What are the latest guidelines for managing hypertension?

Latest Hypertension Management Guidelines

Definition and Classification

The most recent 2024 ESC guidelines define hypertension as persistent blood pressure ≥140/90 mmHg, while the ACC/AHA uses a lower threshold of ≥130/80 mmHg. 1

• Stage 1 hypertension: SBP 140-159 mmHg or DBP 90-99 mmHg (ESC definition) 2, 1
• Stage 2 hypertension: SBP ≥160 mmHg or DBP ≥100 mmHg (ESC definition) 2, 1
• Elevated blood pressure: SBP 130-139 mmHg or DBP 80-89 mmHg 3

The ESC classification system remains the international standard, though clinicians should be aware that American guidelines use lower thresholds which may lead to earlier intervention. 1

Diagnostic Approach

Confirm the diagnosis using home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM) rather than relying solely on office measurements. 1

• Measure BP in both arms simultaneously at initial assessment; use the arm with consistently higher readings for subsequent measurements 1
• Office BP measurements should show persistent elevation on multiple visits before confirming diagnosis 2
• HBPM and ABPM use lower diagnostic thresholds than office measurements for defining hypertension 2

Lifestyle Modifications

All patients with elevated BP or hypertension must implement comprehensive lifestyle changes as first-line therapy. 1, 3

Specific interventions include:

• Weight reduction to achieve and maintain healthy BMI 1, 3
• Dietary modifications: Adopt Mediterranean or DASH diet patterns, restrict free sugar consumption, avoid sugar-sweetened beverages 3, 4, 5
• Sodium restriction: Reduce dietary sodium intake to enhance BP lowering 1, 4
• Potassium supplementation: Increase dietary potassium through fruits and vegetables 4
• Physical activity: Regular aerobic exercise complemented with low- or moderate-intensity dynamic or isometric resistance training 2-3 times per week 3
• Alcohol limitation: Restrict to less than 100g/week of pure alcohol, though abstinence is preferred 3

The DASH diet has been validated in large randomized controlled trials to significantly reduce blood pressure and also lowers cholesterol and homocysteine levels. 5 These lifestyle modifications have partially additive effects and enhance the efficacy of pharmacologic therapy. 4

Pharmacological Treatment Strategy

The 2024 ESC guidelines recommend upfront combination therapy for most adults with confirmed hypertension (BP ≥140/90 mmHg), preferably as single-pill combinations, to improve adherence and achieve faster BP control. 1, 3

First-line medication classes:

• ACE inhibitors or angiotensin receptor blockers (ARBs) 1, 6, 4
• Calcium channel blockers (dihydropyridine CCBs) 1, 7, 4
• Thiazide or thiazide-like diuretics (chlorthalidone or hydrochlorothiazide) 1, 3, 4

Treatment algorithm:

1. Initial therapy: Start with low-dose two-drug combination, preferably a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic 1, 3
2. If BP remains uncontrolled: Increase to full-dose two-drug combination 1
3. If still uncontrolled: Add a third agent to create a three-drug combination (RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic) 1, 3
4. For resistant hypertension: Consider referral to specialist centers and adherence testing with direct observed therapy or drug level measurement 3

Critical caveats:

• Never combine ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 1
• Beta-blockers are NOT first-line agents for general hypertension management unless specific compelling indications exist (coronary artery disease, heart failure, post-myocardial infarction) 1, 3
• For black patients, initial therapy should include either low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 1

Blood Pressure Targets

The 2024 ESC guidelines recommend an aggressive target SBP of 120-129 mmHg for most adults, provided the treatment is well tolerated—this represents a more intensive target than previous guidelines. 1, 3

Target modifications for special populations:

• Patients ≥85 years: More lenient targets may be considered 1, 3
• Moderate-to-severe frailty: More lenient targets may be appropriate 3
• Symptomatic orthostatic hypotension: More lenient targets may be necessary 1, 3
• Adults <65 years: Target SBP/DBP <130/80 mmHg 4
• Adults ≥65 years: Target SBP <130 mmHg 4

Important warning: Overaggressive reduction in diastolic pressure may lead to increased coronary events in patients with established ischemic heart disease. 1

Implementation and Adherence Strategies

Simplify drug regimens by using long-acting medications and single-pill combinations to maximize adherence. 1

• Fixed-dose single-pill combinations are strongly recommended to improve adherence 1, 3
• Medications should be taken at the most convenient time of day for the patient to establish a habitual pattern 3
• Aim to achieve target BP within 3 months of treatment initiation 1
• Regular monitoring is required to ensure BP control and medication adherence 1
• Patient education improves persistence with treatment 1
• Treatment should be maintained lifelong, even beyond age 85 years, if well tolerated 3

Evidence for Cardiovascular Benefit

An SBP reduction of 10 mmHg decreases risk of cardiovascular events by approximately 20-30%, with the largest benefit being stroke risk reduction. 4

• Lowering blood pressure reduces fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions 6, 7
• The benefit is blood pressure reduction itself, not specific pharmacologic properties of individual drug classes 6, 7, 4
• Absolute benefit is greater in patients at higher baseline cardiovascular risk (diabetes, hyperlipidemia), who should receive more aggressive treatment 6, 7
• Despite proven benefits, only 44% of US adults with hypertension have their BP controlled to <140/90 mmHg 4