Hypertension Management Guidelines

First-Line Treatment Approach

The European Society of Cardiology recommends combination therapy with a renin-angiotensin system (RAS) blocker, a calcium channel blocker (CCB), and a thiazide/thiazide-like diuretic as the core strategy for managing hypertension to reduce morbidity and mortality 1, 2
For most patients with confirmed hypertension, initial therapy should include combination treatment with two first-line agents, preferably as a single-pill combination for better adherence 1, 3
The four major drug classes recommended as first-line treatments are ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics 1, 4, 5
Preferred initial combinations include a RAS blocker with either a dihydropyridine CCB or a thiazide/thiazide-like diuretic 2, 6

For Black patients, initial treatment should include a diuretic or CCB, either alone or in combination with a RAS blocker 7, 6
For elderly patients, treatment may need to be initiated more gradually with consideration of frailty and comorbidities 3, 5
For patients with diabetes or chronic kidney disease (CKD) with proteinuria, a RAS blocker should be included in the regimen 7

For most adults <65 years, the target blood pressure is <130/80 mmHg 1
For adults ≥65 years, the target systolic blood pressure is 120-130 mmHg if tolerated 1, 3
For patients with CKD and eGFR >30 mL/min/1.73m², the target systolic blood pressure is 120-129 mmHg 7

The initial assessment should confirm hypertension diagnosis with office and out-of-office measurements 3, 6
Step 1: Start with a two-drug combination (RAS blocker + CCB or diuretic) at low doses 2, 5
Step 3: If blood pressure remains uncontrolled, use triple therapy with RAS blocker + CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1, 2

Resistant hypertension is defined as blood pressure that remains uncontrolled despite treatment with three or more antihypertensive drugs including a diuretic 1, 7
Key management steps include reinforcement of lifestyle measures, addition of low-dose spironolactone, and consideration of referral to a specialist 7, 1

Lifestyle modifications should be recommended for all patients with hypertension, including weight loss, adoption of the DASH dietary pattern, sodium restriction, increased physical activity, and smoking cessation 9, 1, 5

Combining two RAS blockers is not recommended due to increased adverse effects without additional benefit 1, 2
Delayed intensification of therapy when blood pressure remains uncontrolled and poor adherence assessment before adding new medications or increasing doses should be avoided 9, 5

Use single-pill combinations whenever possible and prescribe once-daily dosing regimens to improve medication adherence 9, 5
Implement home blood pressure monitoring to provide feedback to patients and consider multidisciplinary approaches involving pharmacists and other healthcare team members 9, 5