What are the newest guidelines for managing hypertension?

Newest Hypertension Guidelines

The 2024 European Society of Cardiology (ESC) guidelines represent the most recent evidence-based standards, recommending upfront combination therapy with a target systolic blood pressure of 120-129 mmHg for most adults, a more aggressive approach than previous guidelines. 1

Blood Pressure Thresholds and Diagnosis

• Hypertension is defined as persistent BP ≥140/90 mmHg according to the ESC, while the ACC/AHA uses a lower threshold of ≥130/80 mmHg 1, 2
• Confirm diagnosis using home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) rather than relying solely on office measurements 3
• Measure BP in both arms simultaneously at the first visit; if there is a consistent difference, use the arm with the higher reading for all subsequent measurements 3, 1

Treatment Targets

• The 2024 ESC guidelines recommend a target SBP of 120-129 mmHg for most adults, provided treatment is well tolerated 1, 2
• For patients aged ≥85 years, those with moderate-to-severe frailty, or symptomatic orthostatic hypotension, more lenient targets may be appropriate 1, 2
• For adults <65 years, target BP <130/80 mmHg; for those ≥65 years, target SBP <130 mmHg 4
• Achieve target BP within 3 months of initiating treatment 3, 1

Pharmacological Treatment Strategy

Initial Therapy

• The 2024 ESC guidelines recommend upfront combination therapy for adults with confirmed hypertension, preferably as single-pill combinations 1
• First-line medications include ACE inhibitors or ARBs, calcium channel blockers (specifically dihydropyridine CCBs), and thiazide or thiazide-like diuretics 3, 1, 4
• Chlorthalidone and indapamide (thiazide-like diuretics) are preferred over hydrochlorothiazide due to longer duration of action 3

Treatment Algorithm for Non-Black Patients

1. Start with low-dose combination of RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine CCB or thiazide-like diuretic 1, 2
2. Increase to full dose if BP remains uncontrolled 3
3. Add a third agent (typically completing the triple combination of RAS blocker + CCB + thiazide-like diuretic) 1, 2
4. For resistant hypertension, add spironolactone or, if not tolerated or contraindicated, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 3, 1

Treatment Algorithm for Black Patients

1. Start with low-dose ARB plus dihydropyridine CCB, or dihydropyridine CCB plus thiazide-like diuretic (avoid ACE inhibitor or ARB monotherapy) 3, 1
2. Increase to full dose if BP remains uncontrolled 3
3. Add the third agent (diuretic or ACE inhibitor/ARB) 3
4. Add spironolactone or alternative fourth-line agent if still uncontrolled 3

Lifestyle Modifications

• All patients with elevated BP or hypertension should implement lifestyle modifications regardless of medication use 1, 2
• Reduce dietary sodium intake to <1,500 mg/day (optimal target) or at minimum <2,300 mg/day; a 100 mmol/day reduction in sodium lowers SBP by 5.43 mmHg 3
• Increase potassium intake to 90-150 mmol/day for optimal BP lowering effect 3
• Maintain healthy body weight (BMI 18.5-24.9 kg/m²) and waist circumference (<102 cm in men, <88 cm in women) 4
• Perform 30-60 minutes of aerobic exercise 4-7 days per week, complemented with low- or moderate-intensity resistance training 2-3 times per week 2
• Limit alcohol consumption to <100g/week of pure alcohol (maximum 14 drinks/week for men, 9 drinks/week for women), though abstinence is preferred 1, 2
• Follow Mediterranean or DASH dietary patterns emphasizing fruits, vegetables, low-fat dairy products, whole grains, and plant-based proteins 1, 4

Important Caveats and Pitfalls

• Beta-blockers are not recommended as first-line agents in patients without coronary heart disease or heart failure due to lesser benefit on stroke reduction compared with other recommended classes 3, 1, 2
• Never combine ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 1
• SGLT-2 inhibitors and GLP-1 receptor agonists reduce BP by 2-4 mmHg but should be prescribed primarily for glucose lowering and cardiovascular/kidney protection in diabetic patients, not as primary antihypertensive agents 3
• Use validated automated upper arm cuff devices with appropriate cuff size for accurate BP measurement 3
• Single-pill combinations improve adherence and should be used whenever possible 1, 2
• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence 2

Monitoring and Referral

• Monitor BP control regularly to achieve target within 3 months 3, 1
• Check medication adherence if BP remains uncontrolled 3
• Refer to a specialist if BP remains uncontrolled despite optimal therapy or if secondary hypertension is suspected 3, 2
• For resistant hypertension, consider adherence testing with direct observed therapy or drug level measurement 2