What are the current guidelines for managing hypertension and target blood pressure levels?

Blood Pressure Management Guidelines

Diagnosis and Confirmation

Hypertension is diagnosed when office blood pressure is ≥140/90 mmHg on repeated measurements across 2-3 visits, confirmed with home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg. 1

• Use validated automated upper arm cuff devices with appropriate cuff size for accurate measurement 1
• Take the average of at least 2 readings per visit 1
• At first visit, measure BP in both arms simultaneously; if there is a consistent difference, use the arm with higher readings 1

Blood Pressure Targets

The most recent 2024 ESC guidelines recommend an initial target of <140/90 mmHg for all patients, then targeting 120-129/<80 mmHg if well tolerated, with 120 mmHg being the optimal systolic target. 1

Standard Targets:

• General population: 120-129/<80 mmHg (optimal target if tolerated) 1
• Initial target for all patients: <140/90 mmHg 1
• Patients with known CVD: <130 mmHg systolic (strong recommendation) 1
• High-risk patients (diabetes, CKD, high CVD risk): <130 mmHg systolic 1
• Diastolic target: 70-79 mmHg for all patients 1

Age-Specific Targets:

• Adults <65 years: 120-129/<80 mmHg if tolerated 1
• Adults ≥65 years: 130-139 mmHg systolic 1
• Adults ≥85 years: Consider more lenient target <140 mmHg 1

Special Populations Requiring Lenient Targets (<140/90 mmHg):

• Pretreatment symptomatic orthostatic hypotension 1
• Moderate-to-severe frailty at any age 1
• Limited life expectancy (<3 years) 1

Important caveat: The 2023 ESH guidelines diverge significantly, recommending against targeting BP below 120/70 mmHg based on J-curve concerns, though this contradicts recent trial evidence from SPRINT, STEP, and ESPRIT. 1 The 2024 ESC guidelines explicitly reject age-stratified targets based on meta-analyses showing age is not an effect modifier of treatment efficacy up to 85 years. 1

First-Line Pharmacological Treatment

For non-Black patients, initiate therapy with ACE inhibitors, ARBs, long-acting dihydropyridine calcium channel blockers, or thiazide/thiazide-like diuretics. 1

For Black patients, initiate with ARB plus calcium channel blocker or calcium channel blocker plus thiazide/thiazide-like diuretic. 1

Preferred Agents:

• Thiazide-like diuretics: Chlorthalidone or indapamide (preferred over hydrochlorothiazide) 1, 2
• ACE inhibitors: Lisinopril, enalapril 1, 2
• ARBs: Candesartan, losartan 1, 2
• Calcium channel blockers: Amlodipine (long-acting dihydropyridine) 1, 2

Beta-blockers are NOT first-line agents except when there is a compelling indication (heart failure with reduced ejection fraction, recent MI, angina). 1

Treatment Initiation Thresholds

Immediate Drug Therapy:

• BP ≥160/100 mmHg (Grade 2 hypertension): Start immediately 1
• BP 140-159/90-99 mmHg (Grade 1 hypertension) in high-risk patients: Start immediately 1

High-risk criteria include:

• Established CVD 1
• Chronic kidney disease 1
• Diabetes mellitus 1
• Target organ damage 1
• Age 50-80 years 1

Delayed Drug Therapy (after 3-6 months lifestyle modification):

• BP 140-159/90-99 mmHg in low-moderate risk patients without the above conditions 1

Combination Therapy Strategy

Most patients require combination therapy to achieve BP targets; single-pill combinations are preferred to improve adherence. 1

Step-wise Approach for Non-Black Patients:

1. Step 1: Low-dose ACE inhibitor/ARB OR calcium channel blocker OR thiazide-like diuretic 1
2. Step 2: Increase to full dose OR add second agent from different class 1
3. Step 3: Triple therapy with ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic (preferably single-pill combination) 1
4. Step 4: Add spironolactone 25-50 mg 1
5. Step 5: If spironolactone not tolerated, add eplerenone, beta-blocker, alpha-blocker, or centrally acting agent 1

Step-wise Approach for Black Patients:

1. Step 1: ARB + calcium channel blocker OR calcium channel blocker + thiazide-like diuretic 1
2. Step 2: Increase to full dose 1
3. Step 3: Add third agent (diuretic or ACE inhibitor/ARB) 1
4. Step 4: Add spironolactone or alternative fourth-line agent 1

Never combine ACE inhibitors with ARBs due to increased adverse effects without additional benefit. 1

Monitoring and Follow-up

After initiating or changing antihypertensive medications, follow up monthly until BP target is achieved. 1

• Target BP control should be achieved within 3 months 1
• Once controlled, follow up every 3-5 months 1
• Allow at least 4 weeks to observe full medication response unless urgent BP lowering is required 3
• Use home BP monitoring to confirm control (target <135/85 mmHg) 1, 3

Lifestyle Modifications

All patients with BP ≥130/85 mmHg should implement lifestyle modifications, which have additive effects with pharmacotherapy. 1, 2

Evidence-Based Interventions:

• Dietary sodium restriction: <100 mmol/day (2300 mg) for prevention; 65-100 mmol/day (1500-2300 mg) for treatment 1, 4
• Weight management: BMI 18.5-24.9 kg/m²; waist circumference <94 cm (men), <80 cm (women) 1, 4
• Aerobic exercise: 30-60 minutes, 4-7 days per week 1, 4
• DASH diet: Increased vegetables, fruits, fish, nuts, unsaturated fatty acids; low-fat dairy; reduced red meat 1
• Alcohol restriction: <14 units/week (men), <8 units/week (women); ideally avoid completely 1
• Potassium supplementation: Through dietary sources 2

Compelling Indications for Specific Agents

Heart Failure with Reduced Ejection Fraction:

• ACE inhibitors + beta-blockers (first-line) 1, 4

Recent Myocardial Infarction:

• Beta-blockers + ACE inhibitors (first-line) 1, 4

Angina:

• Beta-blockers + ACE inhibitors (first-line) 1, 4

Diabetes Mellitus:

• ACE inhibitors or ARBs (first-line) 1, 4
• Alternative: Thiazides or dihydropyridine calcium channel blockers if no albuminuria 4

Chronic Kidney Disease (non-diabetic):

• ACE inhibitors (first-line) 4
• Target BP: <140-130 mmHg systolic 1

Cerebrovascular Disease:

• ACE inhibitor + diuretic combination (preferred) 4

Pregnancy or Planning Pregnancy:

• Beta-blockers (first-line) 1

Common Pitfalls and Caveats

Diastolic J-curve concern: Lowering diastolic BP to <60 mmHg may increase cardiovascular risk in patients with high CVD risk and treated systolic BP <130 mmHg. 1 The optimal diastolic target is 70-79 mmHg, but emphasis should remain on controlling systolic BP even when diastolic is below this range if treatment is tolerated. 1

Orthostatic hypotension: Check for symptomatic orthostatic hypotension before intensifying therapy, particularly in elderly patients. 1

Frailty assessment: In frail elderly patients, tailor treatment to achieve the best BP possible within target range while monitoring for adverse effects rather than rigidly pursuing intensive targets. 1

Adherence: Single-pill combinations significantly improve adherence and should be used preferentially when combination therapy is required. 1

Task-shifting: Pharmacological treatment can be provided by trained non-physician professionals (pharmacists, nurses) with proper training, prescribing authority, protocols, and physician oversight. 1