What are the recommended management strategies for hypertension (high blood pressure)?

Hypertension Management

For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination pharmacological therapy immediately alongside intensive lifestyle modifications, targeting a systolic BP of 120-129 mmHg if well tolerated. 1, 2

Diagnosis and Confirmation

• Confirm hypertension diagnosis using validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit. 2
• Hypertension is defined as office BP ≥140/90 mmHg, which should be confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg). 2
• Assess for target organ damage (proteinuria, hematuria, elevated creatinine, ECG changes), cardiovascular risk factors, and potential secondary causes. 1, 2
• Calculate 10-year cardiovascular disease risk to guide treatment intensity for patients with borderline hypertension (130-139/80-89 mmHg). 3

Lifestyle Modifications (Essential for ALL Patients)

These interventions reduce cardiovascular morbidity and mortality independent of medication effects and must be implemented aggressively. 2

• Dietary changes: Adopt Mediterranean or DASH diet with increased vegetables, fruits, fish, nuts, low-fat dairy products, and unsaturated fatty acids. 1, 2
• Sodium restriction: Limit intake to 5-6g salt per day (approximately 2,300 mg sodium); avoid table salt and processed foods. 2, 3
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm in men, <80 cm in women. 1, 2
• Exercise: Perform ≥150 minutes/week of moderate-intensity aerobic exercise (or 75 minutes/week vigorous), complemented with resistance training 2-3 times/week. 1, 3
• Alcohol restriction: Limit to <100g/week of pure alcohol (approximately 7 standard drinks/week); preferably avoid completely for best health outcomes. 1, 2
• Sugar restriction: Limit free sugar to maximum 10% of energy intake; discourage sugar-sweetened beverages. 1, 3
• Smoking cessation: Mandatory with appropriate support and referral to cessation programs, as smoking risk outweighs BP benefits from medication. 1, 2

Pharmacological Therapy

Initial Treatment Strategy

Combination therapy is recommended as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1, 2, 3

• Preferred first-line combination: RAS blocker (ACE inhibitor like lisinopril or ARB) with either a dihydropyridine calcium channel blocker (like amlodipine) or thiazide/thiazide-like diuretic (chlorthalidone or indapamide). 1, 2, 4, 5
• Use fixed-dose single-pill combinations to improve adherence. 1, 2
• Exceptions to combination therapy: Consider monotherapy for patients ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or elevated BP (130-139/80-89 mmHg) with concomitant indication for treatment. 1

Treatment Escalation

• If BP not controlled with two-drug combination: Progress to three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic), preferably as single-pill combination. 1, 2, 3
• For resistant hypertension (uncontrolled on 3 drugs): Add spironolactone as fourth-line agent; effective even without biochemical evidence of aldosterone excess. 3, 6
• Beta-blockers: Reserve for compelling indications (angina, post-MI, heart failure with reduced ejection fraction, heart rate control). 1

Critical Pitfall to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB) as this is harmful and not recommended. 1, 2

Blood Pressure Targets

General Adult Population

Target systolic BP 120-129 mmHg and diastolic BP <80 mmHg for most adults, provided treatment is well tolerated. 1, 2, 3

• This represents the most recent 2024 ESC guideline recommendation, superseding older targets of <140/90 mmHg. 1
• If treatment is poorly tolerated and 120-129 mmHg target is not achievable, target systolic BP "as low as reasonably achievable" (ALARA principle). 1

High-Risk Populations

• Diabetes, chronic kidney disease (eGFR >30), or established cardiovascular disease: Target ≤130/80 mmHg. 1, 2, 3
• History of stroke or TIA: Target systolic BP 120-130 mmHg. 2, 3
• Elderly patients ≥65 years: Target systolic BP 130-139 mmHg. 3
• Patients ≥85 years or symptomatic orthostatic hypotension: Consider more lenient target <140/90 mmHg. 3

Special Populations

Black Patients

• Initial therapy should include a diuretic or calcium channel blocker, either alone or in combination with a RAS blocker. 2, 3
• For Black patients from Sub-Saharan Africa, combination therapy including CCB with either thiazide diuretic or RAS blocker is recommended. 2

Chronic Kidney Disease

• Target systolic BP 120-129 mmHg for patients with eGFR >30 mL/min/1.73m². 2, 3
• RAS blockers are specifically recommended when albuminuria/proteinuria is present. 3

Heart Failure

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

Elderly Patients

• Initiate treatment at lower doses and titrate gradually with careful monitoring for orthostatic hypotension. 2
• Intensive BP control may help prevent or partially arrest cognitive decline. 2

Urgent Treatment Situations

Immediate treatment required for: 1

• Accelerated hypertension (severe hypertension with grade III-IV retinopathy)
• Particularly severe hypertension (>220/120 mmHg)
• Impending complications (transient ischemic attack, left ventricular failure)
• Hypertensive emergency: Reduce BP within hours using parenteral agents. 6
• Hypertensive urgency: Reduce BP within days using oral agents. 6

Monitoring and Follow-Up

• Achieve target BP within 3 months of treatment initiation. 2
• Monitor serum creatinine and potassium 2-4 weeks after initiation or dose changes of ACE inhibitors, ARBs, or aldosterone antagonists. 2
• Use home BP monitoring to guide medication adjustments. 2, 3
• Reassess cardiovascular risk annually. 1, 3
• Maintain BP-lowering treatment lifelong, even beyond age 85 years, if well tolerated. 1

Common Pitfalls to Avoid

• Delaying treatment in young adults with hypertension: They have earlier onset of cardiovascular events compared to those with normal BP. 2
• Failing to confirm elevated readings with multiple measurements before diagnosis. 3
• Not considering white coat hypertension when office readings are elevated. 3
• Inadequate dosing or inappropriate drug combinations. 3
• Ignoring lifestyle modifications alongside pharmacological treatment: These provide independent cardiovascular benefits and enhance medication efficacy. 2, 3
• Withholding treatment due to asymptomatic orthostatic hypotension: This is not associated with higher rates of cardiovascular events. 2
• Using once-daily dosing and fixed-dose combinations to improve adherence. 2
• Overlooking secondary causes in resistant hypertension: Screen for hypokalaemia with elevated sodium (Conn's syndrome), sudden onset/worsening hypertension, young age (<30 years requiring treatment), or resistance to ≥3 drugs. 1