What is the latest guideline for managing hypertension?

Latest Hypertension Guidelines

The 2024 European Society of Cardiology (ESC) guidelines represent the most current evidence-based recommendations for hypertension management, establishing a systolic blood pressure target of 120-129 mmHg for most adults and recommending combination therapy as initial treatment for confirmed hypertension (BP ≥140/90 mmHg). 1

Blood Pressure Classification and Diagnosis

The 2024 ESC guidelines introduced a simplified three-tier classification system 1:

• Non-elevated BP: <120/70 mmHg
• Elevated BP: 120-139/70-89 mmHg
• Hypertension: ≥140/90 mmHg

Multiple office blood pressure measurements remain the gold standard for diagnosis, though ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring can aid in confirming diagnosis and long-term monitoring. 1

Blood Pressure Targets

Target systolic BP of 120-129 mmHg for most adults is recommended to reduce cardiovascular disease risk, provided treatment is well tolerated. 1, 2 This represents a shift toward more intensive BP control based on accumulated trial evidence demonstrating significant reductions in cardiovascular morbidity and mortality. 2

When the 120-129 mmHg target cannot be achieved due to poor tolerability, the "as low as reasonably achievable" (ALARA) principle should guide treatment, aiming for the lowest BP the patient can tolerate. 1

Lifestyle Modifications

All patients with elevated BP or hypertension should receive lifestyle modification recommendations, which form the foundation of treatment. 1, 3, 4

Specific Lifestyle Interventions:

• Physical Activity: At least 150 minutes/week of moderate-intensity aerobic exercise, complemented with low- or moderate-intensity resistance training 2-3 times/week 1

• Weight Management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1

• Dietary Pattern: Mediterranean or DASH diet, with sodium restriction being among the most effective interventions for BP reduction 1, 3, 4

• Alcohol Restriction: Limit to <100 g/week of pure alcohol, with complete avoidance preferred for optimal health outcomes 1

• Sugar Restriction: Limit free sugar to maximum 10% of energy intake and discourage sugar-sweetened beverages 1

• Smoking Cessation: Complete tobacco cessation with supportive care and referral to cessation programs 1, 5

Pharmacological Treatment Initiation

For Elevated BP (120-139/70-89 mmHg):

In adults with elevated BP and low/medium CVD risk (<10% over 10 years), lifestyle measures alone are recommended initially. 1

For those with elevated BP and high CVD risk, after 3 months of lifestyle intervention, pharmacological treatment is recommended if confirmed BP remains ≥130/80 mmHg. 1, 2

For Hypertension (≥140/90 mmHg):

Immediate initiation of both lifestyle measures and pharmacological treatment is recommended for all patients with confirmed BP ≥140/90 mmHg, regardless of CVD risk. 1

First-Line Pharmacological Agents

ACE inhibitors, ARBs, dihydropyridine calcium channel blockers (CCBs), and thiazide/thiazide-like diuretics (chlorthalidone, indapamide) are recommended as first-line treatments, as they have demonstrated the most effective reduction in BP and cardiovascular events. 1, 4

Beta-blockers are not recommended as first-line therapy for uncomplicated hypertension but should be combined with other agents when compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, or heart rate control). 1

Combination Therapy Strategy

Combination BP-lowering treatment is recommended as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg), as it provides more effective BP control than monotherapy. 1

Preferred Combinations:

• Two-drug combination: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB or RAS blocker + thiazide/thiazide-like diuretic 1

• Three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1

Fixed-dose single-pill combinations are strongly recommended over free-drug combinations to improve adherence. 1

Exceptions to Initial Combination Therapy:

Consider monotherapy for patients aged ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or those with elevated BP (not hypertension) with concomitant treatment indications. 1

Critical Contraindications

Combining two RAS blockers (ACE inhibitor + ARB) is explicitly not recommended due to increased risk of end-stage renal disease and stroke. 1

Medication Timing and Adherence

Medications should be taken at the most convenient time of day for the patient to establish habitual patterns and improve adherence, rather than adhering to rigid timing protocols. 1 This represents a shift from older recommendations that emphasized specific dosing times.

Duration of Treatment

BP-lowering drug treatment should be maintained lifelong, even beyond age 85 years, if well tolerated. 1 Regular monitoring through self-measurement and clinical visits is essential to maintain adherence and treatment efficacy. 1

Common Pitfalls

The 2024 ESC guidelines acknowledge that more lenient targets may be appropriate for very elderly patients (≥85 years), those with frailty, or symptomatic orthostatic hypotension. 1, 2 However, this should not be used as a blanket justification for inadequate BP control in otherwise healthy older adults.

Treatment should be adjusted every 2-4 weeks until BP control is achieved, with the goal of establishing an effective regimen within 6-8 weeks of initiation. 1