What are the recent guidelines for treating hypertension?

Recent Guidelines for Treating Hypertension

For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination pharmacological therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination, targeting a systolic BP of 120-129 mmHg if tolerated. 1

Blood Pressure Thresholds for Treatment Initiation

• Adults with BP ≥140/90 mmHg should receive both lifestyle modifications and pharmacological treatment promptly, regardless of cardiovascular risk level 1
• Adults with elevated BP (130-139/80-89 mmHg) and high cardiovascular risk (≥10% over 10 years) should receive pharmacological treatment after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1
• Adults with elevated BP and low-to-medium cardiovascular risk should focus on lifestyle modifications, with pharmacological treatment considered if BP remains uncontrolled after 3-6 months 1

Target Blood Pressure Goals

The most recent 2024 European guidelines recommend a systolic BP target of 120-129 mmHg for most adults, provided treatment is well tolerated. 1 This represents a shift toward more intensive BP control compared to older guidelines.

• For patients under 65 years: target <130/80 mmHg if tolerated (but >120/70 mmHg) 1
• For patients 65 years and older: individualized targets considering frailty, independence, and tolerability, but generally <140/90 mmHg if tolerated 1
• For patients 85 years and older: more lenient targets may be appropriate, though treatment should continue lifelong if well tolerated 1
• When intensive targets cannot be achieved, apply the "as low as reasonably achievable" (ALARA) principle 1

First-Line Pharmacological Treatment Strategy

Initial Therapy

Combination therapy is now preferred over monotherapy for most patients with confirmed hypertension. 1 This approach provides more effective BP control and faster achievement of target BP.

Preferred initial combinations: 1, 2

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker, OR
• RAS blocker (ACE inhibitor or ARB) + thiazide/thiazide-like diuretic (chlorthalidone or indapamide)

Single-pill combinations are strongly recommended to improve adherence and simplify regimens 1, 2

Drug Classes with Proven Mortality Benefit

The following four drug classes have demonstrated the most effective reduction in BP and cardiovascular events: 1

• ACE inhibitors (e.g., lisinopril, enalapril) 3
• Angiotensin receptor blockers (ARBs) (e.g., losartan, candesartan) 4
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 5
• Thiazide/thiazide-like diuretics (e.g., chlorthalidone, indapamide, hydrochlorothiazide) 1

Treatment Escalation Algorithm

Step 1: Two-drug combination (RAS blocker + CCB or diuretic), preferably as single-pill combination 1, 2

Step 2: If BP not controlled, escalate to three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic), preferably as single-pill combination 1, 2

Step 3: For resistant hypertension (BP uncontrolled on three drugs including a diuretic), add low-dose spironolactone (25 mg daily) as the preferred fourth agent, with monitoring of potassium and renal function within 1-2 weeks 6

Important caveat: Combining two RAS blockers (ACE inhibitor + ARB) is not recommended due to increased risk of adverse events without additional benefit 1

Special Populations

Black Patients

• Initial therapy should include a diuretic or calcium channel blocker, either alone or in combination with a RAS blocker 2
• There is evidence that losartan's benefit for stroke reduction in patients with left ventricular hypertrophy does not apply to Black patients 4

Patients with Diabetes

• Target BP <130/80 mmHg 2
• RAS blockers are particularly beneficial for those with diabetic nephropathy (albumin-to-creatinine ratio ≥300 mg/g) 4

Patients with Chronic Kidney Disease

• Target systolic BP 120-129 mmHg if tolerated 2
• RAS blockers are first-line for patients with albuminuria or proteinuria due to superior albuminuria reduction 2

Elderly Patients (≥65 years)

• Continue treatment lifelong, even beyond age 85, if well tolerated 1
• Consider more individualized targets based on frailty and tolerability 1

Lifestyle Modifications

Lifestyle modifications should be implemented for all patients with hypertension or elevated BP, as they can prevent or delay onset of hypertension and enhance medication effects. 1

Dietary Interventions

• Sodium restriction to <2,300 mg/day (approximately <100 mEq/24 hours) 1, 2, 7
• Adopt Mediterranean or DASH diet patterns: rich in whole grains, fruits, vegetables, polyunsaturated fats, low-fat dairy products, and low in saturated fat, trans fats, and added sugars 1
• Restrict free sugar consumption to maximum 10% of energy intake; eliminate sugar-sweetened beverages 1
• Increase intake of vegetables high in nitrates (leafy vegetables, beetroot) and foods high in magnesium, calcium, and potassium 1

Physical Activity

• At least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise weekly 1
• Complement with low- to moderate-intensity resistance training 2-3 times per week 1

Weight Management

• Aim for BMI 20-25 kg/m² and waist circumference <94 cm in men, <80 cm in women 1

Alcohol and Tobacco

• Limit alcohol to <100 g/week of pure alcohol (approximately ≤14 units/week for men, ≤8 units/week for women); preferably avoid alcohol completely for best health outcomes 1, 6
• Complete tobacco cessation with referral to smoking cessation programs 1, 2

Medication Adherence Strategies

Nonadherence affects 10-80% of hypertensive patients and is a key driver of poor BP control. 1 The following strategies improve adherence:

• Use single-pill combinations to reduce pill burden 1
• Once-daily dosing over multiple daily doses 1
• Take medications at the most convenient time to establish habitual patterns 1
• Implement home BP monitoring 1
• Provide adherence feedback and empowerment-based counseling 1
• Consider electronic adherence aids (mobile apps, text message reminders) 1

Monitoring and Follow-Up

• Achieve target BP within 3 months of treatment initiation 2
• Evaluate adherence at each visit before escalating therapy 1
• Monitor renal function and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 2
• Consider home BP monitoring with target <135/85 mmHg 6

Common Pitfalls and Caveats

Seasonal BP Variation

• BP exhibits seasonal variation, with average decline of 5/3 mmHg (systolic/diastolic) in summer 1
• Consider downtitration if BP falls below goal during temperature rise, particularly if symptoms of overtreatment appear 1

Substances That Raise BP

• Screen all patients for substances that may increase BP or interfere with antihypertensive medications, including NSAIDs, oral contraceptives, corticosteroids, decongestants, and certain herbal supplements 1

Beta-Blockers

• Beta-blockers are not first-line for uncomplicated hypertension 1
• Combine with other major drug classes when compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, heart rate control) 1

Resistant Hypertension

• Before diagnosing resistant hypertension, confirm adherence, exclude white-coat effect, and screen for secondary causes 6
• Spironolactone is the preferred add-on agent for resistant hypertension 6