — When to start drugs
| Situation | Start |
|---|
| CVD, CKD, diabetes, HMOD, BP ≥160/100, or moderate–high CV risk | Immediately after confirming diagnosis |
| Low CV risk, BP 140–159/90–99 (ESSENTIAL) or 130–159/80–99 (OPTIMAL) | After 3 months of lifestyle change if still above threshold |
Lifestyle change applies before and during drug treatment in everyone.
Step 3 — Lifestyle prescription (everyone)
Combined changes can lower SBP by >10 mmHg — comparable to 1–2 drugs.
- Salt: ≤5 g salt (2 g sodium) per day — about 1 teaspoon; avoid soy sauce, fast food, processed foods, breads, salty cereals
- Potassium: more fruit, vegetables, legumes, low-fat dairy; potassium-enriched low-sodium salt (caution in kidney disease)
- Diet: DASH-style; leafy vegetables, beans, beetroot, nuts, seeds; limit added sugar; high fibre
- Drinks: beetroot juice, green/black tea, hibiscus tea, pomegranate juice, unsweetened cocoa may help
- Alcohol: avoid or limit to 2 standard drinks per week; no binge drinking
- Weight: waist-to-height ratio <0.5; ethnic-specific BMI and waist cut-offs
- Exercise: aerobic ≥30 min on 5–7 days/week; resistance/HIIT 2–3 days/week
- Stress: mindfulness, yoga, meditation, music ≥30 min 3×/week
- Sleep: 7–8 h; no alcohol or large meals within 3 h of sleep; treat sleep apnoea
- Smoking/vaping: stop completely
- Avoid alternative/traditional medicines for hypertension
Step 4 — Choose the starting regimen
| sOBP | Start with |
|---|
| ≥140/90 (hypertension) | Two-drug single-pill combination (ESSENTIAL and OPTIMAL) |
| 130–139/80–89 (elevated BP) — OPTIMAL | Monotherapy (preferred), or low-dose 2-drug single pill if high risk with SBP close to 140 |
| Age >85, frailty, symptomatic orthostatic hypotension, limited life expectancy | Consider starting with monotherapy |
ESSENTIAL: use whatever drugs are available that best match the ideal characteristics — proven outcome benefit, once-daily 24-h control, affordable, well tolerated, evidence in the population treated.
Expected SBP fall: monotherapy ~9 mmHg; two drugs ~15 mmHg; three drugs ~20 mmHg. Prefer adding drugs at low–standard doses over up-titrating one drug (dose escalation gives little extra BP fall but more side effects).
Step 5 — The ISH core drug ladder (OPTIMAL)
A = ACEi or ARB · C = dihydropyridine CCB · D = thiazide or thiazide-like diuretic
| Step | Regimen |
|---|
| 1 | A + C low-dose (half max dose) single pill. Consider A + D if oedema, CCB intolerance or early heart failure |
| 2 | A + C full dose, or low-dose A + C + D |
| 3 | A + C + D full dose (triple) |
| 4 — resistant | Add spironolactone (preferred). Others: amiloride, eplerenone, beta-blocker, clonidine, doxazosin, sacubitril/valsartan. New: baxdrostat, lorundrostat, aprocitentan, esaxerenone (availability varies) |
| 5 | Add any class not yet used; refer to expert centre / consider renal denervation — see ish-htn-resistant-and-secondary |
Review monthly; intensify whenever BP is above target.
Rules at every step:
- Give all drugs together in the morning (or at the most convenient time) — no evidence for bedtime dosing
- Single-pill combinations (2, 3 or 4 drugs) whenever available; free combinations if unaffordable
- Do not combine ACEi + ARB + renin inhibitor
- Caution with MRA or K-sparing drugs if eGFR <30 or K⁺ >4.5 mmol/L
- Diltiazem or verapamil if DHP-CCB unavailable or not tolerated
- Beta-blockers at any step if: heart failure, angina, post-MI, AF needing rate control, SVT/some ventricular arrhythmias, pregnancy or planning pregnancy
Step 6 — Adjust for comorbidities
| Comorbidity | Drug choice |
|---|
| Type 2 diabetes | ACEi/ARB preferred (especially UACR ≥30 mg/g). Add SGLT2i (esp. CKD/HF) and/or GLP-1 RA (esp. obesity/high CV risk). Use home/ambulatory BP (masked, nocturnal and resistant hypertension common) |
| CKD | Include RAS blocker (esp. albuminuria); diuretics usually needed — loop diuretic or chlorthalidone if eGFR <30. SGLT2i if eGFR >20. Finerenone in diabetes with normal K⁺ and UACR ≥30 (consider without diabetes); GLP-1 RA may be added. Check eGFR and K⁺ 2–4 weeks after starting/titrating RAS blocker, SGLT2i, MRA or diuretic; eGFR fall >30% → consider stopping (usually reversible, often over-diuresis) |
| Coronary artery disease | RAS blocker, beta-blocker, antiplatelet, intensive lipid lowering, lifestyle |
| Previous stroke/TIA | RAS blocker + diuretic first; CCB also fine. Beta-blockers less effective for stroke prevention |
| Heart failure | RAS blocker, beta-blocker, ARNI, MRA, SGLT2i per HF guidelines; add DHP-CCB if BP uncontrolled |
| Atrial fibrillation | Manage as general population; beta-blocker for rate control (<80/min). ≥3 BP readings each time. SBP <160 before starting anticoagulation, keep <140 |
| COPD | As general population, beta-blockers when indicated |
| Obstructive sleep apnoea | Weight loss; MRA useful in resistant hypertension. CPAP gives only modest BP fall |
| Dyslipidaemia | Most hypertensives >50 years benefit from lipid lowering based on CV risk |
| Obesity | Weight loss; GLP-1 RA and dual GIP/GLP-1 RA lower BP and improve CV outcomes |
| HIV | Manage as general population (nocturnal hypertension common) |
Ethnicity: Black/African-descent — CCB + diuretic first line (single pill); ARB preferred over ACEi (angioedema, cough). Asian — standard treatment; lower BMI/waist cut-offs.
Seasonal variation: BP ~5 mmHg lower in hot weather. Consider down-titration if BP well below target with symptoms; extreme heat with dehydration risks hypotension on diuretics/RAS blockers.
Step 7 — Adherence (ESSENTIAL)
Non-adherence affects 30–50% and is a leading cause of poor control.
- Check adherence at every visit, especially before adding drugs
- Reduce pill burden — single-pill combinations, once-daily dosing
- Link pill-taking to daily habits; dosette boxes, reminders
- OPTIMAL: self-management counselling, long-term home BP, apps/SMS, telemedicine, team-based care (nurses, pharmacists, community health workers)
- Objective check if needed: urine/plasma drug detection
Step 8 — Follow-up
- Monthly until target reached (in person or virtual)
- Well-controlled low-risk: every 6–12 months
- Well-controlled high-risk: every 3–6 months
- Long-term home BP monitoring (1–2 duplicate readings per week or month; not daily)
- Never accept BP above target without action
Guardrails
- Don't start with monotherapy for BP ≥140/90 unless elderly/frail — single-pill dual therapy is the default
- Don't up-titrate one drug when adding a second at low dose would work better
- Don't combine ACEi with ARB (or a renin inhibitor)
- Don't give spironolactone if K⁺ >4.5 or eGFR <30 without close monitoring
- Don't use bedtime dosing for its own sake — no outcome benefit
- Confirm with home/ambulatory BP when treating elevated BP or targeting <130/80
- Individualise in >85, frail, orthostatic or limited life expectancy
- Check adherence before calling it treatment failure
Related MD2SKILL skills
ish-htn-risk-assessment-workup — risk decides timingish-htn-resistant-and-secondary — uncontrolled on 3 drugsish-htn-pregnancy, ish-htn-children, ish-htn-emergencyendo-pa-screen-hypertension — primary aldosteronism screening
Source
Stergiou GS, Kario K, Aristizabal D, et al. 2026 International Society of Hypertension Global Hypertension Practice Guidelines. J Hypertens. 2026;44. DOI: 10.1097/HJH.0000000000004451. Sections 7–8, 9.7, 10, 12; Tables 9–10; Figures 5–9.