What are the recommended treatments for managing hypertension?

Hypertension Management

For most adults with confirmed hypertension (BP ≥140/90 mmHg), immediately initiate combination pharmacological therapy with two first-line agents—specifically a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic—preferably as a single-pill combination, alongside comprehensive lifestyle modifications. 1, 2

Blood Pressure Targets

Target systolic BP of 120-129 mmHg for most adults if well tolerated, as this range provides optimal cardiovascular risk reduction. 1, 2, 3 The 2024 ESC guidelines represent a significant shift toward more aggressive BP control compared to older recommendations.

• For adults ≥65 years, target systolic BP 130-139 mmHg 2, 3
• For high-risk patients (diabetes, CKD, established CVD), target <130/80 mmHg 2, 3
• If the 120-129 mmHg target is poorly tolerated, apply the ALARA principle ("as low as reasonably achievable") 1

Pharmacological Treatment Algorithm

Initial Therapy (BP ≥140/90 mmHg)

Start with two-drug combination therapy immediately rather than monotherapy, as this achieves BP control more effectively. 1, 2, 3

Preferred initial combinations: 1, 2, 3

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

Always prescribe as single-pill fixed-dose combinations to dramatically improve adherence. 1, 2, 3

Exceptions to combination therapy (consider monotherapy): 1

• Patients aged ≥85 years
• Symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (120-139/70-89 mmHg) with concomitant indication for treatment

Escalation to Triple Therapy

If BP remains uncontrolled after 4 weeks on dual therapy, escalate to RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1, 2, 3

Resistant Hypertension (Fourth-Line)

Add spironolactone when BP remains uncontrolled on triple therapy. 3

First-Line Drug Classes

ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazides/thiazide-like diuretics have demonstrated the most effective reduction in BP and cardiovascular events. 1, 4, 5, 6

Beta-Blockers

Reserve for compelling indications: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control. 1 Combine with other major BP-lowering drug classes when indicated. 1

Lifestyle Modifications (Essential for All Patients)

Weight Management

• Target BMI 20-25 kg/m² 1, 2, 3
• Waist circumference <94 cm (men) or <80 cm (women) 1, 2, 3

Physical Activity

• ≥150 minutes/week of moderate-intensity aerobic exercise (or 75 minutes/week vigorous intensity) 1, 2, 3
• Add resistance training 2-3 times/week (low- to moderate-intensity dynamic or isometric) 1, 2

Dietary Modifications

• Adopt Mediterranean or DASH diet patterns 1, 3
• Restrict sodium intake (avoid table salt, limit processed foods) 1, 3, 6
• Increase potassium intake through fruits and vegetables 6, 7
• Limit free sugar to maximum 10% of energy intake; avoid sugar-sweetened beverages 1, 3

Alcohol Restriction

• Men: <100 g/week of pure alcohol (approximately <14 standard drinks/week) 1, 3
• Women: <56 g/week (approximately <8 standard drinks/week) 3
• Preferably avoid alcohol entirely for best health outcomes 1

Smoking Cessation

• Mandatory recommendation with referral to cessation programs 1, 3

Elevated BP with High Cardiovascular Risk (130-139/80-89 mmHg)

For patients with elevated BP and high CVD risk (≥10% 10-year risk), initiate lifestyle modifications first. 1, 3 If BP remains ≥130/80 mmHg after 3 months of lifestyle intervention, initiate pharmacological treatment. 1, 3

Special Population Considerations

Black Patients

Initial therapy should include a thiazide-like diuretic plus CCB, or CCB plus ARB. 2 Note: The stroke reduction benefit of losartan in patients with left ventricular hypertrophy does not apply to Black patients. 4

Chronic Kidney Disease

• Include RAS blocker when albuminuria/proteinuria is present 2, 3
• Target systolic BP 120-129 mmHg for eGFR >30 mL/min/1.73m² 2, 3

Diabetes

• Initiate treatment at BP ≥140/90 mmHg 2
• Target BP <130/80 mmHg 2, 3
• Losartan specifically indicated for diabetic nephropathy with elevated creatinine and proteinuria (albumin/creatinine ratio ≥300 mg/g) 4

Heart Failure

• HFrEF: Use ACE inhibitor/ARB, beta-blocker, diuretic, and/or mineralocorticoid receptor antagonist 3
• HFpEF: Consider SGLT2 inhibitors 3

Previous Stroke/TIA

Target systolic BP 120-130 mmHg using RAS blockers, CCBs, and diuretics as first-line agents. 2, 3

Elderly Patients (≥85 years)

Continue lifelong BP-lowering treatment if well tolerated. 1, 3 Consider more lenient targets (<140/90 mmHg) if symptomatic orthostatic hypotension or moderate-to-severe frailty present. 3

Critical Pitfalls to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB) due to increased adverse effects without additional benefit. 1, 2, 3

• Failing to confirm diagnosis with multiple measurements before initiating treatment 3
• Not considering white coat hypertension when office readings are elevated 3
• Using monotherapy when combination therapy is indicated 1, 2
• Inadequate dosing or inappropriate drug combinations 3
• Neglecting lifestyle modifications alongside pharmacological treatment 1, 3
• Overlooking lower BP targets in high-risk patients 3
• Measuring BP incorrectly (patient not seated, arm not at heart level, inadequate cuff size) 1, 3

Diagnosis and Monitoring

Initial Diagnosis

• Use validated BP device with patient seated, arm at heart level 1, 3
• Take at least two measurements per visit across multiple visits 1, 3
• Measure standing BP in elderly and diabetic patients to exclude orthostatic hypotension 1

Ambulatory BP Monitoring Indications

• Unusual BP variability 1, 3
• Suspected white coat hypertension 1, 3
• Resistant hypertension (≥3 drugs) 1, 3
• Symptoms suggesting hypotension 1

Cardiovascular Risk Assessment

Calculate 10-year cardiovascular disease risk to guide treatment intensity for borderline hypertension. 1, 2, 3 Reassess annually. 2, 3

Medication Timing

Take medications at the most convenient time of day to establish habitual patterns and improve adherence. 1 Recent evidence does not support specific timing advantages.

Long-Term Management

• Regular BP monitoring using both office and home readings 2, 3
• Maintain treatment lifelong if well tolerated, even beyond age 85 1, 3
• Employ multidisciplinary team approaches involving pharmacists to enhance adherence 2