Ehy 339

European Heart Journal (2018) 00, 1–98 ESC/ESH GUIDELINES
doi:10.1093/eurheartj/ehy339
2018 ESC/ESH Guidelines for the management

of arterial hypertension
The Task Force for the management of arterial hypertension of the
European Society of Cardiology (ESC) and the European Society of
Hypertension (ESH)
Authors/Task Force Members: Bryan Williams* (ESC Chairperson) (UK),

Giuseppe Mancia* (ESH Chairperson) (Italy), Wilko Spiering (The Netherlands),
Enrico Agabiti Rosei (Italy), Michel Azizi (France), Michel Burnier (Switzerland),
Denis L. Clement (Belgium), Antonio Coca (Spain), Giovanni de Simone (Italy),
Anna Dominiczak (UK), Thomas Kahan (Sweden), Felix Mahfoud (Germany),
Josep Redon (Spain), Luis Ruilope (Spain), Alberto Zanchetti† (Italy), Mary Kerins
(Ireland), Sverre E. Kjeldsen (Norway), Reinhold Kreutz (Germany),
Stephane Laurent (France), Gregory Y. H. Lip (UK), Richard McManus (UK),
Krzysztof Narkiewicz (Poland), Frank Ruschitzka (Switzerland),
Roland E. Schmieder (Germany), Evgeny Shlyakhto (Russia), Costas Tsioufis
(Greece), Victor Aboyans (France), Ileana Desormais (France)
* Corresponding authors. Bryan Williams, Institute of Cardiovascular Science, University College London, Maple House, 1st Floor, Suite A, 149 Tottenham Court Road, London
W1T 7DN, UK, Tel: þ44 (0) 20 3108 7907, E-mail: bryan.williams@ucl.ac.uk. Giuseppe Mancia, University of Milano-Bicocca, Milan, Italy; and Hypertension Center Istituto
Universitario Policlinico di Monza, Verano (MB), Piazza dei Daini, 4 – 20126 Milan, Italy, Tel: þ39 347 4327142, E-mail: giuseppe.mancia@unimib.it
†
Professor Zanchetti died towards the end of the development of these Guidelines, in March 2018. He contributed fully to the development of these Guidelines, as a member
of the Guidelines’ Task Force and as a section co-ordinator. He will be sadly missed by colleagues and friends.
The two chairpersons contributed equally to the document.
ESC Committee for Practice Guidelines (CPG), European Society of Hypertension (ESH) Council, ESC National Cardiac Societies having participated in
the review process, ESH National Hypertension Societies having participated in the review process: listed in the Appendix.
ESC entities having participated in the development of this document:
Associations: European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous
Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA).
Councils: Council for Cardiology Practice, Council on Cardiovascular Nursing and Allied Professions, Council on Cardiovascular Primary Care, Council on Hypertension,
Council on Stroke.
Working Groups: Cardiovascular Pharmacotherapy, Coronary Pathophysiology and Microcirculation, e-Cardiology.
Disclaimer. The ESC/ESH Guidelines represent the views of the ESC and ESH and were produced after careful consideration of the scientific and medical knowledge and the evidence
available at the time of their dating. The ESC and ESH are not responsible in the event of any contradiction, discrepancy, and/or ambiguity between the ESC/ESH Guidelines and any other
official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are
encouraged to take the ESC/ESH Guidelines fully into account when exercising their clinical judgment as well as in the determination and the implementation of preventive, diagnostic, or
therapeutic medical strategies. However, the ESC/ESH Guidelines do not override in any way whatsoever the individual responsibility of health professionals to make appropriate and accu-
rate decisions in consideration of each patient’s health condition, and in consultation with that patient and the patient’s caregiver where appropriate and/or necessary. Nor do the ESC/ESH
Guidelines exempt health professionals from taking careful and full consideration of the relevant official updated recommendations or guidelines issued by the competent public health
authorities in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s
responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
The content of these European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines has been published for personal and educational use only.
No commercial use is authorized. No part of the ESC/ESH Guidelines may be translated or reproduced in any form without written permission from the ESC or ESH.
Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle
such permissions on behalf of the ESC (journals.permissions@oup.com).
This article has been co-published in the European Heart Journal (doi: 10.1093/eurheartj/ehy339) and Journal of Hypertension (doi:10.1097/HJH. 10.1097/HJH.0000000000001940), and in
a shortened version in Blood Pressure. All rights reserved. VC European Society of Cardiology and European Society of Hypertension 2018. The articles in European Heart Journal and
Journal of Hypertension are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Any citation can be used when citing this article.
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2 ESC/ESH Guidelines
Document Reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH
Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi
(Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy),
Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cıfkova (Czech Republic), John G. F. Cleland (UK),
Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands),
Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany),
Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France),
Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK),
Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon
(The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain),
Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza
Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy),
Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski
(Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Rofﬁ (Switzerland),
Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal),
Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy),
Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain)
The disclosure forms of all experts involved in the development of these Guidelines are available on the
ESC website www.escardio.org/guidelines
...................................................................................................................................................................................................
Keywords Guidelines • Hypertension • Blood pressure • Blood pressure measurement • Blood pressure treatment
thresholds and targets • Hypertension-mediated organ damage • Lifestyle interventions • Drug therapy •
Combination therapy • Device therapy • Secondary hypertension
..
Table of Contents .. 4.6 Advantages and disadvantages of ambulatory blood pressure
.. monitoring and home blood pressure monitoring . . . . . . . . . . . . . . . . . . 17
..
1 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 .. 4.7 White-coat hypertension and masked hypertension . . . . . . . . . . . . 17
2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 .. 4.7.1 White-coat hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
..
2.1 What is new and what has changed in the 2018 European .. 4.7.2 Masked hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Society of Cardiology/European Society of Hypertension .. 4.8 Screening for the detection of hypertension . . . . . . . . . . . . . . . . . . . . 18
..
arterial hypertension Guidelines? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 .. 4.9 Confirming the diagnosis of hypertension. . . . . . . . . . . . . . . . . . . . . . . 18
3 Definition, classification, and epidemiological aspects .. 4.10 Clinical indications for out-of-office blood
..
of hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 .. pressure measurements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.1 Definition of hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
.. 4.11 Blood pressure during exercise and at high altitude . . . . . . . . . . . . 20
..
3.2 Classification of blood pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 .. 4.12 Central aortic pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.3 Prevalence of hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
.. 5 Clinical evaluation and assessment of hypertension-mediated
..
3.4 Blood pressure relationship with risk of cardiovascular and .. organ damage in patients with hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . 21
renal events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
.. 5.1 Clinical evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
..
3.5 Hypertension and total cardiovascular risk assessment . . . . . . . . . . 12 .. 5.2 Medical history. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.6 Importance of hypertension-mediated organ damage in ... 5.3 Physical examination and clinical investigations. . . . . . . . . . . . . . . . . . 22
..
refining cardiovascular risk assessment in hypertensive patients . . . . . 13 .. 5.4 Assessment of hypertension-mediated organ damage . . . . . . . . . . . 22
3.7 Challenges in cardiovascular risk assessment. . . . . . . . . . . . . . . . . . . . 14 .. 5.4.1 Using hypertension-mediated organ damage to help
..
4 Blood pressure measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 .. stratify risk in hypertensive patients . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.1 Conventional office blood pressure measurement . . . . . . . . . . . . . . 15 .. 5.5 Characteristics of hypertension-mediated organ damage . . . . . . . . 24
..
4.2 Unattended office blood pressure measurement. . . . . . . . . . . . . . . . 15 .. 5.5.1 The heart in hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
4.3 Out-of-office blood pressure measurement . . . . . . . . . . . . . . . . . . . . 16 .. 5.5.2 The blood vessels in hypertension. . . . . . . . . . . . . . . . . . . . . . . 24
..
4.4 Home blood pressure monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 .. 5.5.3 The kidney in hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.5 Ambulatory blood pressure monitoring . . . . . . . . . . . . . . . . . . . . . . . . 16 .. 5.5.4 Hypertensive retinopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
.

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ESC/ESH Guidelines 3
5.5.5 The brain in hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

.. 8.4 White-coat hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
..
5.6 Hypertension-mediated organ damage regression and .. 8.5 Masked hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
..
cardiovascular risk reduction with antihypertensive treatment . . . . . . 25 .. 8.6 Masked uncontrolled hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.7 When to refer a patient with hypertension for .. 8.7 Hypertension in younger adults (age <50 years) . . . . . . . . . . . . . . . . 57
..
hospital-based care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 .. 8.7.1 Isolated systolic hypertension in the young. . . . . . . . . . . . . . . 58
6 Genetics and hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 .. 8.8 Hypertension in older patients (age >_65 years) . . . . . . . . . . . . . . . . . 58
..
7 Treatment of hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 .. 8.9 Women, pregnancy, oral contraception, and
7.1 Beneficial effects of blood pressure-lowering therapy .. hormone-replacement therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
..
in hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 .. 8.9.1 Hypertension and pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
7.2. When to initiate antihypertensive treatment . . . . . . . . . . . . . . . . . . . 28 .. 8.9.2 Oral contraceptive pills and hypertension. . . . . . . . . . . . . . . . 61
..
7.2.1 Recommendations in previous guidelines . . . . . . . . . . . . . . . . 28 .. 8.9.3 Hormone-replacement therapy and hypertension . . . . . . . 61
7.2.2 Drug treatment for patients with grade 1 .. 8.10 Hypertension in different ethnic groups . . . . . . . . . . . . . . . . . . . . . . . 61
..
hypertension at low–moderate cardiovascular risk . . . . . . . . . . . . 28 .. 8.11 Hypertension in diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
7.2.3 Initiation of blood pressure-lowering drug .. 8.12 Hypertension and chronic kidney disease . . . . . . . . . . . . . . . . . . . . . 63
..
treatment in older people with grade 1 hypertension . . . . . . . . . . 29 .. 8.13 Hypertension and chronic obstructive pulmonary disease. . . . . . 64
7.2.4 Initiation of blood pressure-lowering drug
.. 8.14 Hypertension and heart disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
..
treatment in patients with high–normal blood pressure. . . . . . . . 29 .. 8.14.1 Coronary artery disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
7.2.5 Should blood pressure-lowering drug treatment be
.. 8.14.2 Left ventricular hypertrophy and heart failure. . . . . . . . . . . 65
..
initiated on the basis of blood pressure values or the level .. 8.15 Cerebrovascular disease and cognition. . . . . . . . . . . . . . . . . . . . . . . . 66
of total cardiovascular risk?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
.. 8.15.1 Acute intracerebral haemorrhage . . . . . . . . . . . . . . . . . . . . . . 66
..
7.2.6 Initiation of blood pressure-lowering drug treatment . . . . . 30 .. 8.15.2 Acute ischaemic stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
7.3 Blood pressure treatment targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
.. 8.15.3 Previous stroke or transient ischaemic attack . . . . . . . . . . . 66
..
7.3.1 New evidence on systolic blood pressure and .. 8.15.4 Cognitive dysfunction and dementia. . . . . . . . . . . . . . . . . . . . 67
..
diastolic blood pressure treatment targets . . . . . . . . . . . . . . . . . . . . 32 .. 8.16 Hypertension, atrial fibrillation, and other arrhythmias . . . . . . . . . 67
7.3.2 Blood pressure targets in specific subgroups of .. 8.16.1 Oral anticoagulants and hypertension . . . . . . . . . . . . . . . . . . 68
..
hypertensive patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 .. 8.17 Hypertension and vascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
7.4 Treatment of hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 .. 8.17.1 Carotid atherosclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
..
7.4.1 Lifestyle changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 .. 8.17.2 Arteriosclerosis and increased arterial stiffness . . . . . . . . . 68
7.4.2 Dietary sodium restriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 .. 8.17.3 Lower extremity arterial disease . . . . . . . . . . . . . . . . . . . . . . . 69
..
7.4.3 Moderation of alcohol consumption. . . . . . . . . . . . . . . . . . . . . 35 .. 8.18 Hypertension in valvular disease and aortopathy. . . . . . . . . . . . . . . 69
7.4.4 Other dietary changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 .. 8.18.1 Coarctation of the aorta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
..
7.4.5 Weight reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 .. 8.18.2 Prevention of aortic dilation and dissection in
7.4.6 Regular physical activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 .. high-risk subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
..
7.4.7 Smoking cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 .. 8.18.3 Hypertension bicuspid aortic valve-related
7.5. Pharmacological therapy for hypertension . . . . . . . . . . . . . . . . . . . . . 36 .. aortopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
..
7.5.1 Drugs for the treatment of hypertension . . . . . . . . . . . . . . . . 36 .. 8.19 Hypertension and sexual dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . 69
7.5.2 Hypertension drug treatment strategy. . . . . . . . . . . . . . . . . . . 39 .. 8.20 Hypertension and cancer therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
..
7.5.3 The drug treatment algorithm for hypertension . . . . . . . . . . 43 .. 8.21 Perioperative management of hypertension . . . . . . . . . . . . . . . . . . . 70
7.6 Device-based hypertension treatment . . . . . . . . . . . . . . . . . . . . . . . . . 47
.. 9 Managing concomitant cardiovascular disease risk. . . . . . . . . . . . . . . . . . . 71
..
7.6.1 Carotid baroreceptor stimulation .. 9.1 Statins and lipid-lowering drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
(pacemaker and stent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
.. 9.2 Antiplatelet therapy and anticoagulant therapy. . . . . . . . . . . . . . . . . . 71
..
7.6.2 Renal denervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 .. 9.3. Glucose-lowering drugs and blood pressure . . . . . . . . . . . . . . . . . . . 72
7.6.3 Creation of an arteriovenous fistula . . . . . . . . . . . . . . . . . . . . . 48
.. 10 Patient follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
..
7.6.4 Other devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 .. 10.1 Follow-up of hypertensive patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
8 Hypertension in specific circumstances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
.. 10.2 Follow-up of subjects with high–normal blood pressure
..
8.1 Resistant hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 .. and white-coat hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
..
8.1.1 Definition of resistant hypertension . . . . . . . . . . . . . . . . . . . . . 48 .. 10.3 Elevated blood pressure at control visits . . . . . . . . . . . . . . . . . . . . . . 73
8.1.2 Pseudo-resistant hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . 49 .. 10.4 Improvement in blood pressure control in hypertension:
..
8.1.3 Diagnostic approach to resistant hypertension . . . . . . . . . . . 49 .. drug adherence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
8.1.4 Treatment of resistant hypertension. . . . . . . . . . . . . . . . . . . . . 50 .. 10.5 Continued search for asymptomatic hypertension-mediated
..
8.2 Secondary hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 .. organ damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
8.2.1 Drugs and other substances that may cause .. 10.6 Can antihypertensive medications be reduced or stopped?. . . . . 74
..
secondary hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 .. 11 Gaps in the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
8.2.2 Genetic causes of secondary hypertension. . . . . . . . . . . . . . . 51 .. 12 Key messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
..
8.3 Hypertension urgencies and emergencies . . . . . . . . . . . . . . . . . . . . . . 54 .. 13 ‘What to do’ and ‘what not to do’ messages from the Guidelines . . . . .78
8.3.1 Acute management of hypertensive emergencies . . . . . . . . 55 .. 14 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
..
8.3.2 Prognosis and follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 . 15 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

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Abbreviations and acronyms .. ESH European Society of Hypertension

..
.. FEVER Felodipine Event Reduction
ABI Ankle–brachial index .. HAS-BLED Hypertension, Abnormal renal/liver function
ABPM Ambulatory blood pressure monitoring
..
.. (1 point each), Stroke, Bleeding history or
ACCOMPLISH Avoiding Cardiovascular Events Through .. predisposition, Labile INR, Elderly (>65),
..
Combination Therapy in Patients Living With .. Drugs/alcohol concomitantly (1 point each)
Systolic Hypertension ..
.. HbA1c Haemoglobin A1c
ACCORD Action to Control Cardiovascular Risk in .. HBPM Home blood pressure monitoring
Diabetes ..
.. HDL-C HDL cholesterol
ACE Angiotensin-converting enzyme .. HELLP Haemolysis, elevated liver enzymes, and low
ACEi Angiotensin-converting enzyme inhibitor ..
.. platelets
ACR Albumin:creatinine ratio .. HFpEF Heart failure with preserved ejection fraction
ADVANCE Action in Diabetes and Vascular Disease:
..
.. HFrEF Heart failure with reduced ejection fraction
Preterax and Diamicron – MR Controlled .. HMOD Hypertension-mediated organ damage
Evaluation
..
.. HOPE Heart Outcomes Prevention Evaluation
AF Atrial fibrillation .. HYVET Hypertension in the Very Elderly Trial
ALLHAT Antihypertensive and Lipid-Lowering
..
.. i.v. Intravenous
Treatment to Prevent Heart Attack Trial .. IMT Intima-media thickness
..
ALTITUDE Aliskiren Trial in Type 2 Diabetes Using .. INVEST International Verapamil-Trandolapril Study
Cardiovascular and Renal Disease Endpoints .. ISH Isolated systolic hypertension
..
ARB Angiotensin receptor blocker .. JUPITER Justification for the Use of Statins in
ASCOT Anglo-Scandinavian Cardiac Outcomes Trial .. Prevention: an Intervention Trial Evaluating
..
AV Atrioventricular .. Rosuvastatin
BMI Body mass index .. LDH Lactate dehydrogenase
..
BP Blood pressure .. LDL-C LDL cholesterol
bpm Beats per minute .. LEAD Lower extremity artery disease
..
BSA Body surface area .. LIFE Losartan Intervention For Endpoint reduction
CAD Coronary artery disease ..
.. in hypertension
CAPPP Captopril Prevention Project .. LV Left ventricular
CCB Calcium channel blocker ..
.. LVH Left ventricular hypertrophy
CHA2DS2-VASc Congestive heart failure, Hypertension, Age .. MAP Mean arterial pressure
>_75 years, Diabetes mellitus, Stroke, Vascular ..
.. MI Myocardial infarction
disease, Age 65–74 years, Sex category .. MR Magnetic resonance
(female)
..
.. MRA Mineralocorticoid receptor antagonist
CKD Chronic kidney disease .. MRI Magnetic resonance imaging
CK-MB Creatinine kinase-muscle/brain
..
.. MUCH Masked uncontrolled hypertension
CMR Cardiac magnetic resonance .. NORDIL Nordic Diltiazem
..
COLM Combination of OLMesartan and a calcium .. NS Non-significant
channel blocker or diuretic in Japanese elderly .. NT-proBNP N-terminal pro-B natriuretic peptide
..
hypertensive patients .. o.d. Omni die (every day)
CONVINCE Controlled Onset Verapamil Investigation of .. ONTARGET Ongoing Telmisartan Alone and in
..
Cardiovascular End Points .. combination with Ramipril Global Endpoint
COPD Chronic obstructive pulmonary disease .. Trial
..
COPE Combination Therapy of Hypertension to .. PAC Plasma aldosterone concentration
Prevent Cardiovascular Events .. PAD Peripheral artery disease
..
CT Computed tomography .. PATHS Prevention and Treatment of Hypertension
CV Cardiovascular .. Study
..
CVD Cardiovascular disease .. PRA Plasma renin activity
DBP Diastolic blood pressure .. PRC Plasma renin concentration
..
DENERHTN Renal Denervation for Hypertension .. PROGRESS Perindopril protection against recurrent stroke
DHP Dihydropyridine ..
.. study
ECG Electrocardiogram .. PWV Pulse wave velocity
eGFR Estimated glomerular filtration rate
..
.. RAS Renin–angiotensin system
ELSA European Lacidipine Study on Atherosclerosis .. RCT Randomized controlled trial
ENaC Epithelial sodium channel
..
.. RWT Relative wall thickness
ESC European Society of Cardiology .. SBP Systolic blood pressure

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..
SCOPE Study on Cognition and Prognosis in the .. and updated. The Task Force received its entire financial support
Elderly
.. from the ESC and ESH without any involvement from the healthcare
..
SCORE Systematic COronary Risk Evaluation .. industry.
SHEP Systolic Hypertension in the Elderly Program
.. The ESC CPG supervises and coordinates the preparation of new
..
SPC Single-pill combination .. Guidelines. The Committee is also responsible for the endorsement
SPRINT Systolic Blood Pressure Intervention Trial
.. process of these Guidelines. The ESC Guidelines undergo extensive
..
STOP-H Swedish Trial in Old Patients with .. review by the CPG and external experts, and in this case by ESH -
.. appointed experts. After appropriate revisions the Guidelines are
Hypertension ..
SUCH Sustained uncontrolled hypertension .. approved by all the experts involved in the Task Force. The finalized
.. document is approved by the CPG and ESH for publication in the
Syst-China Systolic Hypertension in China ..
Syst-Eur Systolic Hypertension in Europe .. European Heart Journal and in the Journal of Hypertension as well as
.. Blood Pressure. The Guidelines were developed after careful consid-
TIA Transient ischaemic attack ..
TTE Transthoracic echocardiography .. eration of the scientific and medical knowledge and the evidence
.. available at the time of their dating.
VALUE Valsartan Antihypertensive Long-term Use ..
Evaluation .. The task of developing ESC and ESH Guidelines also includes the
.. creation of educational tools and implementation programmes for
VEGF Vascular endothelial growth factor ..
WUCH White-coat uncontrolled hypertension .. the recommendations including condensed pocket guideline ver-
.. sions, summary slides, booklets with essential messages, summary
..
.. cards for non-specialists and an electronic version for digital applica-
.. tions (smartphones, etc.). These versions are abridged and thus, if
1 Preamble ..
.. needed, one should always refer to the full text version, which is
..
Guidelines summarize and evaluate available evidence with the aim of .. freely available via the ESC AND ESH websites and hosted on the
assisting health professionals in selecting the best management strat- .. EHJ AND JOURNAL OF HYPERTENSION websites. The National
..
egies for an individual patient with a given condition. Guidelines and .. Societies of the ESC are encouraged to endorse, translate and imple-
their recommendations should facilitate decision making of health .. ment all ESC Guidelines. Implementation programmes are needed
..
professionals in their daily practice. However, the final decisions con- .. because it has been shown that the outcome of disease may be
cerning an individual patient must be made by the responsible health .. favourably influenced by the thorough application of clinical
..
professional(s) in consultation with the patient and caregiver as .. recommendations.
appropriate. .. Surveys and registries are needed to verify that real-life daily prac-
..
A great number of guidelines have been issued in recent years by .. tice is in keeping with what is recommended in the guidelines, thus
the European Society of Cardiology (ESC) and by the European .. completing the loop between clinical research, writing of guidelines,
..
Society of Hypertension (ESH), as well as by other societies and .. disseminating them and implementing them into clinical practice.
organisations. Because of the impact on clinical practice, quality crite-
.. Health professionals are encouraged to take the ESC and ESH
..
ria for the development of guidelines have been established in order .. Guidelines fully into account when exercising their clinical judgment,
to make all decisions transparent to the user. The recommendations
.. as well as in the determination and the implementation of preventive,
..
for formulating and issuing ESC Guidelines can be found on the .. diagnostic or therapeutic medical strategies. However, the ESC and
ESC website (http://www.escardio.org/Guidelines-&-Education/Clinical-
.. ESH Guidelines do not override in any way whatsoever the individual
..
Practice-Guidelines/Guidelines-development/Writing-ESC-Guidelines). .. responsibility of health professionals to make appropriate and accu-
ESC Guidelines represent the official position of the ESC on a given
.. rate decisions in consideration of each patient’s health condition and
..
topic and are regularly updated. .. in consultation with that patient or the patient’s caregiver where
.. appropriate and/or necessary. It is also the health professional’s
Members of this Task Force were selected by the ESC and ESH to ..
represent professionals involved with the medical care of patients .. responsibility to verify the rules and regulations applicable to drugs
.. and devices at the time of prescription.
with this pathology. Selected experts in the field undertook a com- ..
prehensive review of the published evidence for management of a ..
..
given condition according to ESC Committee for Practice Guidelines ..
..
(CPG) policy and approved by the ESH. A critical evaluation of diag-
.. 2 Introduction
nostic and therapeutic procedures was performed, including assess- ..
ment of the risk–benefit ratio. The level of evidence and the strength .. Substantial progress has been made in understanding the epidemiol-
..
of the recommendation of particular management options were .. ogy, pathophysiology, and risk associated with hypertension, and a
weighed and graded according to predefined scales, as outlined in .. wealth of evidence exists to demonstrate that lowering blood pres-
..
Tables 1 and 2. .. sure (BP) can substantially reduce premature morbidity and mortal-
The experts of the writing and reviewing panels provided declara- .. ity.1–10 A number of proven, highly effective, and well-tolerated
..
tion of interest forms for all relationships that might be perceived as .. lifestyle and drug treatment strategies can achieve this reduction in
real or potential sources of conflicts of interest. These forms were .. BP. Despite this, BP control rates remain poor worldwide and are far
..
compiled into one file and can be found on the ESC website (http:// .. from satisfactory across Europe. Consequently, hypertension
www.escardio.org/guidelines). Any changes in declarations of interest
.. remains the major preventable cause of cardiovascular disease
..
that arise during the writing period were notified to the ESC and ESH . (CVD) and all-cause death globally and in our continent.11–14

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Table 1 ESC Classes of recommendations
Classes of Definition Suggested wording to use

recommendations
Class I Evidence and/or general agreement Is recommended/is

that a given treatment or procedure is indicated
beneficial, useful, effective.
Class II Conflicting evidence and/or a

divergence of opinion about the
usefulness/efficacy of the given
treatment or procedure.
Class IIa Weight of evidence/opinion is in favour Should be considered

of usefulness/efficacy.
Class IIb Usefulness/efficacy is less well May be considered

established by evidence/opinion.
Class III Evidence or general agreement that Is not recommended
©ESC 2018
the given treatment or procedure is
not useful/effective, and in some cases
may be harmful.
.. are: (i) to base recommendations on properly conducted studies,

Table 2 ESC Levels of evidence ..
.. identified from an extensive review of the literature; (ii) to give the
.. highest priority to data from randomized controlled trials (RCTs);
..
.. (iii) to also consider well-conducted meta-analyses of RCTs as strong
.. evidence (this contrasts with network meta-analyses, which we do
..
.. not consider to have the same level of evidence because many of the
.. comparisons are non-randomized); (iv) to recognize that RCTs can-
..
.. not address many important questions related to the diagnosis, risk
.. stratification, and treatment of hypertension, which can be addressed
..
.. by observational or registry-based studies of appropriate scientific
..
.. calibre; (v) to grade the level of scientific evidence and the strength of
.. recommendations according to ESC recommendations (see section
..
.. 1); (vi) to recognize that opinions may differ on key recommenda-
.. tions, which are resolved by voting; and (vii) to recognize that there
... are circumstances in which there is inadequate or no evidence, but
..
.. that the question is important for clinical practice and cannot be
These 2018 ESC/ESH Guidelines for the management of arterial .. ignored. In these circumstances, we resort to pragmatic expert opin-
..
hypertension are designed for adults with hypertension, i.e. aged >_18 .. ion and endeavour to explain its rationale.
years. The purpose of the review and update of these Guidelines was
.. Each member of the Task Force was assigned specific writing tasks,
..
to evaluate and incorporate new evidence into the Guideline recom- .. which were reviewed by section co-ordinators and then by the two
mendations. The specific aims of these Guidelines were to produce
.. chairs, one appointed by the ESC and the other by the ESH. The text
..
pragmatic recommendations to improve the detection and treatment .. was developed over approximately 24 months, during which the
of hypertension, and to improve the poor rates of BP control by pro-
.. Task Force members met collectively and corresponded intensively
..
moting simple and effective treatment strategies. .. with one another between meetings. Before publication, the docu-
These joint 2018 Guidelines follow the same principles upon
.. ment was reviewed by European reviewers selected by the ESC and
..
which a series of hypertension Guidelines were jointly issued by the .. ESH, and by representatives of ESC National Cardiac Societies and
.. ESH National Hypertension Societies.
two societies in 2003, 2007, and 2013. These fundamental principles ..

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2.1 What is new and what has changed in the 2018 ESC/ESH Arterial Hypertension
Guidelines?
Changes in recommendations
2013 2018
Diagnosis Diagnosis
Office BP is recommended for screening and diagnosis of It is recommended to base the diagnosis of hypertension on:
hypertension. • Repeated office BP measurements; or
• Out-of-office BP measurement with ABPM and/or HBPM if logistically
and economically feasible.
Treatment thresholds Treatment thresholds

Highnormal BP (130–139/85–89 mmHg): Unless the necessary Highnormal BP (130–139/85–89 mmHg): Drug treatment may be
evidence is obtained, it is not recommended to initiate considered when CV risk is very high due to established CVD, especially
antihypertensive drug therapy at high–normal BP. CAD.

Treatment of low-risk grade 1 hypertension: Treatment of low-risk grade 1 hypertension:
Initiation of antihypertensive drug treatment should also be In patients with grade 1 hypertension at low–moderate-risk and without
considered in grade 1 hypertensive patients at low–moderate-risk, evidence of HMOD, BP-lowering drug treatment is recommended if the
when BP is within this range at several repeated visits or elevated by patient remains hypertensive after a period of lifestyle intervention.
ambulatory BP criteria, and remains within this range despite a
reasonable period of time with lifestyle measures.

Older patients Older patients
Antihypertensive drug treatment may be considered in the elderly BP-lowering drug treatment and lifestyle intervention is recommended in
(at least when younger than 80 years) when SBP is in the fit older patients (>65 years but not >80 years) when SBP is in the
140–159 mmHg range, provided that antihypertensive treatment is grade 1 range (140–159 mmHg), provided that treatment is well tolerated.
well tolerated.
BP treatment targets BP treatment targets
An SBP goal of <140 mmHg is recommended. • It is recommended that the first objective of treatment should be to
lower BP to <140/90 mmHg in all patients and, provided that the
treatment is well tolerated, treated BP values should be targeted to
130/80 mmHg or lower in most patients.
• In patients <65 years it is recommended that SBP should be lowered
to a BP range of 120–129 mmHg in most patients.
Continued

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BP treatment targets in older BP treatment targets in older patients (65–80 years)

patients (65–80 years)
An SBP target of between 140–150 mmHg In older patients (>_65 years), it is recommended that SBP should be
is recommended for older patients (65–80 years). targeted to a BP range of 130–139 mmHg.
BP treatment targets in patients aged over 80 years BP treatment targets in patients aged over 80 years
An SBP target between 140–150 mmHg should be considered in An SBP target range of 130–139 mmHg is recommended for people older
people older than 80 years, with an initial SBP >_160 mmHg, provided than 80 years, if tolerated.
that they are in good physical and mental condition.
DBP targets DBP targets
A DBP target of <90 mmHg is always recommended, except in A DBP target of <80 mmHg should be considered for all hypertensive
patients with diabetes, in whom values <85 mmHg are patients, independent of the level of risk and comorbidities.
recommended.
Initiation of drug treatment Initiation of drug treatment
Initiation of antihypertensive therapy with a two-drug combination It is recommended to initiate an antihypertensive treatment with a
may be considered in patients with markedly high baseline BP or two-drug combination, preferably in a SPC. The exceptions are frail older
at high CV risk. patients and those at low risk and with grade 1 hypertension (particularly
if SBP is <150 mmHg).
Resistant hypertension Resistant hypertension
Mineralocorticoid receptor antagonists, amiloride, and the alpha-1 Recommended treatment of resistant hypertension is the addition of
blocker doxazosin should be considered if no contraindication low-dose spironolactone to existing treatment, or the addition of further
exists. diuretic therapy if intolerant to spironolactone, with either eplerenone,
amiloride, higher-dose thiazide/thiazide-like diuretic or a loop diuretic,
or the addition of bisoprolol or doxazosin.
Device-based therapy for hypertension Device-based therapy for hypertension
In case of ineffectiveness of drug treatment, invasive procedures Use of device-based therapies is not recommended for the routine
such as renal denervation and baroreceptor stimulation may be treatment of hypertension, unless in the context of clinical studies and
considered. RCTs, until further evidence regarding their safety and efficacy becomes
available.
Recommendation Grading
Grade I Grade IIa Grade IIb Grade III
ABPM = ambulatory blood pressure monitoring; BP = blood pressure; CAD = coronary artery disease; CV = cardiovascular; CVD = cardiovascular disease; DBP = diastolic
blood pressure; HBPM = home blood pressure monitoring; HMOD = hypertension-mediated organ damage; RCT = randomized controlled trial; SBP = systolic blood pressure;
SPC = single-pill combination.

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New sections/recommendations
When to suspect and how to screen for the causes of secondary hypertension
Management of hypertension emergencies
Updated recommendations on the management of BP in acute stroke
Updated recommendations on the management of hypertension in women and pregnancy
Hypertension in different ethnic groups
The effects of altitude on BP
Hypertension and chronic obstructive pulmonary disease
Hypertension and AF and other arrhythmias
Oral anticoagulant use in hypertension
Hypertension and sexual dysfunction
Hypertension and cancer therapies
Perioperative management of hypertension
Glucose-lowering drugs and BP
Updated recommendations on CV risk assessment and management: (i) using the SCORE system to assess risk in
patients without CVD; (ii) the importance of HMOD in modifying CV risk; and (iii) the use of statins and aspirin for
CVD prevention
New concepts
BP measurement
• Wider use of out-of-office BP measurement with ABPM and/or HBPM, especially HBPM, as an option to confirm the diagnosis
of hypertension, detect white-coat and masked hypertension, and monitor BP control.
Less conservative treatment of BP in older and very old patients

• Lower BP thresholds and treatment targets for older patients, with emphasis on considerations of biological rather than
chronological age (i.e. the importance of frailty, independence, and the tolerability of treatment).
• Recommendation that treatment should never be denied or withdrawn on the basis of age, provided that treatment is tolerated.
A SPC treatment strategy to improve BP control

• Preferred use of two-drug combination therapy for the initial treatment of most people with hypertension.
• A single-pill treatment strategy for hypertension with the preferred use of SPC therapy for most patients.
• Simplified drug treatment algorithms with the preferred use of an ACE inhibitor or ARB, combined with a CCB and/or a
thiazide/thiazide-like diuretic, as the core treatment strategy for most patients, with beta-blockers used for specific indications.
New target ranges for BP in treated patients

• Target BP ranges for treated patients to better identify the recommended BP target and lower safety boundaries for treated BP,
according to a patient’s age and specific comorbidities.
Detecting poor adherence to drug therapy

• A strong emphasis on the importance of evaluating treatment adherence as a major cause of poor BP control.
A key role for nurses and pharmacists in the longer-term management of hypertension
• The important role of nurses and pharmacists in the education, support, and follow-up of treated hypertensive patients is
emphasized as part of the overall strategy to improve BP control.
ABPM = ambulatory blood pressure monitoring; ACE = angiotensin-converting enzyme; AF = atrial fibrillation; ARB = angiotensin receptor blocker; BP = blood pressure; CCB
= calcium channel blocker; CV = cardiovascular; CVD = cardiovascular disease; HBPM = home blood pressure monitoring; HMOD = hypertension-mediated organ damage;
SCORE = Systematic COronary Risk Evaluation; SPC = single-pill combination.

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..
3 Definition, classification, and .. 3.2 Classification of blood pressure
..
epidemiological aspects of ..
hypertension Classification of BP
3.1 Definition of hypertension Recommendation Classa Levelb

The relationship between BP and cardiovascular (CV) and renal
events is continuous, making the distinction between normotension It is recommended that BP be classified as
and hypertension, based on cut-off BP values, somewhat arbitrary.2,4,8 optimal, normal, high–normal, or grades I C
However, in practice, cut-off BP values are used for pragmatic rea- 1–3 hypertension, according to office BP.
sons to simplify the diagnosis and decisions about treatment.
Epidemiological associations between BP and CV risk extend from BP = blood pressure.
a
Class of recommendation
very low levels of BP [i.e. systolic BP (SBP) >115 mmHg]. However, b
Level of evidence.
‘hypertension’ is defined as the level of BP at which the benefits of
treatment (either with lifestyle interventions or drugs) unequivocally
outweigh the risks of treatment, as documented by clinical trials. This
evidence has been reviewed (see section 7.2 for detailed discussion 3.3 Prevalence of hypertension
of hypertension diagnostic thresholds) and provides the basis Based on office BP, the global prevalence of hypertension was esti-
for the recommendation that the classification of BP and definition mated to be 1.13 billion in 2015,5 with a prevalence of over 150 mil-
of hypertension remain unchanged from previous ESH/ESC lion in central and eastern Europe. The overall prevalence of
Guidelines (Table 3).15,16,17 hypertension in adults is around 30 - 45%,12 with a global age-
Hypertension is defined as office SBP values >_140 mmHg and/or standardized prevalence of 24 and 20% in men and women, respec-
diastolic BP (DBP) values >_90 mmHg. This is based on evidence from tively, in 2015.5 This high prevalence of hypertension is consistent
multiple RCTs that treatment of patients with these BP values is benefi- across the world, irrespective of income status, i.e. in lower, middle,
cial (see section 7). The same classification is used in younger, middle- and higher income countries.12 Hypertension becomes progressively
aged, and older people, whereas BP centiles are used in children and more common with advancing age, with a prevalence of >60% in
teenagers, in whom data from interventional trials are not available. people aged >60 years.12 As populations age, adopt more sedentary
Details on BP classification in boys and girls <_ 16 years of age can be lifestyles, and increase their body weight, the prevalence of hyperten-
found in the 2016 ESH Guidelines for children and adolescents.18 sion worldwide will continue to rise. It is estimated that the number
Table 3 Classification of office blood pressurea and definitions of hypertension gradeb
Category Systolic (mmHg) Diastolic (mmHg)
Optimal <120 and <80
Normal 120–129 and/or 80–84
High normal 130–139 and/or 85–89
Grade 1 hypertension 140–159 and/or 90–99
Grade 2 hypertension 160–179 and/or 100–109
Grade 3 hypertension >_180 and/or >_110
Isolated systolic hypertensionb >_140 and <90
BP = blood pressure; SBP = systolic blood pressure.

a
BP category is defined according to seated clinic BP and by the highest level of BP, whether systolic or diastolic.
b
Isolated systolic hypertension is graded 1, 2, or 3 according to SBP values in the ranges indicated.
The same classification is used for all ages from 16 years.

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Table 4 Factors influencing cardiovascular risk in patients with hypertension
Demographic characteristics and laboratory parameters
Sexa (men >women)
Agea
Smoking (current or past history)a
Total cholesterola and HDL-C
Uric acid
Diabetesa
Overweight or obesity
Family history of premature CVD (men aged <55 years and women aged <65 years)
Family or parental history of early-onset hypertension
Early-onset menopause
Sedentary lifestyle
Psychosocial and socioeconomic factors
Heart rate (resting values >80 beats/min)
Asymptomatic HMOD
Arterial stiffening:
Pulse pressure (in older people) >_60 mmHg
Carotid–femoral PWV >10 m/s
ECG LVH (Sokolow–Lyon index >35 mm, or R in aVL >_11 mm; Cornell voltage duration product >2440 mm.ms, or Cornell voltage >28 mm in
men or >20 mm in women)
Echocardiographic LVH [LV mass index: men >50 g/m2.7; women >47 g/m2.7 (height in m2.7); indexation for BSA may be used in normal-weight
patients; LV mass/BSA g/m2 >115 (men) and >95 (women)]
Microalbuminuria (30–300 mg/24 h), or elevated albumin–creatinine ratio (30–300 mg/g; 3.4–34 mg/mmol) (preferentially on morning spot urine)b
Moderate CKD with eGFR >30–59 mL/min/1.73 m2 (BSA) or severe CKD eGFR <30 mL/min/1.73 m2 b
Ankle-brachial index <0.9
Advanced retinopathy: haemorrhages or exudates, papilloedema
Established CV or renal disease
Cerebrovascular disease: ischaemic stroke, cerebral haemorrhage, TIA
CAD: myocardial infarction, angina, myocardial revascularization
Presence of atheromatous plaque on imaging
Heart failure, including HFpEF
Peripheral artery disease
Atrial fibrillation
BSA = body surface area; CAD = coronary artery disease; CKD = chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease; ECG = electrocardiogram; eGFR
= estimated glomerular filtration rate; HDL-C = HDL cholesterol; HFpEF = heart failure with preserved ejection fraction; HMOD = hypertension-mediated organ damage; LV
= left ventricular; LVH = left ventricular hypertrophy; PWV = pulse wave velocity; SCORE = Systematic COronary Risk Evaluation; TIA = transient ischaemic attack.
a
CV risk factors included in the SCORE system.
b
Proteinuria and reduced eGFR are independent risk factors.
See Table 6 for CV risk modifiers.

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Table 5 Ten year cardiovascular risk categories (Systematic COronary Risk Evaluation system)
Very high risk People with any of the following:
Documented CVD, either clinical or unequivocal on imaging.

• Clinical CVD includes acute myocardial infarction, acute coronary syndrome, coronary or other arterial revascula-
rization, stroke, TIA, aortic aneurysm, and PAD
• Unequivocal documented CVD on imaging includes significant plaque (i.e. >_50% stenosis) on angiography or
ultrasound; it does not include increase in carotid intima-media thickness
• Diabetes mellitus with target organ damage, e.g. proteinuria or a with a major risk factor such as grade 3
hypertension or hypercholesterolaemia
• Severe CKD (eGFR <30 mL/min/1.73 m2)
• A calculated 10 year SCORE of >_10%
High risk People with any of the following:

• Marked elevation of a single risk factor, particularly cholesterol >8 mmol/L (>310 mg/dL), e.g. familial hyper-
cholesterolaemia or grade 3 hypertension (BP >_180/110 mmHg)
• Most other people with diabetes mellitus (except some young people with type 1 diabetes mellitus and with-
out major risk factors, who may be at moderate-risk)
Hypertensive LVH
Moderate CKD eGFR 30-59 mL/min/1.73 m2)
A calculated 10 year SCORE of 5-10%
Moderate risk People with:

• A calculated 10 year SCORE of 1 to <5%
• Grade 2 hypertension
• Many middle-aged people belong to this category
Low risk People with:

• A calculated 10 year SCORE of <1%
BP = blood pressure; CKD = chronic kidney disease; CVD = cardiovascular disease; eGFR = estimated glomerular filtration rate; LVH = left ventricular hypertrophy; TIA =
transient ischaemic attack; PAD = peripheral artery disease; SCORE = Systematic COronary Risk Evaluation.
of people with hypertension will increase by 15–20% by 2025, reach-

.. hypertension with an increased risk of developing atrial fibrillation
..
ing close to 1.5 billion.19 .. (AF),20 and evidence is emerging that links early elevations of BP to
.. increased risk of cognitive decline and dementia.21,22
..
3.4 Blood pressure relationship with risk .. The continuous relationship between BP and risk of events has
..
of cardiovascular and renal events .. been shown at all ages23 and in all ethnic groups,24,25 and extends
.. from high BP levels to relatively low values. SBP appears to be a bet-
Elevated BP was the leading global contributor to premature death in ..
2015, accounting for almost 10 million deaths and over 200 million .. ter predictor of events than DBP after the age of 50 years.23,26,27
.. High DBP is associated with increased CV risk and is more commonly
disability-adjusted life years.3 Importantly, despite advances in diagno- ..
sis and treatment over the past 30 years, the disability-adjusted life .. elevated in younger (<50 years) vs. older patients. DBP tends to
.. decline from midlife as a consequence of arterial stiffening; conse-
years attributable to hypertension have increased by 40% since ..
1990.3 SBP >_140 mmHg accounts for most of the mortality and dis- .. quently, SBP assumes even greater importance as a risk factor from
.. midlife.26 In middle-aged and older people, increased pulse pressure
ability burden (70%), and the largest number of SBP-related deaths ..
per year are due to ischaemic heart disease (4.9 million), haemor- .. (the difference between SBP and DBP values) has additional adverse
.. prognostic significance.28,29
rhagic stroke (2.0 million), and ischaemic stroke (1.5 million).3 ..
Both office BP and out-of-office BP have an independent and con- ..
.. 3.5 Hypertension and total
tinuous relationship with the incidence of several CV events [hae- ..
morrhagic stroke, ischaemic stroke, myocardial infarction, sudden
.. cardiovascular risk assessment
..
death, heart failure, and peripheral artery disease (PAD)], as well as .. Hypertension rarely occurs in isolation, and often clusters with other
end-stage renal disease.4 Accumulating evidence is closely linking
.. CV risk factors such as dyslipidaemia and glucose intolerance.30,31

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This metabolic risk factor clustering has a multiplicative effect on CV

Table 6 Risk modifiers increasing cardiovascular risk
risk.32 Consequently, quantification of total CV risk (i.e. the likelihood
estimated by the Systemic COronary Risk Evaluation
of a person developing a CV event over a defined period) is an impor- (SCORE) system35
tant part of the risk stratification process for patients with
hypertension.
Social deprivation, the origin of many causes of CVD
Many CV risk assessment systems are available and most project
10 year risk. Since 2003, the European Guidelines on CVD preven- Obesity (measured by BMI) and central obesity (measured by
tion have recommended use of the Systematic COronary Risk waist circumference)
Evaluation (SCORE) system because it is based on large, representa-
Physical inactivity
tive European cohort data sets (available at: http://www.escardio.org/
Guidelines-&-Education/Practice-tools/CVD-prevention-toolbox/SC Psychosocial stress, including vital exhaustion
ORE-Risk-Charts). The SCORE system estimates the 10 year risk of
Family history of premature CVD (occurring at age <55 years in
a first fatal atherosclerotic event, in relation to age, sex, smoking hab-
men and <60 years in women)
its, total cholesterol level, and SBP. The SCORE system also allows
calibration for different CV risk levels across numerous European Autoimmune and other inflammatory disorders
countries and has been externally validated.33 A previous limitation
Major psychiatric disorders
of the SCORE system was that it applied only to patients aged 40–65
years; however, the SCORE system has recently been adapted for Treatment for infection with human immunodeficiency virus
patients over the age of 65 years.34 Detailed information on CV risk
Atrial fibrillation
assessment is available.35
Factors influencing CV risk factors in patients with hypertension LV hypertrophy
are shown in Table 4. Hypertensive patients with documented
CKD
CVD, including asymptomatic atheromatous disease on imaging,
type 1 or type 2 diabetes, very high levels of individual risk factors Obstructive sleep apnoea syndrome
(including grade 3 hypertension), or chronic kidney disease (CKD;
stages 3 - 5), are automatically considered to be at very high (i.e. BMI = body mass index; CKD = chronic kidney disease; CVD = cardiovascular
>_10% CVD mortality) or high (i.e. 5 - 10% CVD mortality) 10 year disease; LV = left ventricular.
CV risk (Table 5). Such patients do not need formal CV risk estima-
tion to determine their need for treatment of their hypertension
and other CV risk factors. For all other hypertensive patients, esti-
mation of 10 year CV risk using the SCORE system is recom-
Table 7 Correction factors for the Systemic
mended. Estimation should be complemented by assessment of COronary Risk Evaluation (SCORE) cardiovascular risk
hypertension-mediated organ damage (HMOD), which can also estimates in first-generation immigrants to Europe35
increase CV risk to a higher level, even when asymptomatic (see
Table 4 and sections 3.6 and 4). Region of origin Multiplication factor
There is also emerging evidence that an increase in serum uric acid
to levels lower than those typically associated with gout is independ- Southern Asia 1.4
ently associated with increased CV risk in both the general popula- Sub-Saharan Africa 1.3
tion and in hypertensive patients. Measurement of serum uric acid is
recommended as part of the screening of hypertensive patients.36 Caribbean 1.3
The SCORE system only estimates the risk of fatal CV events.
Western Asia 1.2
The risk of total CV events (fatal and non-fatal) is approximately
three times higher than the rate of fatal CV events in men and Northern Africa 0.9
four times higher in women. This multiplier is attenuated to less than
Eastern Asia 0.7
three times in older people in whom a first event is more likely to be
fatal.37 Southern America 0.7
There are important general modifiers of CV risk (Table 6) as well
as specific CV risk modifiers for patients with hypertension. CV risk
modifiers are particularly important at the CV risk boundaries, and
especially for patients at moderate-risk in whom a risk modifier might ..
.. 3.6 Importance of hypertension-
convert moderate-risk to high risk and influence treatment decisions ..
with regard to CV risk factor management. Furthermore, CV risk .. mediated organ damage in refining
.. cardiovascular risk assessment in
estimates by the SCORE system may be modified in first-generation ..
immigrants to Europe and CV risk scores in such patients may be .. hypertensive patients
..
adjusted by correction factors (Table 7). Further details of the impact .. A unique and important aspect of CV risk estimation in hypertensive
of CV risk modifiers are available from the ESC 2016 CVD preven- .. patients is the need to consider the impact of HMOD. This was previ-
..
tion Guidelines.35 . ously termed ‘target organ damage’, but HMOD more accurately

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describes hypertension-induced structural and/or functional changes

.. with a markedly abnormal risk factor profile. In the latter, relative risk
..
in major organs (i.e. the heart, brain, retina, kidney, and vasculature) .. is elevated even if absolute risk is low. The use of ‘CV risk age’ has
(Table 4). There are three important considerations: (i) not all fea-
.. been proposed as a useful way of communicating risk and making
..
tures of HMOD are included in the SCORE system (CKD and estab- .. treatment decisions, especially for younger people at low absolute
..
lished vascular disease are included) and several hypertensive .. risk but with high relative risk.35 This works by illustrating how a
HMODs (e.g. cardiac, vascular, and retinal) have well-established .. younger patient (e.g. a 40-year-old) with risk factors but low absolute
..
adverse prognostic significance (see section 5) and may, especially if .. risk has a CV risk equivalent to a much older person (60 years) with
HMOD is pronounced, lead to a high CV risk even in the absence of .. optimal risk factors; thus, the CV risk age of the younger patient is 60
..
classical CV risk factors; (ii) the presence of HMOD is common and .. years. The CV risk age can be automatically calculated using
often goes undetected;38 and (iii) the presence of multiple HMODs .. HeartScore (www.heartscore.org).
..
in the same patient is also common, and further increases CV .. A second consideration is that the presence of concomitant dis-
risk.39–41 Consequently, the inclusion of HMOD assessment is .. ease is often recorded in a binary way in CV risk assessment systems
..
important in patients with hypertension and helps identify high-risk .. (e.g. diabetes, yes/no). This does not reflect the impact of the severity
or very high-risk hypertensive patients who may otherwise be mis- .. or duration of concomitant diseases on total CV risk. For example,
..
classified as having a lower level of risk by the SCORE system.42 This .. long-standing diabetes is clearly associated with high risk, whereas
is especially true for the presence of left ventricular hypertrophy .. the risk is less certain for recent-onset diabetes.34
..
(LVH), CKD with albuminuria or proteinuria, or arterial stiffening43 .. A third conundrum specific to hypertension is what BP value to
(see section 5). The impact of progression of the stages of .. use in CV risk assessment in a patient who is receiving treatment for
..
hypertension-associated disease (from uncomplicated through to .. hypertension. If treatment was commenced recently, it seems appro-
asymptomatic or established disease), according to different grades
.. priate to use the pre-treatment BP value. If treatment has been
..
of hypertension and the presence of CV risk factors, HMOD, or .. long-standing, using the current treated BP value will invariably
comorbidities, is illustrated in Figure 1 for middle-aged individuals.
.. underestimate risk because it does not reflect prior longer-term
..
.. exposure to higher BP levels, and antihypertensive treatment does
3.7 Challenges in cardiovascular risk .. not completely reverse the risk even when BP is well controlled. If
..
assessment .. treatment has been long-standing, then the ‘treated BP value’ should
.. be used, with the caveat that the calculated CV risk will be lower
CV risk is strongly influenced by age (i.e. older people are invariably ..
at high absolute CV risk). In contrast, the absolute risk of younger
.. than the patient’s actual risk. A fourth conundrum is how to impute
people, particularly younger women, is invariably low, even in those
... out-of-office BP values into risk calculators that have been calibrated
BP (mmHg) grading
Hypertension
Other risk factors, High normal Grade 1 Grade 2 Grade 3
disease
HMOD, or disease SBP 130–139 SBP 140–159 SBP 160–179 SBP 180
staging
DBP 85–89 DBP 90–99 DBP 100–109 or DBP 110
No other risk
Low risk Low risk Moderate risk High risk
factors
Stage 1
Moderate to
(uncomplicated) 1 or 2 risk factors Low risk Moderate risk High risk
high risk
Low to Moderate to
3 risk factors High Risk High risk
Moderate risk high risk
HMOD, CKD grade

Stage 2
3, or diabetes Moderate to High to
(asymptomatic High risk High risk
mellitus without high risk very high risk
disease)
organ damage
©ESC/ESH 2018
Established CVD,
Stage 3
CKD grade 4, or
(established Very high risk Very high risk Very high risk Very high risk
diabetes mellitus
disease)
with organ damage
Figure 1 Classification of hypertension stages according to blood pressure levels, presence of cardiovascular risk factors, hypertension-mediated
organ damage, or comorbidities. CV risk is illustrated for a middle-aged male. The CV risk does not necessarily correspond to the actual risk
at different ages. The use of the SCORE system is recommended for formal estimation of CV risk for treatment decisions. BP = blood pressure;
CKD = chronic kidney disease; CV = cardiovascular; DBP = diastolic blood pressure; HMOD = hypertension-mediated organ damage; SBP = systolic
blood pressure; SCORE = Systematic COronary Risk Evaluation.

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according to office BP readings. These various limitations should be

Table 8 Office blood pressure measurement
kept in mind when estimating CV risk in clinical practice.
Patients should be seated comfortably in a quiet environment

Hypertension and CV risk assessment
for 5 min before beginning BP measurements.
Recommendation Classa Levelb Three BP measurements should be recorded, 1–2 min apart,
and additional measurements only if the first two readings differ
CV risk assessment with the SCORE system by >10 mmHg. BP is recorded as the average of the last two BP
is recommended for hypertensive patients readings.
who are not already at high or very high risk
due to established CVD, renal disease, or Additional measurements may have to be performed in patients
I B
diabetes, a markedly elevated single risk fac- with unstable BP values due to arrhythmias, such as in patents
tor (e.g. cholesterol), or hypertensive with AF, in whom manual auscultatory methods should be used
LVH.33,35 as most automated devices have not been validated for BP
measurement in patients with AF.a
CVD = cardiovascular disease; LVH = left ventricular hypertrophy; SCORE = Use a standard bladder cuff (12–13 cm wide and 35 cm long)
Systematic COronary Risk Evaluation.
a for most patients, but have larger and smaller cuffs available for
Class of recommendation.
b
Level of evidence. larger (arm circumference >32 cm) and thinner arms,
respectively.
The cuff should be positioned at the level of the heart, with the
back and arm supported to avoid muscle contraction and iso-
4 Blood pressure measurement metric exercise-dependant increases in BP.
4.1 Conventional office blood pressure When using auscultatory methods, use phase I and V (sudden
reduction/disappearance) Korotkoff sounds to identify SBP and
measurement
DBP, respectively.
Auscultatory or oscillometric semiautomatic or automatic sphyg-
momanometers are the preferred method for measuring BP in the Measure BP in both arms at the first visit to detect possible
doctor’s office. These devices should be validated according to stand- between-arm differences. Use the arm with the higher value as
ardized conditions and protocols.44 BP should initially be measured in the reference.
both upper arms, using an appropriate cuff size for the arm circumfer-
Measure BP 1 min and 3 min after standing from a seated posi-
ence. A consistent and significant SBP difference between arms (i.e.
tion in all patients at the first measurement to exclude ortho-
>15 mmHg) is associated with an increased CV risk,45 most likely
static hypotension. Lying and standing BP measurements should
due to atheromatous vascular disease. Where there is a difference in
also be considered in subsequent visits in older people, people
BP between arms, ideally established by simultaneous measurement,
with diabetes, and people with other conditions in which ortho-
the arm with the higher BP values should be used for all subsequent
static hypotension may frequently occur.
measurements.
In older people, people with diabetes, or people with other causes Record heart rate and use pulse palpation to exclude
of orthostatic hypotension, BP should also be measured 1 min and 3 arrhythmia.
min after standing. Orthostatic hypotension is defined as a reduction
in SBP of >_20 mmHg or in DBP of >_10 mmHg within 3 min of stand- AF = atrial fibrillation; BP = blood pressure; DBP = diastolic blood pressure; SBP
ing, and is associated with an increased risk of mortality and CV = systolic blood pressure.
a
events.46 Heart rate should also be recorded at the time of BP meas- Most automatic devices are not validated for BP measurement in patients with
AF and will record the highest individual systolic pressure wave form rather than
urements because resting heart rate is an independent predictor of an average of several cardiac cycles. This will lead to overestimation of BP.
CV morbid or fatal events,47 although heart rate is not included in
any CV risk algorithm. Table 8 summarizes the recommended proce-
dure for routine office BP measurement. It is emphasized that office
BP is often performed improperly, with inadequate attention to the ..
.. and unobserved, the ‘white-coat effect’ (see section 4.7.1) can be
standardized conditions recommended for a valid measurement of .. substantially reduced48 or eliminated.49 Moreover, the BP values are
office BP. Improper measurement of office BP can lead to inaccurate ..
.. lower than those obtained by conventional office BP measurement
classification, overestimation of a patient’s true BP, and unnecessary .. and are similar to, or even less than, those provided by daytime
treatment. ..
.. ambulatory blood pressure monitoring (ABPM) or home blood pres-
.. sure monitoring (HBPM).50 Use of unattended office BP measure-
4.2 Unattended office blood pressure ..
.. ment in a recent clinical trial [the Systolic Blood Pressure
measurement .. Intervention Trial (SPRINT)]51 generated controversy about its quan-
..
Automated multiple BP readings in the doctor’s office improve the .. titative relationship to conventional office BP measurement (which
reproducibility of BP measurement, and if the patient is seated alone
.. has been the basis for all previous epidemiological and clinical trial

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..
data); its feasibility in routine clinical practice has also been ques- .. available prospective studies have further indicated that HBPM better
tioned. Presently, the relationship between BP readings obtained .. predicts cardiovascular morbidity and mortality than office BP.59
..
with conventional office BP measurement and unattended office BP .. There is also evidence that patient self-monitoring may have a benefi-
measurement remains unclear, but available evidence suggests that .. cial effect on medication adherence and BP control,60,61 especially
..
conventional office SBP readings may be at least 5–15 mmHg higher .. when combined with education and counselling.62 Telemonitoring
than SBP levels obtained by unattended office BP measurements.52 .. and smartphone applications may offer additional advantages,63,64
..
There is also very limited evidence on the prognostic value of unat- .. such as an aid to memory to make BP measurements, and as a con-
tended office BP measurements, i.e. whether they guarantee at least .. venient way to store and review BP data in a digital diary and transmit
..
the same ability to predict outcomes as conventional office BP .. them. We do not recommend the use of apps as a cuff-independent
measurements.53
.. means of measuring BP.
..
..
..
4.3 Out-of-office blood pressure ..
.. 4.5 Ambulatory blood pressure
measurement ..
Out-of-office BP measurement refers to the use of either HBPM or
.. monitoring
.. ABPM provides the average of BP readings over a defined period,
ABPM, the latter usually over 24 h. It provides a larger number of BP ..
measurements than conventional office BP in conditions that are
.. usually 24 h. The device is typically programmed to record BP at
..
more representative of daily life. Recent position papers and practice .. 15 - 30 min intervals, and average BP values are usually provided for
.. daytime, night-time, and 24 h. A diary of the patient’s activities and
guidelines provide comprehensive details for ABPM54 and HBPM,55 ..
and are briefly summarized below.54,56 .. sleep time can also be recorded. A minimum of 70% usable BP
.. recordings are required for a valid ABPM measurement session.
..
.. ABPM values are, on average, lower than office BP values, and the
4.4 Home blood pressure monitoring .. diagnostic threshold for hypertension is >_130/80 mmHg over 24 h,
Home BP is the average of all BP readings performed with a semiau-
..
.. >_135/85 mmHg for the daytime average, and >_120/70 for the night-
tomatic, validated BP monitor, for at least 3 days and preferably for .. time average (all equivalent to office BP >_140/90 mmHg), see Table 9.
6–7 consecutive days before each clinic visit, with readings in the
..
.. ABPM is a better predictor of HMOD than office BP.65
morning and the evening, taken in a quiet room after 5 min of rest, .. Furthermore, 24 h ambulatory BP mean has been consistently shown
with the patient seated with their back and arm supported. Two
..
.. to have a closer relationship with morbid or fatal events,66–68 and is a
measurements should be taken at each measurement session, per- .. more sensitive risk predictor than office BP of CV outcomes such as
formed 1–2 min apart.57
..
.. coronary morbid or fatal events and stroke.68–72
Compared with office BP, HBPM values are usually lower, and the .. BP normally decreases during sleep. Although the degree of night-
diagnostic threshold for hypertension is >_135/85 mmHg (equivalent
..
.. time BP dipping has a normal distribution in a population setting, an
to office BP >_140/90 mmHg) (Table 9) when considering the average .. arbitrary cut-off has been proposed to define patients as ‘dippers’ if
..
of 3–6 days of home BP values. Compared with office BP, HBPM pro- .. their nocturnal BP falls by >10% of the daytime average BP value;
vides more reproducible BP data and is more closely related to .. however, the ‘dipping’ status is often highly variable from day to day
..
HMOD, particularly LVH.58 Recent meta-analyses of the few .. and thus is poorly reproducible.73 Recognised reasons for an absence
.. of nocturnal BP dipping are sleep disturbance, obstructive sleep
..
.. apnoea, obesity, high salt intake in salt-sensitive subjects, orthostatic
.. hypotension, autonomic dysfunction, CKD, diabetic neuropathy, and
Table 9 Definitions of hypertension according to ..
office, ambulatory, and home blood pressure levels .. old age.54 Studies that accounted for daytime and night-time BP in
..
.. the same statistical model found that night-time BP is a stronger pre-
.. dictor of outcomes than daytime BP.54 The night-to-day ratio is also a
Category SBP DBP ..
(mmHg) (mmHg) .. significant predictor of outcome, and patients with a reduced night-
.. time dip in BP (i.e. <10% of the daytime average BP or a night-to-day
Office BPa
..
>_140 and/or >_90 .. ratio >0.9) have an increased cardiovascular risk.54 Moreover, in
.. those in whom there is no night-time dip in BP or a higher night-time
Ambulatory BP ..
.. than daytime average BP, there is a substantially increase in risk.74
Daytime (or awake) mean >_135 and/or >_85 .. Paradoxically, there is also some evidence of increased risk in patients
..
Night-time (or asleep) mean >_120 and/or >_70 .. who have extreme dipping of their night-time BP,75 although the lim-
.. ited prevalence and reproducibility of this phenomenon makes inter-
..
24 h mean >_130 and/or >_80 .. pretation of data difficult.
.. A number of additional indices derived from ABPM recordings
Home BP mean >_135 and/or >_85 ..
.. have some prognostic value, including 24 h BP variability,76 morning
.. BP surge,77 and the ambulatory arterial stiffness index.78 However,
BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood ..
pressure.
.. their incremental predictive value is not yet clear. Thus, these indices
a .. should be regarded as research tools, with no current indication for
Refers to conventional office BP rather than unattended office BP. ..
. routine clinical use.

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.. elevated when measured by HBPM or ABPM.81 The term ‘true nor-

4.6 Advantages and disadvantages of ..
ambulatory blood pressure monitoring .. motension’ is used when both office and out-of-office BP measure-
.. ments are normal, and ‘sustained hypertension’ is used when both
and home blood pressure monitoring ..
.. are abnormal. In white-coat hypertension, the difference between
A major advantage of both ABPM and HBPM is that they enable the .. the higher office and the lower out-of-office BP is referred to as the
diagnosis of white-coat and masked hypertension (see section 4.7).
..
.. ‘white-coat effect’, and is believed to mainly reflect the pressor
The relative advantages and disadvantages of HBPM and ABPM are .. response to an alerting reaction elicited by office BP measurements
shown in Table 10. A particularly important advantage of HBPM is
..
.. by a doctor or a nurse,82 although other factors are probably also
that it is much cheaper and thus more available than ABPM. Another ..
involved.83
is that it provides multiple measurements over several days or even ...
longer periods, which is clinically relevant because day-to-day BP vari-
.. Although the terms white-coat and masked hypertension were
.. originally defined for people who were not being treated for hyper-
ability may have an independent prognostic value.79 Unlike ABPM, ..
.. tension, they are now also used to describe discrepancies between
typical HBPM devices do not provide BP measurements during rou- .. office and out-of-office BP in patients treated for hypertension, with
tine daily activities and during sleep, although recent technical advan- ..
.. the terms masked uncontrolled hypertension (MUCH) (office BP
ces may allow BP during sleep to be measured by HBPM. A further .. controlled but home or ambulatory BP elevated) and white-coat
consideration is the potential impact of impaired cognition on the ..
.. uncontrolled hypertension (WUCH) (office BP elevated but home
reliability of HBPM measurements and rare instances of obsessional .. or ambulatory BP controlled), compared with sustained uncontrolled
behaviour, circumstances that may favour the use of ABPM if out-of- ..
.. hypertension (SUCH)84 (both office and home or ambulatory BP are
office BP readings are required. In general, both methods should be .. uncontrolled).
regarded as complementary rather than absolute alternatives. ..
.. The white-coat effect is used to describe the difference between
Despite the advances in out-of-office BP measurement over the .. an elevated office BP (treated or untreated) and a lower home or
past 50 years, some fundamental questions remain, the most impor- ..
.. ambulatory BP in both untreated and treated patients.
tant of which is whether HBPM- or ABPM-guided therapy results in ..
greater reductions in morbidity and mortality than conventional ..
.. 4.7.1 White-coat hypertension
office BP-guided treatment, which has been the diagnostic strategy ..
for all clinical outcome trials. .. Although the prevalence varies between studies, white-coat hyper-
.. tension can account for up to 30 - 40% of people (and >50% in the
..
.. very old) with an elevated office BP. It is more common with increas-
4.7 White-coat hypertension and masked .. ing age, in women, and in non-smokers. Its prevalence is lower in
..
hypertension .. patients with HMOD, when office BP is based on repeated measure-
White-coat hypertension refers to the untreated condition in which .. ments, or when a doctor is not involved in the BP measurement. A
..
BP is elevated in the office, but is normal when measured by ABPM, .. significant white-coat effect can be seen at all grades of hypertension
HBPM, or both.80 Conversely, ‘masked hypertension’ refers to
.. (including resistant hypertension), but the prevalence of white-coat
..
untreated patients in whom the BP is normal in the office, but is . hypertension is greatest in grade 1 hypertension.
Table 10 Comparison of ambulatory blood pressure monitoring and home blood pressure monitoring
ABPM HBPM
Advantages Advantages
• Can identify white-coat and masked hypertension • Can identify white-coat and masked hypertension
• Stronger prognostic evidence • Cheap and widely available
• Night-time readings • Measurement in a home setting, which may be more relaxed than
• Measurement in real-life settings the doctor’s office
• Additional prognostic BP phenotypes • Patient engagement in BP measurement
• Abundant information from a single measurement session, including • Easily repeated and used over longer periods to assess day-to-day BP
short-term BP variability variability
Disadvantages Disadvantages
• Expensive and sometimes limited availability • Only static BP is available
• Can be uncomfortable • Potential for measurement error
• No nocturnal readingsa
ABPM = ambulatory blood pressure monitoring; BP = blood pressure; HBPM = home blood pressure monitoring.
a
Techniques are being developed to enable nocturnal BP measurement with home BP devices.

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..
HMOD is less prevalent in white-coat hypertension than in sus- .. BP should be remeasured at least every 3 years. Patients with
tained hypertension, and recent studies show that the risk of cardio- .. high–normal BP (130–139/85–89 mmHg) should have their BP
..
vascular events associated with white-coat hypertension is also lower .. recorded annually because of the high rates of progression of
than that in sustained hypertension.68,85,86 Conversely, compared .. high–normal BP to hypertension. This is true also for people in
..
with true normotensives, patients with white-coat hypertension have .. whom masked hypertension is detected.
increased adrenergic activity,87 a greater prevalence of metabolic risk ..
..
factors, more frequent asymptomatic cardiac and vascular damage, ..
and a greater long-term risk of new-onset diabetes and progression .. 4.9 Confirming the diagnosis of
..
to sustained hypertension and LVH.82 In addition, although the out- .. hypertension
of-office BP values are, by definition, normal in white-coat hyperten- .. BP can be highly variable, thus the diagnosis of hypertension should
..
sion, they tend to be higher than those of true normotensive people, .. not be based on a single set of BP readings at a single office visit,
which may explain the increased long-term risk of CV events .. unless the BP is substantially increased (e.g. grade 3 hypertension)
..
reported in white-coat hypertension by recent studies after adjust- .. and there is clear evidence of HMOD (e.g. hypertensive retinopathy
ment for demographic and metabolic risk factors.85,86,88–90 White- .. with exudates and haemorrhages, or LVH, or vascular or renal dam-
..
coat hypertension has also been shown to have a greater CV risk in .. age). For all others (i.e. almost all patients), repeat BP measurements
isolated systolic hypertension and older patients,91 and does not
.. at repeat office visits have been a long-standing strategy to confirm a
..
appear to be clinically innocent.68 The diagnosis should be confirmed .. persistent elevation in BP, as well as for the classification of the hyper-
by repeated office and out-of-office BP measurements, and should
.. tension status in clinical practice and RCTs. The number of visits and
..
include an extensive assessment of risk factors and HMOD. Both .. the time interval between visits varies according to the severity of the
ABPM and HBPM are recommended to confirm white-coat hyper-
..
.. hypertension, and is inversely related to the severity of hypertension.
tension, because the CV risk appears to be lower (and close to sus- .. Thus, more substantial BP elevation (e.g. grade 2 or more) requires
..
tained normotension) in those in whom both ABPM and HBPM are .. fewer visits and shorter time intervals between visits (i.e. a few days
both normal;82 for treatment considerations see section 8.4. .. or weeks), depending on the severity of BP elevation and whether
..
.. there is evidence of CVD or HMOD. Conversely, in patients with BP
.. elevation in the grade 1 range, the period of repeat measurements
4.7.2 Masked hypertension ..
Masked hypertension can be found in approximately 15% of patients
.. may extend over a few months, especially when the patient is at low
.. risk and there is no HMOD. During this period of BP assessment, CV
with a normal office BP.17 The prevalence is greater in younger peo- ..
ple, men, smokers, and those with higher levels of physical activity,
.. risk assessment and routine screening tests are usually performed
.. (see section 3).
alcohol consumption, anxiety, and job stress.54 Obesity, diabetes, ..
CKD, family history of hypertension, and high–normal office BP are
.. These Guidelines also support the use of out-of-office BP meas-
.. urements (i.e. HBPM and/or ABPM) as an alternative strategy to
also associated with an increased prevalence of masked hyperten- ..
sion.17 Masked hypertension is associated with dyslipidaemia and dys-
.. repeated office BP measurements to confirm the diagnosis of hyper-
.. tension, when these measurements are logistically and economically
glycaemia, HMOD,92 adrenergic activation, and increased risk of ..
developing diabetes and sustained hypertension.81,93 Meta-analyses
.. feasible (Figure 2).99 This approach can provide important supple-
.. mentary clinical information, e.g. detecting white-coat hypertension
and recent studies68 have shown that the risk of CV events is substan- ..
.. (see section 4.7.1), which should be suspected, especially in people
tially greater in masked hypertension compared with normotension, .. with grade 1 hypertension on office BP measurement and in whom
and close to or greater than that of sustained hypertension.68,93–96 ..
.. there is no evidence of HMOD or CVD100 (Table 11). A particular
Masked hypertension has also been found to increase the risk of CV .. challenge is the detection of masked hypertension (see section 4.7.2).
and renal events in diabetes, especially when the BP elevation occurs ..
.. Masked hypertension is more likely in people with a BP in the
during the night.95,97 ..
.. high–normal range in whom out-of-office BP should be considered
.. to exclude masked hypertension (see Table 8). Out-of-office BP
4.8 Screening for the detection of ..
.. measurements are also indicated in specific circumstances (see sec-
hypertension .. tion 4.10 and Table 11).
..
Hypertension is predominantly an asymptomatic condition that is ..
best detected by structured population screening programmes or ..
.. 4.10 Clinical indications for out-of-office
opportunistic measurement of BP. When structured population ..
screening programmes have been undertaken, an alarming number of .. blood pressure measurements
..
people (>50%) were unaware they had hypertension.12,98 This high .. Out-of-office BP measurements are increasingly used, especially
rate of undetected hypertension occurred irrespective of the income .. HBPM but also ABPM, to confirm the diagnosis of hypertension.
..
status of the countries studied across the world. .. Out-of-office BP measurement provides important complementary
All adults should have their BP recorded in their medical record .. information, as discussed above. The clinical indications for out-of-
..
and be aware of their BP, and further screening should be undertaken .. office BP measurements are shown in Table 11. HBPM is also increas-
at regular intervals with the frequency dependent on the BP level. For .. ingly used by patients to monitor their BP control, which increases
..
healthy people with an optimal office BP (<120/80 mmHg), BP should .. their engagement and may improve their adherence to treatment
be remeasured at least every 5 years and more frequently when
.. and BP control.61,101,102 It is likely that, with increased availability and
..
opportunities arise. In patients with a normal BP (120–129/80–84), . lower cost of these devices, this will become more commonplace.

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Figure 2 Screening and diagnosis of hypertension. ABPM = ambulatory blood pressure monitoring; BP = blood pressure; HBPM = home blood
pressure monitoring.
Table 11 Clinical indications for home blood pressure monitoring or ambulatory blood pressure monitoring
Conditions in which white-coat hypertension is more common, e.g.:

• Grade I hypertension on office BP measurement
• Marked office BP elevation without HMOD
Conditions in which masked hypertension is more common, e.g.:

• High–normal office BP
• Normal office BP in individuals with HMOD or at high total CV risk
Postural and post-prandial hypotension in untreated and treated patients
Evaluation of resistant hypertension

Evaluation of BP control, especially in treated higher-risk patients
Exaggerated BP response to exercise
When there is considerable variability in the office BP
Evaluating symptoms consistent with hypotension during treatment
Specific indications for ABPM rather than HBPM:

• Assessment of nocturnal BP values and dipping status (e.g. suspicion of nocturnal hypertension, such as in sleep apnoea, CKD, diabetes, endo-
crine hypertension, or autonomic dysfunction)
ABPM = ambulatory blood pressure monitoring; BP = blood pressure; CKD = chronic kidney disease; CV = cardiovascular; HBPM = home blood pressure monitoring; HMOD
= hypertension-mediated organ damage.

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4.11 Blood pressure during exercise and BP measurement

at high altitude
It is important to recognise that BP increases during dynamic and Recommendations Classa Levelb
static exercise, and that the increase is more pronounced for SBP
than for DBP,103 although only SBP can be measured reliably with Screening programmes for hypertension are
non-invasive methods. There is currently no consensus on normal recommended. All adults (18 years or
BP response during exercise. The increase in SBP during exercise is older) should have their office BP measured I B
related to pre-exercise resting BP, age, arterial stiffness, and and recorded in their medical file, and be
abdominal obesity, and is somewhat greater in women than in men aware of their BP.12,98
and in unfit individuals. There is some evidence that an excessive
• Further BP recording is indicated, at least
I C
rise in BP during exercise predicts the development of hyperten-
every 5 years if BP remains optimal.
sion, independently from BP at rest.104 Nevertheless, exercise test-
ing is not recommended as part of the routine evaluation of • Further BP recording is indicated, at least
I C
every 3 years if BP remains normal.
hypertension because of various limitations, including a lack of
standardization of methodology and definitions. Importantly, • If BP remains high–normal, further BP
recording, at least annually, is I C
except in the presence of very high BP values (grade 3 hyperten-
recommended.
sion), patients, or athletes, with treated or untreated hypertension
should not be discouraged from regular exercise, especially aerobic • In older patients (>50 years), more fre-
quent screening of office BP should be
exercise, which is considered beneficial as part of lifestyle changes IIa C
considered for each BP category because
to reduce BP (see section 7.4.1).
of the steeper rise in SBP with ageing.
Evidence is available that BP increases with high altitude expo-
sure, especially above 3000 m and possibly above 2000 m.105 This It is recommended that office BP should be
is due to a number of factors including sympathetic activation. measured in both arms at least at the first
Patients with grade 2 hypertension and increased CV risk should visit because a between-arm SBP difference
I A
check their BP values before and during high altitude (>2500 m) of >15 mmHg is suggestive of atheromatous
exposure. Patients with grade 1 hypertension may reach very high disease and is associated with an increased
altitude (>4000 m) with adequate medical therapy; uncontrolled CV risk.45
severe hypertensive patients (grade 3) should avoid exposure to
If a between-arm difference in BP is
very high altitude.105
recorded, then it is recommended that all
I C
subsequent BP readings use the arm with
4.12 Central aortic pressure the higher BP reading.
Various techniques allow aortic BP (central BP) to be derived from
peripheral BP measurements using dedicated algorithms.106,107 It is recommended that the diagnosis of
Some studies and meta-analyses have shown that in hypertensive hypertension should be based on:
patients, central BP predicts CV events and that there is a differen- • Repeated office BP measurements on
tial effect of antihypertensive drugs on central compared with bra- more than one visit, except when hyper-
chial BP.108 The incremental prognostic value of central vs. tension is severe (e.g. grade 3 and espe-
conventional clinic BP measurement remains unclear.109 An excep- cially in high-risk patients). At each visit,
tion may be isolated systolic hypertension in the young, in whom three BP measurements should be I C
peripheral BP may be disproportionately elevated relative to a nor- recorded, 1–2 min apart, and additional
mal central BP. This occurs in a small fraction of younger people, measurements should be performed if
mainly men with isolated systolic hypertension, and it remains the first two readings differ by >10
unclear whether such patients are at lower risk than suggested by mmHg. The patient’s BP is the average of
their brachial office BP.110,111 the last two BP readings.
Or
• Out-of-office BP measurement with
ABPM and/or HBPM, provided that
I C
these measurements are logistically and
economically feasible.
Continued

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Out-of-office BP (i.e. ABPM or HBPM) is Table 12 Key information to be collected in personal

specifically recommended for a number of and family medical history
clinical indications, such as identifying white-
coat and masked hypertension, quantifying I A Risk factors
the effects of treatment, and identifying pos-
Family and personal history of hypertension, CVD, stroke, or renal
sible causes of side effects17,54,62,68,72 (e.g. disease
symptomatic hypotension).
Family and personal history of associated risk factors (e.g. familial
It is recommended that all hypertensive hypercholesterolaemia)
patients undergo pulse palpation at rest to Smoking history
I C
determine heart rate and search for
Dietary history and salt intake
arrhythmias such as AF.20,47
Alcohol consumption
Other BP measures and indices (pulse pres-
sure, BP variability, exercise BP, and central Lack of physical exercise/sedentary lifestyle
BP) may be considered but are not often History of erectile dysfunction
used for routine clinical use at present. IIb C
Sleep history, snoring, sleep apnoea (information also from partner)
They may provide useful additional informa-
tion in some circumstances and are valuable Previous hypertension in pregnancy/pre-eclampsia
tools for research. History and symptoms of HMOD, CVD, stroke, and renal
disease
ABPM = ambulatory blood pressure monitoring; AF = atrial fibrillation; BP = Brain and eyes: headache, vertigo, syncope, impaired vision, TIA,
blood pressure; CV = cardiovascular; HBPM = home blood pressure monitoring;
sensory or motor deficit, stroke, carotid revascularization, cognitive
SBP = systolic blood pressure.
a impairment, dementia (in the elderly)
b
Level of evidence. Heart: chest pain, shortness of breath, oedema, myocardial infarc-
tion, coronary revascularization, syncope, history of palpitations,
arrhythmias (especially AF), heart failure
5 Clinical evaluation and Kidney: thirst, polyuria, nocturia, haematuria, urinary tract infections
assessment of hypertension- Peripheral arteries: cold extremities, intermittent claudication, pain-

free walking distance, pain at rest, peripheral revascularization
mediated organ damage in
Patient or family history of CKD (e.g. polycystic kidney disease)
patients with hypertension
History of possible secondary hypertension
5.1 Clinical evaluation Young onset of grade 2 or 3 hypertension (<40 years), or sudden
The purpose of the clinical evaluation is to establish the diagnosis and development of hypertension or rapidly worsening BP in older
grade of hypertension, screen for potential secondary causes of patients
hypertension, identify factors potentially contributing to the develop- History of renal/urinary tract disease
ment of hypertension (lifestyle, concomitant medications, or family
Recreational drug/substance abuse/concurrent therapies: corticoste-
history), identify concomitant CV risk factors (including lifestyle and
roids, nasal vasoconstrictor, chemotherapy, yohimbine, liquorice
family history), identify concomitant diseases, and establish whether
there is evidence of HMOD or existing CV, cerebrovascular, or renal Repetitive episodes of sweating, headache, anxiety, or palpitations,
suggestive of Phaeochromocytoma
disease.
History of spontaneous or diuretic-provoked hypokalaemia, epi-
sodes of muscle weakness, and tetany (hyperaldosteronism)
5.2 Medical history
Symptoms suggestive of thyroid disease or hyperparathyroidism
A thorough medical history (Table 12) should address in particular:
History of or current pregnancy and oral contraceptive use
• Time of the first diagnosis of hypertension, including records of
any previous medical screening, hospitalization, etc. History of sleep apnoea
• Record any current and past BP values Antihypertensive Drug Treatment
• Record current and past antihypertensive medications
• Record other medications Current/past antihypertensive medication including effectiveness
• Family history of hypertension, CVD, stroke, or renal disease and intolerance to previous medications
• Lifestyle evaluation, including exercise levels, body weight Adherence to therapy
changes, diet history, smoking history, alcohol use, recreational
drug use, sleep history, and impact of any treatments on sexual
AF = atrial fibrillation; BP = blood pressure; CKD = chronic kidney disease; CVD
function = cardiovascular disease; HMOD = hypertension-mediated organ damage; TIA =
• History of any concomitant CV risk factors transient ischaemic attack.
• Details and symptoms of past and present comorbidities

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..
• Specific history of potential secondary causes of hypertension .. 5.4 Assessment of hypertension-
(see section 8.2) ..
• History of past pregnancies and oral contraceptive use
.. mediated organ damage
.. HMOD refers to structural or functional changes in arteries or end
• History of menopause and hormone replacement therapy ..
• Use of liquorice .. organs (heart, blood vessels, brain, eyes, and kidney) caused by an
.. elevated BP, and is a marker of pre-clinical or asymptomatic CVD.112
• Use of drugs that may have a pressor effect. ..
.. HMOD is common in severe or long-standing hypertension, but can
.. also be found in less severe hypertension. With wider use of imaging,
..
5.3 Physical examination and clinical .. HMOD is becoming increasingly apparent in asymptomatic
.. patients.43 CV risk increases with the presence of HMOD, and more
investigations ..
.. so when damage affects multiple organs.16,113,114 Some types of
Physical examination provides important indications of potential .. HMOD can be reversed by antihypertensive treatment, especially
causes of secondary hypertension, signs of comorbidities, and ..
.. when used early, but with long-standing hypertension, HMOD may
HMOD. Office BP and heart rate should be measured as summarized ..
in section 4. Measurements of office BP on more than one occasion .. become irreversible despite improved BP control.115,116
.. Nevertheless, BP-lowering treatment is still important as it may delay
are usually required to confirm the diagnosis of hypertension unless ..
HBPM or ABPM is used to confirm the diagnosis (see section 4).
.. the further progression of HMOD and will reduce the elevated CV
.. risk of these patients.116 Although poor technical provision and cost
Details of the requirements for a comprehensive clinical examina- ..
tion are outlined in Table 13, and this should be adapted according to
.. may limit the search for HMOD in some countries, it is recom-
.. mended that basic screening for HMOD is performed in all hyperten-
the severity of hypertension and clinical circumstances. Suggested ..
routine clinical investigations are outlined in Table 14. ... sive patients and more detailed assessment is performed when the
.. presence of HMOD might influence treatment decisions. The various
.. investigations to establish HMOD are shown in Table 15.
..
Table 13 Key steps in physical examination ..
..
.. 5.4.1 Using hypertension-mediated organ damage to help
Body habitus
.. stratify risk in hypertensive patients
..
.. As discussed in section 3, hypertensive patients with documented
Weight and height measured on a calibrated scale, with calcula- .. CVD, diabetes, CKD, grade 3 hypertension, or marked cholesterol
tion of BMI ..
.. elevation (e.g. familial hypercholesterolaemia) are already at high or
Waist circumference
.. very high CV risk (>_10% risk of a fatal event). Thus, the presence of
..
. HMOD is unlikely to influence treatment, as these patients should
Signs of HMOD
Neurological examination and cognitive status

Table 14 Routine workup for evaluation of hyperten-
Fundoscopic examination for hypertensive retinopathy sive patients
Palpation and auscultation of heart and carotid arteries

Routine laboratory tests
Palpation of peripheral arteries
Haemoglobin and/or haematocrit
Comparison of BP in both arms (at least once)
Fasting blood glucose and glycated HbA1c
Secondary hypertension
Blood lipids: total cholesterol, LDL cholesterol, HDL
Skin inspection: cafe-au-lait patches of neurofibromatosis cholesterol
(phaeochromocytoma)
Blood triglycerides
Kidney palpation for signs of renal enlargement in polycystic kid-
Blood potassium and sodium
ney disease
Blood uric acid
Auscultation of heart and renal arteries for murmurs or bruits
indicative of aortic coarctation, or renovascular hypertension Blood creatinine and eGFR
Comparison of radial with femoral pulse: to detect radio-femo- Blood liver function tests
ral delay in aortic coarctation
Urine analysis: microscopic examination; urinary protein by dip-
Signs of Cushing’s disease or acromegaly stick test or, ideally, albumin:creatinine ratio
Signs of thyroid disease 12-lead ECG
BMI = body mass index; BP = blood pressure; HMOD = hypertension-mediated eGFR = estimated glomerular filtration rate; ECG = electrocardiogram; HbA1c =
organ damage. haemoglobin A1c.

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Table 15 Assessment of hypertension-mediated organ damage
Basic screening tests for HMOD Indication and interpretation
12-lead ECG Screen for LVH and other possible cardiac abnormalities, and to document heart rate and cardiac
rhythm
Urine albumin:creatinine ratio To detect elevations in albumin excretion indicative of possible renal disease
Blood creatinine and eGFR To detect possible renal disease
Fundoscopy To detect hypertensive retinopathy, especially in patients with grade 2 or 3 hypertension
More detailed screening for HMOD
Echocardiography To evaluate cardiac structure and function, when this information will influence treatment
decisions
Carotid ultrasound To determine the presence of carotid plaque or stenosis, particularly in patients with cerebrovas-
cular disease or vascular disease elsewhere
Abdominal ultrasound and Doppler studies • To evaluate renal size and structure (e.g. scarring) and exclude renal tract obstruction as pos-
sible underlying causes of CKD and hypertension
• Evaluate abdominal aorta for evidence of aneurysmal dilatation and vascular disease
• Examine adrenal glands for evidence of adenoma or phaeochromocytoma (CT or MRI pre-
ferred for detailed examination); see section 8.2 regarding screening for secondary
hypertension
• Renal artery Doppler studies to screen for the presence of renovascular disease, especially in
the presence of asymmetric renal size
PWV An index of aortic stiffness and underlying arteriosclerosis
ABI Screen for evidence of LEAD
Cognitive function testing To evaluate cognition in patients with symptoms suggestive of cognitive impairment
Brain imaging To evaluate the presence of ischaemic or haemorrhagic brain injury, especially in patients with a
history of cerebrovascular disease or cognitive decline
ABI = ankle-brachial index; CKD = chronic kidney disease; CT = computed tomography; ECG = electrocardiogram; eGFR = estimated glomerular filtration rate; HMOD =
hypertension-mediated organ damage; LEAD = lower extremity artery disease; LVH = left ventricular hypertrophy; MRI = magnetic resonance imaging; PWV = pulse wave
velocity.
..
already receive lifestyle interventions, BP-lowering medications, sta- .. HMOD in younger patients with grade 1 hypertension provides
tins, and in some cases antiplatelet therapy, to reduce their risk35 .. unequivocal evidence of hypertension-mediated damage and indi-
..
(see section 9). .. cates a clear need for BP-lowering treatment in patients who may be
The main advantage of detecting HMOD is that it may reclassify a .. reluctant to be treated. For the same reason, the presence of
..
patient’s SCORE risk assessment from low to moderate or from .. HMOD in a patient with high–normal BP would also provide a
moderate to high risk.117 The specific impact of HMOD114 with
.. rationale to consider BP-lowering treatment.
..
regard to the reclassification of risk estimation according to the .. Another important consideration is whether the presence of a
SCORE system has not been clearly defined. The SCORE system
.. specific manifestation of HMOD (e.g. LVH or CKD) might influence
..
already takes account of the grade of hypertension as SBP is included .. the selection of drug treatment for hypertension. This was consid-
in the risk calculation. Moreover, CKD and the presence of vascular
.. ered important in the previous guidelines,17 but is now considered
..
disease on imaging are already specified as high or very high risk .. less important. In patients more likely to have HMOD (i.e. those with
(Table 5). Conditioning of the risk score by the presence of HMOD
.. high grade 1 or grade 2–3 hypertension), we now recommend initial
..
will be most important in middle-aged patients with hypertension, .. treatment with a combination of two drugs, usually an angiotensin-
..
many of whom will be at moderate-risk and at higher risk if HMOD is .. converting enzyme (ACE) inhibitor or angiotensin receptor blocker
detected. Moreover, a risk-conditioning effect of HMOD will also be .. (ARB) in combination with a calcium channel blocker (CCB) or
..
important in younger hypertensive patients who are invariably classi- .. thiazide-type diuretic, which would be the optimal treatment for all
fied as low risk according to the SCORE system. In addition, detecting .. manifestations of HMOD (see section 7).
.

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.. Three-dimensional TTE is a more reliable method for quantitative

5.5 Characteristics of hypertension- ..
mediated organ damage .. analysis,129 specifically for LV mass,130 volumes, and ejection fraction,
.. and has superior reproducibility to two-dimensional TTE but much
5.5.1 The heart in hypertension ..
.. less prognostic validation.131 More detailed information on the use of
Chronically increased left ventricular (LV) workload in hypertensive .. echocardiography to assess the hypertensive heart is available.43
patients can result in LVH, impaired LV relaxation, left atrial enlarge- ..
.. Cardiac magnetic resonance is the gold standard for cardiac anatomi-
ment, an increased risk of arrhythmias, especially AF, and an ..
.. cal and functional quantification.132–134
increased risk of heart failure with preserved ejection fraction
(HFpEF) and heart failure with reduced ejection fraction (HFrEF). ... Abnormal LV geometry in hypertensive patients is frequently asso-
.. ciated with diastolic dysfunction,127,135 which can be further eval-
..
5.5.1.1 Electrocardiogram .. uated by a combination of transmitral flow and tissue Doppler
.. studies.136 Left atrial size is also frequently increased in hypertensive
A 12-lead electrocardiogram (ECG) should be part of the routine ..
.. patients and is associated with adverse CV events128,137 and incident
assessment in all hypertensive patients. The ECG is not a particularly .. AF,138 and is related to diastolic dysfunction.139,140 During the diag-
sensitive method of detecting LVH and its sensitivity varies according ..
to body weight. ECG LVH provides independent prognostic informa-
.. nostic workup for secondary hypertension, a suprasternal view
.. should also be performed for the identification of aortic
tion, even after adjusting for other CV risk factors and echocardio- ..
.. coarctation.141
graphic LV mass.118 In addition to LVH, the presence of a ‘strain ..
pattern’ on an ECG is associated with increased risk.119 The preva- ..
lence of ECG LVH increases with the severity of hypertension.120
..
.. 5.5.2 The blood vessels in hypertension
The most commonly used criteria to define ECG LVH are shown in .. 5.5.2.1 Carotid artery
Table 16.
..
.. Carotid intima-media thickness (IMT) quantified by carotid ultra-
The ECG cannot exclude LVH because it has poor sensitivity. .. sound, and/or the presence of plaques, predicts CV risk.42,142 This
..
When detailed information on cardiac structure and function will .. holds true both for the IMT value at the carotid bifurcations (reflect-
influence treatment decisions, echocardiography is recommended. .. ing primarily atherosclerosis) and for the IMT value at the level of the
..
When LVH is present on the ECG, it can be used to detect changes .. common carotid artery (reflecting primarily hypertension-related
in LVH during follow-up in untreated and treated patients.121,122 .. hypertrophy). A carotid IMT >0.9 mm is considered abnormal,143
..
.. but the upper limit of normality varies with age. The presence of a
5.5.1.2 Transthoracic echocardiography in hypertension .. plaque can be identified by an IMT >_1.5 mm, or by a focal increase in
..
Echocardiographic LVH is a potent predictor of mortality in both .. thickness of 0.5 mm or 50% of the surrounding carotid IMT value.144
hypertensive patients and the general population,123,124 and regres- .. Stenotic carotid plaques have a strong predictive value for both
sion of echocardiographic LVH due to treatment of hypertension
predicts an improved prognosis.125 Two-dimensional transthoracic
echocardiography (TTE) also provides information about LV geome- Table 17 Echocardiographic definitions of left ventric-
ular hypertrophy, concentric geometry, left ventricular
try, left atrial volume, aortic root dimensions, LV systolic and diastolic
chamber size, and left atrial dilatation
function, pump performance, and output impedance.123,126,127
Whether additional parameters other than evidence of increased LV
Parameter Measure Abnormality
mass and left atrial dilatation are useful to help stratify CV risk is
threshold
uncertain.123,126,128 The partition values recommended for the defini-
tion of LVH by echocardiography are shown in Table 17. LVH LV mass/height2.7 (g/m2.7) >50 (men)
>47 (women)
Table 16 The most commonly used simple criteria
and recognised cut-off points for definitions of electro- LVHa LV mass/BSA (g/m2) >115 (men)
cardiogram left ventricular hypertrophy
>95 (women)
ECG voltage criteria Criteria for LVH LV concentric RWT >_0.43
SV1þRV5 (Sokolow–Lyon criterion) >35 mm geometry
R wave in aVL >_11 mm LV chamber size LV end-diastolic >3.4 (men)

diameter/height (cm/m)
SV3þRaVL (Cornell voltage)a >28 mm (men) >3.3 (women)
b
Cornell duration product Left atrial size Left atrial volume/height2 >18.5 (men)
>20 mm (women)
(elliptical) (mL/m2)
>2440 mm.ms >16.5 (women)
ECG = electrocardiogram; LVH = left ventricular hypertrophy. BSA = body surface area; LV = left ventricular; LVH = left ventricular hypertro-
a phy; RWT = relative wall thickness.
Sum of limb and precordial lead voltage. a
b
Product of Cornell voltage x QRS duration (mm.ms). BSA normalization may be used in normal weight patients.

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..
stroke and myocardial infarction, independent of traditional CV risk .. to quantify urinary albumin excretion. A progressive reduction in
factors,42,142 and confer superior prognostic accuracy for future myo- .. eGFR and increased albuminuria indicate progressive loss of renal
..
cardial infarction compared with IMT.145 The presence of carotid pla- .. function, and are both independent and additive predictors of
ques will automatically reclassify patients from intermediate to high .. increased CV risk and progression of renal disease.158
..
risk;146,147 however, routine carotid imaging is not recommended .. Serum creatinine, eGFR, and ACR should be documented in all
unless clinically indicated (i.e. presence of carotid bruit, previous TIA .. hypertensive patients, and if CKD is diagnosed, repeated at least
..
or cerebrovascular disease, or as part of the assessment of patients .. annually.159 One negative urinary dipstick test does not rule out albu-
with evidence of vascular disease). .. minuria, in contrast to a normal ACR.160
..
..
5.5.2.2 Pulse wave velocity ..
.. 5.5.4 Hypertensive retinopathy
Large artery stiffening is the most important pathophysiological .. The prognostic significance of hypertensive retinopathy by fundo-
determinant of isolated systolic hypertension and age-dependent ..
.. scopy has been well documented.161 Detection of retinal haemor-
increase in pulse pressure.148 Carotid-femoral pulse wave velocity .. rhages, microaneurysms, hard exudates, cotton wool spots, and
(PWV) is the gold standard for measuring large artery stiffness.149 ..
.. papilloedema is highly reproducible, indicates severe hypertensive
Reference values for PWV are available in healthy populations and .. retinopathy, and is highly predictive of mortality.161,162 In contrast,
patients at increased CV risk.150 A PWV >10 m/s is considered a con-
..
.. evidence of arteriolar narrowing, either focal or general, and arterio-
servative estimate of significant alterations of aortic function in .. venous nicking at early stages of hypertensive retinopathy have less
middle-aged hypertensive patients.149 The additive value of PWV
..
.. predictive value,163 and limited interobserver and intraobserver
above and beyond traditional risk factors, including SCORE and the .. reproducibility, even with experienced observers.164 Fundoscopy
Framingham risk score, has been suggested by several studies.151
..
.. should be performed in patients with grade 2 or 3 hypertension or
However, routine use of PWV measurement is not practical and is .. hypertensive patients with diabetes, in whom significant retinopathy
..
not recommended for routine practice. .. is more likely. Fundoscopy may be considered in other hypertensive
.. patients. The increasing emergence of new techniques to visualize
..
5.5.2.3 Ankle–brachial index .. the fundus through smartphone technologies should increase the fea-
Ankle-brachial index (ABI) may be measured either with automated .. sibility of more routine fundoscopy.165
..
devices, or with a continuous wave Doppler unit and a BP sphyg- ..
momanometer. A low ABI (i.e. <0.9) indicates lower extremity artery ..
.. 5.5.5 The brain in hypertension
disease (LEAD), is usually indicative of advanced atherosclerosis,152 ..
.. Hypertension increases the prevalence of brain damage, of which
and has predictive value for CV events,153 being associated with an
.. transient ischaemic attack (TIA) and stroke are the most dramatic
almost two-fold greater 10 year CV mortality and major coronary .. acute clinical manifestations. In the asymptomatic phase, brain dam-
event rate, compared with the overall rate in each Framingham cate- ..
.. age can be detected by magnetic resonance imaging (MRI) as white
gory.153 Even asymptomatic LEAD, detected by a low ABI, is associ- ..
.. matter hyperintensities, silent microinfarcts, (most of which are small
ated in men with a high incidence of CV morbid and fatal events, .. and deep, i.e. lacunar infarctions), microbleeds, and brain atro-
approaching 20% in 10 years.153,154 Routine use of ABI is not recom- ..
.. phy.166,167 White matter hyperintensities and silent infarcts are asso-
mended in hypertensive patients, but should be considered in .. ciated with an increased risk of stroke and cognitive decline due to
patients with symptoms or signs of LEAD, or in moderate-risk .. degenerative and vascular dementia.166–169 Availability and cost do
patients in whom a positive test would reclassify the patient as high-
..
.. not permit the widespread use of brain MRI for the evaluation of
risk. .. hypertensive patients, but white matter hyperintensity and silent
..
.. brain infarcts should be sought in all hypertensive patients with neu-
5.5.3 The kidney in hypertension ..
.. rological disturbances, cognitive decline, and, particularly, memory
Hypertension is the second most important cause of CKD after dia- .. loss.168,169 A family history of cerebral haemorrhage at middle age
betes. Hypertension may also be the presenting feature of asympto- ..
.. and early-onset dementia should prompt MRI. Cognitive impairment
matic primary renal disease. An alteration of renal function is most .. in older patients is, at least in part, hypertension-related, and cogni-
commonly detected by an increase in serum creatinine. This is an ..
.. tive evaluation tests should be considered in the clinical assessment
insensitive marker of renal impairment because a major reduction in .. of hypertensive patients with a history suggestive of early cognitive
renal function is needed before serum creatinine rises. Furthermore, ..
.. impairment. The Mini-Mental State Examination has been the most
BP reduction by antihypertensive treatment often leads to an acute .. widely used method in clinical trials, but is now being superseded by
increase in serum creatinine by as much as 20–30%, especially with ..
.. more sophisticated cognitive tests that are more suitable for routine
renin-angiotensin system (RAS) blockers, which has a functional basis .. clinic visits.170
and does not usually reflect manifest renal injury, but the long-term ..
..
clinical significance is unclear.155,156 The diagnosis of hypertension- ..
.. 5.6 Hypertension-mediated organ
induced renal damage is based on the finding of reduced renal func- ..
tion and/or the detection of albuminuria. CKD is classified according .. damage regression and cardiovascular
to estimated glomerular filtration rate (eGFR), calculated by the 2009 .. risk reduction with antihypertensive
..
CKD-Epidemiology Collaboration formula.157 .. treatment
The albumin:creatinine ratio (ACR) is measured from a spot urine
.. As discussed above, HMOD assessment may play a role in stratifying
..
sample (preferably early morning urine), and is the preferred method . the risk of patients with hypertension. In post hoc analyses, BP

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..
treatment-induced regression of some (but not all) manifestations of .. 5.7 When to refer a patient with
asymptomatic HMOD, as a consequence of treatment, is associated ..
.. hypertension for hospital-based care
with a reduction in CV risk, thereby providing additional information .. Hypertension is a very common condition and most patients with
on the effectiveness of treatment in individual patients.16,104,171 This ..
.. hypertension, in most healthcare systems, will be managed in the pri-
has been best illustrated for the treatment-induced regression of .. mary care setting. However, there are circumstances in which a
LVH measured by either ECG or echocardiography.125,172,173 A ..
.. referral for routine hospital-based evaluation and treatment may be
reduced incidence of CV events and slower progression of renal dis- .. required, keeping in mind that in some instances out-of-office or
ease has been reported with a treatment-induced reduction in uri- ..
.. office-based care of hypertensive patients depends on the healthcare
nary protein excretion in both diabetic and non-diabetic patients, .. organization of a given country:
especially for microalbuminuria,174 but results are discordant.175–179
..
..
There is also evidence that treatment-induced changes in eGFR pre- .. • Patients in whom secondary hypertension is suspected (see sec-
dict CV events180 and progression to end-stage renal disease.181,182
..
.. tion 8.2)
Two meta-analyses183,184 failed to document any predictive value of .. • Younger patients (<40 years) with grade 2 or more severe
treatment-induced reductions in carotid IMT for CV events.
.. hypertension in whom secondary hypertension should be
..
Evidence on the predictive power of treatment-induced changes on .. excluded
other measures of HMOD (PWV and ABI) are either limited or
.. • Patients with treatment-resistant hypertension (see section 8.1)
..
absent. Regression of HMOD might not be possible even when BP is .. • Patients in whom more detailed assessment of HMOD would
.. influence treatment decisions
controlled, particularly when HMOD is advanced, because some of .. • Patients with sudden onset of hypertension when BP has previ-
the changes become irreversible. ..
.. ously been normal
The information available on the sensitivity and timing of changes .. • Other clinical circumstances in which the referring doctor feels
in HMOD during antihypertensive treatment is summarized in ..
.. more specialist evaluation is required.
Table 18. If, when, and how often the assessment of HMOD should ..
be performed has not been validated in follow-up studies. HMOD .. There are also rarer circumstances in which a patient with hyper-
.. tension should be referred to hospital for emergency care, which will
can also develop during the course of antihypertensive treatment,185 ..
and this may be accompanied by increased risk.186–188 .. often require inpatient care (see section 8.3).
.
Table 18 Sensitivity to detect treatment-induced changes, reproducibility and operator independence, time to
changes, and prognostic value of changes provided by markers of hypertension-mediated organ damage
CMR = cardiac magnetic resonance; ECG = electrocardiogram; eGFR = estimated glomerular filtration rate; HMOD = hypertension-mediated organ damage; IMT = intima-
media thickness; LVH = left ventricular hypertrophy; PWV = pulse wave velocity.

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Clinical evaluation and HMOD assessment
Recommendations Classa Levelb
Heart
12-lead ECG is recommended for all hypertensive patients.120 I B
Echocardiography:
• Is recommended in hypertensive patients when there are ECG abnormalities or signs or symptoms of LV I B
dysfunction.42,134
• May be considered when the detection of LVH may influence treatment decisions.42,134 IIb B
Blood vessels
Ultrasound examination of the carotid arteries: I B
• May be considered for the detection of asymptomatic atherosclerotic plaques or carotid stenosis in patients with docu-
IIb B
mented vascular disease elsewhere.42
Measurement of PWV may be considered for measuring arterial stiffness.109,189 IIb B
Measurement of ABI may be considered for the detection of advanced LEAD.153,190 IIb B
Kidney
Measurement of serum creatinine and eGFR is recommended in all hypertensive patients.180 I B
Measurement of urine albumin:creatinine ratio is recommended in all hypertensive patients.43,180 I B
Renal ultrasound and Doppler examination should be considered in patients with impaired renal function, albuminuria, or for
IIa C
suspected secondary hypertension.
Fundoscopy
Is recommended in patients with grades 2 or 3 hypertension and all hypertensive patients with diabetes. I C
May be considered in other hypertensive patients. IIb C
Brain
In hypertensive patients with neurological symptoms and/or cognitive decline, brain MRI or CT should be considered for
IIa B
detecting brain infarctions, microbleeds, and white matter lesions.168,169
ABI = ankle–brachial index; CT = computed tomography; ECG = electrocardiogram; eGFR = estimated glomerular filtration rate; HMOD = hypertension-mediated organ dam-
age; LEAD = lower extremity arterial disease; LV = left ventricular; LVH = left ventricular hypertrophy; MRI = magnetic resonance imaging; PWV = pulse wave velocity; TIA =
transient ischaemic attack.
a
b
Level of evidence.
..
6 Genetics and hypertension ..
..
monogenic forms of hypertension have been described such as
glucocorticoid-remediable aldosteronism, Liddle’s syndrome, and
..
A positive family history is a frequent feature in hypertensive .. others, where a single gene mutation fully explains the pathogenesis
patients, with the heritability estimated to vary between 35 and .. of hypertension and dictates the best treatment modality.194–196
..
50% in most studies.191,192 However, hypertension is a highly heter- .. There are also inherited forms of phaeochromocytoma and para-
ogeneous disorder with a multifactorial aetiology. Several genome- .. ganglioma, which are also rare causes of hypertension.197–200
..
wide association studies and their meta-analyses have identified .. Outside of specialist clinics evaluating patients for these rare causes
120 loci that are associated with BP regulation, but together these .. of secondary hypertension, there is no role for genetic testing in
..
only explain about 3.5% of the trait variance.193 Several rare, .. hypertension in routine clinical care.

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.. The recommendations that follow are based on outcome evidence

Genetic testing and hypertension ..
.. from RCTs; however, it must be acknowledged that RCTs based on
.. clinical outcomes have limitations, the most important of which are
..
Recommendations Classa Levelb .. that the data are largely limited to older and high-risk patients, prefer-
.. entially recruited to increase statistical power, and over a relatively
Genetic testing should be considered in spe- ..
cialist centres for patients suspected to have
.. short duration of follow-up, rarely beyond 5 years. This means that
.. recommendations for life-long treatment for younger and lower risk
rare monogenic causes of secondary hyper- IIa B ..
tension or for those with
.. patients are necessarily based on considerable extrapolation. Big
.. data, now being collected by national health system registries, health
phaeochromocytoma.198 ..
.. insurance companies, and prolonged observational follow-up of
Routine genetic testing for hypertensive ..
III C .. RCTs, are becoming an important source of long-term information
patients is not recommended. .. on the effects of chronic treatment,204 which adds to that provided
..
.. by observational studies over several decades.205–207 Such evidence
a
Class of recommendation. .. suggests that the benefit of continued treatment is maintained over
b
Level of evidence. ..
.. decades.206
..
..
.. 7.2. When to initiate antihypertensive
..
.. treatment
7 Treatment of hypertension ..
.. 7.2.1 Recommendations in previous guidelines
.. All guidelines agree that patients with grade 2 or 3 hypertension
7.1 Beneficial effects of blood pressure- ..
.. should receive antihypertensive drug treatment alongside lifestyle
lowering therapy in hypertension .. interventions.208 Guidelines are also consistent in recommending
There are two well-established strategies to lower BP: lifestyle inter- ..
.. that patients with grade 1 hypertension and high CV risk or HMOD
ventions and drug treatment. Device-based therapy is also emerging, .. should be treated with BP-lowering drugs. There has been less con-
but is not yet proven as an effective treatment option. Lifestyle inter- ..
.. sistency about whether BP-lowering drugs should be offered to
ventions can undoubtedly lower BP and in some cases CV risk (see .. patients with grade 1 hypertension and low–moderate CV risk or
section 7.4.1), but most patients with hypertension will also require ..
.. grade 1 hypertension in older patients (>60 years), or the need for
drug treatment. The drug treatment of hypertension is founded on .. BP-lowering drug treatment in patients with high–normal BP lev-
very solid evidence, underpinned by the largest number of outcome- ..
.. els.17,209,210 This uncertainty relates to the fact that low-risk patients
based RCTs in clinical medicine. Meta-analyses of RCTs including .. with high–normal BP or grade 1 hypertension have rarely been
several hundred thousand patients have shown that a 10 mmHg ..
.. included in RCTs, and that in older patients, RCTs have invariably
reduction in SBP or a 5 mmHg reduction in DBP is associated with ..
significant reductions in all major CV events by 20%, all-cause mor-
.. recruited patients with at least grade 2 hypertension. New analyses
.. and RCT data have become available in these important areas and
tality by 10 - 15%, stroke by 35%, coronary events by 20%, and ..
heart failure by 40%.2,8 These relative risk reductions are consis-
.. are discussed below.
..
tent, irrespective of baseline BP within the hypertensive range, the ..
level of CV risk, comorbidities (e.g. diabetes and CKD), age, sex, and
.. 7.2.2 Drug treatment for patients with grade 1
..
ethnicity.2,201 .. hypertension at lowmoderate cardiovascular risk
Relative outcome reductions calculated by two recent meta-
..
.. Recent meta-analyses show significant treatment-induced reductions
analyses are similar to those provided by the original meta-analysis of .. in CV events and mortality in patients with grade 1 hyperten-
..
the effects of BP lowering on outcomes in 1994.202 Thus, the benefits .. sion.8,201,211 However, the first of these analyses included a substan-
of antihypertensive treatment have not been attenuated by the wide- .. tial number of patients who had grade 1 hypertension despite
..
spread concomitant prescription of lipid-lowering and antiplatelet .. existing treatment, and were therefore likely to have had initial BPs
therapies in contemporary medicine. .. above the grade 1 range. Furthermore, many of the patients had dia-
..
Another important objective of antihypertensive therapy is to .. betes and were therefore at high CV risk.211 The second meta-
reduce the development of CKD; however, the slow rate of decline .. analysis, limited to RCTs in patients with grade 1 hypertension and
..
in renal function in most hypertensive patients makes the demonstra- .. low–moderate-risk (five RCTs, 8974 patients), demonstrated a signif-
tion of potential benefits of BP lowering difficult. Consequently, the .. icant reduction in all major CV events by BP-lowering drug treatment
..
protective effect of BP reduction on kidney function can be less .. [combined stroke and coronary artery disease (CAD) reduced by
obvious and has been restricted to patients with diabetes or CKD, in .. 34%, and all-cause mortality by 19% for an SBP reduction of 7
..
whom there is a faster rate of disease progression.203 Some, but not .. mmHg].8 A third analysis demonstrated a benefit of BP lowering in
all, RCTs have also shown a protective effective of BP lowering on .. reducing death and CVD in patients with a baseline BP 140/90 mmHg
..
the progression of CKD towards end-stage renal disease in both dia- .. or higher, but not when baseline BP was lower.201 These findings
betic and non-diabetic nephropathy.2 .. have been supported by the results of a subgroup analysis of the

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..
Heart Outcomes Prevention Evaluation (HOPE)-3 trial, showing a .. because physically and mentally frail and institutionalized patients
significant 27% reduction in major CV outcomes in patients at inter- .. have been excluded in most RCTs of patients with hypertension.214
..
mediate CV risk and baseline SBP values in the grade 1 hypertensive .. Further details of the treatment of hypertension in older patients and
range [i.e. >143.5 mmHg (mean 154 mmHg)] when SBP was lowered .. very old patients is provided in section 8.8.
..
by drug treatment by a mean of 6 mmHg.212 ..
Based on these new data, this Task Force now recommends that ..
.. 7.2.4 Initiation of blood pressure-lowering drug
lifestyle advice should be accompanied by BP-lowering drug treat- .. treatment in patients with highnormal blood pressure
ment in patients with grade 1 hypertension at low–moderate CV
..
.. The previous (2013) Guidelines17 recommended not to initiate anti-
risk. .. hypertensive treatment in people with high–normal BP and
..
.. low–moderate CV risk. This recommendation is further supported
7.2.3 Initiation of blood pressure-lowering drug treat-
.. by new evidence:
..
ment in older people with grade 1 hypertension ..
.. (1) In all RCTs (including SPRINT)51 and meta-analyses2 that have
Discussion about the treatment of ‘the elderly’ or ‘older’ people has .. reported reduced major outcomes by lowering ‘baseline’ BP in the
been complicated by the various definitions of older age used in ..
.. high–normal range, the ‘baseline’ BP was commonly measured on a
RCTs. For example, older was defined as >60 years in the earliest tri- .. background of antihypertensive treatment. Therefore, these studies
als, then as 65, 70, and finally 7551 or 80 years213 in later trials. ..
.. do not provide evidence to support treatment initiation in patients
Chronological age is often a poor surrogate for biological age, with .. without hypertension.8
consideration of frailty and independence influencing the likely toler- ..
.. (2) The HOPE-3 trial,212 in which only 22% of the patients at intermedi-
ability of BP-lowering medications. For the purposes of this guideline, .. ate CV risk had background antihypertensive treatment, showed
the ‘old’ are defined as >_65 years and the ‘very old’ as >_80 years. The ..
.. that BP-lowering treatment did not reduce the risk of major CV
previous Guidelines17 noted that all available evidence on CV event ..
.. events in patients with baseline SBP values in the high–normal
reduction by BP lowering in older patients was obtained in patients
.. range.
whose baseline SBP was >_160 mmHg, and there is strong evidence .. (3) A meta-analysis of 13 RCTs or RCT subgroups (involving 21 128
that these patients should be offered BP-lowering drug ..
.. individuals) in patients at low–moderate CV risk and untreated
treatment.210,214 ..
.. baseline BP in the high–normal and normal range, showed no effect
Undoubtedly, there are RCTs showing outcome benefits with BP- .. of BP-lowering treatment on any CV outcomes.217
lowering treatment in older patients whose baseline BP was in a .. (4) Another recent analysis, including patients with high–normal BP,
lower SBP range, but these patients were often on background anti- ..
.. concluded that primary preventive BP lowering was associated with
hypertensive treatment, thus they cannot be defined as having true .. reduced risk for death and incident CVD if baseline SBP was 140
grade 1 hypertension. This is also the case for the data recently pub-
..
.. mmHg or higher, but at lower BP levels [i.e. high–normal BP (<140/
lished from the SPRINT trial, which included a cohort of patients ..
older than 75 years, in whom more intense BP lowering reduced the
.. 90 mmHg)], treatment was not associated with any benefit in pri-
.. mary prevention.201
risk of major CV events and mortality.51,215 However, in most RCTs ..
showing a protective effect of BP-lowering treatment in patients with
.. (5) The situation may be different in very high-risk patients with a
.. high–normal BP and established CVD. In a meta-analysis of 10
an untreated baseline BP in the grade 1 hypertension range, older ..
patients were well represented. This was further supported by the
.. RCTs or RCT subgroups that also included individuals at high or
.. very high CV risk, mostly with previous CVD and untreated
recent HOPE-3 trial, which showed beneficial effects of BP lowering ..
.. high–normal and normal BP (n = 26 863), BP-lowering drug treat-
on CV outcomes in patients, many with grade 1 hypertension (SBP .. ment, achieving an SBP reduction of 4 mmHg, reduced the risk of
>143 mmHg and mean BP = 154 mmHg), whose mean age was 66 ..
.. stroke but not any other CV events.217 In another analysis of trials
years, and in whom only 22% had prior treatment of hypertension.212 .. including people with previous CAD and a mean baseline SBP of
The evidence supports the recommendation that older patients ..
.. 138 mmHg, treatment was associated with reduced risk for major
(>65 years, including patients over 80 years) should be offered BP- .. CV events (relative risk 0.90; 95% confidence interval 0.84–0.97),
lowering treatment if their SBP is >_160 mmHg. There is also justifica- ..
.. but was not associated with an increased survival (relative risk 0.98;
tion to now recommend BP-lowering treatment for old patients .. 95% confidence interval 0.89–1.07).201 Thus, the benefit for treating
(aged >65 but not >80 years) at a lower BP (i.e. grade 1 hypertension; ..
.. people with high–normal BP appears marginal and, if present,
SBP = 140–159 mmHg).201 BP-lowering drugs should not be with- ..
.. appears to be restricted to those at very high CV risk and estab-
drawn on the basis of age alone. It is well established that BP- .. lished CVD, especially CAD.
lowering treatment withdrawal leads to a marked increase in CV risk. ..
This was exemplified in older patients by a recent subgroup analysis .. We recommend that patients with high–normal BP and
..
of the Hypertension in the Very Elderly Trial (HYVET),213 reporting .. low–moderate CV risk should be offered lifestyle advice, because this
that in patients aged >_80 years, CV risk reduction was greatest in .. reduces their risk of progressing to established hypertension and may
..
those who continued treatment rather than in those whose treat- .. further reduce their CV risk. These patients should not be offered BP-
ment was discontinued.216 As stated above, all of the above recom-
.. lowering drug treatment. Nevertheless, based on the data from the
..
mendations relate to relatively fit and independent older patients, . HOPE-3 trial, drug treatment may be considered in these patients if

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..
their BP is close to the hypertension diagnostic threshold of 140/90 effective strategy to reduce risk is to prevent the development of high
...
mmHg, after a prolonged attempt to control BP with lifestyle changes. .. CV-risk situations with earlier intervention. The assessment of CV risk
BP-lowering drugs may be considered for patients with .. is at the core of the treatment strategy recommended by these
..
high–normal BP and established CVD, especially CAD. In these .. Guidelines because of the frequent coexistence of multiple CV risk fac-
patients, monotherapy may be sufficient. .. tors in hypertensive patients, and to inform the use of concomitant
..
.. medications (e.g. statins, antiplatelet therapies, etc., see section 9) to
.. reduce CV risk. We conclude that, in general, the decision to use BP-
7.2.5 Should blood pressure-lowering drug treatment be ..
initiated on the basis of blood pressure values or the level
.. lowering treatment should not be based solely on the level of CV risk
.. because even in patients at the highest risk (with established CVD),
of total cardiovascular risk? ..
.. when baseline BP is below 140/90 mmHg, the benefits of BP-lowering
Two recent meta-analyses of RCTs8,218 have shown that when BP- ..
.. treatment are at best marginal and most evident in patients with CAD
lowering data are stratified according to CV risk, the relative risk reduc-
.. at the upper end of the high–normal BP range.201
tions do not differ across the various risk strata; not surprisingly, the ..
absolute risk reduction is greater with increasing baseline CV risk. ..
..
These data have been taken as support for the hypothesis that BP- ..
lowering treatment should be based on CV risk and target those at .. 7.2.6 Initiation of blood pressure-lowering drug
..
greatest CV risk, irrespective of their BP.218 However, it has recently .. treatment
been made that whereas patients at high or very high CV risk exhibit .. In patients with grade 2 or 3 hypertension, it is recommended that
..
the greatest absolute reduction in CV outcomes with BP-lowering .. BP-lowering drug treatment should be initiated alongside lifestyle
treatment, they also have the highest residual risk, which means failure .. interventions. In patients with grade 1 hypertension at high risk or
..
of treatment to exert full protection.8 It is the opinion of this Task .. with HMOD, drug treatment should also be initiated simultaneously
Force that these data support earlier treatment of patients with SBP or .. with lifestyle interventions. In lower-risk patients with grade 1 hyper-
..
DBP values >140/90 mmHg when their CV risk is still low–moderate, .. tension, BP-lowering drug treatment should be initiated after 3–6
to prevent the accumulation of HMOD and a high incidence of late
.. months if BP is not controlled by lifestyle interventions alone
..
treatment failure (residual risk), which would otherwise occur if treat- .. (Figure 3). Recommended BP thresholds for the initiation of antihy-
ment was delayed by a purely CV risk-based approach. The most
.. pertensive drug treatment are shown in Table 19.
Figure 3 Initiation of blood pressure-lowering treatment (lifestyle changes and medication) at different initial office blood pressure levels. BP =
blood pressure; CAD = coronary artery disease; CVD = cardiovascular disease; HMOD = hypertension-mediated organ damage.

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Initiation of hypertension treatment according to office BP
Prompt initiation of BP-lowering drug treatment is recommended in patients with grade 2 or 3 hypertension at any level of CV
I A
risk, simultaneous with the initiation of lifestyle changes.2,8
In patients with grade 1 hypertension:

II B
Lifestyle interventions are recommended to determine if this will normalize BP.219
In patients with grade 1 hypertension at low–moderate-risk and without evidence of HMOD, BP-lowering drug treatment is
I A
recommended if the patient remains hypertensive after a period of lifestyle intervention.211,212
In patients with grade 1 hypertension and at high risk or with evidence of HMOD, prompt initiation of drug treatment is rec-
I A
ommended simultaneously with lifestyle interventions.211,212
In fit older patients with hypertension (even if aged >80 years), BP-lowering drug treatment and lifestyle intervention are rec-
I A
ommended when SBP is >_160 mmHg.210,220,221
BP-lowering drug treatment and lifestyle intervention are recommended for fit older patients (>65 years but not >80 years)
I A
when SBP is in the grade 1 range (140–159 mmHg), provided that treatment is well tolerated.212
Antihypertensive treatment may also be considered in frail older patients if tolerated.215 IIb B
Withdrawal of BP-lowering drug treatment on the basis of age, even when patients attain an age of >_80 years, is not recom-
III A
mended, provided that treatment is well tolerated.213
In patients with high–normal BP (130–139/85–89 mmHg): I A

Lifestyle changes are recommended.17,35
Drug treatment may be considered when their CV is very high due to established CVD, especially CAD.217 IIb A
BP = blood pressure; CAD = coronary artery disease; CV = cardiovascular; CVD = cardiovascular disease; HMOD = hypertension-mediated organ damage; SBP = systolic
blood pressure.
a
b
Level of evidence.
c
In patients with grade 1 hypertension and at low–moderate-risk, drug treatment may be preceded by a prolonged period of lifestyle intervention to determine if this approach
will normalize BP. The duration of the lifestyle intervention alone will depend on the level of BP within the grade 1 range, i.e. the likelihood of achieving BP control with lifestyle
intervention alone, and the opportunities for significant lifestyle change in individual patients.
Table 19 Summary of office blood pressure thresholds for treatment
Age group Office SBP treatment threshold (mmHg) Office DBP treatment
threshold (mmHg)
Hypertension 1 Diabetes 1 CKD 1 CAD 1 Stroke/TIA

a
18 - 65 years >_140 >_140 >_140 >_140 >_140a >_90
65 - 79 years >_140 >_140 >_140 >_140a >_140a >_90
>_80 years >_160 >_160 >_160 >_160 >_160 >_90
Office DBP treatment >_90 >_90 >_90 >_90 >_90

threshold (mmHg)
BP = blood pressure; CAD = coronary artery disease; CKD = chronic kidney disease; DBP = diastolic blood pressure; SBP = systolic blood pressure; TIA = transient
ischaemic attack.
a
Treatment may be considered in these very high-risk patients with high–normal SBP (i.e. SBP 130–140 mmHg).

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..
7.3 Blood pressure treatment targets .. baseline values between 130 and 139 mmHg, implying benefit at
.. achieved SBP values of <130 mmHg. Furthermore, a benefit of a 10
7.3.1 New evidence on systolic blood pressure and ..
diastolic blood pressure treatment targets .. mmHg reduction in SBP was also reported for patients with a base-
.. line SBP of <130 mmHg, thereby achieving values <120 mmHg.
The 2013 ESH/ESC hypertension Guidelines17 recommended an ..
office BP treatment target of <140/90 mmHg, regardless of the num- .. However, there were far fewer patients in these subgroups, and this
.. last set of data will have been heavily influenced by the unusually low
ber of comorbidities and level of CV risk. The Guidelines specifically ..
stated that evidence from RCTs, meta-analyses, and post hoc analysis .. BP values in the SPRINT trial, due to the method of BP measurement
.. (see above). Importantly, this analysis showed consistent benefit
of large-scale RCTs all showed no obvious incremental benefit of ..
lowering BP to <130/80 mmHg. Since then, new information has .. from intensive BP lowering in patients at all levels of risk, including
.. those with and without existing CVD, stroke, diabetes, and CKD.
emerged from post hoc analyses of large outcome trials in patients at ..
high CV risk,222–224 registries in patients with coronary disease, and,
.. Finally, in the first meta-analysis,226 the incremental benefit of BP
.. lowering on events progressively decreased as the target BP was low-
more importantly, new RCTs and meta-analyses of all available RCT ..
evidence. In the post hoc RCT analyses and registry data, compared
.. ered. Furthermore, an additional meta-analysis by the same group
.. found that permanent treatment discontinuation because of
with a target SBP of between 130 mmHg and 139 mmHg, lowering ..
SBP to <130 mmHg was, in general, associated with no further bene-
.. treatment-related adverse effects was significantly higher in those tar-
fit on major CV events, except perhaps for further reductions in the
... geted to lower BP values.227 Therefore, advocating more intensive
..
risk of stroke. A consistent finding was that reducing SBP to <120 .. BP-lowering targets for all has to be viewed in the context of an
mmHg increased the incidence of CV events and death.
.. increased risk of treatment discontinuation due to adverse events,
..
A recent RCT relevant to the issue of target BP is SPRINT, which .. which might offset, in part or completely, the limited incremental
.. reduction in CV risk.
compared two different SBP targets (<140 or <120 mmHg) in ..
>9000 patients at high CV risk, but excluded patients with diabetes .. Whilst considering BP targets, it is important to acknowledge that
.. <50% of patients treated for hypertension currently achieve a target
or previous stroke. More intensive BP-lowering treatment (achieved ..
SBP 121 vs. 136 mmHg) was associated with a 25% reduction in .. office SBP of <140 mmHg.11,12 This is a major missed opportunity for
.. CVD prevention in millions of people across the world.
major CV events and a 27% reduction in all-cause death (but no sig- ..
nificant reduction in stroke or myocardial infarction).51 This outcome .. This Task Force recommends that when BP-lowering drugs are
.. used, the first objective should be to lower BP to <140/90 mmHg in
unquestionably provides strong support for the beneficial effects of ..
more vs. less intensive BP-lowering treatment strategies in higher risk .. all patients. Provided that the treatment is well tolerated, treated BP
.. values should be targeted to 130/80 mmHg or lower in most patients,
patients. However, this RCT does not clarify the optimal BP target ..
because the method used for office BP measurement in SPRINT .. although in some groups the evidence is less compelling. In older
.. patients (>65 years), SBP should be targeted to between 130 and
(unattended automatic measurement) had not been used in any pre- ..
vious RCTs that provide the evidence base for the treatment of .. 140 mmHg, and DPB to <80 mmHg. Treated SBP should not be tar-
.. geted to <120 mmHg.
hypertension.225 This is because unattended automated office BP ..
measurement results in lower BP values, relative to conventional
.. Importantly, we specify a target range because the lower safety
.. boundary assumes greater importance when BP is targeted to lower
office BP measurement, due to the absence of the white-coat ..
effect.52,54 Thus, it has been suggested that the BP values reported in
.. levels. Furthermore, in general, when SBP is lowered to <120 mmHg
.. in patients included in RCTs (i.e. older and higher-risk patients, often
SPRINT may correspond to conventional office SBPs in the 130 –140 ..
and 140 –150 mmHg ranges in the more vs. less intensive BP-
.. with comorbidities and CVD), the risk of harm appears to increase
..
lowering groups, respectively. .. and outweigh the benefits.222
Some new information on SBP and DBP targets for drug treatment
..
..
has been provided by two recent, large meta-analyses of RCTs of BP ..
..
lowering. In the first of these meta-analyses, achieved SBP was strati- .. 7.3.2 Blood pressure targets in specific subgroups of
fied according to three SBP target ranges (149–140 mmHg, 139–130 .. hypertensive patients
..
mmHg, and <130 mmHg).226 Lowering SBP to <140 mmHg reduced .. 7.3.2.1. Diabetes mellitus
the relative risk of all major CV outcomes (including mortality); simi- .. RCTs in type 1 diabetes mellitus demonstrate that BP-lowering treat-
..
lar benefits were seen when SBP was lowered to <130 mmHg (aver- .. ment has a renoprotective effect,228 but because these patients tend
age 126 mmHg). Importantly, the latter was also true when the .. to be younger, previous RCTs have had inadequate power to study
..
achieved SBP in the comparator group was 130 - 139 mmHg. .. CV outcomes and to establish optimal BP targets.
Stratification of RCTs for achieved DBP, to either 89 - 80 mmHg or .. In contrast, there have been many BP-lowering treatment RCTs,
..
<80 mmHg, also showed a reduction in all types of CV outcomes .. either exclusively dedicated to patients with type 2 diabetes or
compared with higher DBP values.226 .. hypertension trials that have included a large cohort of patients with
..
The second meta-analysis, which also included the SPRINT trial,2 .. type 2 diabetes.2 Most of these RCTs have shown that BP lowering
noted that every 10 mmHg reduction in SBP reduced the rate of .. to <140/85 mmHg is beneficial in patients with type 2 diabetes and
..
major CV events and death for baseline SBP values >160 mmHg to . hypertension. However, the results have been less clear about

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whether a lower BP target is associated with further benefits. The evi-

.. 7.3.2.2. Older patients
..
dence can be summarized as follows: .. The definition of ‘older’ is complex. As populations age, there is
.. increasingly wide variation between a patient’s chronological age and
i. A large RCT in patients with type 2 diabetes has shown that an
..
.. their functional status, ranging from fit, active, and independent,
achieved SBP of <135 mmHg, compared with 140 mmHg, was ..
.. through to frail and dependent. The anticipated benefits vs. potential
associated with a significant reduction in cardiovascular and all-cause .. harm of BP treatment in older patients will be influenced by the
mortality.229 ..
ii. Evidence from another large RCT in patients with type 2 diabetes
.. patient’s ability to tolerate treatment and their health and functional
.. status. For the purposes of these Guidelines, ‘older’ patients are
showed that, compared with patients with an on-treatment SBP of ..
.. defined as those aged >_65 years.
135 mmHg, reducing SBP to 121 mmHg did not reduce CV mor- .. In the 2013 ESH/ESC hypertension Guidelines, the target SBP for
bidity and mortality or all-cause death, but substantially reduced the ..
.. older hypertensive patients was set at 140–150 mmHg because this
risk of stroke.230 .. was the range of systolic values achieved by major outcome trials
iii. Although one recent meta-analysis concluded that most of the bene- ..
.. demonstrating a beneficial effect of antihypertensive treatment in
fit associated with BP lowering was obtained at higher BP targets (i.e. .. these patients. A similar SBP target was suggested by the HYVET trial,
<150 mmHg but not <140 mmHg),231 other large meta-analyses ..
.. in which treating to an SBP target of <150 mmHg (achieving a mean
have confirmed that in type 2 diabetes, lowering SBP to <140 mmHg .. SBP of 144 mmHg) in the very old (>80 years) demonstrated signifi-
is associated with reductions in all major CV events.1,232–234 ..
.. cant reductions in mortality, fatal stroke, and heart failure, with the
iv. Two of the meta-analyses concluded that the overall benefit of low- .. caveat that the ‘very old’ patients in this study were active and inde-
ering BP in patients with type 2 diabetes (unlike patients without ..
.. pendent.213 More recent evidence supports a lower SBP target for
type 2 diabetes) largely disappears when SBP is lowered to <130/80 .. older patients (>_65 years):
mmHg,1,235 except for the continuing incremental benefit on stroke. ..
..
v. Similar evidence for stroke benefit from lower achieved SBP has also .. (1) The SPRINT trial included a high proportion of patients over
been reported from post hoc analysis of diabetic patients in the
.. the age of 75 years (n = 2636) and demonstrated that more inten-
..
ONTARGET (Ongoing Telmisartan Alone and in combination with .. sive BP-lowering treatment (mean achieved BP = 124/62 mmHg)
Ramipril Global Endpoint Trial) study. In addition, reanalysis of the
.. significantly reduced the risk of major CV events, heart failure, and
..
Action to Control Cardiovascular Risk in Diabetes (ACCORD)230 .. all-cause death (all by >30%) compared with standard treatment
trial in type 2 diabetes, after removing the interaction from the inten- ... (mean achieved BP = 135/67 mmHg).215 It has been noted above
sive glucose-lowering arm and thereby limiting the analysis to BP-
.. that the BP measurement technique used in SPRINT generated
..
lowering effects, showed an overall reduction in CV events with .. lower values than those provided by the conventional office
intensive SBP lowering to <130 mmHg.236
.. BP measurement.225,242 Consequently, the SBP of 124 mmHg
..
vi. Further recent analysis of the ACCORD trial has shown that reduc- .. achieved in the intensively treated older patients in the SPRINT
..
ing SBP to <120 mmHg was associated with increased risk of major .. trial most probably reflects a conventional office SBP range of
CV events.236 .. 130 –139 mmHg.
..
vii. With regard to DBP, earlier evidence suggested a benefit on major .. (2) Although HYVET and most other RCTs in older patients have
CV events when DBP was lowered to <85 mmHg.237,238 More .. recruited relatively fit and independent patients, the SPRINT study
..
recently, in the Action in Diabetes and Vascular Disease: Preterax .. also suggested that there are benefits of more intensive treatment
and Diamicron – MR Controlled Evaluation (ADVANCE) trial,229 .. being extended to older patients who are at the frailer end of the
..
the benefits on CV outcomes was observed at diastolic pressures of .. spectrum of patients meeting the recruitment criteria, with reduced
75 mmHg. This is consistent with evidence from the meta-analyses .. gait speed.215
..
cited above, that it is safe and effective to lower DBP to <80 mmHg ..
in patients with type 2 diabetes. .. Based on the new data, the targets suggested by the previous
.. Guidelines now appear too conservative for many old and very old
..
In summary, In patients with diabetes receiving BP-lowering drugs, .. patients, especially those who are active and independent.
it is recommended that office BP should be targeted to an SBP of 130 .. Consequently, we recommend that in older patients treated for
..
mmHg,229 and lower if tolerated. In older patients (aged >_65 years) .. hypertension, BP should be lowered to <140/80 mmHg, but not
the SBP target range should be 130–140 mmHg213 if tolerated. SBP .. below an SBP of 130 mmHg. Importantly, the impact of BP-lowering
..
should not be lowered to <120 mmHg and DBP should be lowered .. on the well-being of the patient should be closely monitored, because
to <80 mmHg. Attention should also be given to the consistency of .. the increased risk of adverse events (e.g. injurious falls) with lower BP
..
BP control, because visit-to-visit BP variability is associated with .. values could be more pronounced in older patients in the real-life
increased CV and renal disease risk. Furthermore, CV protection has .. setting than in the closely monitored conditions of RCTs. Further
..
been found to be greater when BP control is accompanied by fewer .. details on the approach to treatment of the frail older patient are dis-
visit-to-visit BP variations.239–241
.. cussed in section 8.8.
..
..

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7.3.2.3 Office vs. home and ambulatory blood pressure targets

..
.. 7.4 Treatment of hypertension
No outcome-based RCT has used ABPM or HBPM to guide the .. 7.4.1 Lifestyle changes
..
treatment of hypertension. Thus, ABPM and HBPM BP targets are .. Heathy lifestyle choices can prevent or delay the onset of hyperten-
based on extrapolation from observational data rather than on out- .. sion and can reduce CV risk.17,35 Effective lifestyle changes may be
..
come trials. Although we do not provide formal ABPM or HBPM BP .. sufficient to delay or prevent the need for drug therapy in patients
targets for treated patients, it should be noted that: ..
.. with grade 1 hypertension. They can also augment the effects of BP-
.. lowering therapy, but they should never delay the initiation of drug
(1) In population studies, the difference between office and out-of- ..
office BP levels decreases as office BP decreases, to a point of .. therapy in patients with HMOD or at a high level of CV risk. A major
.. drawback of lifestyle modification is the poor persistence over
around 115 - 120/70 mmHg, at which office and 24 h ABPM mean ..
BP values are usually similar.54 .. time.245,246 The recommended lifestyle measures that have been
.. shown to reduce BP are salt restriction, moderation of alcohol con-
(2) This convergence has also been confirmed in treated patients243 in ..
whom the difference between office BP and ambulatory BP .. sumption, high consumption of vegetables and fruits, weight reduc-
.. tion and maintaining an ideal body weight, and regular physical
values diminishes and becomes negligible at an SBP of approxi- ..
mately 120 mmHg. .. activity.17 In addition, tobacco smoking has an acute prolonged
.. pressor effect that may raise daytime ambulatory BP, but smoking
(3) In treated patients, a target office SBP of 130 mmHg might therefore ..
correspond to a slightly lower mean 24 h SBP, i.e. approximately .. cessation and other lifestyle measures are also important beyond BP
.. (i.e. for CVD and cancer prevention).35
125 mmHg. ..
(4) Although there are no available data, the home SBP target, to be ..
..
equivalent to an office SBP target of 130 mmHg, might also be lower ..
than 130 mmHg.
.. 7.4.2 Dietary sodium restriction
.. There is evidence of a causal relationship between sodium intake and
..
.. BP, and excessive sodium consumption (>5 g sodium per day, e.g.
Office BP treatment targets in hypertensive patients .. one small teaspoon of salt per day) has been shown to have a pressor
..
.. effect and be associated with an increased prevalence of hyperten-
Recommendations Classa Levelb .. sion and the rise in SBP with age.247 Conversely, sodium restriction
..
It is recommended that the first objective of .. has been shown to have a BP-lowering effect in many trials. A recent
.. meta-analysis of these trials showed that a reduction of 1.75 g
treatment should be to lower BP to <140/ ..
90 mmHg in all patients and, provided that
.. sodium per day (4.4 g salt/day) was associated with a mean 4.2/2.1
I A .. mmHg reduction in SBP/DBP, with a more pronounced effect (-5.4/
the treatment is well tolerated, treated BP ..
values should be targeted to 130/80 mmHg
.. -2.8 mmHg) in people with hypertension.248 The beneficial effect of a
.. reduced sodium intake on BP tends to diminish with time, in part due
or lower in most patients.2,8 ..
.. to poor dietary persistence. The BP-lowering effect of sodium
In patients <65 years receiving BP-lowering .. restriction is greater in black people, in older patients, and in patients
..
drugs, it is recommended that SBP should
I A
.. with diabetes, metabolic syndrome, or CKD.249 In people with
be lowered to a BP range of 120–129 .. treated hypertension, effective sodium restriction may reduce the
..
mmHg in most patients.c 2,215,229 .. number or dose of BP-lowering drugs that are necessary to control
.. BP.250,251
In older patients (aged >_65 years) receiving ..
.. The effect of reduced dietary sodium on CV events remains
BP-lowering drugs: .. unclear.252–255 Prospective cohort studies have reported an over-
• It is recommended that SBP should be I A ..
.. all increased risk of mortality and CV events on high sodium intake.
targeted to a BP range of 130–139 ..
mmHg.2,235,244 .. However, they also reported that reducing sodium intake below a
.. certain level (about 3 g of sodium per day) further reduced BP, but
• Close monitoring of adverse effects is ..
I C .. paradoxically was associated with an increased risk of all-cause and
recommended. .. CV mortalities in both the general population and in hypertensive
• These BP targets are recommended for ..
.. people, suggesting a J-curve phenomenon.256 The mechanism of
patients at any level of CV risk and in patients I A .. this apparent increased risk at low sodium intake is not well under-
with and without established CVD.2,8 ..
.. stood and might be confounded by reverse causality. There is no
A DBP target of <80 mmHg should be consid- .. evidence from epidemiological studies that very low sodium intake
..
ered for all hypertensive patients, independent IIa B .. may cause harm.257 Although a few trials and meta-analyses sug-
of the level of risk and comorbidities.226,235 .. gest that reducing salt intake from high to moderate is accompa-
..
.. nied by a lower risk of CV events,254,255,258 to date, no prospective
BP = blood pressure; CV = cardiovascular; CVD = cardiovascular disease; DBP =
.. RCT has provided definitive evidence about the optimal sodium
..
diastolic blood pressure; SBP = systolic blood pressure. .. intake to minimize CV events and mortality. Increased potassium
a
Class of recommendation. .. intake is associated with BP reduction and may have a protective
b
c
Less evidence is available for this target in low–moderate-risk patients. .. effect, thereby modifying the association between sodium intake,
.. BP, and CVD.259

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Globally, usual sodium intake is between 3.5–5.5 g per day (which

.. accompanied by other lifestyle changes such as physical exercise and
..
corresponds to 9 - 12 g of salt per day), with marked differences .. weight loss.35
..
between countries and even between regions within countries. We .. With regard to coffee consumption, caffeine has been shown to
recommend sodium intake to be limited to approximately 2.0 g per .. have an acute pressor effect.267 Nevertheless, coffee consumption is
..
day (equivalent to approximately 5.0 g salt per day) in the general .. associated with CV benefits, as highlighted by a recent systematic
population and to try to achieve this goal in all hypertensive .. review of prospective cohort studies including more than 1 million
..
patients. Effective salt reduction is not easy and there is often poor .. participants and 36 352 CV events.267 Moreover, green or black tea
appreciation of which foods contain high salt levels. Advice should .. consumption may also have a small but significant BP-lowering
..
be given to avoid added salt and high-salt foods. A reduction in pop- .. effect.268,269
ulation salt intake remains a public health priority but requires a .. Regular consumption of sugar-sweetened soft drinks has been
..
combined effort between the food industry, governments, and the .. associated with overweight, metabolic syndrome, type 2 diabetes,
public in general, as 80% of salt consumption involves hidden salt in .. and higher CV risk. The consumption of these drinks should be
..
processed foods. .. discouraged.35
.. Thus, adopting a healthy and balanced diet may assist in BP reduc-
..
7.4.3 Moderation of alcohol consumption .. tion and also reduce CV risk.
..
There is a long-established positive linear association between alco- ..
hol consumption, BP, the prevalence of hypertension, and CVD risk. ..
..
Binge drinking can have a strong pressor effect.17 The Prevention and .. 7.4.5 Weight reduction
Treatment of Hypertension Study (PATHS) investigated the effects
..
.. Excessive weight gain is associated with hypertension, and reducing
of alcohol reduction on BP; the intervention group had a modest 1.2/ .. weight towards an ideal body weight decreases BP.270 In a meta-
0.7 mmHg lower BP than the control group at the end of the 6 month
..
.. analysis, the mean SBP and DBP reductions associated with an aver-
period.260 A Mendelian randomization meta-analysis of 56 epidemio- .. age weight loss of 5.1 kg were 4.4 and 3.6 mmHg, respectively.271
logical studies suggested that reduction of alcohol consumption, even
..
.. Both overweight and obesity are associated with an increased risk of
for light–moderate drinkers, might be beneficial for CV health.261 .. CV death and all-cause mortality. Weight reduction is recommended
Hypertensive men who drink alcohol should be advised to limit their
..
.. in overweight and obese hypertensive patients for control of meta-
consumption to 14 units per week and women to 8 units per week .. bolic risk factors, but weight stabilization may be a reasonable goal
..
(1 unit is equal to 125 mL of wine or 250 mL of beer). Alcohol-free .. for many. The Prospective Studies Collaboration272 concluded that
days during the week and avoidance of binge drinking35 are also ..
.. mortality was lowest at a body mass index (BMI) of approximately
advised. .. 22.5 - 25 kg/m2, whereas a more recent meta-analysis concluded that
..
.. mortality was lowest in subjects with overweight.273,274 Although the
7.4.4 Other dietary changes .. optimal BMI is unclear, maintenance of a healthy body weight (BMI of
..
Hypertensive patients should be advised to eat a healthy balanced .. approximately 20 - 25 kg/m2 in people <60 years of age; higher in
diet containing vegetables, legumes, fresh fruits, low-fat dairy prod- .. older patients) and waist circumference (<94 cm for men and <80
..
ucts, wholegrains, fish, and unsaturated fatty acids (especially olive .. cm for women) is recommended for non-hypertensive individuals to
oil), and to have a low consumption of red meat and saturated fatty .. prevent hypertension, and for hypertensive patients to reduce BP.35
..
acids.262–264 The Mediterranean diet includes many of these nutrients .. Weight loss can also improve the efficacy of antihypertensive medica-
and foods, with a moderate consumption of alcohol (mostly wine .. tions and the CV risk profile. Weight loss should employ a multidisci-
..
with meals). A number of studies and meta-analyses262–265 have .. plinary approach that includes dietary advice, regular exercise, and
shown that the Mediterranean diet is associated with a reduction in .. motivational counselling.35,275 Furthermore, short-term results are
..
CV events and all-cause mortality. An RCT in high-risk individuals on .. often not maintained over the long-term. Weight loss can also be
the Mediterranean diet over 5 years showed a 29% CV risk reduction .. promoted by anti-obesity drugs and, to a greater degree, bariatric
..
compared with a low-fat control diet, and a 39% reduction in .. surgery, which appears to decrease CV risk in severely obese
stroke.265 The Mediterranean diet also significantly reduced ambula-
.. patients. Further details are available in a recent document of the
..
tory BP, blood glucose, and lipid levels.266 The diet should be . ESH and the European Association for the Study of Obesity.276

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7.4.6 Regular physical activity

Lifestyle interventions for patients with hypertension or
Physical activity induces an acute rise in BP, especially SBP, followed high-normal BP
by a short-lived decline in BP below baseline. Epidemiological studies
suggest that regular aerobic physical activity may be beneficial for
both the prevention and treatment of hypertension, and to lower CV
risk and mortality. A meta-analysis of RCTs, which rely on self- Salt restriction to <5 g per day is
I A
reported exercise and are by necessity unblinded, has shown that recommended.248,250,255,258
aerobic endurance training, dynamic resistance training, and isometric
It is recommended to restrict alcohol con-
training reduce resting SBP and DBP by 3.5/2.5, 1.8/3.2, and 10.9/6.2
sumption to:
mmHg, respectively, in general populations.277 Endurance training, I A
but not other types of training, reduces BP more in hypertensive par- • Less than 14 units per week for men.
• Less than 8 units per week for women.35
ticipants (8.3/5.2 mmHg). Regular physical activity of lower intensity
and duration lowers BP less than moderate- or high-intensity training, It is recommended to avoid binge drinking. III C
but is associated with at least a 15% decrease in mortality in cohort
studies.278,279 This evidence suggests that hypertensive patients Increased consumption of vegetables, fresh
should be advised to participate in at least 30 min of moderate- fruits, fish, nuts, and unsaturated fatty acids
(olive oil); low consumption of red meat; I A
intensity dynamic aerobic exercise (walking, jogging, cycling, or swim-
ming) on 5–7 days per week. Performance of resistance exercises on and consumption of low-fat dairy products
2 - 3 days per week can also be advised. For additional benefit in are recommended.262,265
healthy adults, a gradual increase in aerobic physical activity to 300 Body-weight control is indicated to avoid
min a week of moderate intensity or 150 min a week of vigorous- obesity (BMI >30 kg/m2 or waist circumfer-
intensity aerobic physical activity, or an equivalent combination ence >102 cm in men and >88 cm in
thereof, is recommended.35 The impact of isometric exercises on BP women), as is aiming at healthy BMI (about I A
and CV risk is less well established.280 20–25 kg/m2) and waist circumference val-
ues (<94 cm in men and <80 cm in women)
7.4.7 Smoking cessation to reduce BP and CV risk.262,271,273,290
Smoking is a major risk factor for CVD and cancer. Although the
Regular aerobic exercise (e.g. at least 30
rate of smoking is declining in most European countries, especially
min of moderate dynamic exercise on 5–7 I A
in men, it is still common in many regions and age groups, and over-
days per week) is recommended.262,278,279
all the prevalence remains high at 20–35% in Europe.281 There is
also evidence suggesting ill-health effects of passive smoking.282 Smoking cessation, supportive care, and
Studies using ABPM have shown that both normotensive subjects referral to smoking cessation programs are I B
and untreated hypertensive smokers present higher daily BP values recommended.286,288,291
than non-smokers.283 No chronic effect of smoking has been
reported for office BP,284 which is not lowered by smoking cessa- BMI = body mass index; BP = blood pressure; CV = cardiovascular.
a
tion. Smoking is second only to BP in contributing risk to the global Class of recommendation.
b
burden of disease, and smoking cessation is probably the single Level of evidence mostly based on the effect on BP and/or CV risk profile.
most effective lifestyle measure for the prevention of CVD, includ-

ing stroke, myocardial infarction, and PAD.285,286 Therefore, the
history of tobacco use should be established at each patient visit .. 7.5. Pharmacological therapy for
and hypertensive smokers should be counselled regarding smoking ..
.. hypertension
cessation. ..
Brief advice from a physician has a small but significant effect of .. 7.5.1 Drugs for the treatment of hypertension
.. Most patients will require drug therapy in addition to lifestyle meas-
1 - 3% over and above the unassisted 12 month quit rate.287 This can ..
be improved by the use of pharmacological measures, with vareni- .. ures to achieve optimal BP control. In the previous Guidelines, five
.. major drug classes were recommended for the treatment of hyper-
cline and combination nicotine replacement therapy being superior ..
to bupropion or single nicotine replacement therapy.288 In compari- .. tension: ACE inhibitors, ARBs, beta-blockers, CCBs, and diuretics
.. (thiazides and thiazide-like diuretics such as chlortalidone and indapa-
son with placebo, nicotine replacement therapy or treatment with ..
buproprion doubles the chance of quitting, whilst varenicline or ... mide), based on: (i) proven ability to reduce BP; (ii) evidence from
combination nicotine replacement therapy triples the chance of .. placebo-controlled studies that they reduce CV events; and (iii) evi-
..
quitting. Combining behavioural support with pharmacotherapy .. dence of broad equivalence on overall CV morbidity and mortality,
increases the chance of success by 70 - 100% compared with brief
.. with the conclusion that benefit from their use predominantly derives
..
advice alone.289 . from BP lowering. These conclusions have since been confirmed by

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..
recent meta-analyses.1,2,217,292 These meta-analyses have reported .. 7.5.1.1. Blockers of the reninangiotensin system (angiotensin-
cause-specific differences on outcomes between some drugs (e.g. .. converting enzyme inhibitors and angiotensin receptor blockers)
..
less stroke prevention with beta-blockers, and less heart failure pre- .. Both ACE inhibitors and ARBs are among the most widely used
vention with CCBs); however, overall, major CV outcomes and mor- .. classes of antihypertensive drugs. They have similar effective-
..
tality were similar with treatment based on initial therapy with all five .. ness295,296 as each other and other major drug classes on major CV
major classes of treatment. These Guidelines thus recommend that .. events and mortality outcomes.2,292 ARBs are associated with signifi-
..
the same five major classes of drugs should form the basis of antihy- .. cantly lower treatment discontinuation rates for adverse events than
pertensive therapy. There are compelling or possible contraindica- .. those of all other antihypertensive therapies,297 and similar rates to
..
tions for each class of drug (Table 20) and preferential use of some .. placebo.294 ACE inhibitors and ARBs should not be combined for the
drugs for some conditions, as discussed below. There is also evidence .. treatment of hypertension because there is no added benefit on out-
..
that there are differences in the persistence and discontinuation rates .. comes and an excess of renal adverse events.298,299 Dual combina-
of the major drug classes.293,294 .. tion of RAS blockers also led to the premature cessation of another
..
Other classes of drugs have been less widely studied in event- .. trial due to adverse events,291 when a renin inhibitor, aliskiren, was
based RCTs or are known to be associated with a higher risk of
.. combined with either an ACE inhibitor or an ARB in people with dia-
..
adverse effects [e.g. alpha-blockers, centrally acting agents, and min- .. betes. This result halted further research into the clinical utility of alis-
eralocorticoid receptor antagonists (MRAs)]. These are useful addi-
.. kiren for BP treatment.
..
tions to the antihypertensive armamentarium in patients whose BP .. Both ACE inhibitors and ARBs reduce albuminuria more than
cannot be controlled by proven combinations of the aforementioned
.. other BP-lowering drugs and are effective at delaying the progression
..
major drug classes. .. of diabetic and non-diabetic CKD.217 A recent meta-analysis shows
Table 20 Compelling and possible contraindications to the use of specific antihypertensive drugs
Drug Contraindications
Compelling Possible
Diuretics (thiazides/thiazide-like, e.g. chlortha- • Gout • Metabolic syndrome

lidone and indapamide) • Glucose intolerance
• Pregnancy
• Hypercalcaemia
• Hypokalaemia
Beta-blockers • Asthma • Metabolic syndrome

• Any high-grade sinoatrial or atrioventricular block • Glucose intolerance
• Bradycardia (heart rate <60 beats per min) • Athletes and physically active patients
Calcium antagonists (dihydropyridines) • Tachyarrhythmia

• Heart failure (HFrEF, class III or IV)
• Pre-existing severe leg oedema
Calcium antagonists (verapamil, diltiazem) • Any high-grade sinoatrial or atrioventricular block • Constipation
• Severe LV dysfunction (LV ejection fraction <40%)
• Bradycardia (heart rate <60 beats per min)
ACE inhibitors • Pregnancy • Women of child-bearing potential

• Previous angioneurotic oedema without reliable contraception
• Hyperkalaemia (potassium >5.5 mmol/L)
• Bilateral renal artery stenosis
ARBs • Pregnancy • Women of child-bearing potential

• Hyperkalaemia (potassium >5.5 mmol/L) without reliable contraception
• Bilateral renal artery stenosis
ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; HFrEF = heart failure with reduced ejection fraction; LV = left ventricular.

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..
that RAS blockers are the only antihypertensive agents for which evi- .. combination with a potassium-sparing agent, has also been used in
dence is available of a reduced risk of end-stage renal disease.217 .. BP-lowering RCTs, with positive results.303 A recent meta-analysis of
..
ACE inhibitors and ARBs also appear effective in preventing or .. placebo-controlled studies based on thiazides, chlorthalidone, and
regressing HMOD, such as LVH and small artery remodelling, for an .. indapamide reported similar effects on CV outcomes of the three
..
equivalent reduction in BP.292 Both drugs reduce incident AF, which .. types of diuretics.300 Therefore, in the absence of evidence from
may be related to improved LV function and more effective LV struc- .. direct comparator trials and recognizing that many of the approved
..
tural regression.292 ACE inhibitors and ARBs are also indicated post- .. single-pill combinations (SPCs) are based on hydrochlorothiazide
myocardial infarction and in patients with chronic HFrEF, which are .. (see below), we recommend that thiazides, chlorthalidone, and inda-
..
frequent complications of hypertension. .. pamide can all be considered suitable antihypertensive agents. Both
ACE inhibitors are associated with a small increased risk of angio- .. thiazide and thiazide-like diuretics can reduce serum potassium and
..
neurotic oedema, especially in people of black African origin and, in .. have a side effect profile that is less favourable than RAS blockers,
such patients, when RAS blockers are used, an ARB may be preferred. .. which may account for their association with a higher rate of treat-
..
.. ment discontinuation.293,300 They also exhibit dysmetabolic effects
7.5.1.2. Calcium channel blockers .. that increase insulin resistance and the risk of new-onset diabetes.
..
CCBs are widely used for the treatment of hypertension and have .. Potassium may attenuate these effects,304 and a recent study has
similar effectiveness as other major drug classes on BP, major CV
.. shown that the adverse effect of thiazides on glucose metabolism
..
events, and mortality outcomes.2,292 CCBs have a greater effect on .. may be reduced by the addition of a potassium-sparing diuretic.305
stroke reduction than expected for the BP reduction achieved, but
.. Both thiazides and thiazide-like agents are less effective antihyperten-
..
may also be less effective at preventing HFrEF.2,292 However, in anti- .. sive agents in patients with a reduced GFR (eGFR <45 mL/min) and
hypertensive treatment trials, emergent heart failure is the event con-
.. become ineffective when the eGFR is <30 mL/min. In such circum-
..
sidered. Though clinically a very relevant event, it is a difficult .. stances, loop diuretics such as furosemide (or torasemide) should
..
endpoint to quantify precisely, either because symptoms and signs .. replace thiazides and thiazide-like diuretics to achieve an antihyper-
are relatively non-specific or because oedema due to CCBs may .. tensive effect.
..
result in misdiagnosis. Comparison with diuretics may also be difficult ..
because fluid loss may mask signs and symptoms of incipient heart .. 7.5.1.4. Beta-blockers
..
failure rather than preventing it. CCBs have also been compared with .. RCTs and meta-analyses demonstrate that when compared with pla-
other antihypertensive agents in HMOD-based trials, and are .. cebo, beta-blockers significantly reduce the risk of stroke, heart fail-
..
reported to be more effective than beta-blockers in slowing the pro- .. ure, and major CV events in hypertensive patients.300 When
gression of carotid atherosclerosis, and in reducing LVH and .. compared with other BP-lowering drugs, beta-blockers are usually
..
proteinuria.17 .. equivalent in preventing major CV events, except for less effective
CCBs are a heterogeneous class of agents. Most RCTs demon- .. prevention of stroke, which has been a consistent finding.1,2,217 It is
..
strating the benefits of CCBs on outcomes have used dihydropyri- .. possible that the difference originated from small differences in
dines (especially amlodipine). A smaller number of RCTs have .. achieved BP (including central SBP108 between different drug treat-
..
compared non-dihydropyridines (verapamil and diltiazem) with other .. ments), to which cerebrovascular events may be especially sensitive.
drugs, and meta-analyses evaluating the two subclasses (vs. other .. RCTs based on HMOD have also indicated that beta-blockers are
..
drugs) have not shown substantial differences in effectiveness.292 .. somewhat less effective than RAS blockers and CCBs in preventing
.. or regressing LVH, carotid IMT, aortic stiffness, and small artery
..
7.5.1.3. Thiazide/thiazide-like diuretics (e.g. chlorthalidone and .. remodelling.17 In addition, a mortality benefit post-myocardial infarc-
indapamide)
.. tion is uncertain in patients without LV dysfunction.306 Beta-blockers,
..
Diuretics have remained the cornerstone of antihypertensive treat- .. as well as diuretics, and particularly their combination, are also associ-
ment since their introduction in the 1960s. Their effectiveness in pre-
.. ated with increased risk of new-onset diabetes in predisposed sub-
..
venting all types of CV morbidities and mortality has been confirmed .. jects (mostly those with the metabolic syndrome). They also exhibit
in RCTs and meta-analyses.300 Diuretics also appear to be more
.. a somewhat less favourable side effect profile than that of RAS block-
..
effective than other drug classes in preventing heart failure.292 There .. ers, with a higher rate of treatment discontinuation when assessed in
..
has been debate about whether thiazide-like diuretics such as chlor- .. real-life conditions.293 Beta-blockers have been shown to be particu-
thalidone and indapamide should be given preference over classical .. larly useful for the treatment of hypertension in specific situations
..
thiazide diuretics (e.g. hydrochlorothiazide and bendrofluazide), but .. such as symptomatic angina, for heart rate control, post-myocardial
their superiority on outcomes has never been tested in head-to-head .. infarction, HFrEF, and as an alternative to ACE inhibitors or ARBs in
..
RCTs. Chlorthalidone and indapamide have been used in a number .. younger hypertensive women planning pregnancy or of child-bearing
of RCTs showing CV benefits, and these agents are more potent per .. potential.
..
milligram than hydrochlorothiazide in lowering BP, with a longer .. Finally, beta-blockers are not a homogeneous class. In recent years,
duration of action compared with hydrochlorothiazide and no evi- .. the use of vasodilating beta-blockers—such as labetalol, nebivolol,
..
dence of a greater incidence of side effects.301 Lower dose thiazide- .. celiprolol, and carvedilol—has increased. Studies on nebivolol have
like diuretics (typical of modern antihypertensive treatment regi- .. shown that it has more favourable effects on central BP, aortic stiff-
..
mens) also have more evidence from RCTs demonstrating reduc- .. ness, endothelial dysfunction, etc. It has no adverse effect on the risk
tions in CV events and mortality, when compared with lower dose .. of new-onset diabetes and a more favourable side effect profile than
..
thiazide diuretics.302 That said, hydrochlorothiazide, alone or in . classical beta-blockers,307,308 including less adverse effects on sexual

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.. control can be achieved in most recruited patients, and that no

function. Bisoprolol, carvedilol, and nebivolol have been shown to ..
improve outcomes in RCTs in heart failure;136 however, there are no .. more than 5 - 10% of these patients exhibit resistance to the
..
RCTs reporting patient outcomes with these beta-blockers in hyper- .. selected treatment regimen, suggests that ineffective drug therapy is
tensive patients. .. not the source of the problem.
..
.. (2) Physician or treatment inertia. (i.e. failure to adequately upti-
7.5.1.5. Other antihypertensive drugs .. trate treatment). Evidence suggests that inertia311 contributes to
..
Centrally active drugs were widely used in the earliest decades of anti- .. suboptimal BP control, with many patients remaining on monother-
hypertensive treatment when other treatments were not available, .. apy and/or suboptimal doses, despite inadequate BP control.12
..
but are less frequently used now, principally because of their poorer .. (3) Patient adherence to treatment. Evidence is accumulating that
tolerability relative to the newer major classes of drugs. The alpha- .. adherence is a much more important factor than previously recog-
..
blocker doxazosin was effective in the Anglo-Scandinavian Cardiac .. nised. Studies using urine or blood assays for the presence or
Outcomes Trial (ASCOT) as third-line therapy (with no increase in .. absence of medication have shown that adherence to treatment is
..
the risk of heart failure),309 and was more effective than placebo but .. low. This is supported by studies in the general population in which
less effective than spironolactone at lowering BP in resistant hyperten- .. adherence to treatment, based on prescription refilling, was <50%
..
sion in the Prevention And Treatment of Hypertension With .. of the treatment in half of the patients.312 Poor adherence has also
Algorithm-based therapY-2 (PATHWAY-2) study.310 Alpha-blockers
.. be shown to be associated with increased CV risk in various stud-
..
may also be required in specific indications (e.g. the treatment of .. ies313 (see section 10).
symptomatic prostatic hypertrophy). Antihypertensive drugs, other
.. (4) Insufficient use of combination treatment. BP is a multiregu-
..
than the major classes already discussed above, are no longer recom- .. lated variable depending on many compensating pathways.
mended for the routine treatment of hypertension, and are primarily
.. Consequently, combinations of drugs, working through different
..
reserved for add-on therapy in rare cases of drug-resistant hyperten- .. mechanisms, are required to reduce BP in most people with hyper-
.. tension. Thus, monotherapy is likely to be inadequate therapy in
sion where all other treatment options have failed. ..
.. most patients. Indeed, almost all patients in RCTs have required
..
.. combinations of drugs to control their BP.314
7.5.2 Drug treatment strategy for hypertension .. (5) Complexity of current treatment strategies. There is also
Guidelines have generated a variety of different strategies to initiate ..
and escalate BP-lowering medication to improve BP control rates. In .. evidence that adherence to treatment is adversely affected by the
.. complexity of the prescribed treatment regimen. In a recent study,
previous Guidelines, the emphasis was on initial use of different ..
monotherapies, increasing their dose, or substituting for another
.. adherence to treatment was strongly influenced by the number of
.. pills that a patient was prescribed for the treatment of hyperten-
monotherapy. However, increasing the dose of monotherapy produ- ..
.. sion.315 Non-adherence was usually <10% with a single pill, rising to
ces little additional BP lowering and may increase the risk of adverse .. 20% with two pills, 40% with three pills, and very high rates of
effects, whilst switching from one monotherapy to another is frus- ..
trating, time consuming, and often ineffective. For these reasons,
.. partial or complete non-adherence in patients receiving five or
.. more pills.315
more recent Guidelines have increasingly focused on the stepped- ..
care approach, initiating treatment with different monotherapies and
..
.. The above considerations suggest that the most effective
then sequentially adding other drugs until BP control is achieved. .. evidence-based treatment strategy to improve BP control is one that:
..
Despite this, BP control rates have remained poor worldwide. As .. (i) encourages the use of combination treatment in most patients,
shown by recent observations, irrespective of the world region, .. especially in the context of lower BP targets; (ii) enables the use of
..
whether high- or low-income economies, or the level of sophistica- .. SPC therapy for most patients, to improve adherence to treatment;
tion of healthcare provision, only 40% of patients with hyperten- .. and (iii) follows a treatment algorithm that is simple, applies to all
..
sion are treated; of these, only 35% are controlled to a BP of <140/ .. patients, and is pragmatic, with the use of SPC therapy as initial ther-
90 mmHg.12 This failure to achieve BP control in most hypertensive .. apy for most patients, except those with BP in the high–normal range
..
patients, despite numerous iterations of previous Guidelines, suggests .. and in frail older patients (see below).
that these treatment strategies are not working and that a different ..
..
approach is needed. This Task Force believes that one of the most ..
important issues to address in these Guidelines is ‘how do we .. 7.5.2.1. Drug combinations for hypertension treatment
.. Among the large number of RCTs of antihypertensive therapy, only a
improve BP control in treated patients?’. This has become an even ..
more pressing matter because, based on new evidence, current .. few have directly compared different two-drug combinations, with
.. systematic use of the two combinations in both arms. In other trials,
Guidelines are recommending more stringent BP targets (on-treat- ..
ment values of <_ 130/80 mmHg in the general population and <_ 140/
.. treatment was initiated using monotherapy in either arm and another
.. drug (and sometimes more than one drug) was added, usually in a
90mmHg in older hypertensive people), which will make the achieve- ..
ment of BP control even more challenging.
.. non-randomized fashion, according to a pre-specified treatment algo-
.. rithm. In a few trials, the design precluded the use of what might be
Several reasons need to be considered to identify why the current ..
treatment strategy has failed to achieve better BP control rates:
.. considered optimal combinations because multiple monotherapies
.. were being evaluated [e.g. the Antihypertensive and Lipid-Lowering
..
(1) Efficacy of pharmacological therapies. Are the best available .. Treatment to Prevent Heart Attack Trial (ALLHAT), where the add-
treatments, in whatever combination, incapable of controlling BP in
.. on therapy to either a diuretic, CCB, ACE inhibitor, or alpha-blocker
..
most patients? The evidence from RCTs demonstrating that BP . was a beta-blocker, clonidine, or reserpine].316

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..
With this caveat, Table 21 shows that a variety of drug combina- .. diuretics followed by beta-blockers were not associated with a signifi-
tions have been used in at least one active arm of placebo-controlled .. cantly different risk of any CV outcome,233,234,316,319–321 and the
..
trials and have been associated with significant benefit on major CV .. beta-blocker diuretic combination was significantly more effective
events. In trials comparing different regimens (Table 22), all combina- .. than placebo in three trials.322–324 It should be mentioned that the
..
tions have been used in a larger or smaller proportion of patients, .. beta-blocker–diuretic combination may result in more cases of new-
without major differences in benefits. The only exceptions are two .. onset diabetes in susceptible individuals compared with other combi-
..
trials in which a large proportion of the patients received either an .. nations.325 A rarely used combination of thiazide and potassium-
ARB–diuretic combination317 or CCB–ACE inhibitor combina- .. sparing diuretic (amiloride) has also been shown to be equivalent to
..
tion,318 with both regimens being superior to a beta-blocker–diuretic .. CCB-based treatment,310,326 and was recently reported to be associ-
combination in reducing CV outcomes. However, in six other trials
.. ated with fewer metabolic adverse effects compared with thiazide
..
(with seven comparisons), beta-blockers followed by diuretics or .. alone (less hypokalaemia and glucose intolerance).305
..
Table 21 Major drug combinations used in trials of antihypertensive treatment in a stepped approach or as a random-
ized combination (combinations vs. placebo or monotherapy)
Trial Comparator Type of patients SBP difference Outcomes [change in relative risk (%)]
(mmHg)
ACE inhibitor and diuretic combination
PROGRESS27 Placebo Previous stroke or TIA –9 –28% strokes (P <0.001)

229
ADVANCE Placebo Diabetes –5.6 –9% micro/macrovascular events (P = 0.04)
HYVET220 Placebo Hypertensive; >_80 years –15 –34% CV events (P <0.001)
ARB and diuretic combination
SCOPE330 Diuretic þ placebo Hypertensive; >_70 years –3.2 –28% non-fatal strokes (P = 0.04)
CCB and diuretic combination
FEVER331 Diuretic þ placebo Hypertensive –4 –27% CV events (P <0.001)
ACE inhibitor and CCB combination
Syst-Eur332 Placebo Older with ISH –10 –31% CV events (P <0.001)
Syst-China333 Placebo Older with ISH –9 –37% CV events (P <0.004)
Beta-blocker and diuretic combination
Coope and Warrender322 Placebo Older hypertensive –18 –42% strokes (P <0.03)
323
SHEP Placebo Older with ISH –13 –36% strokes (P <0.001)
STOP-H324 Placebo Older hypertensive –23 –40% CV events (P = 0.003)
STOP-H 2334 ACE inhibitor or Hypertensive 0 NS difference in CV events

conventional
antihypertensive
Combination of two RAS blockers/ACE inhibitor 1 ARB or RAS blocker 1 renin inhibitor)
ONTARGET299 ACE inhibitor or ARB High-risk patients More renal events

291
ALTITUDE ACE inhibitor or ARB High-risk diabetic patients More renal events
ACE = angiotensin-converting enzyme; ADVANCE = Action in Diabetes and Vascular Disease: Preterax and Diamicron – MR Controlled Evaluation; ALTITUDE = Aliskiren
Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints; ARB = angiotensin receptor blocker; CCB = calcium channel blocker; CV = cardiovascular; FEVER
= Felodipine Event Reduction; HYVET = Hypertension in the Very Elderly Trial; ISH = isolated systolic hypertension; NS = non-significant; ONTARGET = Ongoing Telmisartan
Alone and in combination with Ramipril Global Endpoint trial; PROGRESS = perindopril protection against recurrent stroke study; RAS = renin-angiotensin system; SBP = sys-
tolic blood pressure; SCOPE = Study on Cognition and Prognosis in the Elderly; SHEP = Systolic Hypertension in the Elderly Program; STOP-H = Swedish Trial in Old Patients
with Hypertension; Syst-China = Systolic Hypertension in China; Syst-Eur = Systolic Hypertension in Europe; TIA = transient ischaemic attack.

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Table 22 Major drug combinations used in trials of antihypertensive treatment in a stepped approach or as a random-
ized combination (combinations vs. other combinations)
Trial Comparator Type of patients SBP difference Outcomes [change in

(mmHg) relative risk (%)]
ACE inhibitor and diuretic combination
CAPPP335 BB þ diuretic Hypertensive þ3 þ5% CV events (NS)
ACCOMPLISH327 ACE inhibitor þ CCB Hypertensive with risk factors þ1 þ21% CV events (P <0.001)
ARB and diuretic combination
LIFE317 BB þ diuretic Hypertensive with LVH –1 –26% stroke (P <0.001)
CCB and diuretic combination
ELSA336 BB þ diuretic Hypertensive 0 NS difference in CV events
CONVINCE233 BB þ diuretic Hypertensive with risk factors 0 NS difference in CV events
VALUE337 ARB þ diuretic High-risk hypertensive –2.2 –3% CV events (P = NS)
COPE338 CCB þ BB Hypertensive þ0.7 NS difference in CV events or stroke
ACE inhibitor and CCB combination
NORDIL339 BB þ diuretic Hypertensive þ3 NS difference in CV events

340
INVEST BB þ diuretic Hypertensive with CAD 0 NS difference in CV events
ASCOT318 BB þ diuretic Hypertensive with risk factors –3 –16% CV events (P <0.001)

327
ACCOMPLISH ACE inhibitor þ diuretic Hypertensive with risk factors –1 –21% CV events (P <0.001)
Beta-blocker and diuretic combination
CAPPP335 ACE inhibitor þ diuretic Hypertensive –3 –5% CV events (P = NS)
LIFE317 ARB þ diuretic Hypertensive with LVH þ1 þ26% stroke (P <0.001)
ALLHAT316 ACE inhibitor þ BB Hypertensive with risk factors –2 NS difference in CV events

316
ALLHAT CCB þ BB Hypertensive with risk factors –1 NS difference in CV events
CONVINCE233 CCB þ diuretic Hypertensive with risk factors 0 NS difference in CV events

339
NORDIL ACE inhibitor þ CCB Hypertensive –3 NS difference in CV events
INVEST340 ACE inhibitor þ CCB Hypertensive with CAD 0 NS difference in CV events

318
ASCOT ACE inhibitor þ CCB Hypertensive with risk factors þ3 þ16% CV events (P <0.001)
Beta-blocker and CCB combination
COPE329 ARB þ CCB Hypertensive þ0.8 NS difference in CV events or stroke
ARB and CCB combination
COPE329 CCB þ diuretic Hypertensive –0.7 NS difference in CV events or stroke

329
COPE CCB þ BB Hypertensive –0.8 NS difference in CV events or stroke
COLM328 ARB þ diuretic Older hypertensive 0 NS difference in CV events
ACCOMPLISH = Avoiding Cardiovascular Events Through Combination Therapy in Patients Living With Systolic Hypertension; ACE = angiotensin-converting enzyme;
ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; ARB = angiotensin receptor blocker; ASCOT = Anglo-Scandinavian Cardiac
Outcomes Trial; BB = beta-blocker; CAD = coronary artery disease; CAPPP = Captopril Prevention Project; CCB = calcium channel blocker; COLM = Combination of
OLMesartan and a calcium channel blocker or diuretic in Japanese elderly hypertensive patients; CONVINCE = Controlled Onset Verapamil Investigation of Cardiovascular
End Points; COPE = Combination Therapy of Hypertension to Prevent Cardiovascular Events; CV = cardiovascular; ELSA = European Lacidipine Study on Atherosclerosis;
INVEST = International Verapamil-Trandolapril Study; LIFE = Losartan Intervention For Endpoint reduction in hypertension; LVH = left ventricular hypertrophy; NORDIL =
Nordic Diltiazem; NS = non-significant; SBP = systolic blood pressure; VALUE = Valsartan Antihypertensive Long-term Use Evaluation.

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..
Three outcome trials directly compared two different combina- .. RAS as well as inducing vasodilatation and/or diuresis, reduces the
tions, each involving a combination of a RAS blocker (ACE inhibitor .. heterogeneity of the BP response to initial treatment and provides a
..
or ARB) and a CCB with other combinations. In the Avoiding .. steeper dose response than is observed with escalating doses of
Cardiovascular Events Through Combination Therapy in Patients .. monotherapy.342 Finally, two-drug combinations as initial therapy
..
Living With Systolic Hypertension (ACCOMPLISH) trial, the ACE .. have been shown to be safe and well tolerated, with no or only a
inhibitor–CCB combination was superior to the same ACE inhibitor .. small increase in the risk of hypotensive episodes,341 even when given
..
in combination with a thiazide diuretic at preventing major CV out- .. to patients with grade 1 hypertension,343 in which adverse events
comes, despite no apparent BP difference between the two arms.327 .. leading to treatment discontinuation are infrequent.294
..
This finding was not confirmed in the Combination of OLMesartan .. Although no RCT has compared major CV outcomes between ini-
and a CCB or diuretic in Japanese older hypertensive patients .. tial combination therapy and monotherapy, observational evidence
..
(COLM)328 and Combination Therapy of Hypertension to Prevent .. suggests that the time taken to achieve BP control is an important
Cardiovascular Events (COPE) trials,329 which reported no significant .. determinant of clinical outcomes, especially in higher risk patients,
..
differences in CV events when a RAS blocker-CCB combination was .. with a shorter time to control associated with lower risk.344
compared with a RAS blocker–thiazide diuretic combination, but .. Furthermore, there is evidence from the more general hypertensive
..
both of these trials had insufficient statistical power. .. population that, compared with patients on initial monotherapy,
Based on the results of outcome RCTs and recent meta-analyses,
.. those who start treatment with a two-drug combination exhibit
..
and evidence of BP-lowering effectiveness, all five major drug classes .. more frequent BP control after 1 year.341,345 This is probably because
can, in principle, be combined with one another, except for ACE
.. initial combination treatment is associated with a better long-term
..
inhibitors and ARBs, whose concomitant use may lead to no addi- .. adherence to the prescribed treatment regimen346 and because initial
tional benefit but increased adverse effects and is thus discouraged.
.. two-drug administration prevents therapeutic inertia (i.e. reluctance
..
We recommend that the treatment of hypertension should be pref- .. or failure to upgrade treatment from one to more drugs when BP is
..
erentially based on combinations of an ACE inhibitor or ARB with a .. uncontrolled).347 Studies from very large hypertension cohorts in
CCB and/or a thiazide/thiazide-like diuretic. These combinations are .. usual care have shown that initial combination treatment results in
..
now widely available in a single pill and in a range of doses, facilitating .. reduced treatment discontinuation and a lower risk of CV events
simplification of treatment, flexible prescribing, and uptitration from .. than initial monotherapy followed by the traditional stepped-care
..
lower to higher doses. Combination therapy that includes an ACE .. approach.312,346 The usual-care settings for these studies may be
inhibitor or ARB with either a CCB or thiazide/thiazide-like diuretic .. especially relevant to study the true impact of treatment strategies
..
are complementary because both CCBs or diuretics activate the .. on adherence and therapeutic inertia, because this can be difficult to
RAS, which will be counteracted by their combination with an ACE .. replicate in a conventional RCT in which the motivation of the clinical
..
inhibitor or ARB. These combinations will also limit potential adverse .. staff and patients, and the monitoring of treatment, are very different
effects associated with diuretic or CCB monotherapy, reducing the .. from usual care. In this regard, the outcome of these real-life studies
..
risk of hypokalaemia due to diuretics and reducing the prevalence of .. of the impact of initial combination therapy on adherence, BP control,
peripheral oedema due to CCBs. These combinations also ensure .. and CV outcomes may be especially relevant.348
..
that the RAS is inhibited as part of the treatment strategy, which is an .. A consideration in the current Guidelines was to persist with the
important consideration for many patient groups (e.g. diabetes, LVH, .. current stepped-care approach to BP treatment, which has been
..
proteinuria). .. interpreted as recommending monotherapy as initial therapy for
Other combinations, such as CCB þ diuretic, also have evidence
.. most patients, reflecting current practice. In fact, the previous
..
from RCTs supporting their use.233,329 These are much less widely .. Guidelines did acknowledge the possibility of initial combination ther-
available as SPCs and do not include blockade of the RAS, which may
.. apy for patients with grade 2 or 3 hypertension, or patients at high or
..
be desirable in many patient groups. .. very high risk. In other words, initial monotherapy was only recom-
Beta-blockers in combination should be preferentially used when
.. mended for grade 1 hypertension and low- or moderate-risk
..
there is a specific clinical indication for their use (e.g. in patients with .. patients. Thus, in reality, the shift in emphasis in this new guidance is
symptomatic angina, for patients requiring heart rate control, post-
.. subtle. However, normalizing the concept of initiating therapy with a
..
myocardial infarction, chronic HFrEF, and as an alternative to ACE .. two-drug combination for most patients with hypertension is likely
..
inhibitors or ARBs in younger hypertensive women planning preg- .. to have a major effect on clinical practice and the speed and quality of
nancy or of child-bearing potential). SPCs of beta-blockers with an .. BP control. We acknowledge that some low- or moderate-risk
..
ACE inhibitor, CCB, or diuretic are available. .. patients with grade 1 hypertension may achieve their BP target with
.. monotherapy, but this is unlikely in patients with an initial SBP >150
..
7.5.2.2 Rationale for initial two-drug combination therapy for most .. mmHg who would require a BP reduction of >_20 mmHg. Moreover,
patients .. the possibility of starting with a low-dose combination of two antihy-
..
As discussed above and with the emphasis in these Guidelines on .. pertensive drugs, even in grade 1 hypertensive patients with
achieving a BP target in most patients of <130/80 mmHg, the majority .. low–moderate-risk, is supported by the reduction of CV events
..
of patients will require combination therapy. Initial combination ther- .. obtained by combination therapy in the upper tertile (grade 1 hyper-
apy is invariably more effective at BP lowering than monotherapy, .. tension) in the HOPE-3 trial.212 In patients with high–normal BP and
..
indeed even low-dose combination therapy is usually more effective .. a high CV risk or in frail older patients, treatment initiation with
than maximal dose monotherapy.341 Furthermore, the combination .. monotherapy may be appropriate in the former because only a small
..
of medications targeting multiple mechanisms, such as blocking the . BP reduction may be required to achieve the BP target, and in the

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..
latter because in older patients baroreflex sensitivity is frequently .. hypertension. Nevertheless, the advantage of treatment simplification
impaired and the risk of hypotension is greater. .. and adherence suggests that use of the polypill may be considered in
..
.. patients with hypertension as substitution therapy, when the need and
7.5.2.3 Uptitration of treatment to three-drug combination therapy .. effectiveness of each polypill component has been previously estab-
..
Studies suggest that two-drug combination therapy will control BP in .. lished by their administration in separate tablets.355
approximately two-thirds of patients.341 For patients whose BP is not ..
..
controlled by two-drug combination therapy, the logical option is to .. 7.5.2.5 Further uptitration of antihypertensive therapy
increase treatment to three-drug combination therapy: usually a RAS .. When BP remains uncontrolled with three-drug combination therapy,
..
blocker, a CCB, and a diuretic. Studies suggest that a three-drug com- .. the patient is classified as having resistant hypertension, assuming that
bination should control BP in >80% of patients.349,350 This rate of BP .. secondary causes of hypertension and poor adherence to treatment
..
control is much greater than the current rate of BP control across .. have been excluded, and that the elevation in BP has been confirmed
Europe in treated hypertensive patients. We do not recommend .. by repeated office BP measurement, ABPM, or HBPM (see section 8.1).
..
three-drug combinations as initial therapy. .. Such patients should be considered for specialist evaluation. Additional
.. treatment options include the addition of low-dose spironolactone
..
7.5.2.4 Rationale for single-pill combination therapy as usual therapy for .. (25 - 50 mg daily)310 or another additional diuretic therapy [higher-
hypertension
.. dose amiloride 10 - 20 mg daily,357 higher dose thiazide or thiazide-like
..
The 2013 ESH/ESC Guidelines17 favoured the use of combinations of .. diuretics, loop diuretics in patients with significant renal impairment
two antihypertensive drugs in a single pill, because reducing the num-
.. (eGFR <45 mL/min/m2), beta-blockers, alpha-blockers, centrally acting
..
ber of pills to be taken daily improves adherence and increases the .. agents (e.g. clonidine), or, rarely, minoxidil] (see section 8.1).
rate of BP control.346,351 This recommendation is endorsed by the
..
..
current Guidelines. It is further supported by data from recent stud- ..
.. 7.5.3 The drug treatment algorithm for hypertension
ies using various methods to assess adherence to treatment, including ..
the quantification of antihypertensive drugs in urine and blood,352,353 .. Reflecting on the evidence above, and recognizing the urgent need to
.. address the factors contributing to the poor control of BP in treated
and estimates such as pill counting or prescription refills, which, ..
although indirect, allow the measurement of adherence on a pro- .. hypertensive patients (see section 7.5.1), this drug treatment algo-
..
longed basis, thereby accounting for its time-variable nature.347,354 .. rithm has been developed to provide a simple and pragmatic treat-
These studies have unequivocally shown a direct inverse relationship .. ment recommendation for the treatment of hypertension, based on
.. a few key recommendations:
between the number of pills and the likelihood of adherence. This ..
approach is now facilitated by the availability of several SPCs with a ..
.. (1) The initiation of treatment in most patients with an SPC comprising
range of dosages, which eliminates the often-stated disadvantage of .. two drugs, to improve the speed, efficiency, and predictability of BP
SPC therapy (i.e. the inability to increase the dose of one drug inde- ..
.. control.
pendently of the other). It is also convenient that the most widely .. (2) Preferred two-drug combinations are a RAS blocker with a CCB or
available SPCs mirror the major drug class combinations recom- ..
.. a diuretic. A beta-blocker in combination with a diuretic or any drug
mended by these Guidelines. The major advantage of an SPC as the ..
usual therapeutic approach for hypertension is that patients can .. from the other major classes is an alternative when there is a spe-
.. cific indication for a beta-blocker, e.g. angina, post-myocardial infarc-
progress from 1, 2, or 3 drug treatments whilst remaining on a simple ..
treatment regimen with a single pill throughout, increasing the likeli-
.. tion, heart failure, or heart rate control.
.. (3) Use monotherapy for low-risk patients with stage 1 hypertension
hood of adherence to therapy and achieving BP control. Such an ..
approach has the potential to double BP control rates in treated
.. whose SBP is <150 mmHg, very high-risk patients with high–normal
.. BP, or frail older patients.
patients from the present low level of 40%. Although, at present, ..
the availability of two-drug SPCs is largely limited to a RAS blocker
.. (4) The use of a three-drug SPC comprising a RAS blocker, a CCB, and
.. a diuretic if BP is not controlled by a two-drug SPC.
with either a CCB or diuretic, it would be desirable to see the devel- ..
opment of an expanded range of low-cost SPCs in different drug for-
.. (5) The addition of spironolactone for the treatment of resistant hyper-
.. tension, unless contraindicated (see section 8.1.4).
mulations, tailored to different clinical requirements. ..
.. (6) The use of other classes of antihypertensive drugs in the rare cir-
Polypills have also emerged as SPCs (i.e. a fixed-dose combination ..
.. cumstances in which BP is not controlled by the above treatments.
of one or more antihypertensive agents with a statin and low-dose
.. (7) Information on availability and recommended doses of individual
aspirin), with the rationale that hypertensive patients are often at suffi- .. drugs, as well as SPCs and free combinations, can be found in
cient CV risk to benefit from statin therapy. Studies of bioequivalence ..
.. national formularies.
suggest that when combined in the polypill, different agents maintain ..
all or most of their expected effect.355 Furthermore, studies per- .. This treatment algorithm focuses on the five major classes of
..
formed in the setting of secondary prevention, particularly in patients .. drugs: ACE inhibitors, ARBs, CCBs, thiazide or thiazide-like diuretics,
with a previous myocardial infarction, have shown that use of the pol- .. and beta-blockers. The algorithm recommends initial therapy for
..
ypill is accompanied by a better adherence to treatment compared .. most patients with a two drug-combination, ideally as an SPC.
with separate medications.356 The ESC Guidelines for the manage- .. Variations from the core drug treatment algorithm for uncomplicated
..
ment of myocardial infarction have recommended polypill use to .. hypertension shown in Figure 4 are specified in Figures 5 to 8.
improve long-term adherence to prescribed therapy (class IIa, level .. Recommended BP target ranges for treated hypertension are shown
..
B).353 No data are available for primary prevention in patients with . in Table 23.

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Consider monotherapy in
1 Pill Initial therapy low risk grade 1 hypertension
Dual combination ACEi or ARB + CCB or diuretic (systolic BP <150mmHg), or in
very old ( 80 years) or frailer patients
Step 2
1 Pill Triple combination ACEi or ARB + CCB + diuretic
Step 3
Triple combination + Resistant hypertension Consider referral to a specialist centre
2 Pills spironolactone or Add spironolactone (25–50 mg o.d.) for further investigation
other drug or other diuretic, alpha-blocker or beta-blocker
Beta-blockers
©ESC/ESH 2018
Consider beta-blockers at any treatment step, when there is a specific
indication for their use, e.g. heart failure, angina, post-MI, atrial fibrillation,
or younger women with, or planning, pregnancy
Figure 4 Core drug treatment strategy for uncomplicated hypertension. The core algorithm is also appropriate for most patients with
HMOD, cerebrovascular disease, diabetes, or PAD. ACEi = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; CCB =
calcium channel blocker; HMOD = hypertension-mediated organ damage; MI = myocardial infarction; o.d. = omni die (every day); PAD = peripheral
artery disease.
Consider monotherapy in low risk

1 Pill Initial therapy ACEi or ARB + beta-blocker or CCB grade 1 hypertension
Dual combination (systolic BP <150mmHg), or in
or CCB + diuretic or beta-blocker very old ( 80 years) or frailer patients
or beta-blocker + diuretic
Consider initiating therapy

when systolic BP is
Step 2
1 Pill Triple combination Triple combination of above 130 mmHg in these very
high risk patients with
established CVD
Step 3
Resistant hypertension
©ESC/ESH 2018
Triple combination + Consider referral to a specialist centre

2 Pills spironolactone or Add spironolactone (25–50 mg o.d.) for further investigation
other drug or other diuretic, alpha-blocker or beta-blocker
Figure 5 Drug treatment strategy for hypertension and coronary artery disease. ACEi = angiotensin-converting enzyme inhibitor;
ARB = angiotensin receptor blocker; BP = blood pressure; CCB = calcium channel blocker; CVD = cardiovascular disease; o.d. = omni die (every day).

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Figure 6 Drug treatment strategy for hypertension and chronic kidney disease. ACEi = angiotensin-converting enzyme inhibitor;
ARB = angiotensin receptor blocker; BP = blood pressure; CCB = calcium channel blocker; CKD = chronic kidney disease; eGFR = estimated
glomerular filtration rate; MI = myocardial infarction; o.d. = omni die (every day).
a
CKD is defined as an eGFR <60 mL/min/1.72 m2 with or without proteinuria.
b
Use loop diuretics when eGFR is <30 mL/min/1.72 m2, because thiazide/thiazide-like diuretics are much less effective/ineffective when
eGFR is reduced to this level.
c
Caution: risk of hyperkalaemia with spironolactone, especially when eGFR is <45 mL/min/1.72 m2 or baseline Kþ >_4.5 mmol/L.
Figure 7 Drug treatment strategy for hypertension and hear failure with reduced ejection fraction. Do not use non-dihydropyridine
CCBs (e.g. verapamil or diltiazem). ACEi = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; CCB = calcium channel
blocker; ESC = European Society of Cardiology; HFrEF = heart failure with reduced ejection fraction; MRA = mineralocorticoid receptor antagonist.
a
Consider an angiotensin receptor/neprilysin inhibitor instead of ACEi or ARB per ESC Heart Failure Guidelines.136
b
Diuretic refers to thiazide/thiazide-like diuretic. Consider a loop diuretic as an alternative in patients with oedema.
c
MRA (spironolactone or eplerenone).

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ACEi or ARB + beta-blocker

Initial therapy
Dual combination or non-DHP CCBa,
or beta-blocker + CCB
ACEi or ARB + beta-blocker

Step 2
Triple combination
+ DHP CCB or diuretic
or beta-blocker + DHP CCB + diuretic
©ESC/ESH 2018
Add oral anticoagulation when indicated according to the CHA2DS2-VASc score, unless contraindicated.
a
Routine combination of beta-blockers with non-dihydropyridine CCBs (e.g. verapamil or diltiazem) is not recommended due to a potential
marked reduction in heart rate.
Figure 8 Drug treatment strategy for hypertension and atrial fibrillation. ACEi = angiotensin-converting enzyme inhibitor; AF = atrial
fibrillation; ARB = angiotensin receptor blocker; CCB = calcium channel blocker; CHA2DS2-VASc = CHA2DS2-VASc = Cardiac failure,
Hypertension, Age >_75 (Doubled), Diabetes, Stroke (Doubled) – Vascular disease, Age 65–74 and Sex category (Female); DHP = dihydropyridine.
a
Non-DHP CCB (non-DHP CCB, e.g. verapamil or diltiazem).
Table 23 Office blood pressure treatment target range
Age group Office SBP treatment target ranges (mmHg) Office DBP
treatment
target range
(mmHg)
a
Hypertension 1 Diabetes 1 CKD 1 CAD 1 Stroke /TIA
18 - 65 years Target to 130 Target to 130 Target to <140 to Target to 130 Target to 130 70–79
or lower if tolerated or lower if tolerated 130 if tolerated or lower if tolerated or lower if tolerated
Not <120 Not <120 Not <120 Not <120
65 - 79 yearsb Target to 130-139 Target to 130-139 Target to 130-139 Target to 130-139 Target to 130-139 70–79
if tolerated if tolerated if tolerated if tolerated if tolerated
>_80 yearsb Target to 130-139 Target to 130-139 Target to 130-139 Target to 130-139 Target to 130-139 70–79
if tolerated if tolerated if tolerated if tolerated if tolerated
Office DBP 70–79 70–79 70–79 70–79 70–79

treatment
target range
(mmHg)
CAD = coronary artery disease; CKD = chronic kidney disease (includes diabetic and non-diabetic CKD); DBP = diastolic blood pressure; SBP = systolic blood pressure; TIA =
transient ischaemic attack.
a
Refers to patients with previous stroke and does not refer to blood pressure targets immediately after acute stroke.
b
Treatment decisions and blood pressure targets may need to be modified in older patients who are frail and independent.
The drug treatment strategy for patients with hypertension

.. concomitant conditions or diseases are present that require spe-
..
should be based on the algorithm shown (Figures 4 to 8), .. cific modification of the drugs, as outlined in the recommendations
unless there are contraindications to these drugs (Table 20), or
.. below.
.

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Drug treatment strategy for hypertension
Among all antihypertensive drugs, ACE inhibitors, ARBs, beta-blockers, CCBs, and diuretics (thiazides and thiazide-like
drugs such as chlorthalidone and indapamide) have demonstrated effective reduction of BP and CV events in RCTs, and thus I A
are indicated as the basis of antihypertensive treatment strategies.2
Combination treatment is recommended for most hypertensive patients as initial therapy. Preferred combinations should
comprise a RAS blocker (either an ACE inhibitor or an ARB) with a CCB or diuretic. Other combinations of the five major I A
233,318,327,329,341–345
classes can be used.
It is recommended that beta-blockers are combined with any of the other major drug classes when there
I A
are specific clinical situations, e.g. angina, post-myocardial infarction, heart failure, or heart rate control.300,341
It is recommended to initiate an antihypertensive treatment with a two-drug combination, preferably in an SPC.

Exceptions are frail older patients and those at low risk and with grade 1 hypertension (particularly if SBP is I B
<150 mmHg).342,346,351
It is recommended that if BP is not controlledc with a two-drug combination, treatment should be increased to a
three-drug combination, usually a RAS blocker with a CCB and a thiazide/thiazide-like diuretic, preferably I A
as an SPC.349,350
It is recommended that if BP is not controlledc with a three-drug combination, treatment should be increased by the addition
of spironolactone or, if not tolerated, other diuretics such as amiloride or higher doses of other diuretics, a beta-blocker, or I B
an alpha-blocker.310
The combination of two RAS blockers is not recommended.291,298,299 III A
ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BP = blood pressure; CCB = calcium channel blocker; CV = cardiovascular; RAS =
renin-angiotensin system; RCT = randomized controlled trial; SBP = systolic blood pressure; SPC = single-pill combination.
a
b
Level of evidence.
c
Adherence should be checked.
.. complex surgical intervention. This has led to the development of an

7.6 Device-based hypertension ..
.. endovascular carotid baroreflex amplification device using a dedi-
treatment ..
Various device-based therapies have emerged, principally targeted at .. cated stent-like device designed to stretch the carotid bulb and
.. increase baroreflex sensitivity. Preliminary data in humans have
the treatment of resistant hypertension. These are discussed below. ..
.. shown evidence of BP-lowering efficacy of this new approach,360 but
.. data from ongoing RCTs are needed to definitively understand its
..
7.6.1 Carotid baroreceptor stimulation (pacemaker and .. longer-term efficacy and safety.
stent) ..
..
Carotid baroreceptor stimulation or baroreflex amplification ..
therapy—externally via an implantable pulse generator or internally .. 7.6.2 Renal denervation
..
via an implantable device designed to increase the strain on the caro- .. The rationale for renal denervation lay with the importance of sym-
tid bulb—can lower BP in patients with resistant hypertension. An .. pathetic nervous system influences on renal vascular resistance, renin
..
RCT with the first generation of an implantable pulse generator .. release, and sodium reabsorption,361 the increased sympathetic tone
showed sustained BP-lowering efficacy (and sympathetic nervous sys- .. to the kidney and other organs in hypertensive patients,361 and the
..
tem inhibition), but with some concerns about procedural and longer .. pressor effect of renal afferent fibres documented in experimental
term safety.358 A second-generation unilateral device has been devel- .. animals.362 Catheter-based renal denervation using radiofrequency,
..
oped to improve safety and sustained efficacy. A propensity score- .. ultrasound, or perivascular injection of neurotoxic agents such as
matched comparison of the first- and second-generation systems .. alcohol has been introduced as a minimally invasive treatment option
..
revealed that BP at 12 months post-implantation was similar, with a .. for patients with resistant hypertension.363 However, the clinical evi-
better safety profile for the second-generation device.359 However,
.. dence in support of renal denervation as an effective BP-lowering
..
no RCT is currently available with this second-generation device. .. technique is conflicting. Several observational studies and national
Another consideration is that implantation is costly and requires a
.. and international registries364 support the BP-lowering efficacy of

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renal denervation originally reported in the Symplicity HTN-1 and

.. 7.6.4 Other devices
..
HTN-2 trials.365 A reduction in sympathetic activity following renal .. The carotid body is located at the bifurcation of the common carotid.
denervation has also been observed.366 However, two RCTs with a
..
.. It is innervated by nerve fibres from the vagus nerve through the cer-
sham procedure control367,368 failed to document the superiority of .. vical ganglion and the carotid sinus nerve.379 Stimulation of the caro-
..
renal denervation compared with the sham procedure in reducing .. tid body drives sympathetic tone, resulting in an increase in BP and
BP, but did confirm the safety of the procedure. Another RCT, the .. minute ventilation. Surgical resection of the carotid body is associated
..
Renal Denervation for Hypertension (DENERHTN) trial,369 showed .. with reductions in BP380 and sympathetic overactivity in patients with
the superiority of renal denervation in combination with optimized .. heart failure.381 Devices for endovascular carotid body modification
..
pharmacotherapy compared with pharmacotherapy alone. The .. by ultrasound-guided ablation have been developed and are currently
PRAGUE-15 study370 documented similar effects between renal .. under investigation.
..
denervation and optimized pharmacotherapy (mainly by adding spi- .. In summary, device-based therapy for hypertension is a fast-
ronolactone) with respect to BP-lowering efficacy; however, the lat- .. moving field. Further sham-controlled studies are needed before
..
ter was associated with more side effects and high discontinuation .. device-based therapies can be recommended for the routine treat-
rates. Beyond resistant hypertension, interim data in the first 80 .. ment of hypertension outside of the framework of clinical trials.
..
patients treated with renal denervation but with no background anti- ..
hypertensive therapy showed a modest effect of renal denervation ..
..
vs. sham control on 24 h ambulatory BP after 3 months.366 This study
is ongoing. Device-based therapies for hypertension
Evaluating the efficacy of renal denervation has been challenging
because the procedure needs to be applied to a population with a Recommendation Classa Levelb
high probability of BP response. This is complicated by (i) the com-
Use of device-based therapies is not recom-
plex pathophysiology of hypertension, (ii) the lack of clinically applica-
mended for the routine treatment of hyperten-
ble measures of sympathetic activity, (iii) the absence of predictors of
sion, unless in the context of clinical studies III B
the long-term BP response following renal denervation, and (iv) the
and RCTs, until further evidence regarding their
absence of reliable markers of procedural success to immediately
safety and efficacy becomes available.367,368
establish whether denervation has been achieved.371 There is evi-
dence indicating that isolated systolic hypertension, characterized by
RCT = randomized controlled trial.
increased aortic stiffness, is associated with a limited response to a
renal denervation372,373 and baroreceptor stimulation (see above). b
Level of evidence.
Except for rare problems related to the catheterization procedure
(access site complications, vessel dissection, etc.), no major complica-
tions or deterioration of renal function have been reported.
Major uncertainties remain as to the clinical role of renal denerva-
tion outside of clinical studies, which should be performed in carefully
8 Hypertension in specific
selected patients at specialist hypertension centres and by experi- circumstances
enced operators.
8.1 Resistant hypertension
7.6.3 Creation of an arteriovenous fistula 8.1.1 Definition of resistant hypertension
The central iliac arteriovenous anastomosis creates a fixed-calibre (4 Hypertension is defined as resistant to treatment when the recom-
mm) conduit between the external iliac artery and vein using a stent- mended treatment strategy fails to lower office SBP and DBP values
like nitinol device (ROX arteriovenous coupler).374,375 Device to <140 mmHg and/or <90 mmHg, respectively, and the inadequate
deployment can be verified and is reversible, resulting in the diversion control of BP is confirmed by ABPM or HBPM in patients whose
of arterial blood (0.8–1 L/min) into the venous circuit with immedi- adherence to therapy has been confirmed. The recommended treat-
ate, verifiable reductions in BP.374,375 The BP-lowering effect of arte- ment strategy should include appropriate lifestyle measures and
riovenous anastomosis was first observed in a study of patients with treatment with optimal or best-tolerated doses of three or more
chronic obstructive pulmonary disease (COPD), in whom a moder- drugs, which should include a diuretic, typically an ACE inhibitor or
ate improvement in the 6 min walking test was shown.376 In the ROX an ARB, and a CCB. Pseudo-resistant hypertension (see below) and
CONTROL HTN trial, patients with resistant hypertension were secondary causes of hypertension should also have been excluded
randomized to receive either standard care or insertion of an arterio- (see section 8.2).
venous coupler in combination with standard care.377 At 6 months, Prevalence studies of resistant hypertension have been limited by
office and ambulatory BP were significantly reduced in the coupler variation in the definition used, and reported prevalence rates range
group compared with the control group. Some important safety from 5–30% in patients with treated hypertension. After applying a
aspects need to be considered. Ipsilateral venous stenosis, which strict definition (see above) and having excluded causes of pseudo-
needed venoplasty and/or stenting, occurred in 29% of patients. resistant hypertension (see section 8.1.2), the true prevalence of
There were no reports of right heart failure or high-output cardiac resistant hypertension is likely to be <10% of treated patients.
failure after device implantation over the short-term, but longer Patients with resistant hypertension are at higher risk of HMOD,
follow-up is clearly needed.377,378 CKD, and premature CV events.382

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..
8.1.2 Pseudo-resistant hypertension .. remedies, or recreational drug use (cocaine, anabolic steroids, etc.)
Several possible causes of pseudo-resistant hypertension should be .. (see Table 24).
..
evaluated and ruled out before concluding that the patient has resist- .. (3) Obstructive sleep apnoea (usually, but not invariably, associated
ant hypertension: .. with obesity).
..
.. (4) Undetected secondary forms of hypertension (see section 8.2).
(1) Poor adherence to prescribed medicines is a frequent cause .. (5) Advanced HMOD, particularly CKD or large-artery stiffening.
of pseudo-resistant hypertension, occurring in <_50% of patients ..
..
assessed by therapeutic drug monitoring, and is directly related to .. Resistant hypertension is associated with older age (especially >75
the number of tablets prescribed315 (see section 10). .. years), male sex, black African origin, higher initial BP at diagnosis of
..
(2) White-coat phenomenon (in which office BP is elevated but BP .. hypertension, highest BP ever reached during the patient’s lifetime,
is controlled at ABPM or HBPM) is not uncommon in these .. frequent outpatient visits, obesity, diabetes, atherosclerotic disease
..
patients, hence the recommendation to confirm office hypertension .. and HMOD, CKD, and a Framingham 10 year coronary risk score
with ABPM or HBPM before confirming the diagnosis of resistant .. >20%.383,384
..
hypertension. ..
(3) Poor office BP measurement technique, including the use of
..
..
cuffs that are too small relative to the arm circumference, can result ..
in a spurious elevation of BP.
.. 8.1.3 Diagnostic approach to resistant hypertension
.. Diagnosis of resistant hypertension requires detailed information
(4) Marked brachial artery calcification, especially in older ..
patients with heavily calcified arteries.
.. about:
..
(5) Clinician inertia, resulting in inadequate doses or irrational com- .. (1) The patient’s history, including lifestyle characteristics, alcohol and
binations of BP-lowering drug therapies.
..
.. dietary sodium intake, interfering drugs or substances, and sleep
.. history.
Other causes of resistant hypertension ..
.. (2) The nature and dosing of the antihypertensive treatment.
(1) Lifestyle factors, such as obesity or large gains in weight, excessive .. (3) A physical examination, with a particular focus on determining the
..
alcohol consumption, and high sodium intake. .. presence of HMOD and signs of secondary hypertension.
(2) Intake of vasopressor or sodium-retaining substances, drugs pre-
.. (4) Confirmation of treatment resistance by out-of-office BP measure-
..
scribed for conditions other than hypertension, some herbal . ments (i.e. ABPM or HBPM).
Table 24 Resistant hypertension characteristics, secondary causes, and contributing factors (adapted from
reference385)
Characteristics of patients with Causes of secondary resistant Drugs and substances that may
resistant hypertension hypertension cause raised BP
Demographics More common causes Prescribed drugs

• Older age (especially >75 years) • Primary hyperaldosteronism • Oral contraceptives
• Obesity • Atherosclerotic renovascular disease • Sympathomimetic agents (e.g. decon-
• More common in black people • Sleep apnoea gestants in proprietary cold
• Excess dietary sodium intake • CKD remedies)
• High baseline BP and chronicity of uncon- • Non-steroidal anti-inflammatory drugs
trolled hypertension • Cyclosporin
• Erythropoietin
• Steroids (e.g. prednisolone and
hydrocortisone)
• Some cancer therapies
Concomitant disease Uncommon causes Non-prescription drugs

• HMOD: LVH and/or CKD • Phaeochromocytoma • Recreational drugs (e.g. cocaine,
• Diabetes • Fibromuscular dysplasia amphetamines, and anabolic
• Atherosclerotic vascular disease • Aortic coarctation steroids)
• Aortic stiffening and isolated systolic • Cushing’s disease • Excessive liquorice ingestion
hypertension • Hyperparathyroidism • Herbal remedies (e.g. ephedra and ma
huang)
BP = blood pressure; CKD = chronic kidney disease; HMOD = hypertension-mediated organ damage; LVH = left ventricular hypertrophy.

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..
(5) Laboratory tests to detect electrolyte abnormalities (hypokalae- .. release (4 - 8 mg/day) as alternatives to spironolactone. Neither was
mia), associated risk factors (diabetes), organ damage (advanced .. as effective as spironolactone, but they did reduce BP significantly vs.
..
renal dysfunction), and secondary hypertension. .. placebo when added to background treatment in resistant hyperten-
(6) Confirmation of adherence to BP-lowering therapy. .. sion.310 Thus, bisoprolol and doxazosin have an evidence base for the
..
.. treatment of resistant hypertension when spironolactone is contrain-
Patients should be screened for a secondary cause of hyperten- .. dicated or not tolerated. Direct vasodilators, such as hydralazine or
sion, especially primary aldosteronism386 or atherosclerotic renal ..
.. minoxidil, are infrequently used because they may cause severe fluid
artery stenosis, particularly in older patients or patients with CKD. .. retention and tachycardia.
Poor adherence to treatment should be considered, but its identifica- ..
.. New BP-lowering drugs (nitric oxide donors, vasopressin antago-
tion may be challenging in routine clinical practice.387 Some methods ..
.. nists, aldosterone synthase inhibitors, neutral endopeptidase inhibi-
are easy to use but of limited value (e.g. standardized questionnaires), .. tors, and endothelin antagonists) are all under investigation.388
whereas others, such as drug screening of urine or blood, show con- ..
siderable promise but are not yet widely available.388 Other methods ..
include the measurement of BP after directly observed treatment Resistant hypertension
intake,389 which has been used in clinical trials,390 but may be more
difficult to implement in routine clinical practice.
It is recommended that hypertension be

8.1.4 Treatment of resistant hypertension
defined as resistant to treatment (i.e. resist-
Effective treatment combines lifestyle changes (especially the reduc-
ant hypertension) when:
tion of sodium intake), discontinuation of interfering substances, and
• Optimal doses (or best-tolerated doses) of
the sequential addition of antihypertensive drugs to the initial triple
an appropriate therapeutic strategy, which
therapy. Ultimately, replacing all current drugs by a simpler treatment
should include a diuretic (typically an ACE
regimen using SPC treatment is recommended to reduce pill burden
inhibitor or an ARB with a CCB and a thia-
and improve adherence to treatment. The optimal drug treatment of
zide/thiazide-type diuretic), fails to lower
resistant hypertension has been poorly studied. The most effective I C
clinic SBP and DBP values to <140 mmHg
strategy seems to be additional diuretic treatment to decrease vol-
and/or <90 mmHg, respectively; and
ume overload, together with the restriction of salt intake, particularly
• The inadequate control of BP has been
in patients with CKD. BP control may be improved by increasing the
confirmed by ABPM or HBPM; and
dose of the existing diuretic or by switching to a more potent
• After exclusion of various causes of
thiazide-like diuretic (chlorthalidone or indapamide). A loop diuretic
pseudo-resistant hypertension (espe-
should replace thiazides/thiazide-like diuretics if the eGFR is <30 mL/
cially poor medication adherence) and
min. Although resistant hypertension may show a BP reduction if the
secondary hypertension.
existing diuretic dose is further increased, most patients require the
administration of additional drugs. There is growing evidence to sug- Recommended treatment of resistant
gest that the fourth-line treatment should involve a blockade of the hypertension is:
biological effects of aldosterone through the use of MRAs391 (spiro- • Reinforcement of lifestyle measures,
nolactone up to 50 mg/day), as shown in the PATHWAY 2 study357 especially sodium restriction.395
and supported by other studies and their meta-analysis.392–394 Not • Addition of low-dose spironolactonec to
all patients will be able to tolerate spironolactone due to antiandro- existing treatment;310,392,394
genic side effects resulting in breast tenderness or gynaecomastia (in • Or the addition of further diuretic ther- I B
6%), impotence in men, and menstrual irregularities in women. apy if intolerant to spironolactone, with
Moreover, the efficacy and safety of spironolactone for the treatment either eplerenone,c amiloride,c a higher-
of resistant hypertension has not yet been established in patients dose thiazide/thiazide-like diuretic, or a
with significant renal impairment. As such, the use of spironolactone loop diuretic;d 357
for resistant hypertension should usually be restricted to patients • Or the addition of bisoprolol or
with an eGFR >_45 mL/min and a plasma potassium concentration of doxazosin.310
<_ 4.5 mmol/L. Moreover, electrolytes and eGFR should be moni-
tored soon after initiation and at least annually thereafter. On theo- ABPM = ambulatory blood pressure monitoring; ACE = angiotensin-converting
retical grounds, alternative additional diuretic therapy to enzyme; ARB = angiotensin receptor blocker; BP = blood pressure; CCB = cal-
cium channel blocker; DBP = diastolic blood pressure; HBPM = home blood
spironolactone (when it is not tolerated due to androgen-like side pressure monitoring.
effects) could include the MRA eplerenone (50 - 100 mg/day). a
b
Amiloride (10 - 20 mg/day) has recently been shown to be as effec- Level of evidence.
c
When spironolactone is not tolerated, replace with amiloride or eplerenone.
tive as spironolactone 25–50 mg daily) in reducing BP in the The use of these drugs should be restricted to patients with an estimated glomer-
PATHWAY2 study.357 It is emphasized that the same cautions about ular filtration rate >_45 mL/min and a plasma potassium concentration of <_ 4.5
the use of these agents should be considered in patients with reduced mmol/L, because of the risk of hyperkalaemia.
d
A loop diuretic should replace thiazides/thiazide-like diuretics if the estimated
eGFR and baseline potassium levels >4.5 mmol/L. The PATHWAY-2 glomerular filtration rate is <30 mL/min.
study also evaluated bisoprolol (5 - 10 mg/day) or doxazosin modified

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..
8.2 Secondary hypertension .. hypertension due to drugs and substances, and rarer monogenic
.. causes, are described below and are summarized inTables 28 and 29.
Secondary hypertension is hypertension due to an identifiable cause, ..
which may be treatable with an intervention specific to the cause. A ..
..
high index of suspicion and early detection of secondary causes of .. 8.2.1 Drugs and other substances that may cause
hypertension are important because interventions may be curative, ..
.. secondary hypertension
especially in younger patients [e.g. corrective surgery for aortic .. Medications and other substances may cause a sufficient increase in
coarctation, renal angioplasty in younger patients with renal artery ..
.. BP to raise the suspicion of secondary hypertension397 (Table 28).
fibromuscular dysplasia, reversal of an endocrine cause of hyperten- .. Consequently, a careful drug history is important when considering a
sion (e.g. by removal of an adrenal adenoma), or drug treatment of a ..
.. diagnosis of secondary hypertension. Moreover, other commonly
monogenic disorder affecting a specific drug-sensitive ion channel .. used drugs such as non-steroidal anti-inflammatory drugs or gluco-
(e.g. selective use of amiloride in Liddle’s syndrome)]. Interventions ..
.. corticoids can antagonize the BP-lowering effect of antihypertensive
that treat the cause of secondary hypertension later in life are less .. medications in patients treated for hypertension, and may contribute
likely to be curative (i.e. remove the need for antihypertensive medi-
..
.. to a loss of BP control.
cation) because longstanding hypertension results in vascular and ..
other organ damage that sustains the elevated BP, but intervention is
..
..
still important because it will often result in much better BP control .. 8.2.2 Genetic causes of secondary hypertension
with less medication.
.. Genetic causes of secondary hypertension are usually due to single-
..
The prevalence of secondary hypertension is reported to be .. gene disorders (see section 6).194,195 They are rare but important
5–15%396 of people with hypertension. Screening all hypertensive
..
.. causes of secondary hypertension because identifying the cause can
patients for secondary hypertension is not feasible or cost-effective; .. point to a specific drug treatment (Table 29).194,195 Common features
..
however, there are some general patient characteristics that suggest .. of these genetic disorders are that they usually present with hyper-
those more likely to have secondary hypertension and in whom .. tension in children, adolescents, or young adults, and most mono-
..
screening should be considered after confirming that BP is elevated .. genic disorders induce hypertension by increasing the renal tubular
with ABPM (Table 25). .. reabsorption of sodium. Thus, they are usually associated with a sup-
..
It is beyond the scope of these Guidelines to describe the detailed .. pressed plasma renin concentration (PRC) or plasma renin activity
clinical management of specific causes of secondary hypertension. .. (PRA), which is unusual in younger patients and especially those
..
However, the commoner causes of secondary hypertension, clinical .. treated with antihypertensive medications (e.g. RAS blockers, CCBs,
history, and screening tests are described in Table 26, and the typical .. or diuretics), that would be expected to increase PRC or PRA. Thus,
..
age distribution of these causes of secondary hypertension is shown in .. the finding of a suppressed PRC or PRA, especially whilst taking these
Table 27. Review of these tables demonstrates that most screening can .. drugs, should raise the suspicion of secondary hypertension due a
..
be undertaken with blood and urine tests, abdominal ultrasound, and .. salt-retaining state. Importantly, beta-blockers in particular, but also
echocardiography. Referral to a specialist centre is recommended for .. non-steroidal anti-inflammatory drugs, alpha-methyl dopa, or cloni-
..
additional investigations to confirm a suspected diagnosis of secondary .. dine, suppress PRC and PRA. These drugs should be discontinued (if
hypertension and for clinical management. Other causes of secondary
.. clinically feasible) for at least 2 weeks before measuring PRC or PRA.
Table 25 Patient characteristics that should raise the suspicion of secondary hypertension
Characteristic
Younger patients (<40 years) with grade 2 hypertension or onset of any grade of hypertension in childhood
Acute worsening hypertension in patients with previously documented chronically stable normotension
Resistant hypertension (see section 8.1)
Severe (grade 3) hypertension or a hypertension emergency (see section 8.3)
Presence of extensive HMOD
Clinical or biochemical features suggestive of endocrine causes of hypertension or CKD
Clinical features suggestive of obstructive sleep apnoea
Symptoms suggestive of phaeochromocytoma or family history of phaeochromocytoma
CKD = chronic kidney disease; HMOD = hypertension-mediated organ damage.

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Table 26 Common causes of secondary hypertension
Cause Prevalence in Suggestive symptoms and signs Screening Investigations

hypertensive
patients
Obstructive sleep apnoea 5–10% Snoring; obesity (can be present in non- Epworth score and ambulatory
obese); morning headache; daytime polygraphy
somnolence
Renal parenchymal disease 2–10% Mostly asymptomatic; diabetes; haematu- Plasma creatinine and electrolytes,
ria, proteinuria, nocturia; anaemia, renal eGFR; urine dipstick for blood and pro-
mass in adult polycystic CKD tein, urinary albumin:creatinine ratio;
renal ultrasound
Renovascular disease
Atherosclerotic renovascular disease 1–10% Older; widespread atherosclerosis (espe- Duplex renal artery Doppler or CT
cially PAD); diabetes; smoking; recurrent angiography or MR angiography
flash pulmonary oedema; abdominal bruit
Fibromuscular dysplasia Younger; more common in women;

abdominal bruit
Endocrine causes
Primary Aldosteronism 5 - 15% Mostly asymptomatic; muscle weakness Plasma aldosterone and renin, and
(rare) aldosterone:renin ratio; hypokalaemia
(in a minority): note hypokalaemia can
depress aldosterone levels
Phaeochromocytoma <1% Episodic symptoms (the 5 ‘Ps’): paroxysmal Plasma or 24 h urinary fractionated
hypertension, pounding headache, perspi- metanephrines
ration, palpitations, and pallor; labile BP; BP
surges precipitated by drugs (e.g. beta-
blockers, metoclopramide, sympathomi-
metics, opioids, and tricyclic
antidepressants)
Cushing’s syndrome <1% Moon face, central obesity, skin atrophy, 24 h urinary-free cortisol
striae and bruising; diabetes; chronic ste-
roid use
Thyroid disease (hyper- or 1 - 2% Signs and symptom of hyper- or Thyroid function tests
hypothyroidism) hypothyroidism
Hyperparathyroidism <1% Hypercalcaemia, hypophosphataemia Parathyroid hormone, Ca2þ
Other causes
Coarctation of the aorta <1% Usually detected in children or adoles- Echocardiogram

cence; different BP (>_20/10 mmHg)
between upper–lower extremities and/or
between right–left arm and delayed radial-
femoral femoral pulsation; low ABI inter-
scapular ejection murmur; rib notching on
chest X-ray
ABI = ankle-brachial index; BP = blood pressure; CKD = chronic kidney disease; CT = computed tomography; eGFR = estimated glomerular filtration rate; MR = magnetic res-
onance; PAD = peripheral artery disease.

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Table 27 Incidence and typical causes of secondary hypertension according to age
Age group Per cent with underlying cause Typical causes
Young children (<12 years) 70 - 85 • Renal parenchymal disease

• Coarctation of the aorta
• Monogenic disorders
Adolescents (12–18 years) 10–15 • Renal parenchymal disease

• Coarctation of the aorta
• Monogenic disorders
Young adults (19–40 years) 5–10 • Renal parenchymal disease

• Fibromuscular dysplasia (especially in women)
• Undiagnosed monogenic disorders
Middle-aged adults (41–65 years) 5–15 • Primary aldosteronism

• Obstructive sleep apnoea
• Cushing’s syndrome
• Phaeochromocytoma
• Renal parenchymal disease
• Atherosclerotic renovascular disease
Older adults (>65 years) 5–10 • Atherosclerotic renovascular disease

• Renal parenchymal disease
• Thyroid disease
Table 28 Medications and other substances that may increase blood presssure397
Medication/substance
Oral contraceptive pill Especially oestrogen containing; cause hypertension in 5% of women, usually mild but can be severe
Diet pills For example, phenylpropanolamine and sibutramine
Nasal decongestants For example, phenylephrine hydrochloride and naphazoline hydrochloride
Stimulant drugs Amphetamine, cocaine, and ecstasy; these substances usually cause acute rather than chronic
hypertension
Liquorice Chronic excessive liquorice use mimics hyperaldosteronism by stimulating the mineralocorticoid recep-
tor and inhibiting cortisol metabolism
Immunosuppressive medications For example, cyclosporin A (tacrolimus has less effect on BP and rapamycin has almost no effect on BP)
and steroids (e.g. corticosteroids and hydrocortisone)
Antiangiogenic cancer therapies Antiangiogenic drugs such as VEGF inhibitors (e.g. bevacizumab), tyrosine kinase inhibitors (e.g. suniti-
nib), and sorafenib have been reported to increase BP
Other drugs and substances Anabolic steroids, erythropoietin, non-steroidal anti-inflammatory drugs, and herbal remedies (e.g. ephe-
that may raise BP dra and ma huang)
BP = blood pressure; VEGF = vascular endothelial growth factor.

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Table 29 Rare genetic causes of secondary hypertension
Condition Phenotype Mechanism and effect
Liddle syndrome Hypokalaemia, metabolic alkalosis, low PRA or Increased renal tubular ENaC activity:
PRC, low PAC responds to treatment with amiloride
Apparent mineralocorticoid Hypokalaemia, metabolic alkalosis, low PRA or Decreased 11b-dehydrogenase isoenzyme 2
excess PRC, low PAC
Gordon syndrome Hypokalaemia, metabolic acidosis, low PRA or Overactivity of sodium chloride co-
PRC, low PAC transporter
Geller syndrome Pregnancy-exacerbated hypertension, low PRA or Agonist effect of progesterone on the min-
PRC, low PAC eralocorticoid receptor
Glucocorticoid remediable Hypokalaemia, metabolic alkalosis, low PRC or Chimeric CYP11b1 to CYP11b2 gene:
hypertension PRA, and increased PAC response to treatment with glucocorticoids
ENaC = epithelial sodium channel; PAC = plasma aldosterone concentration; PRA = plasma renin activity; PRC = plasma renin concentration.
8.3 Hypertension urgencies and

emergencies Table 30 Diagnostic workup for patients with a sus-
pected hypertension emergency
Hypertension emergencies are situations in which severe hyperten-
sion (grade 3) is associated with acute HMOD, which is often life-
Common tests for all potential causes
threatening and requires immediate but careful intervention to lower
BP, usually with intravenous (i.v.) therapy.398 The rate and magnitude Fundoscopy is a critical part of the diagnostic workup
of an increase in BP may be at least as important as the absolute level
of BP in determining the magnitude of organ injury.399 Typical presen- 12-lead ECG
tations of a hypertension emergency are: Haemoglobin, platelet count, fibrinogen
• Patients with malignant hypertension, characterized by Creatinine, eGFR, electrolytes, LDH, haptoglobin
severe hypertension (usually grade 3) associated with fundu-
scopic changes (flame haemorrhages and/or papilloedema), Urine albumin:creatinine ratio, urine microscopy for red cells,
microangiopathy, and disseminated intravascular coagulation, and leucocytes, casts
can be associated with encephalopathy (in about 15% of
cases),400 acute heart failure, and acute deterioration in renal Pregnancy test in women of child-bearing age
function. The hallmark of this condition is small artery fibrinoid Specific tests by indication
necrosis in the kidney, retina, and brain. The term ‘malignant’
reflects the very poor prognosis for this condition if Troponin, CK-MB (in suspected cardiac involvement, e.g. acute
untreated.401–404 chest pain or acute heart failure) and NT-proBNP
• Patients with severe hypertension associated with other
clinical conditions who are likely to require an urgent reduc- Chest X-ray (fluid overload)
tion of BP, e.g. acute aortic dissection, acute myocardial ischae- Echocardiography (aortic dissection, heart failure, or ischaemia)
mia, or acute heart failure.
• Patients with sudden severe hypertension due to phaeo- CT angiography of thorax and/or abdomen in suspected acute
chromocytoma, associated with organ damage. aortic disease (e.g. aortic dissection)
• Pregnant women with severe hypertension or pre-
eclampsia (see section 8.9.1). CT or MRI brain (nervous system involvement)
The most common emergency symptoms will depend of the Renal ultrasound (renal impairment or suspected renal artery
organs affected but may include headache, visual disturbances, chest stenosis)
pain, dyspnoea, dizziness, and other neurological deficits. In patients Urine drug screen (suspected methamphetamine or cocaine
with hypertensive encephalopathy, the presence of somnolence, use)
lethargy, tonic clonic seizures, and cortical blindness may precede a
loss of consciousness; however, focal neurological lesions are rare CK-MB = creatinine kinase-muscle/brain; CT = computed tomography; ECG =
and should raise the suspicion of stroke. electrocardiogram; eGFR = estimated glomerular filtration rate; LDH = lactate
Acute stroke, especially intracerebral haemorrhage, when dehydrogenase; MRI = magnetic resonance imaging; NT-proBNP = N-terminal
pro-B natriuretic peptide.
associated with severe hypertension has often been termed a

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..
hypertension emergency, but a more cautious approach is now rec- .. whether there is a precipitating cause for the acute rise in BP that
ommended for acute BP lowering in the emergency setting of acute .. might affect the treatment plan (e.g. pregnancy);
..
stroke (see section 8.15). .. (2) The recommended timescale and magnitude of BP lowering
The term ‘hypertension urgency’ has also been used to describe .. required for safe BP reduction;
..
severe hypertension in patients presenting to the emergency depart- .. (3) The type of BP-lowering treatment required. With regard to drug
ment in whom there is no clinical evidence of acute HMOD.405 .. treatment, in a hypertension emergency, i.v. treatment with a drug
..
Whilst these patients require BP reduction, they do not usually .. with a short half-life is ideal to allow careful titration of the BP
require admission to hospital, and BP reduction is best achieved with .. response to treatment in a higher dependency clinical area with
..
oral medication according to the drug treatment algorithm presented .. facilities for continuous haemodynamic monitoring.
in Figure 4. However, these patients will require urgent outpatient
..
.. Recommended drug treatments for specific hypertension emer-
review to ensure that their BP is coming under control. ..
.. gencies398,406 are shown in Table 31 and an expanded range of possi-
Acute and severe increases in BP can sometimes be precipitated ..
.. ble drug choices398 is shown in Table 32. Rapid uncontrolled BP
by ingestion of sympathomimetics such as meta-amphetamine or
cocaine. This can result in a hypertension emergency when there is
.. lowering is not recommended as this can lead to complications.397
.. Although i.v. drug administration is recommended for most hyper-
evidence of acute HMOD. ..
.. tension emergencies, oral therapy with ACE inhibitors, ARBs, or
It is emphasized that many patients in an emergency ..
.. beta-blockers is sometimes very effective in malignant hypertension
department with acute pain or distress may experience an acute ele-
.. because the renin system is activated by renal ischaemia. However,
vation in BP that will be restored to normal when the pain and dis- .. low initial doses should be used because these patients can be very
tress are relieved, rather than requiring any specific intervention to ..
.. sensitive to these agents and treatment should take place in hospital.
lower BP. .. Further comprehensive details on the clinical management of hyper-
For patients with a suspected hypertension emergency, a diagnos- ..
.. tension emergencies are available.398
tic workup is shown in Table 30. ..
..
.. 8.3.2 Prognosis and follow-up
..
8.3.1 Acute management of hypertensive emergencies
.. The survival of patients with hypertension emergencies has improved
.. dramatically over past decades,407 but these patients remain at high
Apart from acute BP lowering in stroke, there are no RCTs evaluating ..
different treatment strategies for hypertensive emergencies. The key
.. risk408,409 and should be screened for secondary hypertension (see
.. section 8.2). After discharge from hospital, when BP has reached a
considerations in defining the treatment strategy are: ..
.. safe and stable level on oral therapy, we recommend frequent, at
(1) Establishing the target organs that are affected, whether they
.. least monthly, visits in a specialized setting until the optimal target BP
..
require any specific interventions other than BP lowering, and . is achieved and long-term specialist follow-up thereafter.
Table 31 Hypertensive emergencies requiring immediate blood pressure lowering with intravenous drug therapy
Clinical presentation Timeline and target for BP First-line treatment Alternative

reduction
Malignant hypertension with or Several hours Labetalol Nitroprusside

without acute renal failure Reduce MAP by 20–25% Nicardipine Urapidil
Hypertensive encephalopathy Immediately reduce MAP by Labetalol, nicardipine Nitroprusside

20–25%
Acute coronary event Immediately reduce SBP to <140 Nitroglycerine, labetalol Urapidil
mmHg
Acute cardiogenic pulmonary Immediately reduce SBP to <140 Nitroprusside or nitroglycerine Urapidil (with loop diuretic)
oedema mmHg (with loop diuretic)
Acute aortic dissection Immediately reduce SBP to <120 Esmolol and nitroprusside or Labetalol OR metoprolol
mmHg AND heart rate to <60 nitroglycerine or nicardipine
bpm
Eclampsia and severe pre- Immediately reduce SBP to <160 Labetalol or nicardipine and Consider delivery
eclampsia/HELLP mmHg AND DBP to <105 mmHg magnesium sulfate
BP = blood pressure; bpm = beats per min; DBP = diastolic blood pressure; HELLP = haemolysis, elevated liver enzymes, and low platelets; i.v. = intravenous; MAP = mean
arterial pressure; SBP = systolic blood pressure.

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Table 32 Drug types, doses, and characteristics for treatment of hypertension emergencies
Drug Onset of action Duration Dose Contraindications Adverse effects

of action
Esmolol 1–2 min 10–30 min 0.5–1 mg/kg as bolus; 50–300 Second or third-degree AV Bradycardia
mg/kg/min as continuous block, systolic heart failure,
infusion asthma, bradycardia
Metoprolol 1–2 min 5–8 h 15 mg i.v., usually given as 5 mg Second or third-degree AV Bradycardia
i.v., and repeated at 5 min inter- block, systolic heart failure,
vals as needed asthma, bradycardia
Labetalol 5–10 min 3–6 h 0.25–0.5 mg/kg; 2–4 mg/min Second or third-degree AV Bronchoconstriction,
until goal BP is reached, there- block; systolic heart failure, foetal bradycardia
after 5–20 mg/h asthma, bradycardia
Fenoldopam 5–15 min 30–60 min 0.1 mg/kg/min, increase every Caution in glaucoma
15 min until goal BP is reached
Clevidipine 2–3 min 5–15 min 2 mg/h, increase every 2 min Headache, reflex
with 2 mg/h until goal BP tachycardia
Nicardipine 5–15 min 30–40 min 5–15 mg/h as continuous infu- Liver failure Headache, reflex
sion, starting dose 5 mg/h, tachycardia
increase every 15–30 min with
2.5 mg until goal BP, thereafter
decrease to 3 mg/h
Nitroglycerine 1–5 min 3–5 min 5–200 mg/min, 5 mg/min Headache, reflex
increase every 5 min tachycardia
Nitroprusside Immediate 1–2 min 0.3–10 mg/kg/min, increase by Liver/kidney failure Cyanide intoxication
0.5 mg/kg/min every 5 min until (relative)
goal BP
Enalaprilat 5–15 min 4–6 h 0.62–1.25 mg i.v. History of angioedema
Urapidil 3–5 min 4–6 h 12.5–25 mg as bolus injection;

5–40 mg/h as continuous
infusion
Clonidine 30 min 4–6 h 150–300 mg i.v. over 5–10 min Sedation, rebound
hypertension
Phentolamine 1–2 min 10–30 min 0.5–1 mg/kg bolus injections Tachyarrhythmias,
OR 50–300 mg/kg/min as con- chest pain
tinuous infusion
AV = atrioventricular; BP = blood pressure; i.v. = intravenous.
..
8.4 White-coat hypertension .. as well as an overall increased risk of CV events.68,410–412 It is recom-
As discussed in section 4, white-coat hypertension is defined as an .. mended that people with white-coat hypertension should have an
..
elevated office BP despite a normal out-of-office BP. White-coat .. accurate assessment of their CV risk profile, including a search for
hypertension may be present in many people with an increased office .. HMOD. Office and out-of-office BP (both home and ambulatory BP)
..
BP, with a maximum in grade 1 hypertension, and very old people .. should be measured frequently, e.g. no less than every 2 years.
(>50%). Compared with normotensive people, white-coat hyperten-
.. Treatment should consider lifestyle changes to reduce the elevated
..
sion is associated with an increased prevalence of dysmetabolic risk .. CV risk.85,86,89
factors and asymptomatic organ damage. It is also associated with a
.. Whether or not patients with white-coat hypertension should
..
greater risk of developing type 2 diabetes and sustained hypertension, .. receive antihypertensive drugs is unresolved. In white-coat

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..
hypertension, antihypertensive drugs have been shown to effectively .. (ABPM or HBPM).84 Registry-based studies in Spain have suggested
and persistently lower office BP, with no concomitant reduction .. that MUCH occurs in as many as 30% of treated hypertensive
..
(indeed, even a small increase) of ambulatory BP values.413,414 .. patients,84 and is more common with comorbidities such as diabetes
Whether these BP changes lead to CV protection has not been inves- .. and CKD and in those at highest risk. Moreover, MUCH was more
..
tigated with adequately powered outcome studies and remains .. commonly due to poorly controlled nocturnal rather than daytime
unknown. However, it should be considered that people with white-
.. pressures on ABPM. Presently, no data are available from outcome
..
coat hypertension have inevitably been well represented in trials doc- .. trials for patients with MUCH; however, mindful of their high CV
umenting the protective effect of antihypertensive drugs,415 particu-
.. risk, treatment uptitration should be considered to ensure that that
..
larly those addressing conditions in which white-coat hypertension is .. both office and out-of-office BP are controlled.84
more common, such as grade 1 hypertension or hypertension in
..
..
older patients. In a recent subanalysis of the HYVET trial of the very
old with hypertension, white-coat hypertension was reported to Management of white coat and masked hypertension
account for 55% of the trial population.416 Thus, antihypertensive
drug treatment cannot definitively be excluded for patients with Management of white-coat hypertension
white-coat hypertension and may be considered, in particular, in
white-coat hypertensive people with a higher CV risk profile, such as
those with HMOD, an uncertain out-of-office BP normality pattern In white-coat hypertensive patients, it is rec-
(i.e. ambulatory but not home BP normality or vice versa), or a persis- ommended to implement lifestyle changes
tent office BP elevation at repeated visits.417–420 No CV risk excess aimed at reducing CV risk as well as regular I C
has been reported in patients in whom white-coat hypertension follow-up with periodic out-of-office BP
results from treatment-dependant normalization of out-of-office BP monitoring.
only.418,421 Thus, whether this condition benefits from an uptitration
In patients with white-coat hypertension:
of the existing drug treatment regimen (to also achieve office BP nor-
malization) remains to be determined.
• Drug treatment may be considered in IIb C
people with evidence of HMOD or in
whom CV risk is high or very high.
8.5 Masked hypertension
As reported in section 4.7.2, masked hypertension is defined in people • Routine drug treatment is not indicated. III C
whose BP is normal in the office but elevated on out-of-office BP meas-
Management of masked hypertension
urements. Such people usually have dysmetabolic risk factors and
asymptomatic organ damage, which are substantially more frequent Recommendations
than in people who are truly normotensive.93,410–412,422 The challenge
In masked hypertension, lifestyle changes
is how to diagnose masked hypertension, because most hypertension
are recommended to reduce CV risk, with
screening programmes use office BP measurement, which is normal in I C
regular follow-up, including periodic out-of-
these people. Masked hypertension is commoner in younger rather
office BP monitoring.
than older individuals, and in those with an office BP in the borderline
hypertension range (i.e. 130 - 139/80 - 89 mmHg). It is uncommon in Antihypertensive drug treatment should be
people whose office BP is <130/80 mmHg. Masked hypertension is considered in masked hypertension to nor-
associated with progression to sustained office hypertension, increased malize the out-of-office BP, based on the IIa C
frequency of developing type 2 diabetes, and the presence of HMOD. prognostic importance of out-of-office BP
The long-term risk of fatal and non-fatal CV events approaches that of elevation.
patients with sustained hypertension.68,81,93,95,423 Patients with masked
Antihypertensive drug uptitration should be
hypertension should have an accurate initial assessment of their CV
considered in treated patients whose out-
risk profile. CV risk factors (including organ damage and ideally both
of-office BP is not controlled (i.e. masked IIa C
home and ambulatory BP) should then be periodically monitored.
uncontrolled hypertension), because of the
Factors contributing to the out-of-office BP elevation (e.g. smoking)
high CV risk of these patients.
should be discouraged and lifestyle interventions implemented to
improve out-of-office BP levels. The impact of antihypertensive drug
treatment on CV outcomes in people with masked hypertension has BP = blood pressure; CV = cardiovascular; HMOD = hypertension-mediated
organ damage.
never been studied. Nevertheless, treatment with BP-lowering medica- a
b
tion should be considered because these patients are at high CV risk, Level of evidence.
often have HMOD, and the adverse prognostic importance of out-of-
office BP elevations has been well documented.68,74
8.7 Hypertension in younger adults
8.6 Masked uncontrolled hypertension (age <50 years)
MUCH occurs in some treated patients in whom the office BP The prevalence of hypertension increases with age. Most hyperten-
appears controlled to recommended BP targets, but BP is elevated sion across the age span is due to systolic hypertension; however, ele-
and thus uncontrolled according to out-of-office BP measurements vations of DBP and isolated diastolic hypertension, when they occur,

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..
are more common in younger rather than older patients.211 There is .. For the purposes of these Guidelines, older is defined as >_65 years
a greater likelihood of detecting secondary hypertension in younger .. and the very old as >_80 years.
..
patients (<50 years), where the prevalence of secondary hyperten- .. For many years, advanced age has been a barrier to the treatment
sion may be as high as 10% and should be considered, especially in .. of hypertension because of concerns about potential poor tolerabil-
..
those with more severe hypertension (see section 3). .. ity, and even harmful effects of BP-lowering interventions in people in
All younger adults with grade 2 or more severe hypertension .. whom mechanisms preserving BP homeostasis and vital organ perfu-
..
should be offered lifestyle advice and drug treatment, as well as high- .. sion may be more frequently impaired. This approach is not appro-
risk younger adults with grade 1 hypertension (i.e. with HMOD, .. priate, because evidence from RCTs has shown that in old and very
..
CVD, diabetes, CKD, or those at high CVD risk, although CV risk is .. old patients, antihypertensive treatment substantially reduces CV
often underestimated in younger adults over shorter-term projec- .. morbidity and CV and all-cause mortality220,431 (see section 7).
..
tions, such as 10 years).35 .. Moreover, treatment has been found to be generally well tolerated.
There is controversy about whether younger adults with uncom- .. However, older patients are more likely to have comorbidities such
..
plicated grade 1 hypertension should be treated because of the .. as renal impairment, atherosclerotic vascular disease, and postural
obvious difficulty in conducting conventional clinical outcome trials in .. hypotension, which may be worsened by BP-lowering drugs. Older
..
younger adults in whom the outcomes only occur after many .. patients also frequently take other medications, which may negatively
years.424 There is little doubt that treating stage 1 hypertension in
.. interact with those used to achieve BP control. A further important
..
older patients, even those at low–moderate-risk, reduces CV mor- .. caveat is that RCTs have not included very frail patients, dependent
bidity and mortality.425 Moreover, long-term epidemiological studies
.. patients, and patients with postural hypotension. It is thus uncertain
..
have demonstrated a clear relationship between BP and longer-term .. whether, and to what extent, such patients would benefit from BP-
risk of CV events and mortality in young adults with a BP >130/80
.. lowering treatment in the context of their comorbidities and reduced
..
mmHg.424,426 Furthermore, earlier treatment23 can prevent more .. life expectancy. Thus, in older hypertensive patients, treatment
..
severe hypertension427 and the development of HMOD, which may .. presents more difficulties than in younger people, because the deci-
not be completely reversible with later treatment. Thus, despite the .. sion to treat hypertension must take into account the patient’s clinical
..
absence of RCT evidence demonstrating the benefits of antihyper- .. condition, concomitant treatments, and frailty. That said, age alone
tensive treatment in younger adults with uncomplicated grade 1 .. must never be a barrier to treatment because high BP is an important
..
hypertension, treatment with BP-lowering drugs may be considered .. risk factor even at the most advanced ages. Furthermore, a recent
prudent. If a decision is taken not to offer treatment or treatment is .. study of a cohort of older patients from the general population (thus
..
declined, lifestyle advice should be prescribed, and longer-term fol- .. including those with frailty) has shown that better adherence to anti-
low-up is essential as BP will invariably rise. In younger patients with .. hypertensive treatment was associated with a reduced risk of CV
..
hypertension treated with BP-lowering medication, office BP should .. events and mortality, even when age was >85 years (mean 90
be reduced to <_ 130/80 mmHg if treatment is well tolerated. Other .. years).432
..
interventions, e.g. statins or antiplatelet therapy, should also be con- .. It is recommended that older patients are treated according to the
sidered for higher-risk patients (see section 7.2.5). .. treatment algorithm outlined in section 7. In very old patients, it may
..
.. be appropriate to initiate treatment with monotherapy. In all older
.. patients, when combination therapy is used, it is recommended that
8.7.1 Isolated systolic hypertension in the young ..
.. this is initiated at the lowest available doses. In all older patients, and
Some young, healthy people, and men in particular, may present with .. especially very old or frail patients, the possible occurrence of pos-
isolated grade 1 systolic hypertension (i.e. brachial SBP >_140 - 159 ..
.. tural BP should be closely monitored and symptoms of possible
mmHg and a normal DBP <90 mmHg), and this may be associated .. hypotensive episodes checked by ABPM. Unless required for con-
with a normal central aortic SBP due to excessive peripheral systolic ..
.. comitant diseases, loop diuretics and alpha-blockers should be
pressure amplification.428 It is unclear whether isolated systolic ..
.. avoided because of their association with injurious falls.433,434 Renal
hypertension in the context of a normal aortic pressure is benign. A
.. function should be frequently assessed to detect possible increases in
recent examination of prospective data from the Chicago Heart .. serum creatinine and reductions in eGFR as a result of BP-related
Association Detection Project found that young men with isolated ..
.. reductions in renal perfusion. When treated, BP should be lowered
systolic hypertension had a CV risk similar to that of individuals with ..
.. to a systolic value of 130–139 mmHg and a diastolic value of <80
high–normal BP and that isolated systolic hypertension in the young .. mmHg if tolerated. Treated SBP values of <130 mmHg should be
was closely associated with smoking.429 On the basis of current evi- ..
dence, these young individuals should receive recommendations on .. avoided. A key emphasis in treating older patients, and especially the
.. very old, is to carefully monitor for any adverse effects or tolerability
lifestyle modification (particularly cessation of smoking); whether ..
they should receive drug treatment is unclear, but they do require
.. problems associated with BP-lowering treatment, keeping in mind
.. that adverse effects can be more frequent than reported in RCTs, in
longer-term follow-up as many will develop sustained ..
hypertension.430
.. which specific medical expertise and close patient supervision may
.. minimize adverse effects and tolerability problems.
..
.. An important consideration is frail, dependent older patients,
8.8 Hypertension in older patients .. including those with orthostatic hypotension. These have been
..
(age 65 years) .. excluded from RCTs. The SPRINT trial showed the benefits of BP-
The prevalence of hypertension increases with age, with a prevalence
.. lowering treatment being extended to recruited patients who were
..
of 60% over the age of 60 years and 75% over the age of 75 years. . at the frailer end of the spectrum, including those with reduced gait

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..
speed.215 This suggests that the benefit of treatment is not limited to .. devices tend to under-record the BP and are unreliable in severe pre-
fit and independent older patients; however, to what extent BP- .. eclampsia. Only validated devices should be used in pregnancy.439 ABPM
..
lowering treatment benefits the very frail214 and institutionalized .. is superior to office BP measurement for the prediction of pregnancy
patients remains to be determined. .. outcome.440 ABPM devices recommended for use in pregnancy are
..
In some patients, the best achievable BP may be higher than the rec- .. more accurate than those used for office measurement or HBPM.
ommended target, but it should be recognised that any amount of BP .. ABPM helps avoid unnecessary treatment of white-coat hypertension,
..
lowering is likely to be worthwhile and associated with a reduced risk .. and is useful in the management of high-risk pregnant women with
of major CV events (especially stroke and heart failure) and mortality. .. hypertension and those with diabetic or hypertensive nephropathy.
..
..
8.9 Women, pregnancy, oral .. 8.9.1.3 Investigation of hypertension in pregnancy
..
contraception, and hormone- .. Basic laboratory investigations recommended for monitoring preg-
.. nant hypertensive women include urine analysis, blood count, haema-
replacement therapy ..
.. tocrit, liver enzymes, serum creatinine, and serum uric acid
8.9.1 Hypertension and pregnancy ..
.. (increased in clinically evident pre-eclampsia). Hyperuricaemia in
Hypertensive disorders in pregnancy affect 5–10% of pregnancies
.. hypertensive pregnancies identifies women at increased risk of
worldwide and remain a major cause of maternal, foetal, and neonatal .. adverse maternal and foetal outcomes.441
morbidity and mortality. Maternal risks include placental abruption, ..
.. All pregnant women should be assessed for proteinuria in early
stroke, multiple organ failure, and disseminated intravascular coagula- .. pregnancy to detect pre-existing renal disease and, in the second half
tion. The foetus is at high risk of intrauterine growth retardation ..
.. of pregnancy, to screen for pre-eclampsia. A dipstick test of >_1þ
(25% of cases of pre-eclampsia), prematurity (27% of cases of pre- .. should prompt evaluation of ACR in a single spot urine sample and a
eclampsia), and intrauterine death (4% of cases of pre-eclampsia).435 ..
.. value <30 mg/mmol can reliably rule out proteinuria in pregnancy.442
..
.. In addition to basic laboratory tests, the following investigations
8.9.1.1 Definition and classification of hypertension in pregnancy .. may be considered:
The definition of hypertension in pregnancy is based on office BP val- ..
ues, SBP >_140 mmHg and/or DBP >_90 mmHg,436,437 and is classified .. • Ultrasound investigation of the kidneys and adrenals, and plasma
..
as mild (140–159/90–109 mmHg) or severe (>_160/110 mmHg), in .. or urinary fractionated metanephrine assays in pregnant women
contrast to the conventional hypertension grading. .. with a history suggestive of phaeochromocytoma.
..
Hypertension in pregnancy is not a single entity but comprises: .. • Doppler ultrasound of uterine arteries (performed after 20
.. weeks of gestation) to detect those at higher risk of gestational
• Pre-existing hypertension: precedes pregnancy or develops .. hypertension, pre-eclampsia, and intrauterine growth
..
before 20 weeks of gestation, and usually persists for more than .. retardation.443
6 weeks post-partum and may be associated with proteinuria. .. • A soluble fms-like tyrosine kinase 1:placental growth factor ratio
.. of <_ 38 can be used to exclude the development of pre-
• Gestational hypertension: develops after 20 weeks of gesta- ..
tion and usually resolves within 6 weeks post-partum. .. eclampsia in the next week when suspected clinically.444
..
• Pre-existing hypertension plus superimposed gesta- ..
tional hypertension with proteinuria. .. 8.9.1.4 Prevention of hypertension and pre-eclampsia
.. Women at high or moderate-risk of pre-eclampsia should be advised
• Pre-eclampsia: gestational hypertension with significant protei- ..
nuria (>0.3 g/24 h or >_30 mg/mmol ACR). It occurs more fre-
.. to take 100–150 mg of aspirin daily from weeks 12–36.445 High risk
.. of pre-eclampsia includes any of the following:
quently during the first pregnancy, in multiple pregnancy, in ..
hydatidiform mole, in antiphospholipid syndrome, or with pre- ..
.. • Hypertensive disease during a previous pregnancy
existing hypertension, renal disease, or diabetes. It is often associ- .. • CKD
ated with foetal growth restriction due to placental insufficiency ..
.. • Autoimmune disease such as systemic lupus erythematosus or
and is a common cause of prematurity.438 The only cure for pre- .. antiphospholipid syndrome
eclampsia is delivery. As proteinuria may be a late manifestation ..
.. • Type 1 or type 2 diabetes
of pre-eclampsia, it should be suspected when de novo hyperten- .. • Chronic hypertension.
sion is accompanied by headache, visual disturbances, abdominal ..
pain, or abnormal laboratory tests, specifically low platelets and/ .. Moderate-risk of pre-eclampsia includes one or more of the fol-
or abnormal liver function.
..
.. lowing risk factors:
• Antenatally unclassifiable hypertension: this term is used ..
.. • First pregnancy
when BP is first recorded after 20 weeks of gestation and it is ..
unclear if hypertension was pre-existing. Reassessment 6 weeks .. • Age >_40 years
post-partum will help distinguish pre-existing from gestational
.. • Pregnancy interval of >10 years
.. • BMI of >_35 kg/m2 at first visit
hypertension. ..
.. • Family history of pre-eclampsia
.. • Multiple pregnancy.
8.9.1.2 Blood pressure measurement in pregnancy ..
BP in pregnancy should be measured in the sitting position (or the left ..
.. 8.9.1.5 Clinical management of hypertension in pregnancy
lateral recumbent during labour) with an appropriately sized arm cuff at ..
heart level and using Korotkoff V for DBP. Manual auscultation remains
.. Mild hypertension of pregnancy (BP 140159/90109 mmHg). The
..
the gold standard for BP measurement in pregnancy, because automated . goal of drug treatment of hypertension in pregnancy is to reduce

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maternal risk; however, the agents selected must be safe for the foetus.
.. low platelets syndrome), hospitalization and BP-lowering therapy is
..
The benefits of drug treatment for mother and foetus in hypertension .. essential, and delivery needs to be considered after the maternal con-
..
in pregnancy have not been extensively studied, with the best data .. dition has stabilized.435 Intravenous magnesium sulfate is recom-
from a single trial using alpha-methyldopa, performed 40 years .. mended for the prevention of eclampsia and treatment of seizures.
..
ago.446–448 A further study suggested that tighter vs. less tight control .. The consensus is to lower BP to <160/105 mmHg to prevent acute
of BP in pregnancy showed no difference in the risk of adverse perinatal .. hypertensive complications in the mother. Both labetalol and nicardi-
..
outcomes and overall serious maternal complications. However, sec- .. pine have shown to be safe and effective for the treatment of severe
ondary analysis suggested that tighter control of BP may reduce the .. pre-eclampsia if i.v. BP-lowering therapy is necessary.452 In both
..
risk of developing more severe hypertension and pre-eclampsia.446 .. cases, monitoring of foetal heart rate is necessary. To prevent foetal
Most women with pre-existing hypertension and normal renal .. bradycardia, the cumulative dose of labetalol should not exceed 800
..
function will not have severe hypertension and are a low risk for .. mg/24 h. Intravenous sodium nitroprusside is contraindicated in preg-
developing complications during pregnancy. Indeed, some of these .. nancy because of an increased risk of foetal cyanide poisoning. The
..
women may be able to withdraw their medication in the first half of .. drug of choice when pre-eclampsia is associated with pulmonary
pregnancy because of the physiological fall in BP. Despite the paucity .. oedema is nitroglycerin (glyceryl trinitrate), given as an i.v. infusion of
..
of evidence, European Guidelines17,449,450 have recommended initiat- .. 5 lg/min, and gradually increased every 3–5 min to a maximum dose
ing drug treatment:
.. of 100 lg/min.
..
.. Delivery is indicated (i) urgently in pre-eclampsia with visual distur-
(1) In all women with persistent elevation of BP >_150/95 mmHg; .. bances or haemostatic disorders, and (ii) at 37 weeks in asympto-
(2) In women with gestational hypertension (with or without proteinu- ..
.. matic women.453
ria), pre-existing hypertension with the superimposition of gesta- ..
tional hypertension, or hypertension with subclinical HMOD, when
..
.. Blood pressure post-partum. Post-partum hypertension is common
BP is >140/90 mmHg. .. in the first week. Any drug recommended can be used according to
..
Women with pre-existing hypertension may continue their cur- .. the hypertension treatment algorithm shown in Figure 4, with the cav-
..
rent antihypertensive medication, but ACE inhibitors, ARBs, and .. eats: (i) methyldopa should be avoided because of the risk of post-
direct renin inhibitors are contraindicated due to adverse foetal and .. partum depression and (ii) consideration should be given to drug
..
neonatal outcomes. Methyldopa, labetalol, and CCBs are the drugs of .. choice in breastfeeding women.
choice. Beta-blockers may induce foetal bradycardia; consequently, if
..
..
used, their type and dose should be carefully selected, with atenolol .. 8.9.1.6 Hypertension and breastfeeding
best avoided. Diuretic therapy is generally avoided because plasma
.. All antihypertensive drugs taken by the nursing mother are excreted
..
volume is reduced in women who develop pre-eclampsia. .. into breast milk. Most are present at very low concentrations except
There are no data to define the optimal BP treatment target in
.. for propranolol and nifedipine, with breast milk concentrations simi-
..
pregnant women. Nevertheless, for pragmatic reasons, if treatment is .. lar to those in maternal plasma. Reference to prescribing information
initiated it is important to suggest a treatment target to calibrate how
.. in breastfeeding women is important.
..
much treatment to give. A BP target of <140/90 is suggested for preg- ..
.. 8.9.1.7 Risk of recurrence of hypertensive disorders in a subsequent
nant women receiving antihypertensive therapy. ..
.. pregnancy
.. Women experiencing hypertension in their first pregnancy are at
Severe hypertension of pregnancy (160/110 mmHg). There is ..
no agreed definition of severe hypertension, with values ranging .. increased risk in a subsequent pregnancy. The earlier the onset of
.. hypertension in the first pregnancy, the higher the risk of recurrence
between 160–180 mmHg/>110 mmHg. The 2018 ESC Task Force ..
on cardiovascular disease during pregnancy435 considers an SBP .. in a subsequent pregnancy.
..
>_170 mmHg or DBP >_110 mmHg an emergency in a pregnant ..
woman, who should be immediately admitted to hospital for treat- .. 8.9.1.8 Long-term cardiovascular consequences of gestational
.. hypertension
ment. The selection of the antihypertensive drug and its route of ..
administration depends on the expected time of delivery. .. Women who develop gestational hypertension or pre-eclampsia are
..
Pharmacological treatment with i.v. labetalol, oral methyldopa, or .. at increased risk of hypertension, stroke, and ischaemic heart disease
CCB should be initiated. Intravenous hydralazine is no longer the .. in later adult life.454,455 Lifestyle modifications are indicated to avoid
..
drug of choice as it is associated with more perinatal adverse effects .. complications in subsequent pregnancies and to reduce maternal CV
than other drugs.451 However, hydralazine is still used when other
.. risk in the future. Therefore, annual visits to a primary care physician
..
treatment regimens fail to achieve adequate BP control. Intravenous .. to check BP and metabolic factors are recommended for these
urapidil can also be considered.
.. patients.
..
In hypertensive crises, i.e. in patients with eclampsia or severe pre- .. Further detail on the management of hypertension and other CV
eclampsia (with or without haemolysis, elevated liver enzymes, and
.. disorders in pregnancy is available.435
..

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Management of hypertension in pregnancy
In women with gestational hypertension, pre-existing hypertension superimposed by gestational hyperten-

sion, or with hypertension and subclinical organ damage or symptoms, initiation of drug treatment is recom- I C
mended when SBP is >_140 mmHg or DBP >_90 mmHg.
In all other cases, initiation of drug treatment is recommended when SBP is >_150 mmHg or DBP is >_95
I C
mmHg.
Methyldopa, labetalol, and CCBs are recommended as the drugs of choice for the treatment of hypertension in B
I
pregnancy.447,448 (methyldopa)
C
I
(labetalol or CCBs)
ACE inhibitors, ARBs, or direct renin inhibitors are not recommended during pregnancy. III C
SBP >_170 mmHg or DBP >_110 mmHg in a pregnant woman is an emergency, and admission to hospital is
I C
recommended.
In severe hypertension, drug treatment with i.v. labetalol, oral methyldopa, or nifedipine is recommended. I C
The recommended treatment for hypertensive crisis is i.v. labetalol or nicardipine and magnesium. I C
In pre-eclampsia associated with pulmonary oedema, nitroglycerin given as an i.v. infusion is recommended. I C
In women with gestational hypertension or mild pre-eclampsia, delivery is recommended at 37 weeks.453 I B
It is recommended to expedite delivery in pre-eclampsia with adverse conditions, such as visual disturbances
I C
or haemostatic disorders.
ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; CCB = calcium channel blocker; DBP = diastolic blood pressure; i.v. = intravenous; SBP = systolic
blood pressure.
a
b
Level of evidence.
8.9.2 Oral contraceptive pills and hypertension

.. 8.9.3 Hormone-replacement therapy and hypertension
..
Combined oestrogen–progesterone oral contraceptive pills can be .. Cross-sectional studies have long established that menopause dou-
..
associated with a small but significant increase in BP and the develop- .. bles the risk of developing hypertension, even after adjusting for fac-
ment of hypertension in about 5% of users.456,457 BP usually .. tors such as age and BMI.461 Although hormone-replacement
..
decreases promptly following cessation of these pills; consequently, .. therapy contains oestrogens, there is no convincing evidence that sig-
BP should be monitored before and during oral contraceptive pill .. nificant rises in BP will occur in otherwise normotensive menopausal
..
treatment. The rise in BP appears to be related to the oestrogen con- .. women due to this therapy, or that BP will increase further due to
tent and may be less likely with the progestogen-only oral contracep- .. hormone-replacement therapy in menopausal hypertensive
..
tive pill. Older studies have demonstrated a relationship between the .. women.462 Hormone-replacement therapy and selective oestrogen
oral contraceptive pill and venous thrombosis and venous throm- .. receptor modulators should not be used for primary or secondary
boembolism, and, to a lesser extent, myocardial infarction (especially ... prevention of CVD. In summary, current evidence suggests that the
..
with concomitant smoking history) and stroke.458 More recent stud- .. use of hormone-replacement therapy is not associated with an
ies with newer-generation oral contraceptive pills have reported .. increase in BP. Moreover, it is not contraindicated in women with
..
conflicting results. Thus, the use of oral contraceptives should con- .. hypertension, and women with hypertension may be prescribed
sider the risks and benefits for the individual patient. Changes in BP .. hormone-replacement therapy as long as BP levels can be controlled
..
should be carefully evaluated with follow-up readings.459 .. by antihypertensive medication.
Concomitant CV risk factors (e.g. smoking history) should be
..
..
assessed and oral contraceptive pill use is not recommended if BP is .. 8.10 Hypertension in different ethnic
elevated. In such patients, alternative forms of contraception should
..
.. groups
be offered. Discontinuation of combined oestrogen–progestin oral .. In comparison with the non-black population, hypertension is more
contraceptives in women with hypertension may improve their BP
..
.. prevalent in the black population living in Europe,463 similarly to that
control.460 .. reported for the USA.464 As for the European white population, the

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black European population is heterogenous in nature,463 although in

..
.. 8.11 Hypertension in diabetes
almost all European countries the largest ethnic group originates from ..
the Sub-Saharan African region.463 Hypertension epidemiology, diag-
.. mellitus
.. High BP is a common feature of type 1 and, particularly, type 2
nosis, and treatment have been thoroughly studied in black (i.e. Afro- ..
American) US patients,464 in contrast to the much scarcer database
.. diabetes. Moreover, masked hypertension and a blunted noctur-
.. nal fall in BP are not infrequent in people with diabetes.472
available for European black people, and thus we extrapolate from US ..
.. Recording 24 h ABPM in apparently normotensive people with
data. However, this extrapolation requires some caution as differences .. diabetes may be a useful diagnostic procedure, especially in those
between the North American and the European black population ..
.. with HMOD. Substantial evidence supports the benefits of BP
exist, especially with regard to socioeconomic status, CV risk,465,466 .. reduction in people with diabetes to reduce major macrovascular
and the response to antihypertensive drug treatment.467 BP-related ..
.. and microvascular complications of diabetes, as well as reducing
HMOD, as well as CV and renal complications, are more common and .. mortality. Proven benefits of BP-lowering treatment in diabetes
severe in black patients compared with age-matched white patients at ..
.. also include a significant reduction in the rate of end-stage renal
any BP level.464 Black hypertensive patients exhibit a similar propor- .. disease,231,235 retinopathy,1 and albuminuria.1 Diabetic neuropa-
tional reduction of CV and renal events in response to BP-lowering ..
.. thy has never been included as an outcome in RCTs of BP-
treatment as white patients, with somewhat different treatment modal- .. lowering treatment.
ities. However, to achieve an effective BP reduction and BP control, ..
.. When considering treatment for hypertension, it is important to
salt restriction is particularly important in black patients, in whom it .. exclude significant postural hypotension, which can be marked in
may lead to greater BP falls and more favourably impact on the effec- ..
.. people with diabetes due to autonomic neuropathy.235 Initiation of
tiveness of BP-lowering drug treatment.468 Hypertensive black patients .. antihypertensive drug therapy is recommended when the office BP
also show a reduced antihypertensive response to RAS-blocker mono- ..
.. is >140/90 mmHg. Alongside lifestyle interventions, treatment
therapy, whereas they usually respond more effectively to thiazide or ..
thiazide-like diuretics and CCBs,316,469,470 which in black patients may
.. should usually be initiated with a two-drug combination of an ACE
.. inhibitor or ARB with a CCB or thiazide/thiazide-like diuretic, and
be combined with each other or with a RAS blocker, making the latter ..
more effective. Angioedema appears more common with ACE inhibi-
.. treatment escalated according to the recommended treatment
.. algorithm (see section 7). This approach ensures that the treat-
tors in black patients, which may favour the preferred use of ARBs in ..
this population. Despite some progress in recent years, data on hyper-
.. ment strategy includes an ACE inhibitor or ARB, which has been
.. shown to reduce albuminuria and the appearance or progression
tension prevalence, management, and control in European black ..
patients (and in other immigrant populations such as European individ-
.. of diabetic nephropathy more effectively than other drug
.. classes.235 Combination of an ACE inhibitor with an ARB is contra-
uals from South Asia) are still scarce,463,471 which makes this field an ..
.. indicated because it is accompanied by an excess of renal adverse
important area for future research. There is no evidence that the BP .. events.298,473,474
response to treatment in other ethnic groups differs from that ..
.. Recent RCTs have shown that some antidiabetes agents (the
reported in the general population in Europe. .. selective inhibitors of sodium glucose cotransporter 2 in the kidney)
..
.. can reduce office and ambulatory BP by several mmHg,475,476 and
Hypertension in ethnic groups .. that this occurs even when people are treated with antihypertensive
..
.. drugs. This may help improve BP control (see below), which is espe-
.. cially difficult in diabetes,477 and may reduce the progression of
..
.. CKD478–481 (see also section 8.12).
It is recommended that a two-drug combi- .. There has been considerable debate about the target BP
nation, usually as an SPC, is used as initial I C ..
.. that should be achieved in people with diabetes (see section 7).
therapy for most black patients.c .. We recommend that in people with diabetes, the first objective
..
In black patients, initial antihypertensive .. should be to lower BP to <140/80 mmHg, aiming at an SBP of 130
.. mmHg. Provided that the treatment is well tolerated, treated
treatment should include a diuretic or a
I B ..
CCB, either in combination or with a RAS .. SBP values of <130 mmHg should be considered because of the
d 316,469 ..
blocker. .. benefits on stroke prevention. Achieved SBP values of <120
.. mmHg should always be avoided. BP targets for renoprotection
In other ethnic groups, BP-lowering treat- ..
ment may be based on the core treatment
.. for patients with diabetic kidney disease are discussed in
IIb C .. section 8.12.
algorithm (see Figure 4). ..
.
ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BP
= blood pressure; CCB = calcium channel blocker; RAS = renin–angiotensin sys-
tem; SPC = single-pill combination.
a
b
Level of evidence.
c
Except in patients with low grade 1 hypertension or frail older patients, in whom
initial treatment with a single drug may be more appropriate.
d
Angioedema is more common with ACE inhibitors and thus ARBs may be
preferred.

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..
Treatment strategies in people with diabetes
.. patients with CKD, but only in those with albuminuria and without
.. any beneficial effect on CV events.203 However, a more recent and
..
.. larger meta-analysis has shown a significant reduction in all-cause
Recommendations Classa Levelb .. mortality following BP reduction in patients with CKD.485
..
Antihypertensive drug treatment is recom- .. Reduction of albuminuria has also been considered as a therapeu-
.. tic target. Analyses of data from RCTs have reported that changes in
mended for people with diabetes when I A ..
office BP is >_140/90 mmHg.1,226,235,482 .. urinary albumin excretion are predictors of renal and CV
.. events.186,486 However, there are also studies in which treatment
..
In people with diabetes receiving BP-lower- .. that was less effective at reducing albuminuria was more effective at
ing drugs it is recommended: .. reducing CV events175 and vice versa.176,291 Thus, whether reducing
..
• To target SBP to 130 mmHg and I A .. albuminuria per se is a proxy for CVD prevention remains
<130mmHg if tolerated, but not .. unresolved.
..
<120 mmHg.1,231,235 .. Patients with CKD should receive lifestyle advice, especially
.. sodium restriction, and drug treatment when their office BP is >140/
• In older people (aged >_65 years aged), to ..
target to an SBP range of 130–139 I A .. 90 mmHg. Achieving recommended BP targets in CKD usually
..
mmHg.1,205,235 .. requires combination therapy, which should be initiated as a combi-
• To target the DBP to <80 mmHg, but .. nation of a RAS blocker with a CCB or diuretic in these patients. The
I C .. combination of two RAS blockers is not recommended.291 Loop diu-
not <70 mmHg. ..
.. retics should replace thiazide diuretics when the estimated GFR is
It is recommended to initiate treatment .. <30 mL/min/1.73 m2.
with a combination of a RAS blocker with a ..
CCB or thiazide/thiazide-like diuretic.c
I A
... The evidence with respect to BP targets in patients with CKD is
1,175,205
.. complex. In patients with non-diabetic CKD, one meta-analysis
..
.. showed that the slowest progression on CKD was obtained with a
Simultaneous administration of two RAS .. treated SBP in the range of 110 - 119 mmHg in patients with albumi-
..
blockers, e.g. an ACE inhibitor and ARB, is III A .. nuria >1 g/day.487 In contrast, in patients with a proteinuria <1 g/day,
not indicated.291,298,299 .. the lowest risk of developing CKD (not CV risk) was obtained with
..
.. an SBP of <140 mmHg.487 Another systematic review failed to dem-
ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BP .. onstrate that a BP target of <130/80 mmHg improved clinical out-
= blood pressure; CCB = calcium channel blocker; DBP = diastolic blood pres-
..
.. comes more than a target of <140/90 mmHg in non-diabetic
sure; eGFR = estimated glomerular filtration rate; RAS = renin-angiotensin sys- .. CKD.488 In a large retrospective cohort containing 398 419 treated
tem; SBP = systolic blood pressure. ..
a
Class of recommendation. .. hypertensive patients (30% with diabetes), the nadir SBP and DBP for
b
Level of evidence. .. the lowest risk of end-stage renal disease and mortality were 137 and
c
When eGFR <30 mL/min/1.73 m2, avoid thiazide/thiazide-like diuretics and con- ..
sider using a loop diuretic when a diuretic is required. .. 71 mmHg, respectively, with a clear increase in mortality risk at SBP
.. <120 mmHg.489
..
.. Current evidence suggests that in patients with CKD, BP should be
.. lowered to <140/90 mmHg and towards 130/80 mmHg. Lifestyle
..
.. advice, especially sodium restriction, may be especially effective at
8.12 Hypertension and chronic kidney .. aiding BP lowering in patients with CKD. Because BP lowering
..
disease .. reduces renal perfusion pressure, it is expected and not unusual for
Hypertension is a major risk factor for the development and progres-
.. eGFR to be reduced by 10 - 20% in patients treated for hypertension.
..
sion of CKD, irrespective of the cause of CKD. In patients with CKD, .. Thus, careful monitoring of blood electrolytes and eGFR is essential,
..
resistant hypertension, masked hypertension, and elevated night- .. but clinicians should not be alarmed by the anticipated decline in GFR
time BP are common, and are associated with a lower eGFR, higher .. when treatment is initiated. This decline usually occurs within the first
..
levels of albuminuria, and HMOD.483,484 .. few weeks of treatment and stabilizes thereafter. If the decline in
The effects of lowering BP in patients with CKD have been the .. GFR continues or is more severe, the treatment should be stopped,
..
subject of many meta-analyses. A recent meta-analysis has shown .. and the patient investigated to determine the presence of renovascu-
that BP lowering significantly reduced end-stage renal disease in .. lar disease.
..

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..
Therapeutic strategies for treatment of hypertension in
.. effects.492,493 Beta-blockers may negatively affect the reduced basal
.. lung function in patients with COPD, diminish the effectiveness of
CKD ..
.. emergency beta-agonist administration, reduce the benefit of long-
.. acting beta-agonist treatment, and make the discrimination of asthma
Recommendations Classa Levelb ..
.. and COPD more difficult. That said, when tolerated, the use of car-
In patients with diabetic or non-diabetic
.. diac beta1-selective beta-blockers in patients with COPD has proven
..
CKD, it is recommended that an office BP .. to be safe in different settings, including hypertension.494 It should
I A .. also be noted that diuretics may decrease the plasma level of potas-
of >_140/90 mmHg be treated with lifestyle ..
advice and BP-lowering medication.9,203,485 .. sium (in addition to the hypokalaemic effects of glucocorticoids and
.. beta2-adrenoceptor agonists), worsen carbon dioxide retention
In patients with diabetic or non-diabetic
..
.. (including metabolic alkalosis-related hypoxia in hypoventilated
CKD: .. patients), increase haematocrit, and deteriorate mucus secretion in
• It is recommended to lower SBP to a
I A ..
.. bronchi. Therefore, in general, diuretics are not recommended for
range of 130–139 mmHg.9,487,489 .. widespread use in hypertensive patients with COPD.490,495
..
• Individualized treatment should be con- .. In conclusion, management of hypertensive patients with COPD
sidered according to its tolerability and IIa C .. should include lifestyle changes, among which cessation of smoking is
..
impact on renal function and electrolytes. .. essential. CCBs, ARBs or ACEIs, or the CCB/RAS blocker combina-
.. tion are recommended as the initial drugs of choice. If the BP
RAS blockers are more effective at reducing ..
albuminuria than other antihypertensive
.. response is poor, or depending on other comorbidities, thiazides or
agents, and are recommended as part of the
... thiazide-like diuretics and beta1-selective beta-blockers can be
I A ..
treatment strategy in hypertensive patients .. considered.
in the presence of microalbuminuria or
..
..
proteinuria.487,489 .. 8.14 Hypertension and heart disease
.. 8.14.1 Coronary artery disease
A combination of a RAS blocker with a ..
.. There are strong epidemiological relationships between CAD and
CCB or a diureticc is recommended as initial I A .. hypertension. The INTERHEART study showed that 50% of the
therapy.175 ..
.. population-attributable risk of a myocardial infarction can be
.. accounted for by lipids, with hypertension accounting for 25%.10
A combination of two RAS blockers is not ..
recommended.298
III A .. Another registry-based study of over 1 million patients showed that
.. ischaemic heart disease (angina and myocardial infarction) accounted
..
BP = blood pressure; CCB = calcium channel blocker; CKD = chronic kidney dis-
.. for most (43%) of the CVD-free years of life lost due to hypertension
.. from the age of 30 years.7
ease; eGFR = estimated glomerular filtration rate; RAS = renin-angiotensin sys- ..
tem; SBP = systolic blood pressure. .. More compelling is the beneficial effect of BP treatment on reduc-
a
Class of recommendation. .. ing the risk of myocardial infarction. A recent meta-analysis of RCTs
b
c
In case of eGFR <30 mL/min/1.73 m2, avoid thiazide/thiazide-like diuretics and .. of antihypertensive therapy showed that for every 10 mmHg reduc-
consider using a loop diuretic if required. .. tion in SBP, CAD was reduced by 17%.2 A similar risk reduction has
..
.. been reported by others with more intensive BP control.496 The ben-
.. efits of reducing cardiac events are also evident in high-risk groups,
..
.. such as those with diabetes.231,425
..
.. There remains some inconsistency over the optimal BP target in
.. hypertensive patients with overt CAD, and especially whether there
8.13 Hypertension and chronic ..
.. is a J-curve relationship between achieved BP and CV outcomes in
obstructive pulmonary disease .. CAD.497–500 A recent analysis501 of 22 672 patients with stable CAD
..
Hypertension is the most frequent comorbidity in patients with .. who were treated for hypertension found that, after a median
COPD, and coincidence of the two diseases may affect 2.5% of the .. follow-up of 5.0 years, an SBP of >_140 mmHg and a DBP of >_80
..
adult population.490 Patients with hypertension and COPD are at .. mmHg were each associated with increased risk of CV events. An
particularly high CV risk.490,491 Both conditions share similar environ- .. SBP of <120 mmHg was also associated with increased risk, as was a
..
mental risks and, in addition, hypoxia may exacerbate risk.490,491 .. DBP of <70 mmHg. Similar findings were also reported from another
Treatment of COPD with anticholinergic agents and long-acting .. analysis of RCT data evaluating the relationships between achieved
..
beta-2 adrenoceptor agonists may adversely affect the CV system .. BP and risks of CV outcomes.222 Whether a J-curve phenomenon
(increase heart rate and BP). The presence of COPD also has an .. exists in patients with CAD who have been revascularized remains
..
impact on the selection of antihypertensive drugs, which should con- .. uncertain. Other analyses do not support the existence of a J-curve,
sider their effects on pulmonary function. Concern has been pre- .. even in hypertensive patients at increased CV risk.239 For example, in
..
dominantly directed to the use of beta-blockers, although there is .. patients with CAD and initially free from congestive heart failure
evidence that in COPD these drugs maintain their CV-protective
.. enrolled in ONTARGET, a BP reduction from baseline over the

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..
examined BP range had little effect on the risk of myocardial infarc- .. relaxation (so-called diastolic dysfunction) and is a potent predictor
tion and predicted a lower risk of stroke.502 Thus, a target BP of .. of heart failure, even when LV systolic function is normal and there is
..
approximately <130/80 mmHg in patients with CAD appears safe .. no preceding myocardial infarction (HFpEF). Hypertension-
and can be recommended, but achieving a BP <120/80 mmHg is not .. dependent fibrosis and structural alteration of large and small arteries
..
recommended. .. (microvascular disease) also contribute.
In hypertensive patients with CAD, beta-blockers and RAS block-
.. Treating hypertension has a major impact on reducing the risk of
..
ers may improve outcomes post-myocardial infarction.503 In patients .. incident heart failure and heart failure hospitalization, especially in old
with symptomatic angina, beta-blockers and calcium antagonists are
.. and very old patients.51,213,316 This has been observed using diuretics,
..
the preferred components of the drug treatment strategy. .. beta-blockers, ACE inhibitors, or ARBs, with CCBs being less effec-
.. tive in comparative trials.504
..
.. Reducing BP can also lead to the regression of LVH, which has
.. been shown to be accompanied by a reduction of CV events and
Therapeutic strategies in hypertensive patients with ..
CAD .. mortality.125 The magnitude of LVH regression is associated with
..
.. baseline LV mass, duration of therapy, the SBP reduction,505,506 and
Classa Levelb
.. the drugs used, with ARBs, ACE inhibitors, and CBBs causing more
Recommendations ..
.. effective LVH regression than beta-blockers173 or diuretics.
In patients with CAD receiving BP-lowering drugs, it is .. In patients with HFrEF, antihypertensive drug treatment should
recommended:
..
.. start (if not already initiated) when BP is >140/90 mmHg. It is
.. unclear how low BP should be lowered in patients with heart fail-
• To target SBP to <_ 130 mmHg if toler-
I A
..
ated, but not <120 mmHg.2,496 .. ure. Outcomes for patients with heart failure have repeatedly
.. been shown to be poor if BP values are low, which suggests
• In older patients (aged >_65 years), to tar- ..
.. (although data interpretation is made difficult by the possibility of
get to an SBP range of 130–140 I A .. reversed causality) that it may be wise to avoid actively lowering
mmHg.2,496 ..
.. BP to <120/70 mmHg. However, some patients may achieve even
• To target DBP to <80 mmHg, but not I C
.. lower BP levels than this because of the desirability to remain on
<70 mmHg. ..
.. treatment with guideline-directed heart failure medications, which,
In hypertensive patients with a history of .. if tolerated, should be continued because of their protective
..
myocardial infarction, beta-blockers and
I A
.. effect.136
RAS blockers are recommended as part of .. Heart failure guideline-directed medications are recommended for
..
treatment.503 .. the treatment of hypertension in patients with HFrEF.136 ACE inhibi-
.. tors, ARBs, beta-blockers, and MRAs (e.g. spironolactone and eplero-
In patients with symptomatic angina, beta- ..
.. none) are all effective in improving clinical outcome in patients with
blockers and/or CCBs are I A .. established HFrEF, whereas for diuretics, evidence is limited to symp-
recommended.503 ..
.. tomatic improvement. If further BP lowering is required, a dihydro-
.. pyridine CCB may be considered. Sacubutril/valsartan lowers BP, has
BP = blood pressure; CAD = coronary artery disease; CCB = calcium channel
..
.. also been shown to improve outcomes in patients with HFrEF, and is
blocker; DBP = diastolic blood pressure; RAS = renin–angiotensin system; SBP = ..
systolic blood pressure. .. indicated for the treatment of HFrEF as an alternative to ACE inhibi-
a
Class of recommendation. .. tors or ARBs.507 Non-dihydropiridine CCBs (diltiazem and verapa-
b
.. mil), alpha-blockers, and centrally acting agents, such as moxonidine,
.. should not be used.
..
.. Antihypertensive treatment is commonly needed in patients with
.. HFpEF; the same BP threshold and target for drug treatment indi-
..
.. cated for HFrEF should be used. The optimal treatment strategy for
8.14.2 Left ventricular hypertrophy and heart failure .. hypertensive patients with HFpEF is not known, but the strategy out-
..
Hypertension is the leading risk factor for the development of heart .. lined above for HFrEF patients might also be the one to adopt in
failure,7 and most patients with heart failure will have an antecedent .. HFpEF patients. HFpEF patients commonly have multiple comorbid-
..
history of hypertension. This may be a consequence of CAD, which .. ities that may adversely affect outcomes and complicate
results in HFrEF. Hypertension also causes LVH, which impairs LV .. management.
.

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..
Therapeutic strategies in hypertensive patients with
.. A subsequent RCT, in which SBP was immediately reduced (<4.5 h)
.. from a mean of 200 mmHg to two different target intervals (140–170
heart failure or LVH ..
.. vs. 110–139 mmHg), showed that more intensive BP lowering had no
.. benefit on the same primary outcome and was associated with more
Recommendations Classa Levelb ..
.. renal adverse events.512 Thus, we do not recommend treatment to
In hypertensive patients with heart failure
.. immediately lower BP in patients with acute intracerebral haemor-
..
(with reduced or preserved ejection frac- .. rhage. One possible caveat to this recommendation is patients with
tion), BP-lowering treatment should be con-
IIa B .. acute intracerebral haemorrhage and very severe hypertension (SBP
..
sidered if BP is >_140/90 mmHg.c 136 .. >_220 mmHg), for whom there are much fewer data. A meta-analy-
.. sis513 and secondary outcome data from one RCT511 have suggested a
In patients with HFrEF, it is recommended ..
.. possible benefit on functional recovery at 3 months, and that acute
that BP-lowering treatment comprises an .. lowering of SBP to <180 mmHg in these patients might be beneficial.
ACE inhibitor or ARB, and a beta-blocker
I A ..
.. Thus, careful lowering of BP via i.v. infusion may be considered in
and diuretic and/or MRA if required.136 .. patients with markedly elevated BP (SBP >_220 mmHg).
..
Dihydropyridine CCBs may be added if BP ..
IIb C .. 8.15.2 Acute ischaemic stroke
control is not achieved.d ..
.. The beneficial effects of BP reduction are even less clear in acute
In patients with HFpEF, BP treatment .. ischaemic stroke. A key consideration is whether the patient will
IIa B
..
threshold and target values should be the .. receive thrombolysis, because observational studies have reported
same as for HFrEF.136 .. an increased risk of intracerebral haemorrhage in patients with a
..
Because no specific drug has proven its
.. markedly elevated BP who received thrombolysis.514,515 In patients
I C .. receiving i.v. thrombolysis, BP should be lowered and maintained at
superiority, all major agents can be used. ..
.. <180/105 mmHg for at least the first 24 h after thrombolysis. The
In all patients with LVH: .. benefit of acute BP lowering in patients with acute ischaemic stroke
..
• It is recommended to treat with an RAS I A
.. who do not receive thrombolysis is uncertain. A meta-analysis sug-
blocker in combination with a CCB or ..
.. gested that BP lowering early after acute ischaemic stroke had a neu-
diuretic. 504
.. tral effect on the prevention of death or dependency.516,517 In such
• SBP should be lowered to a range of ..
.. patients with markedly elevated SBP or DBP (i.e. >_220 or >_120
120–130 mmHg.504,506 IIa B .. mmHg, respectively), clinical judgement should define whether to
..
.. intervene with drug therapy, in which case a reasonable goal may be
ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BP .. to lower BP by 15%, with close monitoring, during the first 24 h after
= blood pressure; CCB = calcium channel blocker; HFrEF = heart failure with ..
.. stroke onset.516,518–520 Patients with acute ischaemic stroke and a BP
reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction;
.. lower than this in the first 72 h after stroke do not seem to benefit
LVH = left ventricular hypertrophy; MRA = mineralocorticoid receptor antago- ..
nist; RAS = renin–angiotensin system; SBP = systolic blood pressure. .. from the introduction or reintroduction of BP-lowering medica-
a
Class of recommendation. .. tion.516,521 For stable patients who remain hypertensive (>_140/90
b
c
A lowest safety BP value is not given as many patients receiving intensive treatment .. mmHg) >3 days after an acute ischaemic stroke, initiation or reintro-
for heart failure may achieve much lower BP levels than recommended BP targets. .. duction of BP-lowering medication should be considered.522
d
Non-dihydropyridines are not recommended in HFrEF but may be used in HFpEF.
..
..
.. 8.15.3 Previous stroke or transient ischaemic attack
..
.. RCTs of antihypertensive treatment (placebo controlled) in patients
..
.. with a previous stroke or TIA, in a stable clinical condition, and with
8.15 Cerebrovascular disease and .. BP >140/90 mmHg, have shown that BP lowering reduces the risk of
cognition ..
.. recurrent stroke.338,523 No evidence is yet available that recurrent
Hypertension is a major risk factor for haemorrhagic and ischaemic .. stroke is prevented by initiating therapy when BP is in the
stroke, and a risk factor for recurrent stroke. BP management during ..
.. high–normal range. We recommend resumption of BP-lowering
the acute phase of haemorrhagic and ischaemic stroke remains an .. therapy several days after stroke, or immediately after TIA, for previ-
area of uncertainty. BP is often elevated at presentation with acute
..
.. ously treated or untreated patients with hypertension, for prevention
stroke, but often declines without intervention.508 .. of both recurrent stroke and other CV events.
..
.. The appropriate BP targets to prevent recurrent stroke are uncer-
8.15.1 Acute intracerebral haemorrhage .. tain, but should be considered in the context of a consistent finding in
..
In acute intracerebral haemorrhage, an increased BP is common and is .. many meta-analyses that stroke is the one major CV event that is
associated with a greater risk of haematoma expansion, increased risk .. reduced at lower achieved BP levels. This is supported by the results
..
of death, and a worse prognosis for neurological recovery.509,510 .. from the recent Secondary Prevention of Small Subcortical Strokes 3
Results from an RCT suggested that immediate BP lowering (within .. study244,524 in patients with a recent lacunar stroke, which suggested
..
6 h) to <140/90 mmHg did not show benefit on the primary outcome .. an SBP target of <130 mmHg,525 and other studies.526
of disability or death at 3 months, but might reduce haematoma expan-
.. Prevention of stroke is a consistent benefit of antihypertensive
..
sion and improve functional recovery, and was generally safe.511 . therapy and has been observed in all large RCTs using different drug

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..
regimens. However, individual RCTs comparing modern treatment .. 8.16 Hypertension, atrial fibrillation, and
regimens317,527 and meta-analyses suggest that beta-blockers are less ..
.. other arrhythmias
effective at stroke prevention than other classes of antihypertensive .. Hypertension predisposes to cardiac arrhythmias, including ventricu-
agents.2,528 Although the beta-blocker in these studies was atenolol, ..
.. lar arrhythmias, but most commonly AF,536–538 which should be con-
there are no data with more modern beta-blockers with regards to .. sidered a manifestation of hypertensive heart disease.539 Even
stroke prevention in hypertension. Thus, optimal antihypertensive ..
.. high–normal BP is associated with incident AF,540,541 and hyperten-
treatment for stroke prevention should not include beta-blockers .. sion is the most prevalent concomitant condition in AF patients. AF
unless there is a compelling indication for their use, mindful of the ..
.. adds to the risk of stroke and heart failure. AF necessitates stroke
fact that the most common recurrent event after stroke is a further .. prevention with oral anticoagulation, with monitoring of the associ-
stroke rather than myocardial infarction.529 ..
.. ated risks and prevention of bleeding.542
.. Most patients show a high ventricular rate with AF542 and, in such
..
8.15.4 Cognitive dysfunction and dementia .. patients, beta-blockers or non-dihydropyridine calcium antagonists
..
Several epidemiological and clinical studies have shown that hyper- .. (e.g. diltiazem and verapamil) are recommended as antihypertensive
tension in midlife predicts cognitive decline and dementia (both .. agents. Non-dihydropyridine CCBs should be avoided in patients
..
Alzheimer’s disease and vascular dementia) in older patients.530–533 .. with reduced LV systolic function and may precipitate heart failure in
However, evidence on the beneficial effects of BP lowering on cogni- .. some patients. Beta-blockers are often indicated in these patients,
..
tive decline is scant and conflicting. A meta-analysis534 of 12 studies .. and may need to be combined with digoxin to gain rate control.542
investigating the impact of different antihypertensive drugs on .. In RCTs of hypertensive patients with LVH and/or high CV
.. 543,544
dementia and cognitive function concluded that BP lowering reduced .. risk, RAS blockers have been shown to reduce first occurrence
the incidence and risk of cognitive impairment and dementia by 9%. .. of AF, compared with beta-blockers or CCBs, consistent with similar
..
One study showed that achieving better BP control over 4 years .. effects of RAS blockers in patients with heart failure.545–547 RAS
reduced the progression of cerebral white matter lesions and the .. blockers do not prevent recurrence of paroxysmal or persistent
..
decrease in global cognitive performance.535 .. AF.548–550 In patients with heart failure, beta-blockers551 and
Trials are urgently needed to better define the potential impact of
.. MRAs552 may also prevent AF. The preventive effect of RAS blockers
..
BP lowering on preventing cognitive decline or in delaying dementia .. against the development of AF is indirectly supported by a general
when cognitive dysfunction is already present.
.. practice database in the UK, with approximately 5 million patient
Therapeutic strategies in hypertensive patients with acute stroke and cerebrovascular disease
In patients with acute intracerebral haemorrhage:

III A
• Immediate BP lowering is not recommended for patients with SBP <220 mmHg.509–513
• In patients with SBP >_220 mmHg, careful acute BP lowering with i.v. therapy to <180 mmHg should be considered.509–513 IIa B
In acute ischaemic stroke, routine BP lowering with antihypertensive therapy is not recommended,516,517 with the exceptions: III A
• In patients with acute ischaemic stroke who are eligible for i.v. thrombolysis, BP should be carefully lowered and maintained
IIa B
at <180/105 mmHg for at least the first 24 h after thrombolysis.514,515
• In patients with markedly elevated BP who do not receive fibrinolysis, drug therapy may be considered, based on clinical
IIb C
judgement, to reduce BP by 15% during the first 24 h after the stroke onset.
In hypertensive patients with an acute cerebrovascular event, antihypertensive treatment is recommended:
I A
• Immediately for TIA.526
• After several days in ischaemic stroke.526 I A
In all hypertensive patients with ischaemic stroke or TIA, an SBP target range of 120–130 mmHg should be
IIa B
considered.244,524,526
The recommended antihypertensive drug treatment strategy for stroke prevention is a RAS blocker plus a CCB or a thiazide-
I A
like diuretic.338
BP = blood pressure; CCB = calcium channel blocker; i.v. = intravenous; RAS = renin–angiotensin system; SBP = systolic blood pressure; TIA = transient ischaemic attack.
a
b
Level of evidence.

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..
records, which has reported that ACE inhibitors, ARBs, and beta- .. 8.17 Hypertension and vascular disease
blockers are associated with a lower risk of AF compared with ..
.. 8.17.1 Carotid atherosclerosis
CCBs.553 Hence, RAS blockers should be considered as part of the .. A small number of studies have reported the effects of the various
antihypertensive treatment strategy in hypertensive patients with a ..
.. pharmacological classes of antihypertensive drugs on carotid IMT,
high risk of AF (e.g. LVH), to prevent incident AF. .. and very few on carotid plaques. Reducing BP regresses carotid IMT
..
.. and may delay the intimal atherosclerotic process. There appear to
.. be differential drug effects on IMT regression, with CCBs having
8.16.1 Oral anticoagulants and hypertension ..
Many patients requiring oral anticoagulants (e.g. with AF) will be
.. greater efficacy than diuretics and beta-blockers,146 and ACE inhibi-
.. tors more than diuretics.557 However, the relevance of these findings
hypertensive. Hypertension is not a contraindication to oral anticoa- ..
.. is unclear because most patients receive combinations of treatment
gulant use. However, although its role has been unappreciated in .. and the progression or treatment-induced changes in carotid IMT are
most old and more recent RCTs on anticoagulant treatment,537 ..
.. poorly predictive of future CV events.184,558 Patients with carotid pla-
hypertension does substantially increase the risk of intracerebral hae- .. ques are at high risk of atheroembolic stroke and CV events, and BP
morrhage when oral anticoagulants are used, and efforts should be ..
.. lowering should be complemented by lifestyle advice and treatment
directed towards achieving a BP goal of <130/80 mmHg in patients .. with statins and antiplatelet therapy. A common conundrum faced by
receiving oral anticoagulants. Detailed information on hypertension ..
.. clinicians is the hypertensive patient with a tight carotid stenosis,
and oral anticoagulants has been published recently.526,536 .. especially when bilateral. No study has addressed this scenario and
Anticoagulants should be used to reduce the risk of stroke in most ..
.. therefore advice is necessarily pragmatic, and we recommend a more
AF patients with hypertension, including those with AF in whom .. cautious approach to BP lowering, initiating with monotherapy and
hypertension is the single additional stroke risk factor.554,555 BP con- ..
.. carefully monitoring for adverse effects.
trol is important to minimize the risks of AF-related stroke and oral ..
anticoagulant-related bleeding. Until more data are available, BP val- ..
..
ues in AF patients taking oral anticoagulants should be at least <140 .. 8.17.2 Arteriosclerosis and increased arterial stiffness
mmHg for SBP and <90 mmHg for DBP. Oral anticoagulants should .. Large artery stiffening is a major factor contributing to the rise in SBP
..
be used with caution in patients with persistent uncontrolled hyper- .. and fall in DBP with ageing. Arterial stiffness is usually measured in
tension (SBP >_180 mmHg and/or DBP >_100 mmHg), and urgent
.. studies as PWV. Arterial stiffening results from arteriosclerotic struc-
..
efforts to control BP should be made. . tural changes in large conduit arteries, leading to a loss of arterial
Therapeutic strategies in hypertensive patients with AF
Recommendation Classa Levelb
In patients with AF, screening for hypertension is recommended.536 I C
A beta-blocker or non-dihydropyridine CCB should be considered as part of the treatment of hypertension if rate control is
IIa B
needed.536
Stroke prevention with oral anticoagulation is recommended in patients with AF and hypertension, and a CHA2DS2-VASc
I A
score of >_2 in men and >_3 in women.536,556
Stroke prevention with oral anticoagulants should be considered in AF patients with hypertension, even when hypertension is
IIa B
the single additional risk factor (CHA2DS2-VASc score of 1).536,556
Oral anticoagulants should be used with caution in patients with marked BP elevation (SBP >_180 mmHg and/or DBP
>_100 mmHg); the aim should be to lower SBP to at least <140 mmHg, and SBP lowering to <130 should be considered.
IIa B
If this is not possible, then patients should make an informed decision that they accept that the stroke protection
536
provided by the anticoagulant will be associated with higher bleeding risk.
AF = atrial fibrillation; BP = blood pressure; CCB = calcium channel blocker; CHA2DS2-VASc = Congestive heart failure, Hypertension, Age >_75 years, Diabetes mellitus,
Stroke, Vascular disease, Age 65–74 years, Sex category (female); DBP = diastolic blood pressure; SBP = systolic blood pressure
a
b
Level of evidence.

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..
elasticity, and the distending force resulting from the pressure .. hypertension in patients with aortic coarctation should follow the
exerted on the arterial wall. Thus, all antihypertensive drugs, by .. treatment algorithm outlined in section 7, as there have been no for-
..
reducing BP, reduce arterial stiffness, as the reduction in BP unloads .. mal RCTs to define optimal treatment strategies.567
the stiff components of the arterial wall, leading to a passive decrease ..
..
in PWV. Pharmacodynamic RCTs559 and meta-analyses560,561 suggest .. 8.18.2 Prevention of aortic dilation and dissection in high-
that ACE inhibitors and ARBs may reduce PWV beyond the effect of ..
.. risk subjects
BP lowering on a long-term basis. Whether RAS blockers are more .. Chronic hypertension can be associated with modest aortic root dila-
effective than other antihypertensive drugs in this regard has not ..
.. tation. When more extensive aortic root dilatation is present or the
been demonstrated. Moreover, whether any long-term reduction in .. dilatation extends beyond the aortic root, an additional cause for
aortic stiffness562 translates into a reduction in CV events beyond the ..
.. aortopathy should be sought. All hypertensive patients with aortic
impact of BP lowering alone563 has not been demonstrated. .. dilatation, whether associated with Marfan syndrome, bicuspid aortic
..
.. valve disease, or not, should have their BP controlled <_ 130/80
.. mmHg.568 In patients with Marfan syndrome, prophylactic use of
8.17.3 Lower extremity arterial disease ..
LEAD is often a manifestation of more widespread atherosclerosis .. ACE inhibitors, ARBs, or beta-blockers seems to be able to reduce
.. either the progression of the aortic dilation or the occurrence of
and especially atherosclerotic renal artery disease,564 and these ..
patients are at very high CV risk.190 BP control is an important part of .. complications.568–570 However, there is no evidence for the specific
.. efficacy of these treatments in aortic disease of other aetiologies.
the CV risk-reduction strategy in these patients. Beta-blockers have ..
not been shown to worsen the symptoms of claudication in two ..
..
meta-analyses.565,566 Thus, beta-blockers remain a treatment option .. 8.18.3 Hypertension bicuspid aortic valve-related
in hypertensive patients with LEAD when there is a specific indication .. aortopathy
..
for their use. When critical limb ischaemia is present, BP reduction .. Bicuspid aortic valve disease occurs in 1 in 100 people, more often
should be instituted slowly as it may worsen ischaemia. In patients .. men, and is associated with coexistent aortic coarctation, which
..
with LEAD, antihypertensive treatment should be complemented by .. should be excluded in patients with bicuspid aortic valve disease.
lifestyle changes and especially smoking cessation, as well as statin ..
.. Bicuspid aortic valve disease is associated with an aortopathy, and the
and antiplatelet therapy.190 .. risk of development of aortic dilation is higher in patients with bicus-
..
.. pid aortic valve disease than in the normal population571 and is prob-
Therapeutic strategies in hypertensive patients with .. ably exacerbated by hypertension. Beyond aortic dilation and
LEAD ..
.. aneurysm formation, bicuspid aortic valve disease is also a risk factor
.. for dissection and rupture.572 Thus, BP should be tightly controlled in
..
Recommendations Classa Levelb .. patients with bicuspid aortic valve disease and targeted <_ 130/80
.. mmHg if tolerated. There is popular misconception that BP-lowering
BP-lowering treatment is recommended to ..
reduce CV risk.2,190,503
I A .. treatment has deleterious effects in patients with aortic stenosis and
.. hypertension, when in fact it is well tolerated even in patients with
..
A combination of a RAS blocker, CCB, or .. severe aortic stenosis. Moreover, vasodilating drugs (including RAS
diuretic should be considered as initial IIa B
.. blockers) also appear to be well tolerated. Thus, treatment of hyper-
..
therapy.2 .. tension should be considered in these patients.573
..
Beta-blockers may also be considered.566 IIb C
..
.. 8.19 Hypertension and sexual
..
.. dysfunction
BP = blood pressure; CCB = calcium channel blocker; CV = cardiovascular; ..
LEAD = lower extremity arterial disease; RAS = renin–angiotensin system. .. Sexual dysfunction may have an important negative effect on the
a
Class of recommendation. .. quality of life of both men and women. Compared with the normo-
b
.. tensive population, the prevalence of sexual dysfunction is greater in
.. hypertensive individuals, in whom it presents an important cause of
..
.. low adherence to or discontinuation of antihypertensive treat-
.. ment.574 A large meta-analysis of prospective cohort studies has pro-
8.18 Hypertension in valvular disease and ..
.. vided strong evidence that in men, erectile dysfunction (i.e.
aortopathy .. inadequate penile erection) is a significant independent risk factor for
..
8.18.1 Coarctation of the aorta .. CV events and mortality,575 which means that it may be viewed as an
When feasible, treatment of aortic coarctation is predominantly sur- .. early marker of vascular damage.576 Sexual dysfunction may be trig-
..
gical and usually done in childhood. Even after surgical correction, .. gered or aggravated by treatment with thiazide or thiazide-like diu-
these patients may develop systolic hypertension at a young age and .. retics, conventional beta-blockers, or centrally acting agents (e.g.
..
require long-term follow-up. Few patients with aortic coarctation .. clonidine), while ACE inhibitors, ARBs, CCBs, or vasodilating beta-
remain undetected until adult life, and by then often have severe .. blockers may have neutral or even beneficial effects.574,577
..
hypertension, HMOD (especially LVH and LV dysfunction), and an .. Phosphodiesterase-5 inhibitors are effective against erectile dysfunc-
extensive collateral circulation below the coarctation. Such patients
.. tion in patients with hypertension. They should be given only in the
..
should be evaluated in a specialist centre. The medical therapy for . absence of nitrate administration, but prescription also appears to be

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..
safe in patients with multidrug BP-lowering treatment,578 with some .. leading to potential toxicity.583 Although anticancer therapy takes
caution if treatment includes alpha-blockers.577 However, it seems .. an obvious priority, its temporary discontinuation may be consid-
..
prudent for unstable patients with high CV risk or severe uncon- .. ered when BP values are exceedingly high despite multidrug treat-
trolled hypertension to defer sexual activity until their condition is
.. ment, in the presence of severe hypertension-generated
..
stabilized and treatment for erectile dysfunction can be initiated.575 .. symptoms, or when there is a CV event requiring an immediate
Overall, studies on the effects of hypertension and antihypertensive
.. effective BP control.584
..
therapy on female sexual dysfunction are limited, and the situation is ..
thus less clear than in men,577,579 although in a recent cross-sectional
..
..
analysis among middle-aged and older treated hypertensive women .. 8.21 Perioperative management of
in the SPRINT trial, neither BP values nor antihypertensive medica-
..
.. hypertension
tion was associated with sexual dysfunction.579 ..
.. With the increasing number of patients undergoing surgery, manage-
It is recommended that information on sexual dysfunction is col- .. ment of hypertension in the perioperative period (a term that
lected in all hypertensive patients at diagnosis and regularly at the ..
.. includes the intraoperative phase) has emerged as an important issue
follow-up visits, with special attention to its possible relationship with .. in clinical practice.585 ESC Guidelines have been issued for the assess-
reluctance to start or adherence to drug treatment. In men reporting ..
.. ment of CV variables, risk, and disease management of patients
sexual dysfunction, the antihypertensive agents more likely to be .. undergoing non-cardiac surgery.586 While a BP elevation is per se not
associated with this effect (e.g. beta-blockers and thiazide diuretics) ..
.. a strong risk factor for CV complications in non-cardiac surgery,
should be avoided or replaced, unless strictly necessary for the .. overall CV risk assessment, including the search for HMOD, is impor-
patient’s clinical condition. ..
.. tant in treated and untreated hypertensive patients, and mandatory
.. when a BP elevation is newly detected.537,586 Postponing necessary
..
8.20 Hypertension and cancer therapy .. surgery is usually not warranted in patients with grade 1 or 2 hyper-
Hypertension is the most common CV comorbidity reported in can- .. tension, whereas in those with an SBP >_180 mmHg and/or DBP
..
cer registries, in which an elevated BP is usually found in more than .. >_110 mmHg, deferring the intervention until BP is reduced or con-
one-third of the patients.580 This can be due to the high prevalence of .. trolled is advisable, except for emergency situations. What seems to
..
hypertension at an age in which cancer is also common. However, it .. be also important is to avoid large perioperative BP fluctua-
is also due to the pressor effect of two groups of widely used anti-
.. tions.537,586 This approach is supported by the findings from a recent
..
cancer drugs, the inhibitors of the vascular endothelial growth factor .. RCT that has shown that in patients undergoing abdominal surgery,
signalling pathway (bevacizumab, sorafenib, sunitinib, and pazopanib)
.. an individualized intraoperative treatment strategy, which kept BP
..
and the proteasome inhibitors (carfilzomib). While the former group .. values within a 10% difference from the preoperative office SBP,
of drugs inhibits the production of nitric oxide in the arterial wall, the
.. resulted in reduced risk of postoperative organ dysfunction.587 There
..
latter reduces the vasodilator response to acetylcholine, favouring .. is no clear evidence in favour or against one vs. another antihyperten-
vasoconstriction and vasospasm.581
.. sive treatment mode in patients undergoing non-cardiac surgery, and
..
In patients under treatment with the above-mentioned anti- .. thus the general drug treatment algorithms apply to these patients as
..
cancer drugs, a BP increase has been reported in a variable but .. well.588,589 However, the perioperative use of beta- blockers has
overall high per cent of patients (<_ 30%). The increase frequently .. been the object of controversy for many years, and the concern has
..
occurs during the first months after starting the anticancer therapy, .. recently been revived by meta-analyses showing some increase in the
the temporal association providing evidence for the anticancer .. risk of hypotension, stroke, and mortality in patients on perioperative
..
drug’s pathophysiological role. It follows that office BP should be .. beta-blockers vs. placebo.586,588,589 Continuation of beta-blockers is
measured weekly during the initial part of the first cycle of therapy .. nevertheless recommended in hypertensive patients on chronic
..
and at least every 2–3 weeks thereafter.582 After the first cycle is .. beta-blocker treatment586 in whom their abrupt discontinuation may
completed and BP values appear to be stable, BP can be measured .. lead to BP or heart rate rebounds.537 This may also occur with the
..
at the time of the routine clinical evaluations or assessed by HBPM. .. abrupt discontinuation of central agents such as clonidine. More
Patients developing hypertension (>_140/90 mmHg), or showing an .. recently, the question has been raised whether RAS blockers should
..
increase in DBP >_20 mmHg compared with pretreatment values, .. be discontinued before surgery to reduce the risk of intraoperative
should initiate or optimize antihypertensive therapy, for which RAS .. hypotension.586,590 Preoperative discontinuation of these drugs has
..
blockers and CCBs may be considered the preferred drugs, and a .. also been supported by a recent international prospective cohort
RAS blocker-CCB combination is a frequently needed strategy. .. study, in a heterogenous group of patients, in which withholding ACE
..
CCBs should only be of the dihydropiridine type, because diltiazem .. inhibitors or ARBs 24 h before non-cardiac surgery was associated
and verapamil block the CYP3A4 isoenzyme, which is involved in
.. with a significant reduction in CV events and mortality 30 days after
..
the metabolic pathway of sorafenib, increasing the drug’s levels and . the intervention.591

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Perioperative management of hypertension
It is recommended that newly diagnosed hypertensive patients who are scheduled for elective surgery should be preoperatively
I C
screened for HMOD and CV risk.
It is recommended to avoid large perioperative BP fluctuations during the perioperative period.587 I C
Non-cardiac surgery may not be deferred in patients with grade 1 or 2 hypertension (SBP <180 mmHg; DBP <110 mmHg). IIb C
Perioperative continuation of beta-blockers is recommended in hypertensive patients on chronic treatment with these
I B
drugs.592,593
Abrupt discontinuation of beta-blockers or centrally acting agents (e.g. clonidine) is potentially harmful and is not
III B
recommended.589,594
Transient preoperative discontinuation of RAS blockers should be considered in patients with hypertension undergoing non-
IIa C
cardiac surgery.
BP = blood pressure; CV = cardiovascular; DBP = diastolic blood pressure; HMOD = hypertension-mediated organ damage; RAS = renin–angiotensin system; SBP = systolic
blood pressure.
a
b
Level of evidence.
..
9 Managing concomitant .. 9.2 Antiplatelet therapy and
..
cardiovascular disease risk .. anticoagulant therapy
.. The most common complications of hypertension are related to
..
9.1 Statins and lipid-lowering drugs .. thrombosis.603 Hypertension predisposes to a prothrombotic
Patients with hypertension, and more so those with type 2 diabetes .. state,603 and also predisposes to LEAD, heart failure, or AF, which
..
or metabolic syndrome, often have atherogenic dyslipidaemia charac- .. are common conditions associated with thromboembolism, whether
terized by elevated triglycerides and LDL cholesterol (LDL-C), and .. systemic or venous.
..
low HDL cholesterol (HDL-C).595 The benefit of adding a statin to .. Antiplatelet and anticoagulant therapy use in patients with
antihypertensive treatment was well established in the ASCOT-Lipid .. hypertension was addressed in a Cochrane systematic review,604
..
Lowering Arm study596 and further studies, as summarized in pre- .. which included four randomized trials with a combined total of 44
vious European Guidelines.16,35 The beneficial effect of statin adminis- .. 012 patients. The authors concluded that overall acetylsalicylic
..
tration to patients without previous CV events [targeting an LDL-C .. acid (aspirin) did not reduce stroke or CV events compared
value of <3.0 mmol/L (115 mg/dL)] has been strengthened by the
.. with placebo in primary prevention patients with elevated BP and
..
findings from the Justification for the Use of Statins in Prevention: an .. no previous CVD.604 For secondary prevention, antiplatelet ther-
Intervention Trial Evaluating Rosuvastatin (JUPITER)597 and HOPE-3
.. apy in patients with elevated BP was reported as causing an abso-
..
studies,343,598 showing that lowering LDL-C in patients with baseline .. lute reduction in vascular events of 4.1% compared with
values <3.4 mmol/L (130 mg/dL) reduced the incidence of CV events
.. placebo.604
..
by between 44 and 24%. This justifies the use of statins in hyperten- .. Benefit has not been demonstrated for anticoagulation therapy,
sive patients who have moderate–high CV risk.599
..
.. alone or in combination with aspirin, in patients with hypertension in
As detailed in the recent ESC/EAS Guidelines,599 when overt CVD .. the absence of other indications requiring anticoagulants, such as AF
..
is present and the CV risk is very high, statins should be administered .. or venous thromboembolism.604 In anticoagulated patients, uncon-
to achieve LDL-C levels of <1.8 mmol/L (70 mg/dL) or a reduction of .. trolled hypertension is one of the independent risk factors for intra-
..
>_50% if the baseline LDL-C is between 1.8 and 3.5 mmol/L (70 and .. cranial haemorrhage and major bleeding.605 In such patients,
135 mg/dL).600–602 In patients at high CV risk, an LDL-C goal of <2.6 .. attention to modifiable bleeding risk factors should be made during
..
mmol/L (100 mg/dL) or a reduction of >_50% if the baseline LDL-C is .. all patient contacts. Bleeding risk assessment with clinical risk scores
between 2.6 and 5.2 mmol/L (100 and 200 mg/dL) is recom- .. such as the HAS-BLED [Hypertension, Abnormal renal/liver function
..
mended.602 Beneficial effects of statin therapy have also been shown .. (1 point each), Stroke, Bleeding history or predisposition, Labile INR,
in patients with a previous stroke with LDL-C targets <2.6 mmol/L .. Older (>65), Drugs/alcohol concomitantly (1 point each)] score,
..
(100 mg/dL).525 Whether they also benefit from a target of <1.8 .. includes uncontrolled hypertension (defined as SBP >160 mmHg) as
mmol/L (70 mg/dL) is open to future research. The summary of the .. one of the risk factors for bleeding;606 these should be used to ‘flag
..
available evidence suggests that many patients with hypertension .. up’ patients at particularly high risk (e.g. HAS-BLED >_3) for more
would benefit from statin therapy. .. regular review and follow-up.607

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..
In summary, aspirin is not recommended for primary prevention in .. received attention after the publication of the US Food and Drug
hypertensive patients without CVD.35 For secondary prevention, the .. Administration recommendations for evaluating CV risk in new
..
benefit of antiplatelet therapy in patients with hypertension may be .. therapies to treat type 2 diabetes. New generations of antidiabetes
greater than the harm.35,604 Ticlopidine, clopidogrel, and newer anti- .. drugs, i.e. dipeptidyl peptidase 4 inhibitors and glucagon-like peptide
..
platelet agents such as prasugrel and ticagrelor have not been suffi- .. 1 agonists, slightly reduce BP, and also body weight with glucagon-like
ciently evaluated in patients with high BP.
.. peptide 1 agonists. Two glucagon-like peptide 1 agonists (liraglutide
..
.. and semaglutide) reduced CV and total mortality, but not heart fail-
.. ure, in patients with type 2 diabetes.608,609 More data are required
Treatment of CV risk factors associated with ..
.. with respect to the capacity of glucagon-like peptide 1 agonists and
hypertension .. dipeptidyl peptidase 4 inhibitors to prevent heart failure.
..
.. Inhibitors of sodium-glucose co-transporter-2 are the only
Recommendations Classa Levelb .. glucose-lowering drug class to reduce BP beyond the projected
..
CV risk assessment with the SCORE system
.. impact of weight reduction on BP. Empaglifozine475 and canagliflo-
..
is recommended for hypertensive patients .. zin476 have demonstrated a reduction in heart failure and total and
who are not already at high or very high risk I B
.. CV mortality, and a protective effect on renal function. Several mech-
..
due to established CVD, renal disease, or .. anisms may account for these effects, and increased sodium excre-
diabetes.33
.. tion and improvements in tubuloglomerular balance reducing
..
.. hyperfiltration are suggested mechanisms for the observed CV and
For patients at very high CV risk, statins are .. renal protection, respectively.
recommended to achieve LDL-C levels of ..
..
<1.8 mmol/L (70 mg/dL), or a reduction of I B ..
>_50% if the baseline LDL-C is 1.8–3.5 ..
..
mmol/L (70–135 mg/dL).596,599,602 ..
..
10 Patient follow-up
For patients at high CV risk, statins are rec- ..
.. 10.1 Follow-up of hypertensive patients
ommended to achieve an LDL-C goal of .. After the initiation of antihypertensive drug therapy, it is important to
<2.6 mmol/L (100 mg/dL), or a reduction of I B ..
.. review the patient at least once within the first 2 months to evaluate
>_50% if the baseline LDL-C is 2.6–5.2 .. the effects on BP and assess possible side effects until BP is under
mmol/L (100–200 mg/dL).599,602 ..
.. control. The frequency of review will depend on the severity of
.. hypertension, the urgency to achieve BP control, and the patient’s
For patients at low–moderate CV risk, sta- ..
tins should be considered to achieve an .. comorbidities. SPC therapy should reduce BP within 1 - 2 weeks and
IIa C ..
LDL-C value of <3.0 mmol/L (115 mg/ .. may continue to reduce BP over the next 2 months. Once the BP tar-
dL). 598 .. get is reached, a visit interval of a few months is reasonable and evi-
..
Antiplatelet therapy, in particular low-dose
.. dence has been obtained that no difference exists in BP control
.. between 3 and 6 month intervals.610 Depending on the local organi-
aspirin, is recommended for secondary pre- I A ..
vention in hypertensive patients.35,604
.. zation of health resources, many of the later visits may be performed
.. by non-physician health workers such as nurses.611 For stable
..
Aspirin is not recommended for primary .. patients, HBPM and electronic communication with the physician
prevention in hypertensive patients without
.. may also provide an acceptable alternative to reduce the frequency
III A ..
CVD.35,604 .. of visits.60,612,613 It is nevertheless advisable to assess risk factors and
.. asymptomatic organ damage at least every 2 years.
..
CV = cardiovascular; CVD = cardiovascular disease; LDL-C = LDL cholesterol; ..
SCORE = Systematic COronary Risk Evaluation. ..
a ..
b
.. 10.2 Follow-up of subjects with
Level of evidence. .. high–normal blood pressure and white-
..
.. coat hypertension
..
.. Patients with high–normal BP or white-coat hypertension frequently
.. have additional risk factors, including HMOD, and have a higher risk
9.3. Glucose-lowering drugs and blood ..
.. of developing sustained hypertension427,614–618 (see section 4). Thus,
pressure .. even when untreated, they should be scheduled for regular follow-up
..
The impact of new glucose-lowering drugs on BP and the reduction .. (at least annual visits) to measure office and out-of-office BP, as well
in CV and renal risk, beyond their effect of glucose control, have
.. as to check the CV risk profile. At annual visits, recommendations on

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..
lifestyle changes, which represent the appropriate treatment in many .. on the most important issue: dosing history. Today, the most
of these patients, should be reinforced. .. accurate methods that can be recommended, despite their limita-
..
.. tions, are the detection of prescribed drugs in blood or urine sam-
.. ples. Directly observed treatment, followed by BP measurement
10.3 Elevated blood pressure at control ..
.. over subsequent hours via HBPM or ABPM, can also be very useful
visits ..
.. to determine if BP really is poorly controlled despite witnessed
The finding of an elevated BP should always lead physicians to search
.. consumption of medication in patients with apparent resistant
for the cause(s), particularly the most common ones such as poor .. hypertension. In contrast, questionnaires frequently overestimate
adherence to the prescribed treatment regimen, persistence of a ..
.. drug adherence. The assessment of adherence should be
white-coat effect, and occasional or more regular consumption of salt, .. improved with the development of cheaper and more reliable
drugs, or substances that raise BP or oppose the antihypertensive ..
.. methods of detection that are easily applicable in daily
effect of treatment (e.g. alcohol or non-steroidal anti-inflammatory .. practice.354,626
drugs). This may require tactful but stringent questioning of the patient ..
.. Barriers to optimal adherence may be linked with physician atti-
(and his/her relatives) to identify interfering factors, as well as repeated ..
.. tudes, patient beliefs and behaviour, the complexity and tolerability
measurements of BP in the following weeks to ensure that BP has .. of drug therapies, the healthcare system, and several other factors.
returned to controlled values. If ineffective treatment is regarded as ..
the reason for inadequate BP control, the treatment regimen should
.. Therefore, the assessment of adherence should always be conducted
.. in a no-blame approach, and should favour an open discussion to
be uptitrated in a timely fashion (see section 7); this avoids clinical iner- ..
tia, a major contributor to poor BP control worldwide.311
.. identify the specific barriers limiting the patient’s ability to follow the
.. therapeutic recommendations. Individualized solutions should be
..
.. found. Patients should be encouraged to take responsibility for their
10.4 Improvement in blood pressure .. own CV health.
..
control in hypertension: drug adherence .. Patient adherence to therapy can be improved by several interven-
There is growing evidence that poor adherence to treatment—in .. tions. The most useful interventions are those linking drug intake
..
addition to physician inertia (i.e. lack of therapeutic action when the .. with habits,347 those giving adherence feedback to patients, self-
patient’s BP is uncontrolled)—is the most important cause of poor .. monitoring of BP64 using pill boxes and other special packaging, and
..
BP control.293,619–621 Non-adherence to antihypertensive therapy .. motivational interviewing. Increasing the integration among health-
correlates with higher risk of CV events.312,622
.. care providers with the involvement of pharmacists and nurses
..
Early discontinuation of treatment and suboptimal daily use of the .. increases drug adherence. Using multiple components has a greater
prescribed regimens are the most common facets of poor adherence.
.. effect on adherence, as the effect size of each intervention is generally
..
After 6 months, more than one-third, and after 1 year, about one-half .. modest. Recent data suggest that adherence to treatment may also
of patients may stop their initial treatment.623 Studies based on the
.. be improved with the use of telemetry for transmission of recorded
..
detection of antihypertensive medications in blood or urine have .. home values, maintaining contact between patients and physicians,
shown that low adherence to the prescribed medications can affect
.. and studies are ongoing.627
..
<_ 50% of patients with apparently resistant hypertension,352,624 and .. Prescription of an appropriate therapeutic regimen is crucial.389
.. This might be achieved through: (i) possible drug-related adverse
that poor adherence is strongly and inversely correlated with the ..
number of pills prescribed. Early recognition of a lack of adherence .. events, (ii) using long-acting drugs that require once daily dos-
..
might reduce the number of costly investigations and procedures .. age,628,629 (iii) avoiding complex dosing schedules, (iv) using SPCs
(including interventional treatment), and avoid the prescription of .. whenever possible, and (v) taking into consideration the effect of
..
unnecessary drugs.625 .. treatment on a patient’s budget.
A major emphasis of these Guidelines has been to simplify the .. Compared with the large number of trials for individual drugs and
..
treatment strategy to try and improve adherence to treatment and .. treatments, there are only a limited number of rigorous trials on
BP control, by prescribing a single pill to most patients with hyperten- .. adherence interventions. Thus, the level of evidence indicating that a
..
sion. This is a response to the fact that despite the clear-cut benefits .. sustained improvement in medication adherence can be achieved
of BP treatment in trials, most treated patients do not achieve recom- .. within the resources available today in clinical practice is low. This is
..
mended BP targets in real life. The lower BP targets recommended in .. essentially due to the short duration of most studies, their heteroge-
these Guidelines will mean that BP control rates will be even worse .. neity, and their questionable designs. Whether available interventions
..
unless action is taken to ensure that patients are more likely to .. ameliorate treatment outcomes remains to be demonstrated in
adhere to logical combinations of treatment.
.. adequate trials.
..
Several methods are available to detect poor adherence, but .. A list of the interventions associated with improved patient adher-
most are indirect, poorly reliable, and provide little information
.. ence to treatment is shown in Table 33.

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Table 33 Interventions that may improve drug adherence in hypertension
Physician level
Provide information on the risks of hypertension and the benefits of treatment, as well as agreeing a treatment strategy to achieve and maintain BP
control using lifestyle measures and a single-pill-based treatment strategy when possible (information material, programmed learning, and com-
puter-aided counselling)
Empowerment of the patient
Feedback on behavioural and clinical improvements
Assessment and resolution of individual barriers to adherence
Collaboration with other healthcare providers, especially nurses and pharmacists
Patient level
Self-monitoring of BP (including telemonitoring)
Group sessions
Instruction combined with motivational strategies
Self-management with simple patient-guided systems
Use of reminders
Obtain family, social, or nurse support
Provision of drugs at worksite
Drug treatment level
Simplification of the drug regimen favouring the use of SPC therapy
Reminder packaging
Health system level
Supporting the development of monitoring systems (telephone follow-up, home visits, and telemonitoring of home BP)
Financially supporting the collaboration between healthcare providers (e.g. pharmacists and nurses)
Reimbursement of SPC pills
Development of national databases, including prescription data, available for physicians and pharmacists
Accessibility to drugs
BP = blood pressure; SPC = single-pill combination.
..
10.5 Continued search for asymptomatic .. 10.6 Can antihypertensive medications
hypertension-mediated organ damage .. be reduced or stopped?
..
The importance and need to detect HMOD at initial assessment to .. In some patients in whom treatment is accompanied by effective BP
help risk stratify the patient, and to review the progression or regres-
.. control for an extended period, it may be possible to reduce the
..
sion of HMOD during follow-up, have been described in section 4. .. number and/or dosage of drugs. This may particularly be the case if
The presence of HMOD demonstrates that BP is elevated and that
.. BP control is accompanied by healthy lifestyle changes such as weight
..
the patient would benefit from treatment. The regression of asymp- .. loss, exercise habit, and a low-fat and low-salt diet, which remove
..
tomatic organ damage occurring during treatment can often indicate .. environmental pressor influences. A reduction of medications should
an improved prognosis (see section 5). .. be made gradually, and the patient should be checked frequently

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because reappearance of hypertension can occur quickly, within

weeks, or may take many months. Patients with prior HMOD or pre-
vious accelerated hypertension should not have their treatment
withdrawn.
11 Gaps in the evidence
Gaps in the evidence and need for further studies
What is the optimal population screening programme for detecting hypertension?
What is the optimal method to measure BP in patients with AF?
What is the incremental benefit for CV risk prediction of the addition of out-of-office BP (HBPM and ABPM) to office BP measurement?
What is the incremental benefit, over the SCORE system, of measures of HMOD in reclassifying the CV risk of patients with hypertension?
What are the appropriate BP thresholds and targets for drug treatment in younger hypertensive patients?
What are the optimal BP treatment targets according to HBPM and ABPM?
What are the outcome benefits associated with antihypertensive treatment in patients with resistant hypertension?
What are the benefits of BP treatment for patients with BP in the high–normal range?
What baseline level of CV risk predicts treatment benefit?
More data on the benefits of BP treatment in the very elderly and the influence of frailty
Outcome-based comparison between office BP- and out-of-office BP-guided treatment
Outcome-based comparison between treatments guided by BP control and by HMOD reductions, especially in younger patients
More outcome studies of the optimal SBP treatment target for patients at different levels of baseline CV risk and with different comorbidities,
including diabetes and CKD
More outcome studies of the optimal DBP treatment target
Impact of single-pill vs. multidrug treatment strategies on adherence to treatment, BP control, and clinical outcomes
Outcome-based comparison between treatment strategies based on initial monotherapy vs. initial combination therapy
What is the optimal salt intake to reduce CV and mortality risk?
What are the long-term outcome benefits resulting from the recommended lifestyle changes?
Outcome-based comparison between treatments based on thiazide vs. thiazide-like diuretics
Incremental value of central vs. peripheral BP in risk estimation and risk reduction by treatment
Outcome-based comparison of BP treatment with classical vs. vasodilator beta-blockers
Optimal BP treatment targets in specific clinical conditions (e.g. diabetes, CKD, and post-stroke)
Protective effect of antihypertensive treatment in patients with cognitive dysfunction or dementia
Role of antihypertensive treatment in white-coat hypertension
Role of antihypertensive treatment in masked hypertension
Optimal treatment of hypertension in different ethnic groups
ABPM = ambulatory blood pressure monitoring; AF = atrial fibrillation; BP = blood pressure; CKD = chronic kidney disease; CV = cardiovascular; DBP = diastolic blood pressure; HBPM
= home blood pressure monitoring; HMOD = hypertension-mediated organ damage; SBP = systolic blood pressure; SCORE = Systematic COronary Risk Evaluation.

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..
12 Key messages ..
..
receive drug treatment if their BP is not controlled after a period
of lifestyle intervention alone. For higher-risk patients with grade 1
(1) BP, epidemiology, and risk. Globally, over 1 billion people
..
.. hypertension, including those with HMOD, or patients with higher
have hypertension. As populations age and adopt more sedentary .. grades of hypertension (e.g. grade 2 hypertension, >_160/100
lifestyles, the worldwide prevalence of hypertension will continue
..
.. mmHg), we recommend initiating drug treatment alongside life-
to rise towards 1.5 billion by 2025. Elevated BP is the leading global .. style interventions. These recommendations apply to all adults
..
contributor to premature death, accounting for almost 10 million .. aged <80 years.
deaths in 2015, 4.9 million due to ischaemic heart disease and 3.5 .. (8) Special considerations in frail and older patients. It is
..
million due to stroke. Hypertension is also a major risk factor for .. increasingly recognised that biological rather than chronological
heart failure, AF, CKD, PAD, and cognitive decline. .. age, as well as consideration of frailty and independence, are
..
(2) Definition of hypertension. The classification of BP and the .. important determinants of the tolerability of and likely benefit
definition of hypertension is unchanged from previous European .. from BP-lowering medications. It is important to note that even in
..
Guidelines, and is defined as an office SBP >_140 and/or DBP >_90 .. the very old (i.e. >80 years), BP-lowering therapy reduces mortal-
mmHg, which is equivalent to a 24 h ABPM average of >_130/80 .. ity, stroke, and heart failure. Thus, these patients should not be
..
mmHg, or a HBPM average >_135/85 mmHg. .. denied treatment or have treatment withdrawn simply on the
(3) Screening and diagnosis of hypertension. Hypertension is .. basis of age. For people >80 years who have not yet received
..
usually asymptomatic (hence the term ‘silent killer’). Because of its .. treatment for their BP, treatment is recommended when their
high prevalence, screening programmes should be established to .. office SBP is >_160 mmHg, provided that the treatment is well
..
ensure that BP is measured in all adults at least every 5 years, and .. tolerated.
more frequently in people with a high–normal BP. When hyper-
.. (9) How low should SBP be lowered? This has been a hotly
..
tension is suspected because of an elevated screening BP, the diag- .. debated topic. A key discussion point is the balance of potential
nosis of hypertension should be confirmed either by repeated
.. benefits vs. potential harm or adverse effects. This is especially
..
office BP measurements over a number of visits or by out-of-office .. important whenever BP targets are lowered, as there is a greater
BP measurement using 24 h ABPM or HBPM.
..
.. potential for harm to exceed benefit. Thus, in these Guidelines, we
(4) The importance of cardiovascular risk assessment and .. recommend a target range. The evidence strongly suggests that
detection of HMOD. Other CV risk factors such as dyslipidae-
..
.. lowering office SBP to <140 mmHg is beneficial for all patient
mia and metabolic syndrome frequently cluster with hypertension. .. groups, including independent older patients. There is also evi-
..
Thus, unless the patient is already at high or very high risk due to .. dence to support targeting SBP to 130 mmHg for most patients, if
established CVD, formal CV risk assessment is recommended .. tolerated. Even lower SBP levels (<130 mmHg) will be tolerated
..
using the SCORE system. However, it is important to recognise .. and potentially beneficial for some patients, especially to further
that the presence of HMOD, especially LVH, CKD, or advanced .. reduce the risk of stroke. SBP should not be targeted to <120
..
retinopathy, further increases the risk of CV morbidity and mortal- .. mmHg because the balance of benefit vs. harm becomes concern-
ity, and should be screened for as part of risk assessment in hyper- .. ing at these levels of treated SBP.
..
tensive patients because the SCORE system alone may .. (10) BP targets in old and very old patients. As discussed above,
underestimate their risk. .. independence, frailty, and comorbidities will all influence treatment
..
(5) Think: could this patient have secondary hypertension? .. decisions, especially in older (>_65 years) and very old (>80 years)
For most people with hypertension, no underlying cause will be .. patients. The desired SBP target range for all patients aged >65
..
detected. Secondary (and potentially remediable) causes of hyper- .. years is 130–139 mmHg. This is lower than in previous Guidelines
tension are more likely to be present in people with young onset .. and may not be achievable in all older patients, but any BP lowering
..
of hypertension (<40 years), people with severe or treatment- .. towards this target is likely to be beneficial provided that the treat-
resistant hypertension, or people who suddenly develop significant .. ment is well tolerated.
..
hypertension in midlife on a background of previously normal BP. .. (11) BP targets in patients with diabetes and/or CKD. The BP
Such patients should be referred for specialist evaluation.
.. treatment targets for patients with diabetes or kidney disease have
..
(6) Treatment of hypertension: importance of lifestyle inter- .. been a moving target in previous Guidelines because of seemingly
ventions. The treatment of hypertension involves lifestyle inter-
.. contradictory results from major outcome trials and meta-
..
ventions and drug therapy. Many patients with hypertension will .. analyses. For diabetes, targeting the SBP to <140 mmHg and
require drug therapy, but lifestyle interventions are important
..
.. towards 130 mmHg, as recommended for all other patient groups,
because they can delay the need for drug treatment or comple- .. is beneficial on major outcomes. Moreover, targeting SBP to <130
ment the BP-lowering effect of drug treatment. Moreover, lifestyle
..
.. mmHg, for those who will tolerate it, may further reduce the risk
interventions such as sodium restriction, alcohol moderation, .. of stroke but not other major outcomes. SBP should not be <120
..
healthy eating, regular exercise, weight control, and smoking cessa- .. mmHg. For patients with CKD, the evidence suggests that the tar-
tion all have health benefits beyond their impact on BP. .. get BP range should be 130–139 mmHg.
..
(7) When to consider drug treatment of hypertension. The .. (12) How low should DBP be lowered? The optimal DBP target
treatment thresholds for hypertension are now less conservative .. has been less well defined, but a DBP target of <80 mmHg is rec-
..
than they were in previous Guidelines. We now recommend that .. ommended. Some patients with stiff arteries and isolated systolic
patients with low-moderate-risk grade 1 hypertension (office BP .. hypertension will already have DBP levels below this target. These
..
140–159/90–99), even if they do not have HMOD, should now . are high-risk patients and the low DBP should not discourage

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..
treatment of their elevated SBP to the recommended target, pro- .. medication. We recommend a combination of an ACE inhibitor or
vided that treatment is well tolerated. .. ARB with a CCB or thiazide/thiazide-like diuretic as initial therapy
..
(13) The need to do better on BP control. A key message in these .. for most patients. For those requiring three drugs, we recommend
Guidelines is the need to do better at improving BP control rates. .. a combination of an ACE inhibitor or ARB with a CCB and a
..
Despite the overwhelming evidence of treatment benefit, on aver- .. thiazide/thiazide-like diuretic. We recommend that beta-blockers
age, <50% of patients with treated hypertension achieve an SBP
.. be used when there is a specific indication for their use (e.g. angina,
..
target of <140 mmHg. Physician inertia (inadequate uptitration of .. post-myocardial infarction, HFrEF, or when heart rate control is
treatment, especially from monotherapy) and poor patient adher-
.. required).
..
ence to treatment (especially when based on multiple pills) are .. (17) Hypertension in women and in pregnancy. In women with
now recognised as the major factors contributing to poor BP
.. hypertension who are planning pregnancy, ACE inhibitors or
..
control. .. ARBs and diuretics should be avoided, and the preferred medica-
(14) Start treatment in most patients with two drugs, not
.. tions to lower BP, if required, include alpha-methyl dopa, labetalol,
..
one. Monotherapy is usually inadequate therapy for most people .. or CCBs. The same drugs are suitable if BP lowering is required in
with hypertension; this will be especially true now that the BP
.. pregnant women. ACE inhibitors or ARBs should not be used in
...
treatment targets for many patients are lower than in previous .. pregnant women.
Guidelines. These Guidelines have set out to normalize the con- .. (18) Is there a role for device-based therapy for the treatment
..
cept that initial therapy for the majority of patients with hyperten- .. of hypertension? A number of device-based interventions have
sion should be with a combination of two drugs, not a single drug. .. been developed and studied for the treatment of hypertension. To
..
The only exception would be in a limited number of patients with .. date, the results from these studies have not provided sufficient
a lower baseline BP close to their recommended target, who might .. evidence to recommend their routine use. Consequently, the use
..
achieve that target with a single drug, or in some frailer old or very .. of device-based therapies is not recommended for the routine
old patients in whom more gentle reduction of BP may be desir- .. treatment of hypertension, unless in the context of clinical studies
..
able. Evidence suggests that this approach will improve the speed, .. and RCTs, until further evidence regarding their safety and efficacy
efficiency, and consistency of initial BP lowering and BP control, .. becomes available.
..
and is well tolerated by patients. .. (19) Managing cardiovascular disease risk in hypertensive
(15) A single-pill strategy to treat hypertension. Poor adher- .. patients beyond BP: statins. For hypertensive patients at mod-
..
ence to longer-term BP-lowering medication is now recognised .. erate CVD risk or higher, or those with established CVD, BP low-
as a major factor contributing to poor BP control rates. .. ering alone will not optimally reduce their risk. These patients
..
Research has shown a direct correlation between the number .. would also benefit from statin therapy, which further reduces the
of BP-lowering pills and poor adherence to medications.
.. risk of a myocardial infarction by approximately one-third and
..
Moreover, SPC therapy has been shown to improve adherence .. stroke by approximately one-quarter, even when BP is controlled.
to treatment. SPC therapy is now the preferred strategy for ini-
.. Similar benefits have been seen in hypertensive patients at the bor-
..
tial two-drug combination treatment of hypertension and for .. der between low and moderate-risk. Thus, many more hyperten-
three-drug combination therapy when required. This will con-
.. sive patients would benefit from statin therapy than are currently
..
trol the BP of most patients with a single pill and could trans- .. receiving this treatment.
form BP control rates.
.. (20) Managing cardiovascular disease risk in hypertensive
..
(16) A simplified drug treatment algorithm. We have simplified .. patients beyond BP : antiplatelet therapy. Antiplatelet ther-
..
the treatment strategy so that patients with uncomplicated hyper- .. apy, especially low-dose aspirin, is recommended for secondary
tension and many patients with a variety of comorbidities (e.g. .. prevention in hypertensive patients, but is not recommended for
..
HMOD, diabetes, PAD, or cerebrovascular disease) receive similar .. primary prevention (i.e. in patients without CVD).

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13 ‘What to do’ and ‘what not to do’ messages from the Guidelines
Classification of BP
It is recommended that BP be classified as optimal, normal, or high–normal, or grades 1–3 hypertension, according to office
I C
BP.
Screening for hypertension
Screening programmes for hypertension are recommended. All adults (>_18 years) should have their office BP measured and
I B
recorded in their medical file, and be aware of their BP.
Diagnosis of hypertension
It is recommended to base the diagnosis of hypertension on:

• Repeated office BP measurements on more than one visit, except when hypertension is severe (e.g. grade 3 and especially I C
in high-risk patients). At each visit, three BP measurements should be recorded, 1–2 min apart, and additional measure-
ments performed if the first two readings differ by >10 mmHg. The patient’s BP is the average of the last two BP readings.
OR
• Out-of-office BP measurement with ABPM and/or HBPM, provided that these measurements are logistically and economi- I C
cally feasible.
Office BP thresholds for the initiation of drug treatment for hypertension
Prompt initiation of BP-lowering drug treatment is recommended in patients with grade 2 or 3 hypertension at any level of CV
I A
risk, simultaneously with the initiation of lifestyle changes.
In patients with grade 1 hypertension:

I B
• Lifestyle interventions are recommended to determine if this will normalize BP.
• In patients with grade 1 hypertension at low-moderate-risk and without evidence of HMOD, BP-lowering drug treatment is
I A
recommended if the patient remains hypertensive after a period of lifestyle intervention.c
• In patients with grade 1 hypertension at high risk or with evidence of HMOD, prompt initiation of drug treatment is recom-
I A
mended simultaneously with lifestyle interventions.
In fit older patients with hypertension (even if aged >80 years), BP-lowering drug treatment and lifestyle intervention are rec-
I A
ommended when SBP is >_160 mmHg.
BP-lowering drug treatment and lifestyle intervention are recommended in fit older patients (>65 years but not >80 years)
I A
when SBP is in the grade 1 range (140–159 mmHg), provided that treatment is well tolerated.
In patients with high–normal BP (130–139/85–89 mmHg), lifestyle changes are recommended. I A
Withdrawal of BP-lowering drug treatment on the basis of age, even when patients attain an age of >_80 years, is not recom-
III A
mended, provided that treatment is well tolerated.
Office BP treatment targets
It is recommended that the first objective of treatment should be to lower BP to <140/90 mmHg in all patients, and provided
I A
that the treatment is well tolerated, treated BP values should be targeted to 130/80 mmHg or lower in most patients.
In patients <65 years receiving BP-lowering drugs, it is recommended that SBP should be lowered to a BP range of 120–129
I A
mmHg in most patients.d
In older patients (aged >_65 years) receiving BP-lowering drugs, it is recommended that SBP should be targeted to a BP range of
I A
130–139 mmHg.
Continued

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Treatment of hypertension: lifestyle interventions
Salt restriction to <5 g per day is recommended. I A
It is recommended to restrict alcohol consumption to <14 units per week for men and <8 units per week for women. I A
Increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil); low consumption of red meat;
I A
and consumption of low-fat dairy products are recommended.
Body weight control is indicated to avoid obesity (BMI >30 kg/m2, or waist circumference >102 cm in men and >88 cm in
women) and aim for healthy BMI (about 20–25 kg/m2) and waist circumference values (<94 cm in men and <80 cm in women) I A
to reduce BP and CV risk.
Regular aerobic exercise (e.g. >_30 min of moderate dynamic exercise on 5–7 days per week) is recommended. I A
Smoking cessation and supportive care and referral to smoking cessation programmes are recommended. I B
It is recommended to avoid binge drinking. III A
Treatment of hypertension: drug treatment
Combination treatment is recommended for most hypertensive patients as initial therapy. Preferred combinations should com- I A
prise a RAS blocker (either an ACE inhibitor or an ARB) with a CCB or diuretic. Other combinations of the five major classes
can be used.It is recommended that beta-blockers are combined with any of the other major drug classes when there are spe- I A
cific clinical situations (e.g. angina, post-myocardial infarction, heart failure, or heart rate control).
It is recommended to initiate antihypertensive treatment with a two-drug combination, preferably in an SPC. Exceptions are
I B
frail older patients and those at low risk and with grade 1 hypertension (particularly if SBP is <150 mmHg).342,346,351
It is recommended that if BP is not controllede with a two-drug combination, treatment should be increased to a three-drug
I A
combination, usually a RAS blocker with a CCB and thiazide/thiazide-like diuretics, preferably as an SPC.
It is recommended that if BP is not controllede with a three-drug combination, treatment should be increased by the addition
of spironolactone or, if not tolerated, other diuretics such as amiloride or higher doses of other diuretics, a beta-blocker, or an I B
alpha-blocker.
The combination of two RAS blockers is not recommended. III A
Treatment of hypertension: device-based therapies
Use of device-based therapies is not recommended for the routine treatment of hypertension, unless in the context of clinical
III B
studies and RCTs, until further evidence regarding their safety and efficacy becomes available.
Management of CVD risk in hypertensive patients
CV risk assessment with the SCORE system is recommended for hypertensive patients who are not already at high or very
I B
high risk due to established CVD, renal disease, or diabetes.
For patients at high or very high CV risk, statins are recommended. I B
Antiplatelet therapy, in particular low-dose aspirin, is recommended for secondary prevention in hypertensive patients. I A
Aspirin is not recommended for primary prevention in hypertensive patients without CVD. III A
Routine genetic testing for hypertensive patients is not recommended. III C
ABPM = ambulatory blood pressure monitoring; ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BMI = body mass index; BP = blood pressure;
CCB = calcium channel blocker; CV = cardiovascular; CVD = cardiovascular disease; HBPM = home blood pressure monitoring; HMOD = hypertension-mediated organ dam-
age; RAS = renin–angiotensin system; RCT = randomized controlled trial; SBP = systolic blood pressure; SCORE = Systematic COronary Risk Evaluation; SPC = single-pill
combination.
a
b
Level of evidence.
c
In patients with grade 1 hypertension and low-moderate-risk, drug treatment may be preceded by a prolonged period of lifestyle intervention to determine if this will normalize
BP. The duration of the lifestyle intervention alone will depend on the level of BP within the grade 1 range (i.e. the likelihood of achieving BP control with lifestyle intervention
alone) and the opportunities for significant lifestyle change in individual patients.
d
Less evidence is available for this target in low-moderate-risk patients.
e
Adherence to medication should be checked.

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..
14 Appendix .. Society of Cardiology, Tonje Amb Aksnes; Poland: Polish Cardiac
.. Society, Piotr Jankowski; Portugal: Portuguese Society of
ESC Committee for Practice Guidelines (CPG): Stephan
..
.. Cardiology, Jorge Polonia; Romania: Romanian Society of
Windecker (Chairperson) (Switzerland), Victor Aboyans (France), .. Cardiology, Dragos Vinereanu; Russian Federation: Russian
Stefan Agewall (Norway), Emanuele Barbato (Italy), Héctor Bueno
..
.. Society of Cardiology, Elena I. Baranova; San Marino: San Marino
(Spain), Antonio Coca (Spain), Jean-Philippe Collet (France), Ioan .. Society of Cardiology, Marina Foscoli; Serbia: Cardiology Society of
..
Mircea Coman (Romania), Veronica Dean (France), Victoria Delgado .. Serbia, Ana Djordjevic Dikic; Slovakia: Slovak Society of Cardiology,
(The Netherlands), Donna Fitzsimons (UK), Oliver Gaemperli .. Slavomira Filipova; Slovenia: Slovenian Society of Cardiology, Zlatko
..
(Switzerland), Gerhard Hindricks (Germany), Bernard Iung (France), .. Fras; Spain: Spanish Society of Cardiology, Vicente Bertomeu-
Peter Jüni (Canada), Hugo A. Katus (Germany), Juhani Knuuti .. Martınez; Sweden: Swedish Society of Cardiology, Bo Carlberg;
..
(Finland), Patrizio Lancellotti (Belgium), Christophe Leclercq .. Switzerland: Swiss Society of Cardiology, Thilo Burkard; Tunisia:
(France), Theresa A. McDonagh (UK), Massimo Francesco Piepoli .. Tunisian Society of Cardiology and Cardio-Vascular Surgery, Wissem
..
(Italy), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), .. Sdiri; Turkey: Turkish Society of Cardiology, Sinan Aydogdu;
Marco Roffi (Switzerland), Evgeny Shlyakhto (Russia), Iain A. Simpson .. Ukraine: Ukrainian Association of Cardiology, Yuriy Sirenko;
..
(UK), Miguel Sousa-Uva (Portugal), Jose Luis Zamorano (Spain). .. United Kingdom: British Cardiovascular Society, Adrian Brady.
ESH Council: Costas Tsioufis (President) (Greece), Empar .. ESH National Hypertension Societies actively involved in
..
Lurbe (Spain), Reinhold Kreutz (Germany), Murielle Bochud .. the review process of the 2018 ESC/ESH Guidelines for the manage-
(Switzerland), Enrico Agabiti Rosei (Italy), Bojan Jelakovic (Croatia), .. ment of arterial hypertension: Austria: Austrian Society of
..
Michel Azizi (France), Andrzej Januszewics (Poland), Thomas Kahan .. Hypertension, Thomas Weber; Belarus: Belarussian Hypertension
(Sweden), Jorge Polonia (Portugal), Philippe van de Borne (Belgium), .. League, Irina Lazareva; Belgium: Belgian Hypertension Committee,
..
Bryan Williams (UK), Claudio Borghi (Italy), Giuseppe Mancia (Italy), .. Tine De Backer; Bosnia and Herzegovina: Bosnia and
Gianfranco Parati (Italy), Denis L. Clement (Belgium), Antonio Coca
..
.. Herzegovina Society of Hypertension, Sekib Sokolovic; Croatia:
(Spain), Athanasios Manolis (Greece), Dragan Lovic (Serbia) .. Croatian Society of Hypertension, Bojan Jelakovic; Czech
ESC National Cardiac Societies actively involved in the
..
.. Republic: Czech Society of Hypertension, Jiri Widimsky; Estonia:
review process of the 2018 ESC/ESH Guidelines for the management .. Estonian Society of Hypertension, Margus Viigimaa; Finland: Finnish
of arterial hypertension: Algeria: Algerian Society of Cardiology,
..
.. Hypertension Society, Ilkka Pörsti; France: French Society of
Salim Benkhedda; Armenia: Armenian Cardiologists Association, .. Hypertension, Thierry Denolle; Germany: German Hypertension
Parounak Zelveian; Austria: Austrian Society of Cardiology, Peter
..
.. Society, Bernhard K. Kr€amer; Greece: Hellenic Society of
Siostrzonek; Azerbaijan: Azerbaijan Society of Cardiology, Ruslan .. Hypertension, George S. Stergiou; Italy: Italian Society of
..
Najafov; Belarus: Belorussian Scientific Society of Cardiologists, .. Hypertension, Gianfranco Parati; Latvia: Latvian Society of
Olga Pavlova; Belgium: Belgian Society of Cardiology, Michel De .. Hypertension and Atherosclerosis, Karlis Trusinskis; Lithuania:
..
Pauw; Bosnia and Herzegovina: Association of Cardiologists of .. Lithuanian Hypertension Society, Marius Miglinas; Norway:
Bosnia and Herzegovina, Larisa Dizdarevic-Hudic; Bulgaria: .. Norwegian Society of Hypertension, Eva Gerdts; Poland: Polish
..
Bulgarian Society of Cardiology, Dimitar Raev; Cyprus: Cyprus .. Society of Hypertension, Andrzej Tykarski; Portugal: Portuguese
Society of Cardiology, Nikos Karpettas; Czech Republic: Czech .. Society of Hypertension, Manuel de Carvalho Rodrigues; Romania:
..
Society of Cardiology, Ales Linhart; Denmark: Danish Society of .. Romanian Society of Hypertension, Maria Dorobantu; Russian
Cardiology, Michael Hecht Olsen; Egypt: Egyptian Society of .. Federation: Russian Society of Hypertension, Irina Chazova;
..
Cardiology, Amin Fouad Shaker; Estonia: Estonian Society of .. Serbia: Serbian Society of Hypertension, Dragan Lovic; Slovakia:
Cardiology, Margus Viigimaa; Finland: Finnish Cardiac Society, Kaj .. Slovak Society of Hypertension, Slavomira Filipova; Slovenia:
..
Mets€arinne; The Former Yugoslav Republic of Macedonian: .. Slovenian Hypertension Society, Jana Brguljan; Spain: Spanish
Macedonian FYR Society of Cardiology, Marija Vavlukis; France: .. Society of Hypertension, Julian Segura; Sweden: Swedish Society of
..
French Society of Cardiology, Jean-Michel Halimi; Georgia: .. Hypertension, Stroke and Vascular Medicine, Anders Gotts€ater;
Georgian Society of Cardiology, Zurab Pagava; Germany: German
.. Switzerland: Swiss Society of Hypertension, Antoinette Pechère-
..
Cardiac Society, Heribert Schunkert; Greece: Hellenic Society of .. Bertschi; Turkey: Turkish Society of Hypertension and
Cardiology, Costas Thomopoulos; Hungary: Hungarian Society of
..
.. Atherosclerosis, Serap Erdine; Ukraine: Ukrainian Antihypertensive
Cardiology, Dénes Pall; Iceland: Icelandic Society of Cardiology, Karl .. Society, Yuriy Sirenko; United Kingdom: British and Irish
Andersen; Israel: Israel Heart Society, Michael Shechter; Italy:
..
.. Hypertension Society, Adrian Brady.
Italian Federation of Cardiology, Giuseppe Mercuro; Kosovo: ..
Kosovo Society of Cardiology, Gani Bajraktari; Kyrgyzstan: Kyrgyz
..
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European Heart Journal (2018) 00, 1–98 ESC/ESH GUIDELINES

2018 ESC/ESH Guidelines for the management

Authors/Task Force Members: Bryan Williams* (ESC Chairperson) (UK),

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5.5.5 The brain in hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

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Abbreviations and acronyms .. ESH European Society of Hypertension

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Table 1 ESC Classes of recommendations

Classes of Definition Suggested wording to use

Class I Evidence and/or general agreement Is recommended/is

Class II Conflicting evidence and/or a

Class IIa Weight of evidence/opinion is in favour Should be considered

Class IIb Usefulness/efficacy is less well May be considered

Class III Evidence or general agreement that Is not recommended

.. are: (i) to base recommendations on properly conducted studies,

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Treatment thresholds Treatment thresholds

Treatment thresholds Treatment thresholds

Treatment thresholds Treatment thresholds

BP treatment targets BP treatment targets

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BP treatment targets in older BP treatment targets in older patients (65–80 years)

DBP targets DBP targets

Initiation of drug treatment Initiation of drug treatment

Resistant hypertension Resistant hypertension

Device-based therapy for hypertension Device-based therapy for hypertension

Grade I Grade IIa Grade IIb Grade III

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Less conservative treatment of BP in older and very old patients

A SPC treatment strategy to improve BP control

New target ranges for BP in treated patients

Detecting poor adherence to drug therapy

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3.1 Definition of hypertension Recommendation Classa Levelb

Table 3 Classification of office blood pressurea and definitions of hypertension gradeb

Category Systolic (mmHg) Diastolic (mmHg)

Optimal <120 and <80

Normal 120–129 and/or 80–84

High normal 130–139 and/or 85–89

Grade 1 hypertension 140–159 and/or 90–99

Grade 2 hypertension 160–179 and/or 100–109

Grade 3 hypertension >_180 and/or >_110

Isolated systolic hypertensionb >_140 and <90

BP = blood pressure; SBP = systolic blood pressure.

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Table 4 Factors influencing cardiovascular risk in patients with hypertension

Demographic characteristics and laboratory parameters

Sexa (men >women)

Smoking (current or past history)a

Total cholesterola and HDL-C

Family or parental history of early-onset hypertension

Psychosocial and socioeconomic factors

Heart rate (resting values >80 beats/min)

Ankle-brachial index <0.9

Advanced retinopathy: haemorrhages or exudates, papilloedema

Established CV or renal disease