Initial Management of Hypertension

Diagnosis and Assessment

The European Society of Cardiology recommends confirming hypertension diagnosis using validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit and using the arm with higher readings 1, 2
Hypertension is defined as office BP ≥140/90 mmHg, confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 1, 2
The American College of Cardiology recommends assessing for target organ damage, cardiovascular risk factors, and potential secondary causes of hypertension 3, 4

The European Society of Cardiology recommends implementing dietary changes following DASH or Mediterranean diet patterns, including reduced sodium intake, increased potassium intake, and consumption of low-fat dairy products 5
The European Society of Cardiology recommends encouraging regular physical activity with at least 150 minutes of moderate-intensity aerobic activity per week plus resistance training 2-3 times weekly 5
The European Society of Cardiology recommends weight management with goal of BMI 20-25 kg/m² and healthy waist circumference (5)
The European Society of Cardiology recommends advising alcohol moderation with consumption less than 100g/week of pure alcohol, or preferably complete avoidance 5
The American College of Cardiology recommends complete smoking cessation with appropriate supportive care 5, 4

The European Society of Cardiology recommends starting drug therapy immediately along with lifestyle modifications for patients with BP ≥140/90 mmHg regardless of cardiovascular risk 5, 1
The American Heart Association recommends initiating drug therapy immediately if patients have high cardiovascular risk (established CVD, CKD, diabetes, target organ damage, or aged 50-80 years) with BP 130/80-139/89 mmHg 1, 3
The European Society of Cardiology recommends combination therapy as initial treatment, preferably as a single-pill combination 5
The American College of Cardiology recommends first-line drug therapy including ACE inhibitors or ARBs, dihydropyridine calcium channel blockers, and thiazide or thiazide-like diuretics 5, 3

The European Society of Cardiology recommends initial therapy for most patients with BP ≥140/90 mmHg as a two-drug combination of RAS blocker plus either dihydropyridine CCB or thiazide/thiazide-like diuretic 5, 1
The American Heart Association recommends considering monotherapy for low-risk grade 1 hypertension, patients >80 years, or frail patients 1, 2
The American Heart Association recommends starting with ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic for Black patients 1, 2
The European Society of Cardiology recommends increasing to three-drug combination if BP not controlled with two-drug combination 5, 1
The American Heart Association recommends adding spironolactone or other agents if BP still not controlled 1, 2

The European Society of Cardiology recommends target BP <130/80 mmHg for most adults under 65 years 5
The American College of Cardiology recommends target systolic BP 120-129 mmHg for adults 65-85 years if well tolerated 5, 3
The European Society of Cardiology recommends individualizing targets based on frailty, with systolic BP 130-139 mmHg if well tolerated for adults >85 years 5, 1

The American Heart Association recommends monitoring BP control with goal of achieving target within 3 months 1, 2
The American College of Cardiology recommends checking serum creatinine and potassium 7-14 days after initiation or dose changes of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 3, 4
The American College of Cardiology recommends considering home BP monitoring to guide medication adjustments 3, 4
The American Heart Association recommends scheduling monthly visits until BP target is achieved 1, 4

The American College of Cardiology recommends using ACE inhibitor or ARB as first-line therapy for patients with diabetes, CKD, or established CVD 3, 4
The European Society of Cardiology recommends avoiding combination of two RAS blockers as this is potentially harmful 5, 3
The European Society of Cardiology recommends maintaining BP-lowering treatment lifelong, even beyond age 85 if well tolerated 5, 6

The European Heart Journal recommends starting with two-drug combination therapy as a single-pill combination for non-Black patients, with the preferred initial regimen being ACE inhibitor (or ARB) + dihydropyridine calcium channel blocker, or alternatively, ACE inhibitor (or ARB) + thiazide/thiazide-like diuretic 7
For Black patients, the European Heart Journal suggests the preferred initial approach is ARB + dihydropyridine calcium channel blocker or calcium channel blocker + thiazide/thiazide-like diuretic, as Black patients respond better to calcium channel blockers and diuretics than to RAS blockers as monotherapy 7

The European Heart Journal recommends increasing to three-drug combination therapy, including RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic, if blood pressure remains uncontrolled after 2-4 weeks on dual therapy 7
If still uncontrolled, the European Heart Journal suggests adding spironolactone 25 mg once daily, and if spironolactone is not tolerated or ineffective, considering eplerenone, amiloride, higher-dose thiazide, or loop diuretic 7
The European Heart Journal also recommends adding bisoprolol or doxazosin as fifth-line agents 7