Hypertension Management Guidelines

Initial Treatment Strategy

The European Society of Cardiology recommends initiating combination therapy with a RAS blocker plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic for most adults with confirmed hypertension, targeting systolic BP of 120-129 mmHg if tolerated 1
Weight reduction to ideal body weight through caloric restriction is recommended for all patients 1
Sodium restriction to <2,300 mg/day is advised 2
A dietary pattern of 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products is suggested 2
Alcohol limitation to ≤2 drinks/day for men and ≤1 drink/day for women is recommended 1, 2
Elimination of sugar-sweetened beverages and restriction of free sugar to maximum 10% of energy intake is advised 1
Complete tobacco cessation with referral to smoking cessation programs is recommended 1

The European Heart Journal suggests a preferred initial combination of ACE inhibitor or ARB plus dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination 1
For Black patients, initial therapy should include a diuretic or calcium channel blocker, either in combination or with a RAS blocker 4

A two-drug combination of RAS blocker plus CCB or diuretic is recommended as the first step, preferably as a single-pill combination 1
A three-drug combination of RAS blocker, dihydropyridine CCB, and thiazide/thiazide-like diuretic is suggested if BP remains uncontrolled 1

A standard target of 120-129 mmHg systolic is recommended for most adults if well tolerated 1, 4
For patients with diabetes, a target of <130/80 mmHg is advised 2
For patients with chronic kidney disease, a target of 120-129 mmHg systolic is recommended if tolerated 4

RAS blockers are first-line treatment for patients with albuminuria or proteinuria due to their superior albuminuria reduction 2, 4
SGLT2 inhibitors are recommended for symptomatic patients with heart failure with preserved ejection fraction (HFpEF) 4

Achieving target BP within 3 months is recommended 3
Medication timing should be at the most convenient time to establish routine and improve adherence 1
Monitoring renal function and potassium at least annually is advised when using ACE inhibitor, ARB, or diuretic 2
Maintaining treatment lifelong, even beyond age 85, is recommended if well tolerated 1