ISC 2026 | Similarities and differences among major international hypertension guidelines for stroke prevention

So, I gave a talk about this question of multiple versions of guidelines for stroke prevention last week during the International Stroke Conference. I think the take-home message is that there are more similarities than differences across the major hypertension guidelines, particularly regarding blood pressure thresholds for treatment and treatment targets. So the threshold refers to the blood pressure level at which we initiate treatment. So either lifestyle measures alone or lifestyle plus medication. And the target refers to the level to which we aim to reduce blood pressure. So starting with the thresholds, there are two main approaches across the guidelines. The first is a blood pressure only approach. So it recommends treatment based on the blood pressure value alone without cardiovascular risk stratification. On the other hand, the risk-based approach incorporates tools such as cardiovascular disease risk scores. So the American Heart Association, the European Society of Cardiology guidelines, and also the Brazilian hypertension guidelines, just to name a few, they all recommend medication for systolic blood pressure of 140 millimeters of mercury or above for primary and for secondary prevention. So this is a Class I recommendation. So these guidelines also recommend treatment at 130 millimeters of mercury or greater for secondary stroke prevention. So again, a Class I recommendation for use of medication under these circumstances. For a systolic blood pressure between 130 and 139 millimeters of mercury in primary prevention, these guidelines adopt a risk-based approach. So, for instance, the AHA guideline suggests the use of the Prevent CVD risk score to guide initiation of medication unless the patient already has high-risk conditions such as diabetes or chronic kidney disease. And again, I’m talking about primary prevention. So according to the AHA guideline, if the 10-year CVD risk is 7.5% or greater according to the Prevent CVD risk score, medication is recommended. Otherwise, lifestyle measures are initiated first and blood pressure is reassessed. It doesn’t mean that medication will not be given, but the patient is going to be reassessed in the future shortly just to evaluate whether medication should be started. European guidelines use the SCORE2 and similar calibrated risk tools. So overall, these recommendations are also Class I and strong recommendations. So the rationale of using this risk-based approach for primary prevention is to avoid undertreatment of high-risk individuals and also to treat those who are most likely to benefit. The risk stratification tools, ideally, they are tailored to specific populations. So rather than being just conflicting, these guidelines are largely complementary. And the different guidelines also may reflect differences in healthcare systems, available resources. So they are based on a general core and they are adapted to particular contexts. And finally, now regarding the targets for secondary prevention, most guidelines recommend a systolic blood pressure target below 130 millimeters of mercury if tolerated. And then for primary prevention, there are some minor differences. So the AHA guidelines suggest aiming for below 120 millimeters of mercury if tolerated. And the European guidelines, whether for primary or secondary prevention, suggest a range of 120 to 129 millimeters of mercury if tolerated. So all the guidelines emphasize the need to consider particular characteristics of the patients, but overall, the consensus across the guidelines is that for most patients, the target of systolic blood pressure is below 130 millimeters of mercury based on the current evidence.

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