New ESH Hypertension Guidelines Aim for Simplified Message

1 Jul 2023 • The European Society of Hypertension (ESH) has released an updated, comprehensive hypertension guideline, which has many parts that are similar to a previous 2018 document but which also expands on other areas, like the management of high blood pressure in specific patient populations and in the presence of various comorbidities.

While there are no major surprises in the guidelines, there are multiple advances and added-value changes, including clear advice on how to measure blood pressure, an upgrade for beta-blockers in the treatment algorithms, and a new definition and treatment recommendations for "true resistant hypertension."


  • The definition of hypertension remains unchanged from the previous guidelines ― repeated office systolic blood pressure values of ≥140 mm Hg and/or diastolic blood pressure values of ≥90 mm Hg.
  • Use of out-of-office blood pressure measurement, particularly home measurement, has been deemed as useful in long-term management. The preferred method is automated cuff-based blood pressure measurement.
  • On thresholds for initiating antihypertensive therapy, the guidelines recommend that treatment be initiated for most patients when systolic blood pressure is ≥140 mm Hg or diastolic blood pressure is ≥90 mm Hg.
  • Co-chair of the task force, Dr. Kreutz noted that the new guidelines have tried to simplify recommendations on target pressures. "We have tried to simplify guidance to focus on a target of around 130 for almost all patients. Before, it wasn't so clear. There were different targets for different groups of patients with various comorbidities or older patients. But now we are saying the range of 120 to 139 is suitable for the vast majority of patients."
  • They advise starting with a two-drug combination for most patients. The preferred combinations including a renin-angiotensin blocker (either an ACE inhibitor or an ARB) with a calcium blocker or a thiazide/thiazide-like diuretic, preferably in a single-pill combination to reduce pill burden and improve adherence and outcome.
  • A new feature of the guidelines is the upgrading of beta-blockers in the treatment algorithms. "We are now positioning beta-blockers as drugs that can be used at any step of the treatment algorithm if there is a guideline directed indication or other conditions for which they are thought to be beneficial."
  • The guidelines also recommend that all drugs be given as once-daily preparations and that they be taken preferably in the morning.
  • The guidelines have introduced a new term, "true resistant hypertension," defined as systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg in the presence of the following conditions: the maximum recommended and tolerated doses of a three-drug combination comprising a renin-angiotensin system blocker (either an ACE inhibitor or an ARB), a calcium blocker, and a thiazide/thiazide-like diuretic were used; inadequate blood pressure control has been confirmed by ambulatory (preferable) or home blood pressure measurement; and various causes of pseudo-resistant hypertension (especially poor medication adherence) and secondary hypertension have been excluded.
  • For these patients with true resistant hypertension, two treatment approaches are recommended.
  • For those who do not have advanced kidney disease (glomerular filtration rate >40 mL/min), renal denervation can be considered. This is a new II B recommendation.

Source: Medscape | Read full story

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