What are the current guidelines for treating hypertension (high blood pressure)?

Current Guidelines for Blood Pressure Treatment

For adults with confirmed hypertension (BP ≥140/90 mmHg), initiate pharmacological treatment with combination therapy using a single-pill combination from three drug classes: thiazide/thiazide-like diuretics, ACE inhibitors or ARBs, and long-acting dihydropyridine calcium channel blockers, targeting <140/90 mmHg for most patients and <130/80 mmHg for those with cardiovascular disease, diabetes, or chronic kidney disease. 1

First-Line Pharmacological Agents

The WHO strongly recommends any of the following four drug classes as first-line agents 1:

• Thiazide and thiazide-like diuretics (chlorthalidone, indapamide, hydrochlorothiazide)
• ACE inhibitors (lisinopril, enalapril)
• Angiotensin receptor blockers (ARBs: candesartan, losartan)
• Long-acting dihydropyridine calcium channel blockers (amlodipine)

The 2024 ESC guidelines confirm these same four classes have demonstrated the most effective reduction of BP and cardiovascular events. 1

Initial Treatment Strategy

Start with combination therapy preferably as a single-pill combination for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1 The preferred two-drug combinations are:

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker
• RAS blocker (ACE inhibitor or ARB) + thiazide/thiazide-like diuretic 1

Exceptions where monotherapy may be considered 1:

• Patients aged ≥85 years
• Those with symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (120-139/70-89 mmHg) with specific treatment indications

Treatment Escalation Algorithm

If BP not controlled on two-drug combination: Escalate to three-drug combination using RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1

If BP not controlled on three-drug combination: Add spironolactone (mineralocorticoid receptor antagonist) as the fourth agent. 1

If spironolactone not effective or tolerated: Consider eplerenone, or add beta-blocker (if not already indicated), then centrally acting agents, alpha-blockers, hydralazine, or potassium-sparing diuretics. 1

Never combine two RAS blockers (ACE inhibitor + ARB together) due to increased risk of end-stage renal disease and stroke. 1

Blood Pressure Targets

For patients without comorbidities: Target <140/90 mmHg 1

For patients with known cardiovascular disease: Target systolic BP <130 mmHg (strong recommendation) 1

For high-risk patients (high CVD risk, diabetes mellitus, chronic kidney disease): Target systolic BP <130 mmHg 1

For patients aged <65 years: Target <130/80 mmHg if tolerated (but maintain >120/70 mmHg) 1

Caution regarding diastolic BP: Avoid lowering diastolic BP to <60 mmHg in patients with high cardiovascular risk and treated systolic BP <130 mmHg, as this may increase cardiovascular events. Optimal diastolic BP appears to be 70-80 mmHg in this population. 1

Follow-Up Schedule

After initiation or medication change: Monthly follow-up until BP target is reached 1

Once BP is controlled: Follow-up every 3-5 months 1

Target timeframe for BP control: Achieve target within 3 months to ensure adherence and reduce cardiovascular risk 1

Special Considerations for Drug Selection

Beta-blockers are not recommended as first-line therapy for uncomplicated hypertension but should be combined with other major drug classes when compelling indications exist: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control. 1

For Black patients: Initiate treatment with calcium channel blocker or thiazide diuretic rather than ACE inhibitor or ARB as monotherapy. 1

Timing of medication: Administer at the most convenient time of day for the patient to improve adherence; diurnal timing does not affect cardiovascular outcomes. Take medications at the same time daily in a consistent setting. 1

Lifestyle Modifications

Implement lifestyle changes for all patients with BP ≥120/80 mmHg 1, 2:

• Weight loss if overweight/obese
• Dietary sodium reduction and potassium supplementation
• Healthy dietary pattern (low sodium, high potassium)
• Regular physical activity
• Alcohol moderation or elimination

These interventions are partially additive and enhance pharmacological therapy efficacy. 2

Common Pitfalls to Avoid

Do not use inadequate diuretic dosing: Thiazide-type diuretics remain underused despite being more affordable and enhancing efficacy of multidrug regimens. 1

Do not delay escalation: If BP is >20/10 mmHg above goal, initiate therapy with two agents immediately (one usually being a thiazide-type diuretic). 1

Do not ignore adherence: Use single-pill combinations, once-daily dosing, link medication-taking with daily habits, provide home BP monitoring, and employ multidisciplinary team approaches to improve adherence. 1

Do not prescribe thiazides with beta-blockers as preferred combination: This combination increases risk of developing diabetes. 1