What are the new guidelines for managing hypertension in patients?

Current Hypertension Management Guidelines

The 2024 ESC guidelines represent the most recent evidence-based approach to hypertension management, recommending upfront combination therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg), targeting systolic BP of 120-129 mmHg, and introducing a new "elevated BP" category (120-139/70-89 mmHg) that requires lifestyle modifications and may warrant pharmacological treatment in high-risk patients. 1, 2

Blood Pressure Classification

The 2024 ESC guidelines define hypertension differently than older US guidelines:

• Non-elevated BP: <120/70 mmHg 1
• Elevated BP: 120-139/70-89 mmHg (new category requiring intervention) 2, 3, 4
• Stage 1 Hypertension: 140-159/90-99 mmHg 3
• Stage 2 Hypertension: ≥160/≥100 mmHg 3

Note that the 2017 ACC/AHA guidelines use lower thresholds (≥130/80 mmHg for hypertension), but the 2024 ESC guidelines maintain the traditional ≥140/90 mmHg definition while emphasizing earlier intervention through the elevated BP category. 5, 6

Diagnosis and Confirmation

Out-of-office BP measurement is strongly recommended to confirm elevated BP and hypertension before initiating treatment. 1

• Measure BP in both arms simultaneously; use the arm with consistently higher readings 2
• Home BP monitoring and ambulatory BP monitoring improve diagnostic accuracy 2, 5
• Multiple office measurements on several occasions are required before treatment decisions 5
• Standing BP measurements are mandatory in elderly patients and those with diabetes to detect orthostatic hypotension 5

Pharmacological Treatment Approach

When to Start Medication

For confirmed hypertension (≥140/90 mmHg): Start lifestyle modifications AND pharmacological treatment simultaneously, regardless of cardiovascular risk. 3, 4

For elevated BP (120-139/70-89 mmHg): Start medication after 3 months of lifestyle intervention if the patient has high cardiovascular risk or specific high-risk conditions (coronary artery disease, heart failure, stroke, diabetes, chronic kidney disease). 3, 4

First-Line Medications

The following drug classes have demonstrated effective reduction of BP and cardiovascular events: 1

• ACE inhibitors or ARBs (renin-angiotensin system blockers)
• Dihydropyridine calcium channel blockers (CCBs)
• Thiazide or thiazide-like diuretics (chlorthalidone, indapamide)

Beta-blockers are NOT first-line agents for uncomplicated hypertension and should only be used when compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, heart rate control). 1, 3

Treatment Algorithm

Step 1: Initial Therapy

• Start with combination therapy for most patients with confirmed hypertension (≥140/90 mmHg) 1, 2
• Preferred combinations: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB OR RAS blocker + thiazide/thiazide-like diuretic 1
• Use fixed-dose single-pill combinations to improve adherence 1, 2

Exceptions to combination therapy (consider monotherapy with slower up-titration):

• Age ≥85 years 1
• Moderate-to-severe frailty 1
• Symptomatic orthostatic hypotension 1
• Elevated BP (120-139/70-89 mmHg) with indication for treatment 1

Step 2: If BP Not Controlled on Two Drugs

• Escalate to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1, 3
• Preferably as single-pill combination 1

Step 3: If BP Not Controlled on Three Drugs (Resistant Hypertension)

• Add spironolactone as fourth agent 1
• If spironolactone not effective or tolerated: consider eplerenone, beta-blocker (if not already used), centrally acting agent, alpha-blocker, hydralazine, or potassium-sparing diuretic 1
• Consider referral to specialist centers and adherence testing 3

Special Populations

Black patients: Initial therapy should be low-dose ARB + dihydropyridine CCB OR dihydropyridine CCB + thiazide-like diuretic 2

Patients ≥85 years or with frailty: More lenient targets and slower titration are appropriate 1, 3

Treatment Targets

Target systolic BP: 120-129 mmHg for most adults, provided treatment is well tolerated. 2, 3

This represents a more aggressive target than previous guidelines and should be achieved within 3 months to ensure adherence and reduce cardiovascular risk. 1, 2

More lenient targets may be considered for:

• Age ≥85 years 3
• Moderate-to-severe frailty 3
• Symptomatic orthostatic hypotension 3
• Limited life expectancy 1

Lifestyle Modifications

All patients with elevated BP or hypertension must implement lifestyle modifications concurrently with or before pharmacological treatment. 2, 3

Specific interventions include:

• Weight reduction to ideal body weight 3, 5
• Regular physical activity: Aerobic exercise complemented with low- or moderate-intensity resistance training 2-3 times/week 3, 5
• Sodium restriction: Eliminate table salt 5
• Alcohol moderation: <100g/week of pure alcohol (abstinence preferred) 3
• Healthy diet: Mediterranean or DASH diet patterns, restrict free sugar and avoid sugar-sweetened beverages 3
• Smoking cessation 5

Implementation Strategies to Improve Adherence

• Medications should be taken at the most convenient time of day to establish habitual patterns; current evidence shows no benefit of specific diurnal timing on cardiovascular outcomes 1, 2
• Use long-acting drugs and single-pill combinations to simplify regimens 2, 5
• Patient education improves treatment persistence 2, 5
• Teleconsultation, multidisciplinary care, or nurse-led care can help achieve BP control 1
• Regular monitoring ensures BP control and medication adherence 2, 5

Critical Pitfalls to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB) - this increases adverse effects without additional benefit. 1, 2

Do not use beta-blockers as first-line therapy unless compelling indications exist (post-MI, angina, heart failure, rate control). 1, 3

Avoid overaggressive diastolic BP lowering in patients with established ischemic heart disease, as this may increase coronary events. 6

Always measure standing BP in elderly patients and those with diabetes to detect orthostatic hypotension before intensifying therapy. 5

Improper BP measurement technique leads to inaccurate readings and inappropriate treatment decisions - follow standardized protocols. 5

Comparison with Older Guidelines

The 2003 JNC 7 guidelines recommended thiazide-type diuretics as preferred initial monotherapy for most patients with uncomplicated hypertension, with a target BP of <140/90 mmHg (or <130/80 mmHg for patients with diabetes or chronic kidney disease). 1 The 2024 ESC guidelines represent a paradigm shift by recommending upfront combination therapy, more aggressive BP targets (120-129 mmHg systolic), and earlier intervention in the elevated BP category. 1, 2