Multisociety Jordan National Hypertension Clinical Protocols Initiative
Multisociety Jordan National Hypertension Clinical Protocols Initiative
A Collaborative Program of Nine Jordanian Medical Societies Coordinated by the Jordan Cardiac Society (JCS)
Participating Societies:
Jordan Cardiac Society (JCS)
Jordan Atherosclerosis Society (JAS)
Jordan Society of General Practitioners (JSGP)
Jordan Society of Internal Medicine (JSIM)
Jordan Society of Nephrology (JSN)
Jordan Society of Family Medicine (JSFM)
Jordan Emergency Medicine Society (JEMS)
Jordan Endocrine and Diabetes Society (JEDS)
Jordan Nutrition Society (JNS)
Based on:
ESH/ESC 2024
ACC/AHA 2025 and CCS Updates, and
International Society of Hypertension 2020
Preface :
Each population requires its most suitable guideline, and the best blood pressure categorization …
(In Jordan, many patients are inherently high risk due to prevalent cardiovascular factors, yet awareness and access to consistent treatment remain limited. Therefore, blood pressure categorization and treatment strategies must balance scientific evidence with local realities.)
1. Diagnosis Protocol
Hypertension is diagnosed when:
• Office blood pressure ≥140/90 mmHg , Confirmed on at least two separate visits(This corresponds approximately to home BP ≥135/85 mmHg)
OR on
• Home blood pressure ≥135/85 mmHg
OR on
• 24-hour ambulatory blood pressure monitoring ≥130/80 mmHg
Except If BP severe or there is target-organ damage, hypertension may be diagnosed immediately in one visit and treated without waiting for repeated visits.
• Office ≥140/90 with home <135/85 → suggests white-coat hypertension “WCH” (elevated office BP ≥140/90 with normal home BP <135/85).
• WCH Occurs in about 15–30% of patients with high office readings.
• Important to avoid misdiagnosis and unnecessary treatment.
• Cardiovascular risk is higher than normal BP but lower than sustained hypertension.
• About 30–40% may progress to true hypertension over time.
Accurate measurement is essential:
• Use validated upper-arm automated devices
• Avoid cuffless devices
• Ensure correct cuff size
• Confirm diagnosis with home or ambulatory monitoring whenever possible
Hypertension Screening (Adults and Children)
• Adults: Screen all adults ≥18 years during routine clinical visits.
• Normal BP: recheck every3 years; elevated BP: reassess annually or sooner.
• High-risk adults (diabetes, CKD, obesity, family history): screen more frequently.
• Children and adolescents: begin BP screening from age 3 years, once yearly.
• High-risk children (obesity, kidney disease, diabetes, congenital heart disease): measure BP at every visit.
When to Suspect Secondary Hypertension:
• Resistant hypertension despite ≥3 medications
• Onset of hypertension before age 40
• Abrupt onset or sudden worsening of previously controlled hypertension
• Hypokalemia
• Worsening in renal function
• Asymmetric kidney size
• Persistent diastolic hypertension after age >55 years
• Disproportionate target-organ damage for the level of BP
• Non-Dipping Nocturnal Blood Pressure
Most Common Causes of Secondary Hypertension
(Approximate clinical frequency)
Common
• Primary aldosteronism
≈ 5–10% of all hypertension
≈ 15–25% of resistant hypertension
• Obstructive sleep apnea
≈ 5–10%
• Chronic kidney disease (renal parenchymal disease)
≈ 3–5%
Less common :
• Renal artery stenosis
≈ 1–5%(Unilateral stenosis → usually hypertension only.
Bilateral stenosis → hypertension + renal failure risk)
• Thyroid disorders
≈ 1–2%
Rare
• Pheochromocytoma / paraganglioma
≈ 0.1–0.6%
• Cushing syndrome
< 1%
• Hyperparathyroidism
< 1%
• Coarctation of the aorta
< 0.1%
Key Clinical Message
• Secondary hypertension accounts for about 5–10% of all hypertension.
• Approximately 90–95% of patients have primary (essential) hypertension.
Initial Evaluation for Suspected Secondary Hypertension
Basic tests for all patients
• Serum creatinine and eGFR
• Serum electrolytes (especially potassium)
• Urinalysis ± urine albumin/creatinine ratio
• Fasting glucose or HbA1c
• Lipid profile
Screening for common secondary causes
• Aldosterone–Renin Ratio (ARR) → screen for primary aldosteronism
• Sleep study when obstructive sleep apnea is suspected
• TSH → screen for thyroid disorders
Renal evaluation
• Renal ultrasound (kidney size and asymmetry)
• Renal artery imaging (CT angiography / MR angiography / Doppler) when renal artery stenosis is suspected
Endocrine evaluation when clinically suspected( Plasma free metanephrines → pheochromocytoma)
Important principle
• Testing should be guided by clinical suspicion, not performed routinely in all patients with hypertension.
2. Cardiovascular Risk Assessment Protocol
Every patient must undergo cardiovascular risk assessment.
You can use one formal calculator:
• PREVENT or /ASCVD (American model)
OR
• SCORE2 or SCORE2-OP (European model)
You can also estimate CV risk for the patient clinically. Do not wait for a calculator when risk is clinically obvious:
Automatically treat as High Risk if the patient has:
• Established atherosclerotic vascular disease
• Diabetes
• Chronic kidney disease (estimated glomerular filtration rate <60 or albuminuria)
• Target organ damage
• Multiple major cardiovascular risk factors
Or 2 major risk factors of the following :
• Hypertension
• Smoking
• Diabetes
• Dyslipidemia
• Family history of premature vascular disease
3. When to Start Medication
Start immediately if:
• Blood pressure ≥160/100 mmHg
Start at:
• ≥140/90 mmHg
Start earlier (≥130/80 mmHg) if High Risk:
• Diabetes
• Chronic kidney disease
• Established vascular disease
• High calculated cardiovascular risk
• Multiple major risk factors
Lifestyle treatment is mandatory for all patients.
4. Treatment Targets
General target for low risk patients:
• <140/90 mmHg
(Preferred target if tolerated:
• <130/80 mmHg)
High-risk patients:
• Actively aim for <130/80 mmHg
Elderly or frail:
• Individualize
• Avoid systolic blood pressure <120 mmHg unless well tolerated
Safety always comes first.
5. Drug Therapy Protocol
Stage 1 (140–159/90–99):
• Monotherapy acceptable
• Low-dose single-pill combination encouraged
Stage 2 (≥160/100) or stage 3 180/110 :
• Start dual or triple low dose immediately
Preferred first-line classes:
• Angiotensin-converting enzyme inhibitor OR angiotensin receptor blocker
• Long-acting calcium channel blocker
• Thiazide or thiazide-like diuretic (chlorthalidone or indapamide preferred)
Use single-pill combinations whenever possible.
6. Resistant Hypertension Protocol
Definition:
• Blood pressure ≥140/90 mmHg despite three drugs including a diuretic
OR
• Controlled blood pressure requiring four or more drugs
Step 1 – Confirm true resistance:
• Assess medication adherence
• Evaluate for secondary hypertension
Step 2 – Review contributing factors:
• Excess sodium intake
• Obesity
• Alcohol excess
• Nonsteroidal anti-inflammatory drugs
• Hormonal therapy
• Steroids
• Obstructive sleep apnea
Step 3 – Optimize regimen:
Ensure combination includes:
• Renin-angiotensin system blocker
• Long-acting calcium channel blocker
• Thiaszide or Thiazide-like (Indapamide)diuretic
If severe renal impairment is present, consider loop diuretic:
(When eGFR <30:
• Thiazide / thiazide-like diuretics lose effectiveness
• Loop diuretics become preferred)
Step 4 – Add-On Therapy (If 4 Drugs Are Needed)
• Spironolactone — first-line add-on therapy if serum K <5 mmol/L and renal function permits
• Beta-blocker may be considered particularly when:
– Coronary artery disease
– Heart failure
– Atrial fibrillation or tachyarrhythmia
– High sympathetic tone / tachycardia
Step 5 – Evaluate secondary causes systematically.
Step 6 Hypertensive Crisis Protocol
Severe Asymptomatic Hypertension(Urgency older term): Evaluation and Treatment
• By definition, there is no acute target-organ injury
Evaluation
• Perform history and physical examination to distinguish severe asymptomatic hypertension from hypertensive emergency
• Focus on:
• medication adherence as if severe BP elevation occurs due to medication nonadherence, restarting the patient’s usual antihypertensive therapy may be all that is required.
• Look for signs of target-organ damage:
• neurologic deficits
• papilledema
• pulmonary edema
• arrhythmia
• unequal pulses
• renal dysfunction
• Look for signs of target-organ damage:
• neurologic deficits
• papilledema
• pulmonary edema
• arrhythmia
• unequal pulses(Aortic dissection)
• renal dysfunction
Blood Pressure Measurement
• Measure in both arms initially
• Use the higher reading
Importance of Rest
• A 30-minute rest period is recommended when BP is severely elevated
• In more than 30% of patients, BP falls to an acceptable level without intervention after rest
Preferred Oral Agents for Severe Asymptomatic Hypertension-Urgency cases:
• Captopril — onset 15–30 min (rapid BP reduction; commonly used in ED).
• Nifedipine ER (extended-release) — onset 30–60 min (avoid short-acting nifedipine; exception: in pregnancy it may be used orally (swallowed) in severe,not SL).
• Prazosin — onset 1–2 h (use cautiously due to risk of first-dose orthostatic hypotension; start with a low initial dose and monitor blood pressure).
• Amlodipine — onset 4–6 h (preferred at discharge for longer BP control).
In Hypertensive Emergency
Management principles
• Admit to ICU / monitored unit
• Use IV antihypertensives
• Reduce MAP by 20–25% in the first hour
• Then reach 160/100–110 mmHg within 2–6 hours
• Normalize BP gradually over 24–48 h
• If IV nitroglycerin is the only available agent, it can be used for hypertensive emergency but is not ideal for all situations.
Best indications:
• Acute pulmonary edema
• Acute coronary syndrome
Not preferred for:
• Stroke or ICH→ (Nicardipine or Labetalol preferred)
• Hypertensive encephalopathy → (Nicardipine or Labetalol preferred)
• Aortic dissection → (Beta-blocker first: Esmolol or Labetalol; Nitroprusside may be added if BP remains uncontrolled)
Dose:
• Start 5 mcg/min IV infusion
• Titrate every 5 minutes
Goal:
• Reduce BP 20–25% (to ~160/100)in the first hour, then gradually.
• IV Hydralazine: direct arterial vasodilator.
• Mainly used in hypertensive emergencies of pregnancy (preeclampsia/eclampsia).
• Dose: 5–10 mg IV bolus, repeat every 20–30 min if needed.
• Limitations: unpredictable BP drop and reflex tachycardia; therefore not first-line in most hypertensive emergencies.
General Rule (ESH-Aligned)
• Reduce mean arterial pressure (MAP) by no more than 20–25% within the first hour.
• Avoid rapid or excessive reduction to prevent cerebral, coronary, or renal ischemia.
Exceptions – Condition-Specific Targets
• Aortic Dissection
• Immediate reduction of systolic BP to <120 mmHg within 20 minutes
• Control heart rate to <60 bpm
• Initiate beta-blocker before vasodilator when possible
• Acute Ischemic Stroke ( No Thrombolysis)
• Do not lower BP unless >220/120 mmHg
• If treatment is required, reduce cautiously:
• ≤15% during the first 24 hours
Blood Pressure Control Before Thrombolysis (Acute Ischemic Stroke)
Eligibility for thrombolysis requires:
• BP <185/110 mmHg before thrombolytic therapy
If BP is above this level:
Lower blood pressure cautiously using short-acting IV agents:
• Labetalol
– 10–20 mg IV over 1–2 minutes
– May repeat once
• Nicardipine infusion
– Start 5 mg/h IV
– Increase by 2.5 mg/h every 5–15 min
– Maximum 15 mg/h
• Clevidipine infusion (where available)
After thrombolysis
• Maintain BP <180/105 mmHg for the first 24 hours
Important principle
• BP reduction should be controlled and modest
• Avoid rapid or excessive lowering to prevent cerebral hypoperfusion
• Intracerebral Hemorrhage (ICH)
• Target systolic BP ≈140 mmHg
• Achieve reduction within the first 6 hour
• If stable, then you further reduce blood pressure more slowly to approximately 160/100–110 mmHg over the next 2–6 hours.
• Gradual normalization may then occur over the following 24–48 hours.
The presence of organ damage defines the emergency, not the number alone.
8.
10. Hypertension in pregnancy:
SBP ≥140 mmHg or DBP ≥90 mmHg.
• Gestational hypertension: occurs after 20 weeks with previously normal BP.
• Chronic hypertension: present before pregnancy or before 20 weeks.
• Most international guidelines (ESC, NICE, WHO, Canada):
• Start treatment at ≥140/90 mmHg.
• Target often <140/90 mmHg
Preeclampsia diagnosis(Emerency case ) :
• BP ≥140/90 mmHg after 20 weeks
• Plus proteinuria or organ dysfunction, including:
• renal impairment
• liver dysfunction
•thrombocytopenia
• neurological symptoms
Most international guidelines consider the following agents as preferred options:
• Labetalol
• Methyldopa
• Nifedipine
Additional option (especially in acute severe hypertension):
• Hydralazine (IV), particularly for acute BP control in severe hypertension during pregnancy.
Oral hydralazine is not contraindicated, but it is not preferred because safer and more predictable agents are available for maintenance therapy in pregnancy.
Medications to avoid
• Renin–angiotensin system blockers
• ACE inhibitors
• ARBs
• direct renin inhibitors
Acute Severe Hypertension in Pregnancy
(for Multisociety Hypertension Protocol)
Multidisciplinary team :
• obstetricians
• cardiologists
• nephrologists
• nurses and midwives
Definition
• Severe hypertension:
SBP ≥160 mmHg or DBP ≥110 mmHg
• Requires urgent treatment within 30–60 minutes to reduce risk of:
• maternal stroke
• placental abruption
• fetal compromise
First-Line Drug Treatment for acute severe hypertension in pregnancy :
Immediate-Release Oral Nifedipine
• Dose: 10–20 mg orally (swallowed)
• Do NOT give sublingually
• Repeat after 20 minutes if BP remains ≥160/110
• Maximum: 30 mg in the first hour
• Onset: ~5–10 minutes
Role
• One of the first-line therapies for acute severe hypertension in pregnancy
• Particularly useful when IV access is not available or delayed
Alternative First-Line Options
• IV Labetalol
• IV Hydralazine
All three agents are recommended by major obstetric guidelines.
Important Administration Note
• Immediate-release nifedipine must be given orally (swallowed “not” SL).
• Sublingual administration is not recommended because it may cause rapid hypotension and maternal–fetal complications.
Key Clinical Principle
• Immediate-release nifedipine is accepted in obstetrics for acute severe hypertension.
• It is generally avoided in other hypertensive emergencies because of the risk of uncontrolled BP reduction.
Reference
ACOG Committee Opinion No. 692 – Referenced by: ACC / AHA cardiovascular reviews .
Emergent Therapy for Acute-Onset Severe Hypertension in Pregnancy
12. Lifestyle Protocol
All patients:
• Reduce sodium intake
• Increase dietary potassium if safe
• Maintain healthy weight
• Exercise regularly
• Stop smoking
• Limit alcohol
Potassium-enriched salt may be considered in patients without hyperkalemia risk.
13. Nocturnal Hypertension Protocol
• Diagnosed only by ambulatory monitoring
• Associated with higher cardiovascular and renal risk
• Consider evening dosing
• Treat sleep apnea when present
• Avoid excessive lowering in elderly (<110/65)
Final Position – JCS 2026
This document:
• Applies European diagnostic standards
• Integrates 2025 American updates
• Intensifies treatment in high-risk patients
• Emphasizes structured risk assessment
• Promotes single-pill strategy
• Incorporates maternal and stroke safety protocols
• Provides structured evaluation for resistant hypertension
Core Messages
Diagnose accurately.
Assess cardiovascular risk in every patient.
Treat earlier in high-risk individuals.
Aim safely for below 130/80 when appropriate.
