What are the latest guidelines for managing hypertension in adults?

Management of Hypertension Based on Latest Guidelines

For adults with confirmed hypertension, initiate upfront combination therapy with two first-line antihypertensive agents (preferably as a single-pill combination) targeting blood pressure <130/80 mm Hg, while simultaneously implementing comprehensive lifestyle modifications including sodium restriction, DASH diet, regular exercise, and weight management. 1, 2

Blood Pressure Classification and Treatment Initiation

BP Categories and Action Thresholds

• Normal BP (<120/80 mm Hg): Reassess annually with lifestyle counseling 2
• Elevated BP (120-129/<80 mm Hg): Implement lifestyle modifications only; reassess in 3-6 months 1, 2
• Stage 1 Hypertension (130-139/80-89 mm Hg): Calculate 10-year ASCVD risk
  • If ASCVD risk <10%: Start lifestyle modifications, reassess in 3-6 months 2
  • If ASCVD risk ≥10%: Initiate both lifestyle modifications AND pharmacotherapy immediately 1, 2
• Stage 2 Hypertension (≥140/90 mm Hg): Start combination pharmacotherapy plus lifestyle modifications; reassess in 1 month 1, 2
• Hypertensive urgency (≥180/110 mm Hg): Prompt evaluation and treatment within 1 week 2

Confirming the Diagnosis

Before initiating treatment, confirm hypertension with accurate office measurements, obtain home BP monitoring or 24-hour ambulatory monitoring to exclude white coat hypertension, and assess medication adherence 1, 2

Pharmacological Treatment Algorithm

First-Line Drug Classes

The four major drug classes are equally effective as initial therapy: thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide), ACE inhibitors or ARBs, long-acting dihydropyridine calcium channel blockers, and in some guidelines, beta-blockers 1, 3, 4

Initial Monotherapy (Stage 1 HTN with ASCVD Risk ≥10%)

Start with one agent from the major classes at standard doses 2:

• ACE inhibitor: Lisinopril 10 mg once daily (range 20-40 mg) 5
• ARB: Losartan 50 mg once daily (range 25-100 mg) 6
• Calcium channel blocker: Amlodipine 5-10 mg once daily 4
• Thiazide-like diuretic: Chlorthalidone 12.5-25 mg once daily 1, 4

Initial Combination Therapy (Stage 2 HTN or Uncontrolled on Monotherapy)

The 2024 European Society of Cardiology guidelines represent the most current evidence, recommending upfront low-dose combination therapy for most patients with confirmed hypertension, preferably as single-pill combinations to improve adherence. 1 This differs from older approaches that started with monotherapy.

Preferred two-drug combinations (avoid combining two RAS blockers): 1, 2

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

Triple Therapy for Resistant Hypertension

If BP remains uncontrolled on dual therapy, advance to triple-drug combination: 1, 2

• ACE inhibitor or ARB + calcium channel blocker + thiazide-like diuretic (preferably as single-pill combination)

Fourth-Line Therapy

For resistant hypertension (uncontrolled on maximally tolerated triple therapy after confirming adherence): 1

• Add spironolactone 25-50 mg daily (most effective fourth agent) 1
• If spironolactone not tolerated: Consider eplerenone 50-200 mg (may require twice-daily dosing), or vasodilating beta-blocker (labetalol, carvedilol, nebivolol) 1
• Only after these options: Consider hydralazine, amiloride, centrally acting agents, or alpha-blockers 1

Critical Caveat on Combination Therapy

While the 2024 ESC guidelines provide a Class I recommendation for upfront combination therapy based on observational data showing better BP control and adherence, no prospective randomized trials have proven superiority of upfront combination therapy over monotherapy for cardiovascular outcomes in isolated hypertension treatment. 1 However, the totality of evidence including polypill trials supports this approach.

Blood Pressure Targets

Standard Targets

• Adults <65 years: <130/80 mm Hg 1, 2, 3
• Adults ≥65 years (ambulatory, community-dwelling): Systolic <130 mm Hg if tolerated 1, 2
• Patients with diabetes or chronic kidney disease: <130/80 mm Hg 3

European Approach

The 2024 ESC guidelines suggest a systolic BP target of 120-129 mm Hg for most adults if well tolerated, representing a more aggressive approach than previous recommendations 3

Older Adults with Comorbidities

For adults ≥65 years with high comorbidity burden and limited life expectancy, use clinical judgment and team-based approach to balance treatment benefits versus risks, with careful titration and close monitoring 1

Lifestyle Modifications (Essential for All Patients)

Dietary Interventions

• DASH diet pattern: 8-10 servings fruits/vegetables daily, 2-3 servings low-fat dairy, whole grains, lean protein 3, 7, 4
• Sodium restriction: <2,300 mg/day (ideally <1,500 mg/day for greater effect) 3, 7, 4
• Potassium supplementation: 3,500-5,000 mg/day through dietary sources 3
• Sugar elimination: Remove sugar-sweetened beverages, limit free sugar to ≤10% of energy intake 3

The DASH diet may be the single most effective lifestyle intervention for BP reduction, with effects comparable to single-drug therapy. 7, 8

Weight and Physical Activity

• Weight management: Achieve and maintain healthy BMI (18.5-24.9 kg/m²) 3, 4, 9
• Regular exercise: 150 minutes/week moderate-intensity aerobic activity or 75 minutes/week vigorous activity 4, 10

Substance Use

• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women (maximum 14/week men, 9/week women) 3, 9
• Complete tobacco cessation: Refer to smoking cessation programs 3

Additional Considerations

• Stress management: Individualized cognitive behavioral modification in appropriate circumstances 10, 9
• Discontinue interfering substances: NSAIDs, stimulants, oral contraceptives 1

Follow-Up Schedule and Monitoring

BP Reassessment Intervals

• Normal BP: Annually 2
• Elevated BP or Stage 1 HTN (low risk): 3-6 months 2
• Stage 1 HTN (high risk) or Stage 2 HTN: 1 month after treatment initiation 2
• Target achievement: Within 3 months of initiating or intensifying therapy 3

Laboratory Monitoring

Monitor renal function and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 3

Home BP Monitoring

Essential for accurate diagnosis and ongoing management; use proper technique with validated devices 1, 2

Strategies to Improve Treatment Adherence

Practical Implementation

• Once-daily dosing: Prescribe long-acting formulations taken once daily 1, 2
• Single-pill combinations: Strongly preferred over separate pills to enhance adherence 1, 2
• Team-based care: Utilize pharmacists, nurses, and other healthcare workers 1, 2
• Technology integration: Electronic health records, patient registries, telehealth strategies 1, 2
• Motivational interviewing: Goal-setting strategies and patient engagement 2

Common Pitfall

Up to 25% of patients never fill their initial prescription, and only 20% maintain sufficient adherence to achieve trial-demonstrated benefits 1. Address this proactively with simplified regimens and close follow-up.

Special Considerations for Resistant Hypertension

Definition

BP ≥130/80 mm Hg despite adherence to three or more antihypertensive agents from different classes at optimal doses (including a diuretic), or requiring four or more medications 1

Systematic Evaluation

• Confirm with accurate office measurements and home/ambulatory monitoring to exclude white coat effect 1
• Assess medication adherence directly 1
• Screen for secondary causes (renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing's syndrome, obstructive sleep apnea) 1
• Identify contributing lifestyle factors and interfering substances 1

Treatment Optimization

• Maximize diuretic therapy: Switch to chlorthalidone or indapamide instead of hydrochlorothiazide 1
• Use loop diuretics in patients with CKD (eGFR <30 mL/min/1.73m²) 1
• Add mineralocorticoid receptor antagonist (spironolactone preferred) 1
• Refer to hypertension specialist if BP remains uncontrolled 1

Duration of Treatment

Maintain antihypertensive treatment lifelong, even beyond age 85, if well tolerated, as hypertension remains a cardiovascular risk factor throughout life 3