Complex Blood Pressure Management Approach

Initial Assessment and Treatment Strategy

The European Society of Cardiology recommends that for most patients with confirmed hypertension (BP ≥140/90 mmHg), combination BP-lowering treatment is recommended as initial therapy, using a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide/thiazide-like diuretic, preferably as a single-pill combination 1, 2
Elevated BP is defined as systolic BP 120-139 mmHg or diastolic BP 70-89 mmHg, according to the European Heart Journal 1
Hypertension is defined as BP ≥140/90 mmHg, as stated by the European Heart Journal 1
For patients with elevated BP, assess cardiovascular disease (CVD) risk to guide treatment decisions, as recommended by the European Heart Journal 3
In patients with elevated BP and low/medium CVD risk (<10% over 10 years), start with lifestyle modifications, according to the European Heart Journal 1
For patients with elevated BP and high CVD risk, after 3 months of lifestyle intervention, start pharmacological treatment if confirmed BP ≥130/80 mmHg, as recommended by the European Heart Journal 1

ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics (chlorthalidone, indapamide) have demonstrated the most effective reduction of BP and CVD events, according to the European Heart Journal 1
Fixed-dose single-pill combinations improve adherence and should be used when possible, as stated by the European Heart Journal 1
Beta-blockers should be reserved for patients with specific indications (angina, post-MI, HFrEF, heart rate control), as recommended by the European Heart Journal 1

For most patients with confirmed hypertension (≥140/90 mmHg), start with a two-drug combination, according to the European Heart Journal 1
Preferred combinations: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB or thiazide/thiazide-like diuretic, as recommended by the European Heart Journal 1
If BP not controlled with a two-drug combination, escalate to a three-drug combination, according to the European Heart Journal 1
Recommended three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination, as stated by the European Heart Journal 1

Target systolic BP to 120-129 mmHg for most adults to reduce CVD risk, if well tolerated, as recommended by the European Heart Journal 1, 5
If this target cannot be achieved due to poor tolerance, aim for a systolic BP level that is "as low as reasonably achievable" (ALARA principle), according to the European Heart Journal 1
For patients with diabetes or CKD with eGFR >30 mL/min/1.73m², target systolic BP to 120-129 mmHg, as recommended by the European Heart Journal 5

For patients <85 years who are not frail, follow the same guidelines as for younger people, according to the European Heart Journal 5
Maintain BP-lowering treatment lifelong, even beyond age 85, if well tolerated, as recommended by the European Heart Journal 1
Test for orthostatic hypotension before starting or intensifying treatment, according to the European Heart Journal 5
After lifestyle intervention, start pharmacological treatment when confirmed BP ≥130/80 mmHg, as recommended by the European Heart Journal 5
Target systolic BP to 120-129 mmHg if tolerated, according to the European Heart Journal 5
For moderate-to-severe CKD with confirmed BP ≥130/80 mmHg, use lifestyle optimization and BP-lowering medication, as recommended by the European Heart Journal 5
SGLT2 inhibitors are recommended for hypertensive patients with CKD and eGFR >20 mL/min/1.73m², according to the European Heart Journal 5
RAS blockers are more effective at reducing albuminuria than other agents, as stated by the European Heart Journal 4

Aim for a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women), as recommended by the European Heart Journal 2
Adopt Mediterranean or DASH diets, according to the European Heart Journal 2
Limit alcohol consumption (preferably avoid completely), as recommended by the European Heart Journal 1, 2
Restrict free sugar consumption, especially sugar-sweetened beverages, according to the European Heart Journal 1
Stop tobacco use and refer to smoking cessation programs, as recommended by the European Heart Journal 1
Engage in regular physical activity including both aerobic and resistance training, according to the European Heart Journal 2
Reduce sodium intake, as recommended by the European Heart Journal 1

Take medications at the most convenient time of day to establish a habitual pattern, as recommended by the European Heart Journal 1
Use multidisciplinary approaches including physicians, nurses, pharmacists, dietitians, and physiotherapists, according to the European Heart Journal 6
Consider home BP monitoring to improve control and patient empowerment, as recommended by the European Heart Journal 6
Address the five dimensions of adherence: socio-economic factors, health system factors, therapy-related factors, condition-related factors, and patient-related factors, according to the European Heart Journal 6

Delaying combination therapy in patients with confirmed hypertension ≥140/90 mmHg, as stated by the European Heart Journal 1
Using monotherapy when combination therapy would be more effective, according to the European Heart Journal 1
Combining two RAS blockers (ACE inhibitor and ARB), which is not recommended, as stated by the European Heart Journal 1
Failing to screen for secondary hypertension in adults diagnosed with hypertension before age 40, as recommended by the European Heart Journal 7
Discontinuing treatment prematurely - BP-lowering treatment should be maintained lifelong if tolerated, according to the European Heart Journal 1