What are the current guidelines for managing Hypertension (HTN)?

Current Guidelines for Managing Hypertension (HTN)

The 2024 European Society of Cardiology (ESC) guidelines recommend initiating antihypertensive drug therapy when blood pressure is ≥140/90 mmHg irrespective of age, or at 130-139/80-89 mmHg in high-risk patients despite lifestyle modifications. 1

Blood Pressure Thresholds for Treatment

When to Start Medication

• BP ≥140/90 mmHg: Initiate antihypertensive drug therapy regardless of age 1, 2
• BP 130-139/80-89 mmHg: Initiate treatment after 3 months of lifestyle modifications if patient has:
  • Established cardiovascular disease (CVD)
  • Target organ damage
  • Diabetes mellitus
  • Chronic kidney disease (CKD)
  • 10-year CVD risk ≥10% 1, 2

Blood Pressure Targets

• General population: <130/80 mmHg 2, 3
• Elderly patients (>80 years): <140/80 mmHg with gradual dose titration 2
• Patients with diabetes, CKD, or established CVD: <130/80 mmHg 2
• Minimum acceptable control (audit standard): <150/90 mmHg for non-diabetic patients 1

First-Line Pharmacological Treatment

Four main classes of medications are recommended as first-line therapy:

1. ACE inhibitors
2. Angiotensin receptor blockers (ARBs)
3. Calcium channel blockers (CCBs)
4. Thiazide or thiazide-like diuretics 1, 2, 3

Patient-Specific Considerations

• Black patients: Consider calcium channel blocker as first-line therapy 2
• Diabetes or CKD with proteinuria: ACE inhibitor or ARB preferred 2
• Heart failure: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 2

Combination Therapy

Most hypertensive patients (>70%) will require at least two antihypertensive agents for adequate BP control 2, 3:

• Effective combinations:

  • ACE inhibitor or ARB + calcium channel blocker
  • ACE inhibitor or ARB + thiazide diuretic
  • Calcium channel blocker + thiazide diuretic 2

• Important caution: Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without added benefit 2

• Fixed-dose combinations are recommended when no cost disadvantages exist 1

Lifestyle Modifications

All people with hypertension, borderline, or high-normal blood pressure should implement these changes:

1. Dietary modifications:

   • DASH diet rich in fruits, vegetables, whole grains, low-fat dairy
   • Sodium restriction (<2,300 mg/day)
   • Increased potassium intake 2, 4

2. Physical activity:

   • At least 150 minutes of moderate-intensity aerobic exercise weekly
   • Consider adding resistance training 2-3 times per week 1, 2

3. Weight management:

   • Target BMI of 20-25 kg/m² or waist-to-height ratio <0.5 2, 5

4. Alcohol limitation:

   • ≤2 standard drinks/day for men
   • ≤1.5 standard drinks/day for women 2

5. Smoking cessation 1

Management of Resistant Hypertension

Resistant hypertension is defined as BP above target despite lifestyle changes and concurrent use of at least three antihypertensive agents (including a CCB, an ACE inhibitor or ARB, and a diuretic) 6.

Management approach:

1. Confirm medication adherence
2. Verify elevated BP with out-of-office measurements
3. Exclude secondary causes of hypertension
4. Add mineralocorticoid receptor antagonist (spironolactone) as fourth-line agent 6

Cardiovascular Risk Reduction in Hypertensive Patients

Aspirin Therapy

• Secondary prevention: Recommended for all patients unless contraindicated 1
• Primary prevention: Consider 75 mg daily if:
  • Age ≥50 years
  • BP controlled to <150/90 mmHg
  • Target organ damage, diabetes, or 10-year CVD risk ≥20% 1

Statin Therapy

• Secondary prevention: Recommended for all hypertensive patients with CVD
• Primary prevention: Recommended for hypertensive patients with 10-year CVD risk ≥20% 1
• Target: Lower total cholesterol by 25% or LDL cholesterol by 30%, or reach <4.0 mmol/l or <2.0 mmol/l respectively (whichever is greater) 1

Monitoring and Follow-up

• Follow-up within 2-4 weeks after starting or changing medications
• Monitor serum creatinine/eGFR and potassium levels at baseline and at least annually
• Annual monitoring for stable patients 2

Common Pitfalls to Avoid

1. Overly aggressive BP lowering in frail elderly patients can lead to falls and dizziness 2
2. Failing to monitor renal function when using ACE inhibitors or ARBs 2
3. Setting unrealistic lifestyle goals instead of promoting gradual sustainable changes 2
4. Using ACE inhibitors or ARBs during pregnancy (contraindicated due to risk of fetal damage) 2
5. Combining ACE inhibitors with ARBs (increases adverse effects without additional benefit) 2