What are the latest guidelines for managing hypertension?

Latest Guidelines on Hypertension Management

The 2024 European Society of Cardiology (ESC) guidelines define hypertension as persistent blood pressure ≥140/90 mmHg and recommend prompt initiation of both lifestyle measures and pharmacological treatment for individuals with confirmed hypertension. 1

Definition and Classification

• The European Society of Cardiology/European Society of Hypertension (ESC/ESH) defines hypertension as persistent blood pressure ≥140/90 mmHg, while the American College of Cardiology/American Heart Association (ACC/AHA) defines it as ≥130/80 mmHg 1, 2
• Elevated blood pressure is defined as SBP 130-139 mmHg or DBP 80-89 mmHg 2
• Stage 1 hypertension is defined as SBP 140-159 mmHg or DBP 90-99 mmHg (ESC/ESH) or SBP 130-139 mmHg or DBP 80-89 mmHg (ACC/AHA) 1, 2
• Stage 2 hypertension is defined as SBP ≥160 mmHg or DBP ≥100 mmHg (ESC/ESH) or SBP ≥140 mmHg or DBP ≥90 mmHg (ACC/AHA) 1, 2

Diagnosis and Blood Pressure Measurement

• Multiple office BP measurements are the gold standard for diagnosis 2
• Home BP monitoring and ambulatory BP monitoring are recommended to confirm diagnosis 1, 2
• Standing pressures must be measured in elderly people and patients with diabetes due to potential orthostatic hypotension 2
• For initial assessment, measure BP in both arms simultaneously; if there is a consistent difference, use the arm with the higher BP 1

Lifestyle Modifications

• All patients with elevated BP or hypertension should implement lifestyle modifications 2
• Key modifications include:
  • Weight reduction to achieve ideal body weight 2, 3
  • Regular physical activity (aerobic activity complemented with resistance training 2-3 times/week) 2, 4
  • Reduction in sodium intake (eliminating table salt) 2, 3
  • Moderation of alcohol intake (<21 units/week for males, <14 units/week for females) 2, 5
  • Healthy diet patterns such as Mediterranean or DASH diets 2, 4
  • Smoking cessation 2

Pharmacological Treatment

• First-line antihypertensive medications include:

  • ACE inhibitors or angiotensin receptor blockers (ARBs) 1, 4
  • Calcium channel blockers (preferably dihydropyridine) 1, 4
  • Thiazide or thiazide-like diuretics 1, 4

• The 2024 ESC guidelines recommend upfront combination therapy for adults with confirmed hypertension, preferably as single-pill combinations, to improve adherence and achieve faster BP control. 1, 2

• Treatment algorithm:

  1. Start with low-dose combination therapy (two drugs) for most patients with hypertension 1, 2
  2. If BP remains uncontrolled, increase to full dose 1
  3. If still uncontrolled, add a third agent (typically a thiazide/thiazide-like diuretic if not already included) 1
  4. For resistant hypertension (uncontrolled BP on triple therapy), add spironolactone as fourth-line agent 1
  5. If spironolactone is not tolerated, consider eplerenone, amiloride, doxazosin, or beta-blockers 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, 2
• More lenient targets may be considered for patients aged ≥85 years, those with frailty, or those with symptomatic orthostatic hypotension 2
• Treatment should be maintained lifelong, even beyond age 85 if well tolerated 2, 6

Special Populations

Black Patients

• Initial therapy should include either:
  • Low-dose ARB + dihydropyridine CCB, or
  • Dihydropyridine CCB + thiazide-like diuretic 1

Resistant Hypertension

• Defined as BP that remains above goal despite three optimally dosed antihypertensive medications including a diuretic 2, 7
• Add spironolactone as fourth-line agent 1
• Ensure medication adherence through direct observed therapy or drug level measurement 6, 7
• Refer to specialist centers for appropriate work-up 1, 7

Implementation and Adherence

• Simplify drug regimens by using long-acting drugs and single-pill combinations 1, 2
• Regular monitoring is required to ensure BP control and medication adherence 2
• Patient education improves persistence with treatment 2
• Aim to achieve target BP within 3 months 1

Common Pitfalls and Caveats

• Improper BP measurement technique can lead to inaccurate readings and inappropriate treatment decisions 2
• ACE inhibitors and ARBs should not be used in combination due to increased risk of adverse effects without additional benefit 1, 2
• Beta-blockers are not advised for treatment of general population unless specific indications exist (e.g., coronary artery disease, heart failure) 2, 6
• Overaggressive reduction in diastolic pressure may lead to increased coronary events in patients with established ischemic heart disease 1
• Orthostatic hypotension must be monitored, especially in elderly patients and those with diabetes 2