What are the management guidelines for essential hypertension (Esc) in 2025?

2024 ESC Guidelines for Management of Essential Hypertension

According to the 2024 European Society of Cardiology (ESC) guidelines, all patients with confirmed hypertension (BP ≥140/90 mmHg) should receive a combination of lifestyle interventions and pharmacological therapy, with initial treatment typically consisting of a two-drug combination as a single-pill formulation. 1

Diagnosis and Screening

• Hypertension diagnosis requires:

  • Office BP readings ≥140/90 mmHg on multiple occasions
  • Preferably confirmed by out-of-office measurements (home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg)
  • Non-elevated BP is defined as <120/70 mmHg
  • Elevated BP is defined as 120-139/70-89 mmHg 1, 2

• Screening recommendations:

  • Primary aldosteronism screening should be considered in all adults with confirmed hypertension (Class IIa)
  • Comprehensive screening for secondary hypertension is recommended for young adults <40 years (Class I) 1, 2

Treatment Initiation

• For confirmed hypertension (≥140/90 mmHg):

  • Immediate initiation of both lifestyle interventions and pharmacological therapy is recommended
  • Target BP control within 3 months 1, 2

• For elevated BP (120-139/70-89 mmHg):

  • Treatment depends on cardiovascular risk assessment using SCORE2/SCORE2-OP tools
  • Pharmacological treatment recommended for:
    • SBP 130-139 mmHg with high-risk conditions (established CVD, diabetes, CKD)
    • SBP 130-139 mmHg with 10-year CVD risk ≥10%
    • SBP 130-139 mmHg with 10-year CVD risk 5-<10% AND risk modifiers 1, 2

Lifestyle Modifications

• Essential for all patients with elevated BP or hypertension:
  • Weight management: target ideal body weight or minimum 1 kg loss if overweight
  • Physical activity: 90-150 minutes/week aerobic exercise plus resistance training 2-3 times/week
  • Dietary modifications: DASH diet, sodium restriction, increased potassium intake
  • Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women
  • Smoking cessation 2, 3

Pharmacological Treatment Algorithm

1. Initial therapy for most patients with BP ≥140/90 mmHg:

   • Two-drug combination as a single-pill formulation (Class I, Level B)
   • Preferred combinations: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB or diuretic 1

2. If BP not controlled with two-drug combination:

   • Increase to three-drug combination (Class I, Level B)
   • Typically RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic
   • Preferably as a single-pill combination 1

3. If BP not controlled with three-drug combination:

   • Add spironolactone (Class IIa, Level B) 1

4. If spironolactone ineffective or not tolerated:

   • Consider eplerenone instead of spironolactone, or
   • Add beta-blocker (if not already indicated), or
   • Add centrally acting BP-lowering medication, alpha-blocker, hydralazine, or potassium-sparing diuretic (Class IIa, Level B) 1

5. Important caution:

   • Combining two RAS blockers (ACE inhibitor and ARB) is not recommended (Class III, Level A) 1

Special Populations and Comorbidities

• Elderly patients (≥85 years), those with symptomatic orthostatic hypotension, or moderate-to-severe frailty:

  • More lenient BP targets may be appropriate 2

• Resistant hypertension:

  • Consider referral to specialist centers
  • Adherence testing with direct observed therapy or drug level measurement should be considered (Class IIa) 1, 2

• Comorbidity-specific recommendations:

  • Heart failure with reduced EF: GDMT beta blockers (avoid non-DHP calcium antagonists)
  • Heart failure with preserved EF: Diuretics (consider ACEI/ARB and beta blockers)
  • Chronic kidney disease: ACEI or ARB
  • Diabetes with albuminuria: ACEI or ARB
  • Atrial fibrillation: ARBs preferred 2

Monitoring and Follow-up

• Regular BP monitoring with goal to achieve target within 3 months
• Serum creatinine and potassium monitoring when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists
• Annual monitoring of renal function, electrolytes, and cardiovascular risk factors 2

The 2024 ESC guidelines represent a significant update in hypertension management, emphasizing early combination therapy, single-pill formulations to improve adherence, and a structured approach to treatment escalation for optimal blood pressure control and reduction of cardiovascular risk.