What is the up-to-date treatment algorithm for hypertension?

Updated Hypertension Treatment Algorithm

Based on the most recent 2024 ESC Guidelines, initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg) should be combination treatment with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1

Blood Pressure Targets

• Target systolic BP of 120-129 mmHg for most adults, provided treatment is well tolerated 1
• If poorly tolerated, use the "as low as reasonably achievable" (ALARA) principle 1
• For patients with diabetes or chronic kidney disease: <130/80 mmHg 1
• For patients ≥85 years: individualize based on frailty and tolerability 1

Lifestyle Modifications (Foundation for All Patients)

All patients should implement lifestyle changes regardless of medication status: 1

• Dietary sodium restriction: <100 mmol/day (approximately 2.3g sodium or 6g salt) 1
• Mediterranean or DASH diet: emphasizing fruits, vegetables, low-fat dairy, whole grains, reduced saturated fat 1
• Weight management: BMI 20-25 kg/m², waist circumference <94 cm (men) or <80 cm (women) 1
• Physical activity: 30-60 minutes of aerobic exercise 4-7 days/week, plus resistance training 2-3 times/week 1
• Alcohol limitation: <100g/week of pure alcohol; preferably avoid entirely 1
• Tobacco cessation: mandatory with referral to cessation programs 1
• Sugar restriction: limit free sugars to <10% of energy intake, avoid sugar-sweetened beverages 1

Pharmacological Treatment Algorithm

Step 1: Initial Therapy

For most patients with BP ≥140/90 mmHg: 1

• Start two-drug combination (preferred over monotherapy)
• Preferred combinations:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB, OR
  • RAS blocker + thiazide/thiazide-like diuretic (chlorthalidone or indapamide)
• Use single-pill combination when available 1

Exceptions to combination therapy (consider monotherapy): 1

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

For Black patients: 1

• Start with ARB + dihydropyridine CCB, OR
• Dihydropyridine CCB + thiazide/thiazide-like diuretic

Step 2: Escalation to Three Drugs

If BP not controlled on two-drug combination: 1

• Add third drug: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic
• Preferably as single-pill combination 1
• Never combine two RAS blockers (ACE inhibitor + ARB) 1

Step 3: Resistant Hypertension

If BP remains uncontrolled on optimal three-drug regimen: 1

1. Reinforce lifestyle measures, especially sodium restriction 1
2. Add low-dose spironolactone (first choice) 1
3. If spironolactone not tolerated or ineffective: 1
   • Eplerenone, OR
   • Amiloride, OR
   • Higher dose thiazide/thiazide-like diuretic, OR
   • Loop diuretic (if eGFR <30 mL/min/1.73m²)
4. Further options: 1
   • Bisoprolol or doxazosin
   • Beta-blocker (if not already prescribed)
   • Centrally acting agent (clonidine)
   • Alpha-blocker
   • Hydralazine

Step 4: Refractory Cases

• Catheter-based renal denervation may be considered in high-volume centers after multidisciplinary assessment and shared decision-making 1

Special Populations and Compelling Indications

Diabetes Mellitus

• Target BP: <130/80 mmHg 1
• First-line agents: ACE inhibitor or ARB (especially with albuminuria), thiazide diuretics, or dihydropyridine CCBs 1
• All first-line classes are effective 1

Chronic Kidney Disease

• Target BP: <130/80 mmHg 1
• First-line: RAS inhibitors (reduce albuminuria) 1
• Add CCBs and diuretics (loop diuretics if eGFR <30 mL/min/1.73m²) 1
• Monitor eGFR, albuminuria, and electrolytes 1

Heart Failure with Reduced Ejection Fraction

• Target BP: <130/80 mmHg 1
• Required agents: RAS blockers, beta-blockers, mineralocorticoid receptor antagonists 1
• Consider ARNI (sacubitril-valsartan) as alternative to ACE inhibitor/ARB 1
• CCBs only if needed for BP control 1

Post-Myocardial Infarction or Angina

• Beta-blockers and ACE inhibitors as first-line 1, 2

Cerebrovascular Disease (Secondary Prevention)

• ACE inhibitor + diuretic combination preferred 2
• Restart antihypertensive therapy after first few days post-stroke/TIA 1

Key Implementation Principles

• Medication timing: Take at most convenient time to improve adherence (no specific time-of-day advantage) 1
• Achieve target within 3 months of treatment initiation 1
• Maintain treatment lifelong, even beyond age 85 if well tolerated 1
• Monitor adherence regularly 1
• Use generic medications when available to reduce costs 1

Common Pitfalls to Avoid

• Do not use monotherapy as initial treatment for most patients with BP ≥140/90 mmHg 1
• Do not combine ACE inhibitor with ARB 1
• Do not use beta-blockers as first-line unless compelling indication (angina, post-MI, heart failure, rate control) 1
• Do not delay treatment in high-risk patients (diabetes, CVD, CKD, target organ damage) 1
• Do not ignore lifestyle modifications even when starting medications 1