What are the new criteria and treatment guidelines for managing hypertension?

New Criteria and Treatment Guidelines for Hypertension Management

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

Definition and Classification

• Hypertension is defined as persistent blood pressure ≥140/90 mmHg 1
• Elevated blood pressure (previously called prehypertension) is defined as SBP 130-139 mmHg or diastolic blood pressure (DBP) 80-89 mmHg 1
• Stage 1 hypertension: SBP 140-159 mmHg or DBP 90-99 mmHg 1
• Stage 2 hypertension: SBP ≥160 mmHg or DBP ≥100 mmHg 1

When to Initiate Treatment

Lifestyle Modifications

• All individuals with elevated BP or hypertension should implement lifestyle modifications 1
• Lifestyle modifications include weight loss/maintenance of healthy BMI (20-25 kg/m²), waist circumference <94 cm in men and <80 cm in women, regular exercise, sodium restriction, and moderation of alcohol intake 1
• Specific dietary recommendations include Mediterranean or DASH diets, restriction of free sugar consumption to <10% of energy intake, and avoidance of sugar-sweetened beverages 1
• Regular exercise should include aerobic activity complemented with low- or moderate-intensity dynamic or isometric resistance training 2-3 times/week 1
• Alcohol consumption should be limited to less than 100g/week of pure alcohol, though abstinence is preferred for best health outcomes 1
• Smoking cessation is strongly recommended 1

Pharmacological Treatment

• For individuals with confirmed BP ≥140/90 mmHg, prompt initiation of both lifestyle measures and pharmacological treatment is recommended regardless of cardiovascular risk 1
• For those with elevated BP (130-139/80-89 mmHg) and high cardiovascular risk (≥10% over 10 years) or with specific high-risk conditions (established CVD, diabetes, moderate/severe CKD, etc.), pharmacological treatment should be initiated after 3 months of lifestyle intervention 1
• This represents a significant shift from previous guidelines, expanding treatment to more patients with elevated BP who have risk factors 1

First-Line Medications

• First-line antihypertensive medications include: 1

  • ACE inhibitors (e.g., lisinopril) 2
  • Angiotensin receptor blockers (ARBs)
  • Dihydropyridine calcium channel blockers (e.g., amlodipine) 3
  • Thiazide or thiazide-like diuretics (e.g., chlorthalidone, indapamide)

• Beta-blockers are recommended only when there are compelling indications such as angina, post-myocardial infarction, heart failure with reduced ejection fraction, or for heart rate control 1

Treatment Strategy

• Combination therapy is now recommended for most patients with confirmed hypertension (≥140/90 mmHg) as initial therapy 1
• Preferred combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or a diuretic 1
• Fixed-dose single-pill combinations are recommended to improve adherence 1
• If BP is not controlled with a two-drug combination, escalation to a three-drug combination is recommended (typically RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic) 1
• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

Treatment Targets

• The 2024 ESC guidelines recommend a target SBP of 120-129 mmHg for most adults, provided the treatment is well tolerated 1
• If this target cannot be achieved due to side effects, the "as low as reasonably achievable" (ALARA) principle should be applied 1
• This represents a more aggressive target than previous guidelines, which often recommended <140/90 mmHg 1
• More lenient targets may be considered for patients aged ≥85 years, those with moderate-to-severe frailty, or those with symptomatic orthostatic hypotension 1

Special Considerations

• For resistant hypertension, referral to specialist centers should be considered 1
• Adherence testing with either direct observed therapy or drug level measurement should be considered for resistant hypertension 1
• Medications should be taken at the most convenient time of day for the patient to establish a habitual pattern and improve adherence 1
• Treatment should be maintained lifelong, even beyond the age of 85 years, if well tolerated 1

Common Pitfalls and How to Avoid Them

• Underestimating the importance of lifestyle modifications - these should be emphasized for all patients, not just as an alternative to medication 4, 5
• Inadequate initial therapy - starting with monotherapy when combination therapy would be more effective 1
• Not using fixed-dose combinations when available - these improve adherence significantly 1
• Failing to maintain long-term follow-up - hypertension is a chronic condition requiring lifelong management 1
• Neglecting to assess for secondary causes of hypertension in resistant cases 1
• Not considering patient-specific factors that might affect medication choice or tolerability 4

The new guidelines represent a significant shift toward earlier intervention, more aggressive BP targets, and greater use of combination therapy to achieve better cardiovascular outcomes and reduce mortality.