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CTRCD, treatment of hypertension with ACE-I or ARB as first-line therapy is recommended to reduce the risk of CTRCD. Combination therapy with an ACE-I or ARB and a dihydropyridine CCB is recommended in patients with cancer with systolic BP ≥ 160 mmHg and diastolic BP ≥100 mmHg due to the more rapid onset of BP control with the combination compared with ACE-I/ARB monotherapy (Figures 33 and 34). If severe hypertension is diagnosed (systolic BP ≥180 mmHg or diastolic BP ≥110 mmHg), the competing cancer and CV risks should be evaluated by a MDT, and any cancer therapy associated with hypertension should be deferred or temporarily withheld until the BP is controlled to values ,160 mmHg (systolic BP) and ,100 mmHg (diastolic BP). Culprit cancer therapy can be restarted once BP is controlled, with consideration for dose reduction. In patients with resistant cancer therapy-related hypertension, spironolactone, oral or transdermal nitrates, and/or hydralazine should be considered. In patients with cancer with evidence of high sympathetic tone, stress, and/or pain, beta-blockers including carvedilol or nebivolol should be considered. Diuretics, preferably spironolactone, may be considered in patients with cancer with hypertension and evidence of increased fluid retention, with monitoring of BP, electrolytes, and renal function.

The decisions to initiate BP treatment and BP targets during the management of cancer-drug induced hypertension depend upon the context of the cancer and prognosis (Figure 34). CS should be treated according to the 2018 ESC/European Society of Hypertension (ESH) Guidelines for the management of arterial hypertension.138

Recommended threshold for asymptomatic hypertension treatment

in differentclinicalscenarios

CS Home BP mmHg Curable cancer during treatment Metastatic cancer Prognosis >3 years Metastatic cancer Prognosis 1–3 years Metastatic cancer Prognosis <1 year

160+ Treat Treat Treat Treat Treat

140–159 Treat Treat Treat Consider treatment May treat

135–139 Treat May treat Consider treatment May treat None

130–134 May treat None None None None

<130 None None None None None

Class 1 Class 1Ia Class 1Ib

Figure 33 Recommended threshold for asymptomatic hypertension treatment in different clinical scenarios. BP, blood pressure; CS, cancer survivors. Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026