What are the most recent guidelines for managing hypertension?

Most Recent Hypertension Management Guidelines

The 2024 European Society of Cardiology (ESC) guidelines represent the most current evidence-based approach to hypertension management, recommending a systolic blood pressure target of 120-129 mmHg for most adults and prompt initiation of combination pharmacological therapy for confirmed hypertension (BP ≥140/90 mmHg) alongside lifestyle modifications. 1

Blood Pressure Classification and Diagnosis

The 2024 ESC guidelines introduced a simplified three-level BP categorization system: 2

• Non-elevated BP: <120/70 mmHg 1
• Elevated BP: Systolic 120-139 mmHg or diastolic 70-89 mmHg 1
• Hypertension: ≥140/90 mmHg 1

Accurate BP measurement is critical for proper diagnosis. Multiple office measurements should be obtained at several visits before confirming hypertension, with standing BP measurements mandatory in elderly patients and those with diabetes to detect orthostatic hypotension. 1, 3 Home and ambulatory BP monitoring can confirm diagnosis and improve treatment monitoring. 3

Treatment Initiation Thresholds

For Confirmed Hypertension (BP ≥140/90 mmHg)

Immediate initiation of both lifestyle modifications and pharmacological treatment is recommended for all patients with confirmed hypertension, regardless of cardiovascular disease (CVD) risk level. 1 This represents a shift toward more aggressive early intervention based on accumulated evidence showing that a 20/10 mmHg BP difference associates with 50% difference in cardiovascular risk. 1

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

For patients with elevated BP and low-to-medium CVD risk (<10% over 10 years), begin with lifestyle modifications alone. 1 However, if CVD risk is sufficiently high (≥10% over 10 years) and BP remains ≥130/80 mmHg after 3 months of lifestyle intervention, pharmacological treatment should be initiated. 1

Blood Pressure Targets

The primary treatment target is systolic BP 120-129 mmHg for most adults, provided treatment is well tolerated. 1, 2 This intensive target is supported by multiple meta-analyses demonstrating that more aggressive BP lowering reduces cardiovascular and renal outcomes. 2

Modified Targets for Special Populations

More lenient targets should be considered for: 1, 3

• Patients aged ≥85 years
• Those with moderate-to-severe frailty
• Patients with symptomatic orthostatic hypotension

When intensive targets cannot be achieved due to poor tolerance, apply the "as low as reasonably achievable" (ALARA) principle. 1

Lifestyle Modifications

Lifestyle modifications are the first-line treatment for all patients with elevated BP or hypertension and should be maintained even when pharmacological therapy is initiated. 1 These modifications can prevent or delay hypertension onset and enhance antihypertensive drug efficacy. 1

Essential Lifestyle Interventions

Dietary modifications: 1

• Adopt Mediterranean or DASH diet patterns rich in whole grains, fruits, vegetables, polyunsaturated fats, and low-fat dairy products
• Restrict sodium intake by eliminating table salt and avoiding processed foods high in sodium (target <6 g/day)
• Increase potassium-rich foods (leafy vegetables, beetroot, avocados, nuts, legumes)
• Limit free sugar consumption to maximum 10% of energy intake and avoid sugar-sweetened beverages

Weight management: 1

• Achieve and maintain BMI 20-25 kg/m²
• Target waist circumference <94 cm in men and <80 cm in women

Physical activity: 1

• Regular aerobic exercise complemented with low-to-moderate intensity resistance training 2-3 times per week

Alcohol restriction: 1

• Limit consumption to <100 g/week of pure alcohol (approximately 8-14 g per standard drink)
• Preferably avoid alcohol completely for best health outcomes

Smoking cessation: 1

• Complete tobacco cessation with supportive care and referral to cessation programs

Additional beneficial interventions: 1

• Stress reduction and mindfulness practices
• Reduce exposure to air pollution and cold temperatures

Pharmacological Treatment Strategy

First-Line Medications

The five major drug classes with proven efficacy in reducing BP and CVD events are: 1

1. ACE inhibitors
2. Angiotensin receptor blockers (ARBs)
3. Dihydropyridine calcium channel blockers (CCBs)
4. Thiazide diuretics
5. Thiazide-like diuretics (chlorthalidone, indapamide)

Initial Treatment Approach

Combination therapy is recommended as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1 This approach achieves more effective BP control compared to monotherapy. 1

Preferred initial combinations: 1

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB
• RAS blocker (ACE inhibitor or ARB) + thiazide/thiazide-like diuretic

Fixed-dose single-pill combinations are strongly recommended to improve adherence and simplify treatment regimens. 1, 3

Exceptions to Combination Therapy

Consider monotherapy initiation for: 1

• Patients aged ≥85 years
• Those with symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (systolic 120-139 mmHg or diastolic 70-89 mmHg) with concomitant indication for treatment

Treatment Escalation

If BP remains uncontrolled on two-drug combination, escalate to three-drug combination: 1

• RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic
• Preferably as single-pill combination

Critical Contraindications

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

Beta-blockers are not recommended as first-line therapy for general hypertension management unless specific compelling indications exist (angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control). 1, 3 When indicated, beta-blockers should be combined with other major BP-lowering drug classes. 1

Medication Timing and Adherence

Patients should take medications at the most convenient time of day to establish habitual patterns and improve adherence. 1, 3 Recent evidence does not support specific timing recommendations (morning vs. evening) for cardiovascular benefit. 1

Strategies to enhance adherence: 3

• Use long-acting once-daily medications
• Implement single-pill combinations
• Simplify regimens whenever possible
• Provide patient education about treatment importance

Long-Term Management

BP-lowering treatment should be maintained lifelong, even beyond age 85 years, if well tolerated. 1 Nonadherence affects 10-80% of hypertensive patients and is a key driver of suboptimal BP control. 1

Monitoring Considerations

Screen all patients for substances that may increase BP or interfere with antihypertensive medications. 1 Consider reducing or eliminating these substances when appropriate, or treat BP to target regardless if substances are required. 1

Account for seasonal BP variation: 1

• BP typically declines by 5/3 mmHg (systolic/diastolic) in summer
• Changes are larger in treated hypertensives
• Consider medication downtitration if BP falls below goal with symptoms of overtreatment during warm weather

Common Pitfalls and Caveats

Improper BP measurement technique leads to inaccurate readings and inappropriate treatment decisions. 3 Always follow standardized measurement protocols with appropriate cuff sizes and patient positioning. 3

Failure to assess standing BP in high-risk populations (elderly, diabetics) can miss orthostatic hypotension, leading to falls and adverse events. 1, 3

Inadequate treatment intensity remains a global problem: Less than 50% of adults with hypertension worldwide receive BP-lowering medication, and fewer than 14% achieve BP control to <140/90 mmHg. 1 In the United States, control rates declined from 54% (2013-2014) to 44% (2017-2018). 1

Polypharmacy without single-pill combinations reduces adherence. 1, 3 Simplifying regimens with fixed-dose combinations significantly improves treatment persistence. 1

Delayed treatment initiation for confirmed hypertension increases cardiovascular risk. 1 The 2024 ESC guidelines emphasize prompt initiation of pharmacological therapy alongside lifestyle modifications for all patients with BP ≥140/90 mmHg. 1