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..................................... people across Europe, over 1 billion globally, with a prevalence of 3045% in adults, increasing with age to more than 60% in people aged >60 years, and accounting for 10 million deaths globally per annum.577 Despite extensive evidence for the effectiveness of BPlowering treatments at reducing CVD risk and death, the detection, treatment, and control of BP in Europe and globally remains suboptimal.578

This section covers recommendations for the diagnosis and treatment of hypertension to be applied in routine primary and secondary care. More detail and guidance for complex cases/tertiary care are available in the 2018 ESC/European Society of Hypertension (ESH) Guidelines for the management of arterial hypertension.4

Summary of recommendations for the clinical management of hypertension

Recommendations Classa Levelb

Classification of BP It is recommended that BP should be classified as optimal, normal, high-normal, or grades 1 - 3 hypertension, according to office BP. I C 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 in high-risk patients) or  Out-of-office BP measurement with ABPM and/ or HBPM when feasible. I I C

C

Assessment of HMOD To evaluate for the presence of HMOD, measurement of serum creatinine, eGFR, electrolytes, and ACR is recommended for all patients. A 12lead ECG is recommended for all patients, and echocardiography is recommended for those with ECG abnormalities or signs/symptoms of LV dysfunction. Fundoscopy or retinal imaging is recommended for patients with grades 2 or 3 hypertension and all hypertensive patients with DM.548551 I B Thresholds for initiation of drug treatment of hypertension For grade 1 hypertension, treatment initiation based on absolute CVD risk, estimated lifetime benefit, and the presence of HMOD is recommended.552,553 I C For patients with grade 2 hypertension or higher, drug treatment is recommended.4,552 I A Office BP treatment targets It is recommended that the first objective of treatment is to lower BP to <140/90 mmHg in all patients, and that subsequent BP targets are tailored to age and specific comorbidities.552,554 I A In treated patients aged 1869 years, it is recommended that SBP should ultimately be lowered to a target range of 120 - 130 mmHg in most patients.552,554556 I A In treated patients aged >_70 years, it is recommended that SBP should generally be targeted to <140 and down to 130 mmHg if tolerated.552,554,557 I A In all treated patients, DBP is recommended to be lowered to <80 mmHg.555,558,559 I A Treatment of hypertension: lifestyle interventions Lifestyle interventions are recommended for people with high-normal BP or higher.c I A

Continued Treatment of hypertension: drug treatment

It is recommended to initiate antihypertensive treatment with a two-drug combination in most patients, preferably as a single-pill combination. Exceptions are frail older patients and those with low-risk, grade 1 hypertension (particularly if SBP <150 mmHg).560565 I B It is recommended that the preferred combinations include a RAS blocker (i.e. an ACE inhibitor or ARB) with a CCB or diuretic, but other combinations of the five major classes can be used (ACE inhibitor, ARB, beta-blocker, CCB, thiazide/thiazide-like diuretic).566569 I A It is recommended, if BP remains uncontrolled with a two-drug combination, that treatment be increased to a three-drug combination, usually a RAS blocker with a CCB and a diuretic, preferably as a single-pill combination.563,570,571 I A It is recommended, if BP is not controlled by a three-drug combination, that treatment should be increased by the addition of spironolactone, or if not tolerated, other diuretics such as amiloride or higher doses of other diuretics, an alpha-blocker or beta-blocker, or clonidine.555,572574 I B The combination of two RAS blockers is not recommended.575,576 III A Management of CVD risk in hypertensive patients Statin therapy is recommended for many patients with hypertension.d Section 4.6 Antiplatelet therapy is indicated for secondary prevention in patients with hypertension.e Section 4.9

ABPM = ambulatory blood pressure monitoring; ACE = angiotensin-converting enzyme; ACR = albumin-to-creatinine ratio; ARB = angiotensin receptor blocker; ASCVD = atherosclerotic cardiovascular disease; BP = blood pressure; CCB = calcium channel blocker; DBP = diastolic blood pressure; DM = diabetes mellitus; ECG = electrocardiogram; eGFR = estimated glomerular filtration rate; HBPM = home blood pressure monitoring; HMOD = hypertension-mediated organ damage; LV = left ventricular; RAS = reninangiotensin system; SBP = systolic blood pressure. aClass of recommendation. bLevel of evidence. cSee section 4.3 for details. dSee section 4.6 for details. eSee section 4.9 for details. ESC 2021

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