What are the current guidelines for managing hypertension and target blood pressure levels?

Current Blood Pressure Management Guidelines

Diagnosis and Confirmation

Hypertension is diagnosed when office blood pressure is ≥140/90 mmHg on repeated measurements across 2-3 visits, confirmed with home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg. 1

• Use validated automated upper arm cuff devices with appropriate cuff size 1
• Measure BP in both arms at first visit; use the arm with consistently higher readings 1
• Take the average of at least 2 readings per visit 1

Blood Pressure Targets

The 2024 European Society of Cardiology guidelines recommend an initial default systolic BP target of 120-129 mmHg in most adults if tolerated, with 120 mmHg being the optimal target. 1

Target Algorithm by Patient Category:

• General population <65 years: 120-129/<80 mmHg (optimal if tolerated) 1
• Initial target for all patients: <140/90 mmHg, then intensify to 120-129/<80 mmHg 1
• Patients with known CVD or 10-year CVD risk ≥10%: <130/80 mmHg 2, 3
• High-risk patients (diabetes, CKD, organ damage): <130/80 mmHg 2
• Diastolic target: 70-79 mmHg for all patients 2
• Age ≥85 years or moderate-to-severe frailty: Consider more lenient target <140/90 mmHg 1
• Pretreatment symptomatic orthostatic hypotension: Consider target <140/90 mmHg 1

Critical caveat: The 2024 ESC guidelines explicitly reject age-stratified targets (unlike 2023 ESH guidelines) because meta-analyses show age is not an effect modifier of BP-lowering efficacy up to 85 years. 1 Target BP "as low as reasonably achievable" if the 120-129 mmHg range cannot be tolerated. 1

Treatment Initiation Thresholds

Start immediate drug therapy for BP ≥160/100 mmHg (Grade 2 hypertension) in all patients. 1

For BP 140-159/90-99 mmHg (Grade 1 hypertension):

• High-risk patients: Start drug therapy immediately 1
  • High-risk criteria: established CVD, chronic kidney disease, diabetes mellitus, target organ damage, or age 50-80 years 1
• Low-moderate risk patients: Start lifestyle interventions; if BP remains elevated after 3-6 months, initiate drug therapy 1

For BP 130-139/80-89 mmHg:

• Consider drug therapy if 10-year cardiovascular risk ≥10% 2
• All patients should implement lifestyle modifications 2

First-Line Pharmacological Treatment

The 2024 ESC guidelines recommend ACE inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers, and thiazide/thiazide-like diuretics as first-line agents. 1

Race-Based Algorithm:

Non-Black patients:

1. Start with low-dose ACE inhibitor or ARB 1
2. Add dihydropyridine calcium channel blocker 1
3. Increase to full doses 1
4. Add thiazide/thiazide-like diuretic 1
5. Add spironolactone (or if not tolerated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 1

Black patients:

1. Start with low-dose ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide/thiazide-like diuretic 1
2. Increase to full doses 1
3. Add diuretic or ACE inhibitor/ARB 1
4. Add spironolactone (or alternatives as above) 1

Beta-Blocker Position:

Beta-blockers are NOT first-line agents except when there is a compelling indication (heart failure with reduced ejection fraction, recent MI, angina). 1 This represents a major divergence from 2023 ESH guidelines, which included beta-blockers as first-line therapy. 1

Compelling Indications for Specific Agents:

• Heart failure with reduced ejection fraction: ACE inhibitors + beta-blockers 2
• Recent myocardial infarction: Beta-blockers + ACE inhibitors 2
• Diabetes mellitus or non-diabetic CKD: ACE inhibitors or ARBs 2
• Pregnancy or planning pregnancy: Beta-blockers 2

Combination Therapy Strategy

Most patients require combination therapy to achieve BP targets; single-pill combinations are strongly preferred to improve adherence. 2, 4

• Consider monotherapy only in low-risk Grade 1 hypertension, patients aged >80 years, or frail patients 1
• Simplify regimen with once-daily dosing 1
• Never combine ACE inhibitors with ARBs due to increased adverse effects without additional benefit 2
• Fixed low-dose combinations have tolerability profiles similar to placebo 4

Monitoring and Follow-Up

Target BP control must be achieved within 3 months of initiating or adjusting therapy. 1, 2

• Follow up monthly after initiating or changing medications until target is achieved 2
• Allow at least 4 weeks to observe full response to medication adjustments (unless urgent lowering required) 5
• Once controlled, follow up every 3-5 months 2
• Confirm control with home BP monitoring (target <135/85 mmHg) 2
• Aim to reduce BP by at least 20/10 mmHg with each intervention 1

Lifestyle Modifications

All patients with BP ≥130/85 mmHg must implement lifestyle modifications, which have additive effects with pharmacotherapy. 2

• Dietary sodium restriction: <100 mmol/day (2300 mg) for prevention; 65-100 mmol/day (1500-2300 mg) for treatment 2
• Weight management: BMI 18.5-24.9 kg/m²; waist circumference <94 cm (men), <80 cm (women) 2
• Aerobic exercise: 30-60 minutes, 4-7 days per week 2
• DASH diet: Increased vegetables, fruits, fish, nuts, unsaturated fatty acids; low-fat dairy; reduced red meat 2
• Alcohol restriction: <14 units/week (men), <8 units/week (women); ideally avoid completely 2

Critical Pitfalls and Safety Considerations

Diastolic J-curve: Lowering diastolic BP to <60 mmHg may increase cardiovascular risk in patients with high CVD risk and treated systolic BP <130 mmHg. 2 Monitor diastolic BP closely when intensifying therapy.

Orthostatic hypotension: Check for symptomatic orthostatic hypotension before intensifying therapy, particularly in elderly patients. 2 Hold or reduce medication if systolic BP falls below 110 mmHg. 6

Frailty considerations: In frail elderly patients, achieve the best BP possible within target range while monitoring for adverse effects rather than rigidly pursuing intensive targets. 2 More lenient targets (<140/90 mmHg) may be considered for moderate-to-severe frailty or limited life expectancy. 1

Electrolyte monitoring: When using thiazide/thiazide-like diuretics, check serum potassium and sodium within 2-4 weeks of initiation or dose escalation. 6 Elderly patients are at higher risk for hyponatremia. 6

Adherence optimization: Single-pill combinations significantly improve adherence and should be used preferentially when combination therapy is required. 2 Only 44% of US adults with hypertension have their BP controlled to <140/90 mmHg, highlighting the adherence challenge. 3

Chlorthalidone advantages: Chlorthalidone provides sustained 24-hour BP reduction and was used in landmark cardiovascular outcome trials (ALLHAT, SHEP), demonstrating superior efficacy to hydrochlorothiazide. 6 It remains effective even when eGFR is <30 mL/min/1.73 m². 6