Hypertension Management Guidelines

Lifestyle Modifications

The European Society of Cardiology recommends sodium restriction to approximately 2g per day, regular physical activity, weight management, adoption of healthy dietary patterns, alcohol limitation, smoking cessation, and restriction of free sugar consumption for all patients with elevated blood pressure 1
Regular physical activity, such as moderate-intensity aerobic exercise of ≥150 min/week plus resistance training 2-3 times/week, is recommended for patients with hypertension 1, 2
Weight management targeting a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) is recommended for patients with hypertension 1
Adoption of healthy dietary patterns, such as Mediterranean or DASH diets, is recommended for patients with hypertension 1, 2
Alcohol limitation to less than 100g/week of pure alcohol, with complete avoidance preferred, is recommended for patients with hypertension 1
Smoking cessation is recommended for all patients with hypertension 1, 2
Restriction of free sugar consumption, particularly sugar-sweetened beverages, is recommended for patients with hypertension 1

The European Society of Cardiology recommends ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, or thiazide/thiazide-like diuretics as first-line medication classes for the treatment of hypertension 1, 2
Combination therapy with a RAS blocker (ACE inhibitor or ARB) and either a dihydropyridine CCB or diuretic is recommended as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg) 1, 2
Fixed-dose single-pill combinations are recommended to improve adherence 1
For patients with albuminuria (UACR ≥30 mg/g), ACE inhibitor or ARB is recommended as first-line therapy 3, 2
For patients with coronary artery disease, ACE inhibitor or ARB is recommended as first-line therapy 3, 2
For patients requiring beta-blockers, combination with any of the other major BP-lowering drug classes is recommended 1
For black patients, calcium channel blockers or thiazide diuretics may be more effective than ACE inhibitors or ARBs when used as monotherapy 2

For all patients with elevated BP, lifestyle modifications should be implemented 1, 2
For BP 130/80-139/89 mmHg with high CVD risk, pharmacological treatment should be initiated after 3 months of lifestyle intervention 1, 2
For BP ≥140/90 mmHg, both lifestyle measures and pharmacological treatment should be initiated promptly 1, 2
Initial pharmacological approach should include combination therapy (RAS blocker + CCB or diuretic) for most patients 1
If BP is not controlled with two-drug combination, progression to a three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic) is recommended 1

The European Society of Cardiology recommends never combining two RAS blockers (ACE inhibitor and ARB) due to increased risk of adverse effects without additional benefit 1, 2
BP target should aim for treated systolic BP values of 120-129 mmHg in most adults, if well tolerated 4
Monitor kidney function and electrolytes when using ACE inhibitors, ARBs, or diuretics 3, 2
Medication timing should be taken at the most convenient time of day to establish a habitual pattern and improve adherence 1
Lifelong treatment is recommended, even beyond age 85 if well tolerated 1