What are the guidelines for managing elevated blood pressure and hypertension?

Guidelines for the Management of Elevated Blood Pressure and Hypertension

The 2024 European Society of Cardiology (ESC) guidelines recommend a comprehensive approach to managing elevated blood pressure and hypertension, with lifestyle modifications and pharmacological therapy tailored to blood pressure levels and cardiovascular risk. 1

Blood Pressure Classification

• Blood pressure is categorized as non-elevated (<120/70 mmHg), elevated (120-139/70-89 mmHg), and hypertension (≥140/90 mmHg) 1, 2
• Diagnosis of hypertension should be based on multiple measurements, preferably using out-of-office blood pressure measurement with ambulatory blood pressure monitoring (ABPM) and/or home blood pressure monitoring (HBPM) 1
• For screening BP of 140-159/90-99 mmHg, confirmation with out-of-office measurements is recommended 1
• For BP ≥160/100 mmHg, prompt confirmation is needed, with urgent evaluation for BP ≥180/110 mmHg to exclude hypertensive emergency 1

Lifestyle Modifications

• Lifestyle modifications are recommended for all patients with elevated BP or hypertension 1
• Sodium restriction to approximately 2g per day (equivalent to about 5g of salt) is recommended 1, 3
• Regular physical activity: ≥150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2-3 times/week 1
• Maintaining a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Following Mediterranean or DASH dietary patterns 1, 3
• Limiting alcohol consumption (less than 100g/week) or preferably avoiding it completely 1
• Restricting free sugar consumption, particularly sugar-sweetened beverages 1
• Smoking cessation with appropriate supportive care 1

Pharmacological Treatment Approach

• For confirmed hypertension (≥140/90 mmHg), immediate initiation of both lifestyle and pharmacological therapy is recommended regardless of cardiovascular risk 1
• For elevated BP (120-139/70-89 mmHg) with high cardiovascular risk (≥10% over 10 years), pharmacological treatment is recommended after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1
• First-line medications include ACE inhibitors, ARBs, dihydropyridine calcium channel blockers (CCBs), and thiazide/thiazide-like diuretics 1, 4, 5
• Beta-blockers are recommended when there are specific indications such as angina, post-myocardial infarction, heart failure, or for heart rate control 1

Initial Treatment Strategy

• Combination therapy is recommended for most patients with confirmed hypertension (≥140/90 mmHg) as initial therapy 1
• Preferred combinations are a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic 1, 6
• Fixed-dose single-pill combinations are recommended to improve adherence 1, 2
• If BP is not controlled with a two-drug combination, a three-drug combination is recommended (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1
• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

Blood Pressure Targets

• The target systolic BP for most adults is 120-129 mmHg, provided treatment is well tolerated 1
• When this target cannot be achieved due to poor tolerability, the "as low as reasonably achievable" (ALARA) principle should be applied 1
• For patients with elevated BP and low/medium cardiovascular risk (<10% over 10 years), lifestyle modifications alone can reduce cardiovascular risk 1

Special Populations

• Young adults (<40 years) with hypertension should undergo comprehensive screening for secondary hypertension 1
• In pregnant women with chronic or gestational hypertension, drug treatment is recommended for BP ≥140/90 mmHg, targeting BP below 140/90 mmHg but not below 80 mmHg for diastolic BP 1
• For elderly patients (≥85 years), those with orthostatic hypotension, or moderate-to-severe frailty, more individualized approaches may be needed 1, 2

Monitoring and Follow-up

• Regular monitoring of BP and annual reassessment of cardiovascular risk is recommended 2
• Multidisciplinary approaches to hypertension management, including appropriate task-shifting away from physicians, are recommended to improve BP control 1
• Self-monitoring of BP at home is recommended to achieve better BP control and improve patient empowerment and adherence 1

Interventional Approaches

• Renal denervation is not recommended as a first-line intervention for hypertension due to lack of adequately powered outcome trials 1
• Renal denervation is not recommended for patients with moderate-to-severely impaired renal function or secondary causes of hypertension 1

The management of hypertension requires lifelong commitment to both lifestyle modifications and pharmacological therapy, with regular monitoring and adjustments based on BP control and tolerability.