Latest Guidelines on Hypertension Management
The 2024 European Society of Cardiology (ESC) guidelines recommend upfront combination therapy for adults with confirmed hypertension, preferably as single-pill combinations, with a target systolic blood pressure of 120-129 mmHg for most adults. 1, 2
Definition and Classification
- Hypertension is defined as persistent blood pressure ≥140/90 mmHg according to the European Society of Cardiology (ESC), while the American College of Cardiology (ACC) and American Heart Association (AHA) define it as ≥130/80 mmHg 1
- Stage 1 hypertension: SBP 140-159 mmHg or DBP 90-99 mmHg (ESC) or SBP 130-139 mmHg or DBP 80-89 mmHg (ACC/AHA) 1
- Stage 2 hypertension: SBP ≥160 mmHg or DBP ≥100 mmHg (ESC) or SBP ≥140 mmHg or DBP ≥90 mmHg (ACC/AHA) 1
Diagnosis and Assessment
- Home BP monitoring and ambulatory BP monitoring are recommended to confirm diagnosis 1
- Measure BP in both arms simultaneously during initial assessment; 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 as first-line therapy 1, 3
- Recommended lifestyle changes include:
- Weight reduction (can reduce BP by 5-20 mmHg per 10 kg weight loss) 4
- Regular physical activity (can reduce BP by 4-9 mmHg) 4
- Reduction in sodium intake (can reduce BP by 2-8 mmHg) 4
- Moderation of alcohol intake (can reduce BP by 2-4 mmHg) 4
- Healthy diet patterns such as Mediterranean or DASH diets 1, 2
- Combination of two or more lifestyle modifications may have additive benefits 4
Pharmacological Treatment
First-Line Medications
- First-line antihypertensive medications include: 1, 3
- ACE inhibitors or angiotensin receptor blockers (ARBs)
- Calcium channel blockers (CCBs)
- Thiazide or thiazide-like diuretics
Treatment Strategy
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
- Increase to full dose if BP remains uncontrolled
- Add a third agent if still uncontrolled
For black patients, initial therapy should include either low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 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: 1, 2
- Patients aged ≥85 years
- Those with frailty
- Those with symptomatic orthostatic hypotension
Special Considerations and Caveats
- ACE inhibitors and ARBs should not be used in combination due to increased risk of adverse effects without additional benefit 1
- Beta-blockers are not advised for treatment of the general population unless specific indications exist (e.g., coronary artery disease, heart failure) 1, 2
- Overaggressive reduction in diastolic pressure may lead to increased coronary events in patients with established ischemic heart disease 1
- The WHO Essential Medicines List includes ACE inhibitors, calcium channel blockers, angiotensin receptor blockers, and thiazide diuretics for management of hypertension 5
- Single-pill combination antihypertensive medications were added to the WHO Essential Medicines List in 2019 5
Implementation and Adherence
- Simplify drug regimens by using long-acting drugs and single-pill combinations 1
- Regular monitoring is required to ensure BP control and medication adherence 1
- Patient education improves persistence with treatment 1
- Aim to achieve target BP within 3 months 1
- Treatment should be maintained lifelong, even beyond the age of 85 years, if well tolerated 2