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. 1

• 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 better BP control and reduces cardiovascular events. 1, 2, 3

Preferred initial combinations: 1, 2, 3

• RAS blocker (ACE inhibitor OR ARB) + dihydropyridine calcium channel blocker
• 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

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

• ACE inhibitors
• ARBs
• Dihydropyridine calcium channel blockers
• Thiazides and thiazide-like drugs (chlorthalidone, indapamide)

Beta-Blockers

Reserve beta-blockers for compelling indications rather than routine first-line use: 1

• Angina
• Post-myocardial infarction
• Heart failure with reduced ejection fraction (HFrEF)
• Heart rate control

Combine beta-blockers with any other major BP-lowering drug class when indicated. 1

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

For patients with elevated BP and sufficiently high CVD risk (≥10% over 10 years), initiate lifestyle modifications first. 1, 3 After 3 months, if BP remains ≥130/80 mmHg, add pharmacological treatment. 1, 3

For patients with elevated BP and low/medium CVD risk (<10% over 10 years), continue lifestyle measures alone. 1

Lifestyle Modifications (Essential for ALL Patients)

Weight Management

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

Physical Activity

• Minimum 150 minutes/week of moderate-intensity aerobic exercise (or 75 minutes/week vigorous) 2, 3, 4
• Add low- to moderate-intensity resistance training 2-3 times/week 1, 3
• Dynamic exercise (brisk walking) is preferred over isometric (weight training) 1

Dietary Modifications

• Adopt Mediterranean or DASH diet patterns 1, 3
• Restrict sodium intake: avoid table salt and eliminate excessively salty processed foods 1, 3, 4
• Increase consumption of fruits, vegetables, fish, nuts, and unsaturated fatty acids 3
• Limit free sugar to maximum 10% of energy intake; discourage sugar-sweetened beverages 1, 3

Alcohol Restriction

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

Smoking Cessation

• Mandatory recommendation: stop all tobacco use, initiate supportive care, and refer to cessation programs 1, 3

Special Population Considerations

Black Patients

Initial therapy should include a thiazide-like diuretic plus CCB, or CCB plus ARB. 2, 3 Note that losartan's stroke reduction benefit in patients with left ventricular hypertrophy does not apply to Black patients. 5

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 reduces progression of diabetic nephropathy with elevated creatinine and proteinuria (albumin/creatinine ratio ≥300 mg/g) 5

Heart Failure

• HFrEF: Use ACE inhibitor/ARB, beta-blocker, diuretic, and/or mineralocorticoid receptor antagonist 2, 3
• HFpEF: Consider SGLT2 inhibitors 3

Previous Stroke/TIA

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

Coronary Artery Disease

• Target BP <130/80 mmHg 2
• Use RAS blockers and beta-blockers as first-line agents 2

Elderly Patients (≥85 years)

Continue lifelong BP-lowering treatment if well tolerated, even beyond age 85. 1, 3 Consider more lenient targets (<140/90 mmHg) for those with symptomatic orthostatic hypotension or moderate-to-severe frailty. 3

Critical Pitfalls to Avoid

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

Other common errors: 2, 3

• Failing to confirm elevated readings with multiple measurements before diagnosis
• Not considering white coat hypertension when office readings are elevated
• Inadequate dosing or inappropriate drug combinations
• Overlooking lifestyle modifications alongside pharmacological treatment
• Not addressing lower BP targets in high-risk patients

Medication Timing and Adherence

Take medications at the most convenient time of day to establish a habitual pattern and improve adherence. 1 There is no evidence that evening dosing is superior to morning dosing. 1

Single-pill fixed-dose combinations are mandatory whenever possible to enhance adherence. 1, 2, 3

Employ multidisciplinary team approaches involving pharmacists to further enhance adherence. 2

Monitoring and Follow-Up

• Confirm hypertension with multiple measurements using validated devices 2, 3
• Patient should be seated with arm at heart level, taking at least two readings per visit 1, 2, 3
• Use ambulatory BP monitoring for unusual variability, suspected white coat hypertension, or resistant hypertension 1, 3
• Regular BP monitoring using both office and home readings 2, 3
• Annual cardiovascular risk reassessment 2, 3
• Measure standing BP in elderly or diabetic patients to exclude orthostatic hypotension 1