What are the current hypertension guidelines for blood pressure targets, treatment initiation thresholds, first‑line pharmacologic agents, lifestyle modifications, and special considerations in the elderly, Black patients, resistant hypertension, and pregnancy?

Latest Hypertension Guidelines

The 2024 European Society of Cardiology (ESC) guidelines represent the most current evidence-based recommendations for hypertension management, superseding previous iterations and establishing new standards for blood pressure targets, treatment initiation, and pharmacologic approaches.

Blood Pressure Targets

The 2024 ESC guidelines recommend a primary systolic blood pressure target of 120–129 mmHg when well tolerated, with a minimum acceptable goal of <140/90 mmHg for most adults. 1

• For patients with established cardiovascular disease, chronic kidney disease, or diabetes, the target is <130/80 mmHg 1, 2
• In adults aged ≥80 years, a less stringent target of <150/90 mmHg is appropriate, though <140/90 mmHg may be considered if the patient is otherwise healthy and tolerates treatment well 1
• Critical caveat: In high-risk patients whose systolic BP is controlled below 130 mmHg, diastolic BP should not be lowered below 60 mmHg, as this may paradoxically increase cardiovascular events 2

Treatment Initiation Thresholds

All adults with confirmed office BP ≥140/90 mmHg should begin immediate pharmacologic therapy combined with lifestyle modifications. 1, 2

• Patients with established cardiovascular disease and systolic BP 130–139 mmHg should also start treatment 2
• Those without cardiovascular disease but with high cardiovascular risk, diabetes, or chronic kidney disease and systolic BP 130–139 mmHg may benefit from treatment 2
• Confirm diagnosis with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) when feasible, but do not delay treatment while awaiting confirmation 1, 2

First-Line Pharmacologic Agents

Initial therapy should consist of a single-pill two-drug combination from different classes, preferably including a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) plus either a calcium channel blocker (CCB) or thiazide-like diuretic. 1, 2

Standard Combinations:

• ACE inhibitor or ARB + dihydropyridine CCB (preferred for most patients) 1, 2
• ACE inhibitor or ARB + thiazide-like diuretic (particularly effective for volume-dependent hypertension) 1, 2
• Chlorthalidone is preferred over hydrochlorothiazide due to longer duration of action (24–72 hours vs 6–12 hours) and superior cardiovascular outcome data from ALLHAT 3

Escalation to Triple Therapy:

• When BP remains ≥140/90 mmHg despite optimized dual therapy, add the third agent to create RAS blocker + CCB + thiazide diuretic 1, 2
• This triple combination achieves control in >80% of patients 3

Fourth-Line for Resistant Hypertension:

• Spironolactone 25–50 mg daily is the preferred fourth-line agent, providing additional reductions of approximately 20–25/10–12 mmHg 1, 3
• Alternative fourth-line options include eplerenone, amiloride, higher-dose thiazide, loop diuretic, bisoprolol, or doxazosin 1

Lifestyle Modifications

Lifestyle interventions should be initiated simultaneously with pharmacologic therapy, not sequentially, and can provide additive BP reductions of 10–20 mmHg. 1, 2

• Sodium restriction to <2 g/day: 5–10 mmHg systolic reduction 1, 3
• DASH dietary pattern: 11.4/5.5 mmHg reduction 3
• Weight loss (≈10 kg for BMI ≥25 kg/m²): 6.0/4.6 mmHg reduction 3
• Regular aerobic exercise (≥30 minutes most days, ≈150 minutes/week): 4/3 mmHg reduction 3
• Alcohol limitation: ≤100 g/week (≈7 standard drinks) 1

Special Populations

Black Patients:

Initial therapy should include a thiazide diuretic or CCB, either in combination or with a RAS blocker. 1

• For Black patients from Sub-Saharan Africa, combination therapy with CCB + thiazide diuretic or CCB + RAS blocker is preferred 1
• Two or more antihypertensive medications are typically required to achieve target BP in Black adults 1

Elderly (≥80 years):

• Target systolic BP <150/90 mmHg, or <140/90 mmHg if otherwise healthy and treatment is tolerated 1
• Individualize targets based on frailty and risk of orthostatic hypotension 2

Chronic Kidney Disease:

• Target systolic BP 120–129 mmHg in adults with moderate-to-severe CKD (eGFR >30 mL/min/1.73 m²) if tolerated 1
• RAS blockers are recommended as part of the treatment strategy when microalbuminuria or proteinuria is present 1

Diabetes:

• Target BP <130/80 mmHg 1
• The general population target of <140/90 mmHg applies, with no evidence supporting more aggressive targets in most diabetic patients 1, 4

Pregnancy:

• Immediate BP lowering is not recommended for systolic BP <220 mmHg in acute intracerebral hemorrhage 1
• For hypertensive patients with acute cerebrovascular events, antihypertensive treatment is recommended immediately for TIA and after several days in ischemic stroke 1

Resistant Hypertension

Resistant hypertension is defined as BP ≥140/90 mmHg despite three antihypertensive medications including a diuretic at optimal doses. 1, 3

Management Algorithm:

1. Reinforce lifestyle measures, especially sodium restriction to <2 g/day 1
2. Add low-dose spironolactone (25–50 mg daily) to existing treatment 1
3. If spironolactone is not tolerated: eplerenone, amiloride, higher-dose thiazide, or loop diuretic 1
4. Consider bisoprolol or doxazosin as additional options 1
5. Catheter-based renal denervation may be considered in medium-to-high volume centers for patients uncontrolled on three-drug combinations who express preference after shared risk-benefit discussion 1

Before Adding Medications:

• Verify medication adherence first—non-adherence is the most common cause of apparent treatment resistance 1, 3, 2
• Review for interfering substances: NSAIDs, decongestants, oral contraceptives, systemic corticosteroids, stimulants, herbal supplements (ephedra, licorice) 3
• Screen for secondary hypertension when BP is severely elevated (≥180/110 mmHg): primary aldosteronism, renal artery stenosis, obstructive sleep apnea, pheochromocytoma 3

Monitoring

• Reassess BP within 2–4 weeks after initiating or adjusting medication 1, 2
• Goal: achieve target BP within 3 months of therapy modification 1, 2
• Check serum potassium and creatinine 2–4 weeks after initiating RAS blockers or diuretics 3, 2
• Once at goal, follow-up every 3–5 months 2

Critical Pitfalls to Avoid

• Do not combine an ACE inhibitor with an ARB (dual RAS blockade increases hyperkalemia and acute kidney injury without cardiovascular benefit) 1, 3, 2
• Do not use beta-blockers as first-line therapy unless compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, atrial fibrillation) 1, 3, 2
• Do not delay treatment intensification when BP remains ≥140/90 mmHg; prompt action within 2–4 weeks is required 1, 3
• Do not use non-dihydropyridine CCBs (diltiazem, verapamil) in patients with heart failure due to negative inotropic effects 3
• Do not assume treatment failure without confirming adherence, excluding white-coat hypertension, and ruling out secondary causes 3, 2