The latest guideline from the European Society of Cardiology (ESC) sets a new, lower threshold for starting patients on medication to control blood pressure.
People with a 10-year risk of cardiovascular disease of 10% or more, or with comorbidities that place them at high risk (such as diabetes), should be started on antihypertensive therapy at ≥130/80 mmHg, with a treatment goal for most patients of 120-129 mmHg (systolic).
The ESC guideline says that there is increasing evidence that blood pressure (BP)-lowering improves cardiovascular disease outcomes even in people whose BP is raised but does not meet traditional thresholds.
It states the new treatment goal should be pursued as long as it is well tolerated by the patient.
The guideline also recommends initiating therapy with two antihypertensive agents and use of single-pill combinations wherever possible.
In contrast to the European Society for Hypertension, but in common with NICE, ESC guidelines do not recommend beta-blockers as first-line therapy. The ESC says this class of drug should only be used when there is a compelling indication for their use (myocardial infarction or heart its with reduced ejection fraction) or other classes are contraindicated, because they are less effective at preventing stroke and more frequently discontinued as a result of side effects.
The ESC task force says that adherence to treatment in hypertension is often poor, with discrepancies between what patients say they do and what healthcare professionals observe. So objective assessment using blood or urine samples is recommended where feasible.
To improve adherence, patients should be encouraged to take their medication at a time that is most convenient to them, rather than at a particular time of day (morning or bedtime).
The ESC says more flexible BP targets should be considered in patients aged 85 years or over, or with moderate-to-severe frailty or limited life expectancy. A new recommendation is to deprescribe medication in frail patients, especially if blood pressure declines as frailty worsens.
There are also a number of new lifestyle modification recommendations, including restricting sugar consumption, particularly sugary drinks, and – although recommended weekly alcohol limits are provided (14 units a week for men, 8 units a week for women) – abstaining for alcohol use altogether is preferred to improve outcomes.
1. 2024 ESC guidelines for the management of elevated blood pressure and hypertension. Eur Heart J; 30 August 2024: https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehae178/7741010#479375729
