What are the latest guidelines for the management of hypertension?

Latest Guidelines for Hypertension Management (2024)

The 2024 European Society of Cardiology (ESC) guidelines recommend a target systolic blood pressure of 120-129 mmHg for most adults with hypertension to reduce cardiovascular disease risk and mortality. 1

Definition and Diagnosis

• Hypertension is defined as:
  • Office BP ≥140/90 mmHg
  • Home BP ≥135/85 mmHg
  • 24-hour ambulatory BP ≥130/80 mmHg

Risk Assessment and Treatment Initiation

When to Start Pharmacological Treatment

• Confirmed BP ≥140/90 mmHg: Prompt initiation of both lifestyle measures and pharmacological treatment regardless of cardiovascular risk 1
• Elevated BP (130-139/80-89 mmHg): Consider drug treatment after 3 months of lifestyle intervention if cardiovascular risk is high enough 1

Lifestyle Modifications

All patients with hypertension or elevated blood pressure should implement the following:

1. Diet:

   • Follow Mediterranean or DASH diet patterns 1
   • Restrict sodium intake
   • Limit free sugar consumption to <10% of energy intake
   • Avoid sugar-sweetened beverages 1

2. Physical Activity:

   • 150-300 minutes/week of moderate-intensity aerobic activity
   • Add resistance training 2-3 times/week 1

3. Weight Management:

   • Aim for BMI 20-25 kg/m²
   • Waist circumference <94 cm (men) and <80 cm (women) 1

4. Alcohol Consumption:

   • Limit to <100g/week (approximately 7-12 standard drinks)
   • Preferably avoid alcohol completely for best health outcomes 1

5. Smoking:

   • Complete cessation with referral to smoking cessation programs 1

Pharmacological Treatment

First-Line Medications

The following are recommended as first-line treatments:

• ACE inhibitors
• Angiotensin receptor blockers (ARBs)
• Dihydropyridine calcium channel blockers (CCBs)
• Thiazide/thiazide-like diuretics (especially chlorthalidone and indapamide) 1

Treatment Strategy

1. Initial Therapy:

   • Combination therapy is recommended for most patients with confirmed hypertension (≥140/90 mmHg)
   • Preferred combinations: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB or diuretic 1
   • Use single-pill combinations whenever possible to improve adherence 1

2. If BP Not Controlled:

   • Progress to triple therapy: RAS blocker + CCB + thiazide/thiazide-like diuretic 1
   • Preferably as a single-pill combination

3. Resistant Hypertension:

   • Add spironolactone if BP remains uncontrolled on triple therapy
   • Consider eplerenone or beta-blockers if spironolactone not tolerated

Important Cautions

• Never combine two RAS blockers (ACE inhibitor + ARB) 1
• Beta-blockers should be used as first-line only when there are specific indications (angina, post-MI, heart failure, or for heart rate control) 1

Treatment Targets

• Target systolic BP for most adults: 120-129 mmHg 1
• When target cannot be achieved due to poor tolerance, aim for "as low as reasonably achievable" (ALARA principle) 1
• Maintain treatment lifelong, even beyond age 85 if well tolerated 1

Special Populations

Older Adults

• Treatment should be maintained lifelong if well tolerated, even beyond age 85 1
• Consider frailty, orthostatic hypotension, and individual tolerance when setting targets

Patients with Comorbidities

• Specific treatment algorithms apply for patients with:
  • Coronary artery disease
  • Heart failure
  • Chronic kidney disease
  • Diabetes

Practical Implementation Tips

• Medication timing: Take at the most convenient time of day to establish a habitual pattern 1
• Use fixed-dose single-pill combinations to improve adherence 1
• Regular monitoring of BP (home and office)
• Regular assessment of medication adherence
• Address side effects promptly to improve long-term compliance

Common Pitfalls to Avoid

1. Inadequate BP measurement technique leading to inaccurate diagnosis
2. Failure to use combination therapy when indicated
3. Not using single-pill combinations when available
4. Inadequate dose titration
5. Overlooking lifestyle modifications as an essential component of treatment
6. Discontinuing medications when BP is controlled
7. Not considering secondary causes in resistant hypertension

The 2024 ESC guidelines represent the most current evidence-based approach to hypertension management, with a focus on earlier intervention, combination therapy, and lower BP targets to reduce cardiovascular morbidity and mortality.