2024 ESC Hypertension Guidelines

What's New in 2024

The 2024 ESC Guidelines introduce major changes in BP classification, treatment targets, and initial pharmacotherapy compared to the 2018 ESC/ESH guidelines.

Topic	2024 Recommendation	Previous (2018)
BP Categories	3 categories: Non-elevated (<120/70), Elevated (120–139/70–89), Hypertension (≥140/90)	5 categories: Optimal, Normal, High-normal, Grade 1–3
Treatment Target	SBP 120–129 mmHg for most adults 1 LOE A	SBP <140 mmHg (130 in some groups)
CV Risk Tool	SCORE2 / SCORE2-OP replaces old ESC SCORE	ESC SCORE (fatal CVD events only)
Initial Therapy	Combination therapy preferred for most with confirmed HTN ≥140/90	Monotherapy acceptable as first-line
Pill Strategy	Single-pill combinations (SPC) to improve adherence 1 LOE B	Multi-pill regimens standard
BP Confirmation	Out-of-office BP (ABPM/HBPM) for ALL patients 1 LOE B	Office BP alone acceptable for diagnosis
Elevated BP	NEW category — actively managed with lifestyle ± drugs if high CV risk	"High-normal" — no specific management pathway
Renal Denervation	NOT recommended as first-line 3 LOE C	Considered for resistant HTN

Pearl: The new "Elevated BP" category (SBP 120–139 or DBP 70–89) replaces both "normal" and "high-normal" from 2018, creating a unified risk assessment and lifestyle intervention pathway for this group.

Blood Pressure Classification

The 2024 guideline simplifies BP into 3 categories (down from 5 in 2018). Classification is based on office BP and uses the HIGHER of SBP or DBP to determine category.

Category	SBP (mmHg)		DBP (mmHg)	Clinical Action
Non-elevated BP	<120	AND	<70	No action required; recheck in 3–5 years
Elevated BP (NEW)	120–139	OR	70–89	CV risk assessment; lifestyle intervention; consider drugs if high-risk
Hypertension	≥140	OR	≥90	Confirm diagnosis; initiate treatment per risk stratification

Pearl: "Elevated BP" is the biggest conceptual change. It merges old "normal" (120–129/80–84) and "high-normal" (130–139/85–89) into one actionable category — requiring CV risk assessment and lifestyle intervention in all, and drug therapy consideration in those with high CV risk.

Pitfall: Category is set by whichever value (SBP or DBP) falls in the higher bracket. A patient with SBP 135 and DBP 65 has Elevated BP (based on SBP), NOT Non-elevated (based on DBP).

Pitfall: These categories apply to OFFICE BP only. Out-of-office thresholds are lower (see BP Measurement section). Do not apply office categories to ABPM/HBPM values.

Blood Pressure Measurement & Diagnostic Thresholds

Out-of-office BP measurement is recommended for all patients to confirm the diagnosis of hypertension and detect white-coat or masked hypertension. 1 LOE B

Hypertension Diagnostic Thresholds by Method

Measurement Method	SBP (mmHg)	DBP (mmHg)	COR/LOE
Office BP	≥140	≥90	1 B
Home BP (HBPM)	≥135	≥85	1 B
24-hour ABPM mean	≥130	≥80	1 B
Daytime ABPM	≥135	≥85	1 B
Nighttime ABPM	≥120	≥70	1 B

Key Measurement Recommendations

Measure BP in both arms at first visit — use arm with higher reading for all subsequent measurements. A between-arm SBP difference >10 mmHg may indicate arterial stenosis. 1 LOE B
All patients should have pulse palpation at rest to detect arrhythmias such as AF. 1 LOE C
Use out-of-office BP for ongoing management to guide titration and detect symptomatic hypotension. 1 LOE B

Pearl: Out-of-office BP detects white-coat HTN (~25% of diagnosed patients) and masked HTN (~15%). Office BP alone misclassifies up to 30% of patients — always confirm with ABPM or HBPM when screening BP is 120–159/90–99.

Pearl: For HBPM: instruct patients to measure morning and evening, 2 readings each time, for ≥3 days (ideally 7 days). Discard first-day readings. Average remaining values.

Pitfall: Avoid diagnosing HTN based on a single office visit. The 2024 guideline strongly recommends ABPM or HBPM confirmation for all BP ranges 120–159/90–99.

Cardiovascular Risk Assessment

The 2024 guideline mandates a risk-based approach to treatment decisions. Use SCORE2 (ages 40–69) or SCORE2-OP (age ≥70) to estimate 10-year fatal + non-fatal CVD risk in patients without established high-risk conditions. 1 LOE B

CV Risk Stratification Algorithm (Fig 9)

Step 1 — Classify BP: Measure office BP → categorize as Non-elevated, Elevated, or Hypertension.

Step 2 — Screen for high-risk conditions: Established CVD, moderate-to-severe CKD, diabetes mellitus, familial hypercholesterolaemia, or severe HMOD? → If ANY present: automatically HIGH CV risk — do NOT calculate SCORE2. 1 LOE B

Step 3 — Calculate SCORE2: If no high-risk condition → → Open SCORE2 Calculator. Multiply 10-year risk of fatal + non-fatal CVD events. 1 LOE B

Step 4 — Apply risk modifiers: Family hx premature CVD, socioeconomic deprivation, elevated Lp(a), chronic inflammatory disease (RA, SLE, psoriasis), major psychiatric disorders, treatment for HIV, ethnic group with increased risk.

Step 5 — Determine risk category: Elevated BP + increased CV risk (SCORE2 ≥10% if age <70, or presence of risk modifiers) → consider as equivalent to hypertension for treatment decisions. 1 LOE B

Conditions That Automatically Confer HIGH CV Risk

Condition	Criteria
Established CVD	Prior MI, stroke/TIA, PAD, coronary/carotid/peripheral revascularization, heart failure
CKD (moderate-severe)	eGFR <60 mL/min/1.73m² OR urine ACR ≥30 mg/g. Calculate eGFR
Diabetes mellitus	Type 1 or Type 2 diabetes
Familial hypercholesterolaemia	Confirmed genetic or clinical FH diagnosis
Severe HMOD	LVH on echo, eGFR 30–59 mL/min/1.73m², albuminuria 30–300 mg/g, advanced retinopathy, aortic stiffness (cf-PWV >10 m/s)

Pearl: SCORE2 estimates FATAL + NON-FATAL CVD events — a major improvement over the old ESC SCORE which only predicted fatal events. This captures the full burden of cardiovascular disease.

Pitfall: Do NOT use SCORE2 in patients with established CVD, diabetes, CKD, or FH — they are automatically classified as high risk. SCORE2 is only for individuals without these conditions.

Diagnosing Hypertension

The 2024 guideline provides a structured approach to confirming the diagnosis of hypertension based on screening office BP level.

Diagnostic Confirmation Algorithm (Fig 10)

Screening BP 120–139/70–89 (Elevated): Confirm with ABPM or HBPM. If confirmed elevated → lifestyle intervention + CV risk assessment. Re-screen annually. 1 LOE B

Screening BP 140–159/90–99: Confirm with ABPM or HBPM (preferred). If out-of-office measurements not logistically or economically feasible, repeat office BP on more than one visit. 1 LOE B

Screening BP 160–179/100–109: Confirm as soon as possible (within 1 month) with ABPM, HBPM, or repeated office BP. Consider starting treatment while awaiting confirmation. 1 LOE C

Screening BP ≥180/110: Exclude hypertensive emergency (assess for acute HMOD). If no emergency, confirm diagnosis and initiate treatment promptly. 1 LOE C

Pearl: Always confirm HTN diagnosis with out-of-office measurements when feasible — this is a strong (COR 1) recommendation for all BP ranges. The only exception is BP ≥180/110 where treatment should not be delayed.

Pitfall: White-coat hypertension (elevated office BP with normal out-of-office BP) affects ~25% of patients. Without ABPM/HBPM confirmation, these patients may be unnecessarily treated.

Hypertension-Mediated Organ Damage (HMOD)

HMOD assessment identifies subclinical target organ damage that reclassifies risk and influences treatment decisions. Estimate renal function: CKD-EPI eGFR | Cockcroft-Gault CrCl

Routine Tests (Recommended for ALL Hypertensive Patients)

Test	Target Organ	HMOD Criteria	COR/LOE
12-lead ECG	Heart	LVH: Sokolow-Lyon >35 mm, Cornell voltage >28 mm (M) / >20 mm (F)	1 B
Serum creatinine + eGFR	Kidney	eGFR <60 mL/min/1.73m². Calculate	1 A
Urine ACR	Kidney	ACR ≥30 mg/g (microalbuminuria 30–300; macroalbuminuria >300)	1 A
Fasting glucose / HbA1c	Metabolic	Screen for diabetes (reclassifies to high-risk if positive)	1 B
Lipid panel	Metabolic	Total cholesterol, LDL-C, HDL-C, triglycerides (SCORE2 input)	1 B

Additional HMOD Assessments

Test	Target Organ	HMOD Criteria	COR/LOE
Echocardiography	Heart	LVH (LVMI >115 g/m² M, >95 g/m² F), diastolic dysfunction, LA enlargement	1 B
Fundoscopy	Eye	Grade III–IV retinopathy (haemorrhages, exudates, papilloedema)	1 C (if BP >180/110, DM, or malignant HTN)
Carotid ultrasound	Vasculature	IMT >0.9 mm or presence of plaque	2a B
ABI	Vasculature	<0.9 (indicates PAD)	2a B
Pulse wave velocity	Vasculature	cf-PWV >10 m/s (arterial stiffness)	2b B

Pearl: Echocardiography is recommended for ALL hypertensive patients with ECG abnormalities or signs/symptoms of cardiac disease — it is more sensitive than ECG for LVH detection.

Pearl: If moderate-to-severe CKD is diagnosed, repeat serum creatinine, eGFR, and urine ACR at least annually. 1 LOE C

Pitfall: Routine genetic testing for hypertension is NOT recommended. 3 LOE C

Blood Pressure Treatment Targets

The 2024 guideline lowers treatment targets significantly. For most adults, treated SBP should be 120–129 mmHg — a major change from the 2018 target of <140 mmHg.

Population	Target SBP (mmHg)	Notes	COR/LOE
Most adults	120–129	If well tolerated; applies to treated values	1 A
Poorly tolerated	ALARA (as low as reasonably achievable)	Lowest tolerated BP without symptomatic hypotension	1 A
Elderly (≥85 years)	120–129 if tolerated	Individualize in moderate-to-severe frailty; test orthostatic BP	1 A
Diabetes	120–129	If tolerated; aligns with SPRINT and ACCORD outcomes	1 A
CKD (eGFR >30)	120–129	Individualize for lower eGFR or post-transplant	1 A
Post-stroke/TIA	120–129	If tolerated; reduce recurrent stroke risk	1 A
Pregnancy	<140/90 but NOT <80 DBP	Avoid excessive lowering (placental perfusion)	1 C

Pearl: The 2024 target of SBP 120–129 is a MAJOR shift from 2018 (was <140). This aligns with SPRINT trial findings showing significant CV benefit from intensive BP lowering. These are TREATED values — not diagnostic thresholds.

Pearl: Maintain BP-lowering drug treatment lifelong, even beyond age 85 years, if well tolerated. 1 LOE A

Pitfall: Treatment targets (120–129) ≠ diagnostic thresholds (≥140/90). These are fundamentally different numbers. Never confuse them.

Pitfall: In frail or elderly patients, ALWAYS test for orthostatic hypotension before starting or intensifying treatment. Lie for 5 min, then measure BP at 1 and 3 min after standing. A drop >20 SBP or >10 DBP requires caution. 1 LOE B

Lifestyle Interventions

Lifestyle modifications are recommended for ALL patients with elevated BP or hypertension, regardless of whether drug therapy is initiated. Combined interventions can reduce SBP by 10–15 mmHg.

Intervention	Target	Expected SBP Reduction	COR/LOE
Sodium restriction	~2 g/day sodium (~5 g NaCl, ~1 tsp salt)	~5 mmHg	1 A
Mediterranean / DASH diet	High in fruits, vegetables, whole grains, fish; low in saturated fat	~5 mmHg	1 A
Weight management	BMI 20–25 kg/m²; WC <94 cm (M), <80 cm (F)	~5 mmHg per 10 kg lost	1 A
Aerobic exercise	≥150 min/week moderate OR ≥75 min/week vigorous	~5 mmHg	1 A
Isometric resistance training	2–3 sessions/week (complement to aerobic exercise)	~4 mmHg	1 A
Alcohol reduction	<100 g/week pure alcohol; preferably avoid entirely	~4 mmHg	1 B
Sugar-sweetened beverage reduction	Discourage SSBs including fruit juices	~2 mmHg	1 B
Smoking cessation	Complete cessation; refer to supportive care	Reduces CV risk (not direct BP effect)	1 A

Pearl: Combined lifestyle interventions can lower SBP by 10–15 mmHg — equivalent to a single antihypertensive drug. For elevated BP with low CV risk, lifestyle alone may be sufficient.

Pearl: Isometric resistance training (e.g., wall sits, handgrip exercises) 2–3x/week is a new addition — evidence shows significant BP reduction alongside aerobic exercise. 1 LOE A

Pitfall: Smoking cessation does not directly lower BP, but it is the single most effective lifestyle change for reducing overall CV mortality. Always prioritize cessation even though the "SBP reduction" column says N/A.

Antihypertensive Pharmacotherapy

Initial Pharmacotherapy Algorithm (Fig 18)

Step 1 — Start combination therapy: For most patients with confirmed HTN (BP ≥140/90), initiate dual combination: RAS blocker (ACEi OR ARB) + dihydropyridine CCB OR thiazide/thiazide-like diuretic. 1 LOE B

Step 2 — Use single-pill combination (SPC): Fixed-dose SPC improves adherence and BP control. Prescribe as a single pill whenever available. 1 LOE B

Step 3 — Exceptions for monotherapy: Consider monotherapy for: patients aged ≥85 years, symptomatic orthostatic hypotension, moderate-to-severe frailty, OR those with elevated BP (120–139/70–89) who have a concomitant indication (e.g., beta-blocker for AF rate control). 1 LOE B

NEVER combine two RAS blockers: ACEi + ARB is contraindicated — increased risk of hyperkalaemia, syncope, and renal dysfunction. 3 LOE A

Step 4 — Triple therapy if needed: If BP not at target on dual therapy → add third drug: RAS blocker + CCB + thiazide/thiazide-like diuretic. Preferably as SPC. 1 LOE B

Step 5 — Resistant HTN pathway: If BP still not at target on optimised triple therapy → see Resistant Hypertension section.

First-Line Drug Classes

Class	Examples	Mechanism	Key Indications Beyond HTN	COR
ACE Inhibitors	Ramipril, Perindopril, Lisinopril, Enalapril	Block ACE → ↓AngII → vasodilation + ↓aldosterone	HFrEF, post-MI, DM with proteinuria, CKD	1 A
ARBs	Valsartan, Telmisartan, Candesartan, Losartan	Block AT1 receptor → same downstream as ACEi without bradykinin	Same as ACEi; preferred if ACEi intolerant (cough in ~10%)	1 A
DHP CCBs	Amlodipine, Nifedipine ER, Felodipine, Lercanidipine	Block L-type Ca²⁺ channels → vascular smooth muscle relaxation	Elderly, ISH, angina, Raynaud phenomenon, Black patients	1 A
Thiazide-like diuretics	Chlorthalidone (12.5–25 mg), Indapamide (1.5–2.5 mg)	Block NCC in DCT → natriuresis + vasodilation at low doses	Volume overload, elderly, ISH, Black patients, HF	1 A

Second-Line / Compelling-Indication Drug Classes

Class	Examples	Key Indications	COR
Beta-blockers	Bisoprolol, Nebivolol, Metoprolol succinate, Carvedilol	Post-MI, HFrEF, angina, AF rate control, pregnancy (labetalol)	1 A (compelling indication only)
MRAs	Spironolactone (25–50 mg), Eplerenone	Resistant HTN (4th-line), HFrEF, primary aldosteronism	1 A (resistant HTN)
Alpha-blockers	Doxazosin	Resistant HTN add-on; BPH symptoms	2b B
SGLT2 Inhibitors	Empagliflozin, Dapagliflozin	HTN + DM + CKD; HFrEF/HFpEF — modest BP-lowering (~3–5 mmHg)	1 A (cardiorenal benefit)

Treatment Initiation by BP Category and CV Risk

BP Category	CV Risk	Initial Approach	COR/LOE
Elevated BP (120–139/70–89)	Low / Moderate	Lifestyle only; re-assess in 3–6 months	1 B
Elevated BP (120–139/70–89)	High (CVD, DM, CKD, FH)	Lifestyle + consider drug therapy if confirmed BP ≥130/80 with SCORE2 ≥10%	1 A
Hypertension (140–159/90–99)	Low / Moderate	Lifestyle × 3 months → if BP still above target, start combination drug therapy	1 A
Hypertension (140–159/90–99)	High	Lifestyle + combination drug therapy immediately	1 A
Hypertension (≥160/100)	Any	Lifestyle + combination drug therapy immediately	1 A

Pearl: Beta-blockers are NOT first-line for uncomplicated hypertension. They are recommended only when there is a compelling indication (post-MI, HFrEF, angina, AF rate control, or pregnancy).

Pitfall: Chlorthalidone and indapamide are preferred over HCTZ — they have longer duration of action and stronger evidence for CV outcome reduction. Consider switching patients on HCTZ to chlorthalidone 12.5–25 mg.

Pitfall: Thiazide (HCTZ) is NOT the same as thiazide-like (chlorthalidone, indapamide). The 2024 guideline recommends thiazide-LIKE diuretics as the preferred class for first-line combination therapy.

Resistant Hypertension

Definition: Office BP ≥140/90 mmHg (or home BP ≥135/85, or 24h ABPM ≥130/80) despite treatment with ≥3 antihypertensive drugs at maximally tolerated doses, one of which is a diuretic, with confirmed adherence.

Resistant Hypertension Management Algorithm (Fig 22)

Step 1 — Confirm true resistance: Verify BP is elevated on ABPM (exclude white-coat effect). Confirm patient is actually taking medications (directly observed therapy, drug levels in urine/blood if available).

Step 2 — Exclude pseudo-resistance: Non-adherence (most common cause), white-coat effect, incorrect BP measurement technique, suboptimal drug doses, interfering substances (NSAIDs, decongestants, OCPs, stimulants, liquorice, excess alcohol).

Step 3 — Screen for secondary causes: Primary aldosteronism (ARR), renal artery stenosis, OSA, CKD, pheochromocytoma. See Secondary HTN section.

Step 4 — Add spironolactone 25–50 mg/day: Strongest evidence for fourth-line add-on therapy. Monitor K⁺ and creatinine at 1–2 weeks. Avoid if K⁺ >4.5 mmol/L or eGFR <30. 1 LOE A

Step 5 — If spironolactone intolerant: Bisoprolol, doxazosin, amiloride, or eplerenone as alternatives. 2b LOE B

Step 6: If still uncontrolled after optimised quad therapy → consider specialist referral. Renal denervation is NOT recommended as first-line. 3 LOE C

Pearl: Spironolactone has the strongest evidence of any add-on therapy for resistant HTN (PATHWAY-2 trial). 1 LOE A. Start at 25 mg/day and uptitrate to 50 mg if K⁺ remains <5.0 mmol/L.

Pitfall: Up to 50% of "resistant" HTN is actually pseudo-resistance. The most common cause is medication non-adherence — studies using urine drug screening show non-adherence rates of 25–65% in resistant HTN populations. Always verify adherence before escalating therapy.

Pitfall: Renal denervation is NOT recommended as first-line therapy for hypertension 3 LOE C, and is NOT recommended for patients with eGFR <40 mL/min/1.73m². 3 LOE C

Secondary Hypertension

Screen for secondary causes in: all young adults (<40) with HTN, all patients with resistant HTN, hypokalemia, adrenal incidentaloma, or clinical features suggestive of an identifiable cause. 1 LOE B

Screening Tests by Cause

Cause	Screening Test	Prevalence in HTN	Key Clinical Clues
Primary aldosteronism	Aldosterone-to-renin ratio (ARR)	5–10%	Resistant HTN, hypokalemia (spontaneous or diuretic-induced), adrenal incidentaloma
Renal artery stenosis	Duplex US, CT angiography, MR angiography	1–5%	Abdominal bruit, flash pulmonary edema, >30% ↑creatinine with ACEi/ARB
Pheochromocytoma	24h urine metanephrines OR plasma free metanephrines	<1%	Paroxysmal HTN, palpitations, headache, sweating (classic triad)
Cushing syndrome	24h urinary free cortisol, overnight dexamethasone suppression, midnight salivary cortisol	<1%	Central obesity, striae, moon facies, proximal myopathy, glucose intolerance
Thyroid disease	TSH, free T4	1–3%	Hyper: ISH, tachycardia. Hypo: diastolic HTN, bradycardia
Primary renal disease	eGFR, urine ACR, renal US	2–5%	Elevated creatinine, proteinuria, abnormal renal morphology
Obstructive sleep apnoea	STOP-BANG questionnaire, polysomnography	25–50% (in resistant HTN)	Snoring, daytime somnolence, obesity, nocturnal HTN on ABPM
Coarctation of aorta	Arm–leg BP gradient, CT/MR aortography	Rare	Young adults, upper limb HTN with weak femoral pulses, radio-femoral delay

Primary Aldosteronism Screening Algorithm (Fig 13)

Step 1 — Who to screen: All resistant HTN, hypokalemia (spontaneous or diuretic-induced), adrenal incidentaloma, early-onset HTN (<40 years), or family hx of early HTN/stroke.

Step 2 — Test: Measure morning ARR (aldosterone-to-renin ratio). Hold interfering drugs 2–4 weeks if possible. DHP CCBs and alpha-blockers have least effect on ARR.

Step 3 — Positive screen: → Confirmatory testing (salt loading, fludrocortisone suppression, or captopril challenge).

Step 4 — If confirmed: CT adrenals → adrenal vein sampling if surgical candidate → unilateral adrenalectomy vs. MRA (spironolactone/eplerenone) for bilateral disease.

Pearl: Primary aldosteronism is FAR more common than previously thought (5–10% of all HTN, higher in resistant HTN). It is the most common curable cause of secondary HTN — yet it remains vastly underdiagnosed because ARR is not routinely checked.

Pitfall: Multiple drugs affect the ARR: beta-blockers suppress renin → falsely ↑ ARR (false positive); ACEi/ARBs/MRAs increase renin and suppress aldosterone → falsely ↓ ARR (false negative). DHP CCBs and alpha-blockers have the least effect and can be used as bridge therapy during screening.

Special Populations

Hypertension in Pregnancy

Recommendation	COR/LOE
Initiate drug Rx when confirmed office SBP ≥140 or DBP ≥90 mmHg (gestational or chronic HTN)	1 B
Target BP: <140/90 but do NOT lower DBP below 80 mmHg (placental perfusion risk)	1 C
First-line drugs: DHP CCBs (nifedipine ER preferred), labetalol, methyldopa	1 C
RAS blockers (ACEi/ARBs) are CONTRAINDICATED — teratogenic (fetal renal agenesis, oligohydramnios)	3 B
Pre-eclampsia/eclampsia crisis: IV labetalol or nicardipine + IV magnesium sulfate	1 C
Low- to moderate-intensity exercise recommended in all pregnant women without contraindications to reduce GH/pre-eclampsia risk	1 B

Pitfall: ACEi and ARBs are TERATOGENIC — discontinue immediately if pregnancy is confirmed or planned. Switch to pregnancy-safe alternatives (nifedipine ER, labetalol, methyldopa).

Diabetes Mellitus

Recommendation	COR/LOE
BP threshold for drug Rx: Confirmed BP ≥130/80 mmHg (after max 3 months lifestyle in low-risk; immediately in high-risk)	1 A
Target SBP: 120–129 mmHg if tolerated	1 A
Pre-diabetes / obesity: Drug Rx if BP ≥140/90 OR when CVD risk ≥10% and BP 130–139/80–89	1 A
SGLT2 inhibitors recommended for HTN + DM + CKD with eGFR >20 mL/min/1.73m²	1 A
First-line: RAS blocker (ACEi or ARB) — renoprotective in diabetic nephropathy	1 A

Pearl: In diabetes, the BP treatment threshold is LOWER (≥130/80) than the general population (≥140/90). This reflects the higher CV risk in diabetic patients.

Chronic Kidney Disease

Recommendation	COR/LOE
Drug Rx threshold: Confirmed BP ≥130/80 mmHg	1 A
Target SBP: 120–129 mmHg if eGFR >30; individualize for lower eGFR or transplant. → Calculate eGFR	1 A
First-line: RAS blocker (ACEi or ARB) — slows CKD progression + reduces proteinuria	1 A
SGLT2 inhibitor if eGFR >20 mL/min/1.73m² — reduces CKD progression + CV events	1 A
Renal denervation NOT recommended if eGFR <40 mL/min/1.73m²	3 C

Estimate renal function: CKD-EPI eGFR | Cockcroft-Gault CrCl

Cardiac Disease

Condition	Recommended Regimen	COR/LOE
Post-MI	Beta-blocker + RAS blocker (ACEi/ARB)	1 A
Symptomatic angina	Beta-blocker + CCB (DHP or non-DHP)	1 A
HFrEF / HFmrEF	ACEi (or ARNi) + beta-blocker + MRA + SGLT2i	1 A
HFpEF	SGLT2 inhibitor for modest BP-lowering + outcome benefit	1 A
Stroke prevention	RAS blocker + CCB or thiazide-like diuretic. Target SBP 120–129.	1 A
AF + HTN	RAS blocker preferred (may reduce AF recurrence). Assess stroke risk: CHA₂DS₂-VASc	1 A

Elderly and Frail Patients (≥85 years)

Recommendation	COR/LOE
Treat as younger adults if not moderately-to-severely frail and treatment is well tolerated	1 A
Maintain treatment lifelong — continue even beyond age 85 years	1 A
Test orthostatic BP before starting or intensifying: lie 5 min → measure BP at 1 and 3 min standing	1 B
Orthostatic hypotension: Non-pharmacological approaches first (slow position changes, compression stockings, adequate hydration). Switch to drugs less likely to cause OH.	1 A

Pearl: Age alone is NOT a reason to withhold antihypertensive therapy. Even patients ≥85 years benefit from treatment if tolerated. The key is monitoring for orthostatic hypotension and frailty.

Stroke and TIA

Recommendation	COR/LOE
Post-ischaemic stroke/TIA: Start BP-lowering therapy before hospital discharge	1 B
Target SBP: 120–129 mmHg if tolerated	1 A
Preferred regimen: RAS blocker + CCB or thiazide-like diuretic	1 A
Acute ICH with SBP ≥220: Do NOT acutely reduce SBP by >70 mmHg from initial levels in first hour	3 B

Pitfall: In acute intracerebral haemorrhage, rapid aggressive BP lowering (dropping SBP by >70 mmHg in the first hour) can worsen outcomes. Gradual, controlled reduction is safer.

Hypertensive Emergencies & Urgencies

Hypertensive Emergency: SBP ≥180 and/or DBP ≥120 mmHg WITH acute hypertension-mediated organ damage (HMOD): hypertensive encephalopathy, acute heart failure/pulmonary edema, acute coronary syndrome, aortic dissection, eclampsia, acute renal failure, or retinal haemorrhages/papilloedema.

Emergency Management Algorithm

Step 1: ICU/monitored setting. Consider intra-arterial BP monitoring for continuous titration.

Step 2: IV antihypertensives — choose based on clinical scenario:
• Labetalol 20–80 mg IV bolus → 0.5–2 mg/min infusion (most versatile)
• Nicardipine 5–15 mg/h IV infusion (good for stroke, renal impairment)
• Nitroprusside 0.5–10 μg/kg/min (for acute HF; watch cyanide toxicity)
• Esmolol 500 μg/kg bolus → 50–200 μg/kg/min (aortic dissection, perioperative)
• Urapidil 12.5–25 mg IV bolus (widely used in Europe)

Step 3 — BP targets:
• General: reduce BP by 20–25% in first 1–2 hours
• Aortic dissection: SBP <120 mmHg within 20 minutes + HR <60 bpm
• Ischaemic stroke (thrombolysis candidate): SBP <185/110 before tPA

Step 4: Gradual further reduction over 24–48 hours toward target. Avoid overshoot — excessive lowering risks stroke, MI, or acute kidney injury.

Hypertensive Urgency: SBP ≥180 and/or DBP ≥120 mmHg WITHOUT acute HMOD. Manage with oral agents (restart or intensify existing therapy), close follow-up within 24–72 hours. No ICU required.

Pitfall: Avoid immediate-release (sublingual) nifedipine — it causes unpredictable, precipitous BP drops. Use only IV titratable agents in emergencies.

Pearl: The distinction between emergency (HMOD present) and urgency (no HMOD) is critical. Urgencies do NOT require IV agents or ICU — oral dose adjustments with close follow-up are appropriate.

Key Do's and Don'ts

DO

Measure out-of-office BP (ABPM or HBPM) in ALL patients for diagnostic confirmation and treatment monitoring. 1 LOE B
Use a risk-based approach — calculate SCORE2 for patients without established high-risk conditions.
Start combination therapy (RAS blocker + CCB or diuretic) for most patients with confirmed HTN ≥140/90. 1 LOE B
Prescribe single-pill combinations (SPC) to improve adherence and BP control. 1 LOE B
Target SBP 120–129 mmHg (treated values) in most adults. 1 LOE A
Screen for secondary HTN in all young adults (<40) and patients with resistant HTN. 1 LOE B
Test for orthostatic hypotension in elderly patients before starting or intensifying therapy. 1 LOE B
Add spironolactone 25–50 mg as 4th-line for resistant hypertension. 1 LOE A
Continue BP-lowering treatment lifelong, even beyond age 85 years if tolerated. 1 LOE A

DON'T

Combine ACEi + ARB — increased hyperkalaemia, syncope, and renal dysfunction risk. 3 LOE A
Use renal denervation as first-line therapy for any form of hypertension. 3 LOE C
Withhold treatment based on age alone — benefit persists even in patients ≥85 years.
Aggressively lower BP in acute ICH if SBP <220 mmHg (avoid >70 mmHg drop in 1st hour). 3 LOE B
Diagnose hypertension without confirming with out-of-office BP (misses ~25% white-coat HTN).
Use RAS blockers (ACEi/ARBs) in pregnancy — they are TERATOGENIC. 3 LOE B
Order routine genetic testing for monogenic hypertension in unselected patients. 3 LOE C
Use SCORE2 in patients with established CVD, DM, CKD, or FH — they are automatically high risk.
Use HCTZ when chlorthalidone or indapamide are available — thiazide-like diuretics have stronger CV outcome evidence.