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Blood pressure

Blood pressure control

Blood pressure (BP) control is a crucial component of all strategies to prevent cardiovascular disease (CVD), stroke and kidney failure. Primordial prevention of developing arterial hypertension is part of all population strategies. In people with elevated BP, the initiation of therapy will be based on the total CVD risk and on the BP level. Appropriate lifestyle modifications can reduce BP and are always the first step to take whether or not with (immediate) drug therapy. Different antihypertensive drug classes are available to control BP if lifestyle changes alone fail to do so. The choice of the drugs will depend on co-morbidities, efficacy and safety of the drugs and on economic issues. The BP target is generally a level < 140/90 mmHg, which may vary in the elderly and in patients with diabetes mellitus.

Observational cohort studies from all over the world have shown that the arterial blood pressure (BP) bears an independent and continuous relationship with the incidence of ischaemic heart disease, stroke, heart failure, peripheral artery disease and chronic kidney disease (CKD) [1-5].

Randomised controlled trials have demonstrated that BP reduction is associated with prevention of different clinical entities of cardiovascular disease (CVD).

Definitions and categories

Although no biological distinction can be made between “normal BP” and “hypertension” (HT), clinical practice requires definitions and categories of BP; they have been defined based on either office BP levels or out-of-office levels. These categories are given in table 1. Ambulatory blood pressure monitoring (ABPM) is the best method to establish the diagnosis of HT (true, white, masked hypertension).

Definitions and classification of office BP levels and out-of-office hypertension levels

Category Systolic BP   Diastolic BP
Office BP
Optimal  < 120  and  < 80
Normal  120 - 129  and/or  80 - 84
High normal  130 - 139  and/or  85 - 89
Grade 1 HT  140 - 159  and/or  90 - 99
Grade 2 HT  160 - 179  and/or  100 - 109
Grade 3 HT  >=180  and/or  >=110
Isolated Systolic HT  >=140  and  < 90
Ambulatory HT
Daytime >= 135     >= 85
Night-time  >= 120    >= 70
24-hour  >= 130    >= 80
Home HT  >= 135    >= 85

HT: hypertension


For the prevention of CVD, the primordial goal is to prevent the development of high BP with age. This can be achieved by lifestyle adaptations from childhood onwards. One should keep BP at optimal levels by maintaining sufficient exercise, an ideal body mass index (BMI) and a well-balanced diet.

Unfortunately, the majority of Europeans do not follow these recommendations and develop high BP in adulthood or later in life. The age-standardized prevalence of raised BP in the population aged 18+ years in European countries in 2014 varied between 15 and 32% [6].

The decision to start a BP-lowering drug treatment depends on the BP level and on the total CVD risk of the patient. The total CVD risk can be estimated and four different categories were defined in the 2016 ESC guidelines on CVD prevention in clinical practice [1]. Immediate drug treatment is recommended in patients with grade 3 HT, irrespective of the total CV risk as well as in patients with grade 1 or 2 HT who are at very high CVD risk. Drug treatment should also be considered in patients with grade 1 or 2 HT who have a high risk of CVD. In patients with a low or moderate total CVD risk with grade 1 or 2 HT, lifestyle measures are recommended, and drug treatment may be considered if lifestyle measures fail to bring the BP down to the target level.


In table 2, recommended BP targets are given based on the 2016 ESC guidelines on CVD prevention [1]. The approach in the very old (80+ years) is dependent on the overall physical and mental status of these patients. An expert opinion provides more details on how to evaluate these conditions, the BP targets and drugs to use for these patients [4].

Table 2: Recommended BP targets

Recommendations Class* Level°
SBP < 140 mmHg and DBP < 90 mmHg are recommended in all hypertensive patients treated < 60 years old I B
In patients > 60 years old with SBP >= 160 mmHg it is recommended to reduce SBP to 150 - 140 mmHg I B
In fit patients < 80 years old, a target SBP < 140 mmHg may be considered if treatment is well-tolerated. For some of these patients, a target < 120 mmHg may be considered if they are at (very) high-risk and tolerate multiple BP lowering drugs II b B
For > 80 year individuals with initial SBP >=160 mmHg, recommendation is to bring SBP down to 150 - 140 mmHg provided they are in good physical and mental conditions I B
In frail elderly patients, a careful treatment intensity (e.g. number of BP-lowering drugs) and BP targets should be considered and clinical effects of treatment should be carefully monitored. II a B
BP targets in type 2 DM are generally recommended to be < 140/85 mmHg but a lower target of < 130/80 mmHg is recommended in selected patients (e.g. younger patients at high-risk for specific complications) for additional gains in terms of reduction of stroke, retinopathy and albuminuria risk. Recommended BP target in patients with type 1 DM is < 130/80 mmHg I B

DM: diabetes mellitus; SBP: systolic blood pressure; DBP: diastolic blood pressure.

* Class of recommendation

° Level of evidence

Control through lifestyle changes

Lifestyle changes are always the key initial stage in BP control. The most important measures are summarized in table 3. More details can be found in the recommended reading list [1-5].

Table 3: Lifestyle measures to control BP

Lifestyle Measures
Weight Maintain a 20 - 25 kg/m² BMI
Control overweight, obesity and central obesity
Physical activity Please check the physical activity page for detailed recommendations
Sodium intake Salt limited to < 5 g/day
Diet Minimum of 5 servings of fruit and vegetables per day
Alcohol Limit alcohol intake to 2 glasses per day (20 g/d of alcohol) for men and 1 glass per day (10 g/d of alcohol) for women.

Control through drug therapy

Benefits of treatment are mainly driven by BP reduction per se, not by drug type. The choice of the drugs will, therefore, depend on co-morbidities, adverse effects, the efficacy of the drug, and economic issues. For instance, the beta-blockers and thiazide diuretics are not recommended as first choice drugs in hypertensive patients with multiple metabolic risk factors due to an increased risk of diabetes. Renin-angiotensin- aldosterone system blockers are primarily recommended for BP control in patients with diabetes, particularly if they are suffering from proteinuria or micro-albuminuria.

Some of the antihypertensive drug classes have benefits in addition to BP reduction, in particular in the presence of CKD, diabetes, heart failure and coronary heart disease.

Combination treatment is needed to control BP in most patients with HT. Initiation of BP lowering therapy with a two-drug combination may be considered in patients with significantly high BP or at high CVD risk. Combination of two drugs at fixed doses in a single pill may be considered to improve compliance.

Different antihypertensive drug classes are available and allow effective and safe BP control in most patients to be achieved. In table 4, suggestions are made for certain drugs to be preferred in specific conditions [1-5].

Table 4: Drugs to be preferred in specific conditions

Condition Drug Class
 LVH  ACE inhibitor, Ca-antagonist, ARB
Renal dysfunction
 ACE inhibitor, ARB
 Previous MI  Beta-blocker, ACE inhibitor, ARB
 Angina pectoris  Beta-blocker, Ca-antagonist
 Heart Failure  Diuretic, beta-blocker, ACE inhibitor, ARB, Mineralocorticoid receptor antagonist
 Aortic aneurysm  Beta-blocker
 Atrial fibrillation,rate control  Beta-blocker, non-dihydropyridine Ca-antagonist
 ESRD, proteinuria  ACE inhibitor, ARB
 Peripheral arterydisease  ACE inhibitor, Ca-antagonist
Isolated systolic hypertension(elderly) Diuretic, Ca-antagonist, ACE inhibitor
Diabetes mellitus ACE inhibitor, ARB
Pregnancy Methyldopa, beta-blocker, Ca-antagonist
Asymptomatic atherosclerosis Ca-antagonist, ACE inhibitor

LVH: left ventricular hypertrophy; MI: myocardial infarction; ESRD: end-stage renal disease; ACE inhibitor: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker.


[1] Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Eur Heart J 2016; 37: 2315–2381.

[2] Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34: 2159-2219.

[3] Fagard R, Mancia G, Cifkova R. Chapter 14 Blood pressure. In: Gielen S, De Backer G, Piepoli MF, Wood D, editors. The ESC Textbook of Preventive Cardiology. 2nd ed. United Kingdom: Oxford University Press, 2016.

[4] Benetos A, Bulpitt CJ, Petrovic M, Ungar A, Agabiti Rosei E, Cherubini A, J Redon J, Grodzicki T, Dominiczak A, Strandberg T, Mancia G.

An Expert Opinion from the European Society of Hypertension–European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects. Hypertension 2016; 67: 820-825.

[5]  Olsen MH, Angell SY, Asma S, Boutouyrie P, Burger D, Chirinos JA, Damasceno A,  Delles C, Gimenez-Roqueplo AP,  Hering D,  Lopez-Jaramillo P,  Martinez F,  Perkovic V, Rietzschel ER, Schillaci G, Schutte AE,  Scuteri A, Sharman JE,  Wachtell K,  Wang JG. A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future

generations: the Lancet Commission on hypertension. Lancet 2016; S0140-6736 (16)31134-5

[6] Wilkins E, Wilson L, Wickramasinghe K, Bhatnagar P, Leal J, Luengo-Fernandez R, Burns R, Rayner M, Townsend N (2017). European Cardiovascular Disease Statistics 2017. European Heart Network, Brussels.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer, and Sanofi and Regeneron in the form of educational grants.

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