A comparison of international hypertension management guidelines in primary care settings: Focus on studies done between 2017 to 2025

Background: Hypertension remains the leading modifiable risk factor for global morbidity and mortality, affecting over 1.3 billion adults worldwide and contributing to more than 10 million premature deaths annually. Despite the availability of multiple international clinical practice guidelines, substantial variation persists in diagnostic thresholds, treatment initiation criteria, risk stratification, and blood pressure targets. These inconsistencies may contribute to disparities in hypertension detection, management, and control, particularly between high-income countries (HICs) and low- and middle-income countries (LMICs), where the burden of disease is greatest.

Objective: This systematic review aimed to compare international hypertension management guidelines used in primary care settings, with a focus on differences in diagnostic criteria, treatment recommendations, risk stratification approaches, and reported patient outcomes across income settings.

Methods: A PRISMA 2020-compliant systematic review was conducted using MEDLINE, PubMed, PubMed Central, Cochrane Library, Web of Science, ResearchGate, and Google Scholar. Studies published in English between 2017 and 2025 were identified using a PICO-based search strategy. Eligible studies compared two or more international hypertension guidelines relevant to adult primary care populations. Data extraction was performed using a structured framework, narrative synthesis was applied, and methodological quality was assessed using the Critical Appraisal Skills Programme (CASP) tool.

Results: Following screening of 35,495 records, four high-quality review studies met the inclusion criteria. Across guidelines, there was broad consensus on the importance of lifestyle modification and stepwise pharmacological therapy using first-line agents. However, notable differences were observed in diagnostic blood pressure thresholds—most prominently the lower threshold of ≥130/80 mmHg recommended by the ACC/AHA—as well as in treatment targets, cardiovascular risk assessment models, and implementation strategies. Guideline quality varied significantly by income setting, with LMIC guidelines more likely to lack transparent editorial independence and rigorous methodological reporting.

Conclusion: International hypertension guidelines share common foundational principles but differ in clinically meaningful ways that may influence diagnosis, treatment intensity, and patient outcomes in primary care. Harmonisation of guideline development processes, improved contextual adaptation for LMICs, and greater emphasis on implementation feasibility are essential to reducing global hypertension-related disparities and improving long-term cardiovascular outcomes.