Arterial Hypertension Clinical Practice Guidelines (2018)

European Society of Cardiology/European Society of Hypertension

Reviewed and summarized by Medscape editors

October 02, 2018

The guidelines on management of arterial hypertension were released on September 1, 2018, by the ESC/ESH.[1]

Classification of Office Blood Pressure (BP)

It is recommended that BP be classified and hypertension graded as follows:

  • Optimal – Systolic BP (SBP) <120 mm Hg and diastolic BP (DBP) <80 mm Hg

  • Normal – SBP 120-129 mm Hg and/or DBP 80-84 mm Hg

  • High normal - SBP 130-139 mm Hg and/or DBP 85-89 mm Hg

  • Grade 1 - SBP 140-159 mm Hg and/or DBP 90-99 mm Hg

  • Grade 2 - SBP 160-179 mm Hg and/or DBP 100-109 mm Hg

  • Grade 3 - SBP ≥180 mm Hg and/or DBP ≥110 mm Hg

  • Isolated systemic hypertension - SBP ≥140 mm Hg and DBP < 90 mm Hg


Office BP Thresholds for Initiation of Pharmacotherapy

Grade 2/3 with any level of cardiovascular (CV) risk - Prompt initiation of BP-lowering drug treatment is recommended, simultaneously with initiation of lifestyle changes.

Grade 1 - Lifestyle interventions are recommended; if CV risk is low and there is no evidence of hypertension-mediated organ damage (HMOD), BP-lowering drug treatment is recommended if hypertension persists after a period of lifestyle intervention; if CV risk is high or there is evidence of HMOD, prompt initiation of drug treatment is recommended simultaneously with lifestyle interventions.

Fit older patients with hypertension (even >80 yr) - BP-lowering drug treatment and lifestyle intervention are recommended when SBP is ≥160 mm Hg.

Fit older patients (>65 yr but not >80 yr) with grade 1 SBP - BP-lowering drug treatment and lifestyle intervention are recommended, provided that treatment is well tolerated.

Patients with high-normal BP - Lifestyle changes are recommended.

Withdrawal of BP-lowering drug treatment on the basis of age (even ≥80 yr) is not recommended, provided that treatment is well tolerated.

Office BP Treatment Targets

First objective of treatment - Lower BP to <140/90 mm Hg in all patients; if treatment is well tolerated, treated BP values should be targeted to 130/80 mm Hg or lower in most patients.

Patients <65 yr receiving BP-lowering drugs - Lowering SBP to 120-129 mm Hg is recommended in most patients.

Patients ≥65 yr receiving BP-lowering drugs – Target SBP range of 130-139 mm Hg is recommended.

Lifestyle Interventions for Hypertension

Restriction of salt to <5 g/day is recommended.

Restriction of alcohol to <14 units/wk for men and <8 units/wk for women is recommended, along with avoidance of binge drinking.

Increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil); low consumption of red meat; and consumption of low-fat dairy products are recommended.

Body weight control is indicated to avoid obesity and aim for healthy body mass index (BMI; ~20-25 kg/m2) and waist circumference (<94 cm in men; <80 cm in women).

Regular aerobic exercise (eg, ≥30 min moderate dynamic exercise, 5-7 days/wk) is recommended.

Smoking cessation and supportive care and referral to smoking cessation programs are recommended.

Pharmacologic Treatment of Hypertension

Combination treatment is recommended for most hypertensive patients as initial therapy, preferably including a renin-angiotensin system (RAS) blocker (angiotensin-converting enzyme [ACE] inhibitor or angiotensin-receptor blocker [ARB]) with a calcium-channel blocker (CCB) or diuretic; other combinations of the five major classes can be used. It is recommended to combine beta blockers with any of the other major drug classes when specific clinical situations require it.

Recommended initial antihypertensive treatment - A two-drug combination, preferably in a single-pill combination (SPC)—except in (a) frail older patients and (b) patients with low CV risk and with grade 1 hypertension (particularly SBP <150 mm Hg).

Recommended treatment if BP is not controlled with a two-drug combination - Increase to a three-drug combination, usually an RAS blocker with a CCB and thiazide/thiazidelike diuretics, preferably as an SPC.

Recommended treatment if BP is not controlled with a three-drug combination - Addition of spironolactone or, if this is not tolerated, other diuretics such as amiloride or higher doses of other diuretics, a beta blocker, or an alpha blocker.

The combination of two RAS blockers is not recommended.

Device-Based Treatment of Hypertension

Device-based therapies are not currently recommended for routine treatment.

Management of CVD Risk in Hypertensive Patients

CV risk assessment with SCORE system - Recommended for patients not already at high or very high CV risk from established CV disease (CVD), renal disease, or diabetes.

Statins – Recommended for patients at high or very high CV risk.

Antiplatelet therapy (in particular low-dose aspirin) - Recommended for secondary prevention.

Aspirin - Not recommended for primary prevention in patients without CVD.

Routine genetic testing - Not recommended.


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