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• Assess risk factors for ASCVD (see section 3.2), or the presence of cardiac, vascular, or renal disease • Detect evidence of HMOD, e.g. LV hypertrophy, renal disease, or retinopathy • Consider potential secondary causes of hypertension, e.g. renovascular disease, hyperaldosteronism, or pheochromocytoma (see Table 17). Also, carefully evaluate substance abuse (e.g. cocaine), drugs that may increase BP (e.g. cyclosporine, sympaticomimetics), liquorice, etc. More detail on work-up of suspected secondary hypertension is provided elsewhere.4 Echocardiography is recommended in patients with ECG abnormalities, and should be considered when the result will influence clinical decision-making. Fundoscopy is recommended in grade 2 or 3 hypertension and in all patients with DM. The routine measurement of other biomarkers and use of vascular imaging are not recommended.548551

4.7.5. Treatment of hypertension The treatment of hypertension involves lifestyle interventions for all patients and drug therapy for most patients.

4.7.5.1 Lifestyle interventions to lower blood pressure and/or reduce cardiovascular risk Lifestyle interventions are indicated for all patients with high-normal BP or hypertension because they can delay the need for drug treatment or complement the BP-lowering effect of drug treatment. Moreover, most lifestyle interventions have health benefits beyond their effect on BP. Lifestyle is discussed extensively in section 4.3.

4.7.5.2 Initiation of drug treatment Drug treatment decisions in CVD prevention are mostly based on absolute CVD risk, risk modifiers, comorbidities, estimated benefit of treatment, frailty, and patient preferences. The same is true for hypertension. Drug treatment of grade 1 hypertension (SBP 140 - 159 mmHg) has level A evidence for reducing CVD risk. In younger patients, however, the absolute 10-year CVD risk is often low, and lifetime benefit of treatment should be considered and communicated before instituting treatment (Figure 6 and section 3.2.3.6). In many such cases, the absolute lifetime benefit per 10-mmHg reduction in SBP is at least moderate to high [Figure 15 (lifetime benefit calibrated in low-to-moderate CVD risk countries]. Also, the presence of HMOD mandates treatment of grade 1 hypertension. For grade 2 hypertension or higher (SBP >160 mmHg), treatment is recommended, because not only is the lifetime benefit of reducing BP almost universally high in such patients, there is also the importance of reducing the risk of HMOD resulting in other morbidities such as renal disease, haemorrhagic cerebrovascular disease, and HF.

4.7.5.3 Blood pressure treatment targets When drug treatment is used, the aim is to control BP to target within 3 months. Evidence now suggests that the BP targets in the previous iteration of this guideline2 were too conservative, especially for older patients. In line with the stepwise approach (section 3.2.3.1), it is now recommended that the first step in all treated patients should achieve a treated SBP <140 mmHg and diastolic BP (DBP) <80 mmHg.552,554 The recommended ultimate SBP treatment target range for younger patients (1869 years) is 120130 mmHg, although some patients may safely achieve lower treated SBP levels than this and, if they are well tolerated, there is no need to backtitrate treatment.552,554556 The ultimate target SBP for patients aged >_70 years is <140 mmHg and down to 130 mmHg if tolerated.552,554,557,580 This change in the BP target range for older people compared with the 2016 ESC prevention guidelines2 is supported by evidence that these treatment targets are safely achieved in many older patients and are associated with significant reductions in the risk of major stroke, HF, and CV death.557,580 It also takes into account that the even lower SBP in the intensively treated group in SPRINT (Systolic Blood Pressure Intervention Trial) (mean 124 mmHg) probably reflects a conventional office SBP range of 130139 mmHg.555 It is recognized, however, that the evidence supporting more strict targets is less strong for very old people (>80 years) and those who are frail. Also, in these older and especially frail

Table 16 Routine tests for patients with hypertension

Routine tests Haemoglobin and/or haematocrit Fasting blood glucose and/or HbA1c Blood lipids: total cholesterol, LDL-C, HDL-C, triglycerides Blood potassium and sodium Blood uric acid Blood creatinine and eGFR Blood liver function tests Urine analysis: microscopic; urinary protein by dipstick or, ideally, ACR 12-lead ECG ACR = albumin-to-creatinine ratio; ECG = electrocardiogram; eGFR = estimated glomerular filtration rate; HbA1c = glycated haemoglobin; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol. Table 17 Patient characteristics that should raise the suspicion of secondary hypertension.

Characteristics Younger patients (<40 years) with grade 2 hypertension or onset of any grade of hypertension in childhood Acute worsening of hypertension in patients with previously documented chronically stable normotension Resistant hypertension (BP uncontrolled despite treatment with optimal or best-tolerated doses of three or more drugs including a diuretic, and confirmed by ABPM or HBPM) Severe (grade 3) hypertension or a hypertension emergency Presence of extensive HMOD Clinical or biochemical features suggestive of endocrine causes of hypertension or CKD Clinical features suggestive of OSA Symptoms suggestive of pheochromocytoma or family history of pheochromocytoma ABPM = ambulatory blood pressure monitoring; BP = blood pressure; CKD = chronic kidney disease; HBPM = home blood pressure monitoring; HMOD = hypertension-mediated organ damage; OSA = obstructive sleep apnoea. Adapted from 4

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