Hypertension — Management Guideline
Source: ESC Guidelines for the Management of Elevated Blood Pressure and Hypertension, European Heart Journal, 2024
Guideline: Strong
Guideline: Conditional
Guideline: Not recommended
ClinicoQ pathway suggestion (not from the cited guideline)
Diagnosis
Diagnostic criteria
Office blood pressure ≥140/90 mmHg on repeated measurement confirms hypertension. An 'elevated BP' category (120–139/70–89 mmHg) is also recognized. Out-of-office monitoring is recommended to confirm diagnosis.
⚠ Alarm features (investigate before diagnosing)
- Severely elevated BP (≥180/120 mmHg) with symptoms of end-organ damage — hypertensive emergency
- Sudden-onset severe hypertension in a young patient (consider secondary causes)
- Signs of target-organ damage: papilledema, new neurological deficit, acute kidney injury, acute pulmonary edema
Initial workup
| Test | When to order |
|---|---|
| Home or ambulatory BP monitoring | To confirm diagnosis before starting treatment, unless BP is severely elevated. |
| Basic metabolic panel, lipid panel, urinalysis | At diagnosis, to assess cardiovascular risk and screen for secondary causes. |
| ECG | At diagnosis, to screen for LVH or prior cardiac disease. |
| Secondary hypertension workup | Resistant hypertension, onset before age 30, or clinical features suggesting a secondary cause. |
Treatment
Standard risk
1
Low-dose combination therapy (2 agents), preferably as a single pill
Strong (Guideline recommendation)
- Dose
- Combine two of: ACE inhibitor or ARB, dihydropyridine CCB (e.g., amlodipine 5 mg), thiazide-like diuretic
- Duration
- Ongoing, reassess at 2–4 weeks
- Evidence level
- High
- Avoid if
- ACEi/ARB in pregnancy or bilateral renal artery stenosis; CCB-related edema intolerance
- If no response ClinicoQ pathway
- Titrate to full dose, then add a third agent (e.g., spironolactone) if BP remains above target
2
Add spironolactone for resistant hypertension
Conditional (Guideline recommendation) — for resistant hypertension after a 3-drug regimen
- Dose
- 25 mg once daily, titrate as tolerated
- Duration
- Ongoing
- Evidence level
- Moderate
- Avoid if
- Hyperkalemia; significant renal impairment
- If no response ClinicoQ pathway
- Add a beta-blocker (third-line unless a compelling indication exists) or refer for evaluation of secondary causes / renal denervation
High cardiovascular risk or diabetes
1
Start therapy once BP ≥130/80 mmHg (rather than waiting for 140/90)
Strong (Guideline recommendation)
- Dose
- Same first-line combination as above
- Duration
- Ongoing
- Evidence level
- High
- Avoid if
- Same as above
- If no response ClinicoQ pathway
- Intensify treatment to reach a target systolic BP of 120–129 mmHg if tolerated
✕ Treatments the guideline advises against
Beta-blockers as first-line therapy: Guideline explicitly downgrades beta-blockers from first-line to third-line, reserved for a compelling indication (e.g., prior MI, HFrEF) or contraindication to preceding drug classes.
⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.