What are the most recent guidelines for managing hypertension?

Most Recent Guidelines for Managing Hypertension

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. 1

Diagnosis and Blood Pressure Measurement

• Hypertension is defined as persistent systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg
• Multiple office BP measurements are the gold standard for diagnosis
• Self-monitoring and ambulatory blood pressure monitoring (ABPM) can aid in diagnosis and long-term monitoring
• BP exhibits seasonal variation with lower levels at higher temperatures and higher at lower temperatures (average decline of 5/3 mmHg systolic/diastolic in summer) 1

Treatment Thresholds

1. Confirmed BP ≥140/90 mmHg: Prompt initiation of lifestyle measures and pharmacological treatment regardless of cardiovascular risk 1

2. BP 130-139/80-89 mmHg:

   • After 3 months of lifestyle intervention, pharmacological treatment is recommended for those with high cardiovascular risk (≥10% 10-year risk) 1
   • The 2024 ESC guidelines expand this recommendation to include those with established CVD, hypertension-mediated organ damage, diabetes, moderate/severe CKD, or familial hypercholesterolemia 1

Treatment Targets

• Most adults: Target SBP 120-129 mmHg 1
• If poorly tolerated: Target "as low as reasonably achievable" (ALARA principle) 1
• Special populations:
  • Adults ≥85 years: Consider more lenient target (BP <140/90 mmHg) 1
  • Patients with diabetes, renal impairment, or established CVD: Target BP ≤130/80 mmHg 1

Lifestyle Modifications

All patients with elevated BP should implement the following lifestyle changes:

1. Diet:

   • Salt reduction (avoid added salt and high-sodium processed foods)
   • Mediterranean or DASH diet (rich in whole grains, fruits, vegetables, polyunsaturated fats)
   • Restrict free sugar consumption to <10% of energy intake
   • Avoid sugar-sweetened beverages 1

2. Physical Activity:

   • Regular aerobic exercise (150-300 minutes/week of moderate-intensity or 75-150 minutes/week of vigorous-intensity)
   • Complement with resistance training 2-3 times/week 1

3. Weight Management:

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

4. Alcohol Consumption:

   • Limit to <100g/week of pure alcohol (approximately 2 standard drinks/day for men, 1.5 for women)
   • Preferably avoid alcohol consumption entirely 1

5. Smoking Cessation:

   • Complete cessation recommended with referral to smoking cessation programs 1

Pharmacological Treatment

First-Line Medications

The following drug classes are recommended as first-line treatments 1, 2:

• ACE inhibitors (e.g., lisinopril, ramipril)
• ARBs (e.g., losartan, valsartan)
• Dihydropyridine calcium channel blockers (e.g., amlodipine)
• Thiazide/thiazide-like diuretics (e.g., chlorthalidone, indapamide)

Treatment Strategy

1. Initial therapy: Combination BP-lowering treatment is recommended for most patients with confirmed hypertension (BP ≥140/90 mmHg) 1

   • Preferred combinations: RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic
   • Fixed-dose single-pill combinations are recommended for better adherence

2. If BP not controlled with two drugs: Add a third drug, typically a RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1

3. Beta-blockers: Recommended when there are specific indications (angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control) 1, 2

4. Important caution: Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

Special Populations

1. Non-Black patients: Start with ACE inhibitor/ARB, add dihydropyridine CCB, then add thiazide/thiazide-like diuretic 2

2. Black patients: Start with ARB plus CCB, or CCB plus thiazide diuretic 2

3. Diabetes and CKD: First choice is ACE inhibitor or ARB 2

4. Elderly patients (≥75 years): Target BP <140/90 mmHg, use simplified regimens, monitor for orthostatic hypotension 2

Common Pitfalls and Caveats

1. Medication adherence: Poor adherence affects 10-80% of hypertensive patients and is a key driver of suboptimal BP control 1

   • Take medications at the most convenient time of day to establish a habitual pattern
   • Use fixed-dose combinations when possible

2. Seasonal BP variation: Consider adjusting treatment during significant temperature changes, as BP tends to be higher in cold weather and lower in warm weather 1

3. Medication interactions: Be cautious with NSAIDs (can reduce effectiveness of ACE inhibitors, ARBs, and diuretics) and potassium supplements (can increase risk of hyperkalemia with ACE inhibitors, ARBs, and aldosterone antagonists) 2

4. Monitoring: Check renal function and potassium within 1-2 weeks of initiating ACE inhibitors and ARBs 2

5. Lifelong treatment: BP-lowering drug treatment should be maintained lifelong, even beyond age 85, if well tolerated 1