ESC Guidelines for Stage 1 Hypertension
The 2024 ESC guidelines recommend initiating lifestyle modifications for all patients with stage 1 hypertension (BP 140-159/90-99 mmHg), and adding pharmacological treatment if BP remains ≥140/90 mmHg after 3 months of lifestyle changes, or immediately if the patient has high cardiovascular risk. 1
Risk Stratification Determines Treatment Urgency
The ESC approach is fundamentally risk-based, not just BP-based:
High-risk patients (established CVD, hypertension-mediated organ damage, diabetes, familial hypercholesterolemia, moderate-to-severe CKD, or SCORE2/SCORE2-OP 10-year CVD risk ≥10%) should start both lifestyle modifications AND pharmacological treatment immediately at BP ≥140/90 mmHg 1
Moderate-risk patients (SCORE2/SCORE2-OP risk 5-<10% with risk modifiers or abnormal risk testing) should receive pharmacological treatment if BP remains ≥130/80 mmHg after 3 months of lifestyle modifications 1
Lower-risk patients with stage 1 hypertension can trial lifestyle modifications alone for several months, but drug treatment should be added if BP control is not achieved 1
This contrasts sharply with older ESC guidance—the 2024 guidelines now extend treatment recommendations below the traditional 140/90 mmHg threshold for higher-risk patients 2.
Lifestyle Modifications (Class I Recommendations)
All patients must implement these changes 1:
- Weight reduction to BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 3
- Sodium restriction to <5 g/day (approximately 1200-2300 mg sodium) 1, 3
- Alcohol minimization to ≤100 g/week of pure alcohol (≤20 g/day men, ≤10 g/day women) 1, 3
- Regular aerobic exercise 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous-intensity activity, supplemented with resistance training 2-3 times weekly 1
- DASH dietary pattern rich in fruits, vegetables, low-fat dairy, with reduced saturated fat 1, 3
- Smoking cessation for overall cardiovascular health 1, 3
- Potassium supplementation or potassium-enriched salt substitutes (Class IIa, avoid in advanced CKD) 1
Pharmacological Treatment Approach
When medications are indicated 1:
First-line agents (Class I):
- ACE inhibitors or ARBs
- Dihydropyridine calcium channel blockers
- Thiazide or thiazide-like diuretics
Initial strategy: The 2024 ESC guidelines strongly emphasize single-pill combination therapy as initial treatment for most patients with confirmed hypertension ≥140/90 mmHg to achieve rapid BP control within 3 months 1, 3. This represents a major shift toward more aggressive initial treatment compared to traditional step-up approaches.
Beta-blockers are NOT first-line unless specific cardiac indications exist (heart failure, coronary disease, arrhythmias) or in pregnancy, due to inferior stroke prevention compared to other agents 1.
Blood Pressure Targets
The 2024 ESC uses a stepped target approach 1:
- First target: <140/90 mmHg for all patients
- Optimal target: 120-129 mmHg systolic (if tolerated, but not <120 mmHg) for adults 18-65 years 1, 3
- Older adults (≥65 years): 130-139 mmHg systolic if tolerated 1
- Diastolic: 70-79 mmHg (avoid <70 mmHg) 1
This differs from ACC/AHA guidelines which recommend a single target of <130/80 mmHg for most adults 1.
Follow-Up and Monitoring
- Reassess BP and cardiovascular risk after 3-6 months of lifestyle modifications 3
- After starting medications, follow-up within 2 months to assess response and adjust therapy 1
- Achieve BP control within 3 months of initiating pharmacological treatment 1
- Once controlled, monitor every few months with risk factor reassessment every 2 years 1
- Consider home BP monitoring or ABPM to confirm diagnosis and exclude white coat hypertension 3
Critical Pitfalls to Avoid
Do not delay treatment in high-risk patients: The 2024 ESC guidelines explicitly state that delaying BP control in high-risk hypertensive patients is associated with worse outcomes 1. Start medications immediately alongside lifestyle changes in these patients.
Do not undertreate with monotherapy: Most patients require combination therapy to achieve target BP 1. Single-pill combinations improve adherence and achieve faster control.
Do not ignore the 3-month rule: If lifestyle modifications alone do not achieve BP <140/90 mmHg after 3 months in lower-risk patients, pharmacological treatment must be added 3. Prolonged delays allow ongoing vascular damage.
Do not use beta-blockers as first-line: Unless cardiac indications exist, beta-blockers are inferior for stroke prevention and should not be initial therapy 1.