What are the guidelines for managing blood pressure?

Guidelines for Blood Pressure Management

According to the 2024 European Society of Cardiology guidelines, blood pressure is now categorized into three levels: non-elevated (<120/70 mmHg), elevated (120-139/70-89 mmHg), and hypertension (≥140/90 mmHg), with treatment recommendations based on these categories and cardiovascular risk assessment. 1

Blood Pressure Classification and Measurement

• Blood pressure should be measured using a validated device with the patient seated, arm at heart level, with at least two measurements at each visit 2, 3
• The 2024 ESC guidelines classify blood pressure as:
  • Non-elevated: <120/70 mmHg
  • Elevated: 120-139/70-89 mmHg
  • Hypertension: ≥140/90 mmHg 1
• Ambulatory or home blood pressure monitoring is recommended for confirming elevated BP and hypertension, especially with unusual BP variability, suspected white coat hypertension, or resistant hypertension 1, 3

Treatment Thresholds and Targets

• For confirmed hypertension (≥140/90 mmHg): Immediate initiation of both lifestyle interventions and pharmacological therapy is recommended regardless of cardiovascular risk 1
• For elevated BP (120-139/70-89 mmHg): Treatment decisions should be based on cardiovascular risk assessment:
  • With high-risk conditions (established CVD, diabetes, CKD) or 10-year CVD risk ≥10%: Pharmacological treatment is recommended 1
  • Without high-risk conditions and 10-year CVD risk <10%: Lifestyle modifications alone are recommended 1
• The default target systolic BP is 120-129 mmHg and diastolic BP is 70-79 mmHg for most patients 1, 2
• Relaxed targets may be appropriate for adults ≥85 years, those with orthostatic hypotension, moderate-to-severe frailty, or limited life expectancy 1

Lifestyle Modifications

• Lifestyle interventions are crucial and should be implemented alongside pharmacological therapy in patients with hypertension 1
• Effective lifestyle modifications include:
  • Regular physical activity (30-60 minutes of aerobic exercise 4-7 days per week) 2, 3
  • Weight reduction to achieve healthy body weight (BMI 18.5-24.9 kg/m²) 2, 3
  • Dietary sodium restriction 2, 3
  • Limiting alcohol consumption 2, 3
  • Following a diet reduced in saturated fat and cholesterol, emphasizing fruits, vegetables, and low-fat dairy products 2, 3

Pharmacological Management

• For most patients with confirmed hypertension (≥140/90 mmHg), combination therapy is recommended as initial treatment 1, 2
• Preferred initial combination is a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker (CCB) or diuretic 1, 2
• Fixed-dose single-pill combinations are recommended to improve adherence 1
• If BP is not controlled with a two-drug combination, increasing to a three-drug combination is recommended (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1
• For resistant hypertension, adding spironolactone should be considered 1
• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

Special Populations

• Patients with diabetes, chronic kidney disease, or established cardiovascular disease may require lower BP targets 2, 3
• In elderly patients (≥85 years), those with orthostatic hypotension, or moderate-to-severe frailty, treatment should be maintained if well tolerated, with more relaxed BP targets 1

Monitoring and Follow-up

• After treatment initiation, patients should be seen frequently (every 1-3 months) until BP is controlled 1
• BP should be controlled preferably within 3 months 1
• Regular monitoring of BP (office and home readings when possible) is necessary 2, 3
• Annual reassessment of cardiovascular risk is recommended 2, 3

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis 3
• Not considering white coat hypertension when office readings are elevated 3
• Inadequate dosing or inappropriate combinations of antihypertensive medications 3
• Not addressing lifestyle modifications alongside pharmacological treatment 3
• Overlooking the need for lower BP targets in high-risk patients 3
• Not considering secondary causes in resistant hypertension or young patients 3

The 2024 ESC guidelines represent a significant update in hypertension management, with new BP categories and treatment thresholds that emphasize early intervention based on cardiovascular risk assessment to reduce morbidity and mortality.