Blood pressure

Updated by Guy De Backer and Tine De Backer, 1 September 2021

Blood pressure (BP) control is a crucial component of all strategies to prevent coronary heart disease, heart failure, cerebrovascular disease, lower extremity arterial disease, chronic kidney disease and atrial fibrillation. Observational cohort studies from all over the world have shown that the arterial BP bears an independent and continuous relationship with the incidence of these diseases and in randomized controlled trials it has been demonstrated that BP reduction is associated with prevention of these diseases (1-6).

Despite extensive evidence for the effectiveness of BP-lowering treatments at reducing cardiovascular disease (CVD) risk and death, the detection, treatment, and control of elevated BP in Europe and globally remains suboptimal (7-9).

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 and to continue 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, efficacy and safety of the drugs, on co-morbidities and on economic issues.

This section covers recommendations for the diagnosis and treatment of hypertension to be applied in routine primary and secondary care. More details are available in the 2018 ESC/European Society of Hypertension (ESH) guidelines for the management of arterial hypertension (2) and in the 2021 ESC Guidelines on CVD prevention in clinical practice (1).

Definitions and categories

Although no direct 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 on out-of-office levels using either ambulatory blood pressure monitoring (ABPM) and/or Home BP monitoring (HBPM). In table 1 categories of conventionally measured seated office BP are presented and in table 2 definitions of HT are given according to office, ambulatory or home BP levels.

Table 1: Categories for conventionally measured seated office BP.

DBP = diastolic blood pressure; SBP = systolic blood pressure; HT= hypertension
^a Isolated systolic HT is graded 1, 2, or 3 according to SBP values in the ranges indicated.

Table 2: Definitions of HT according to office, ambulatory or home BP levels.

BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood pressure.

Control

For the prevention of CVD, the primordial goal is to prevent the development of elevated BP with age. This can be achieved by lifestyle adaptations from childhood onwards. One should keep BP at optimal levels by maintaining sufficient physical exercise, an ideal body mass index (BMI) and a well-balanced diet. Also in persons with a genetic or other predisposition for developing HT, lifestyle measures can help to control BP.
Unfortunately, a majority of Europeans do not follow these recommendations and develop high BP in adulthood or later in life. HT affects more than 150 million people across Europe, over 1 billion globally, with a prevalence of ~30–45% in adults, increasing with age to more than 60% in people aged >60 years, and accounting for ~10 million deaths globally per annum (10).

Lifestyle interventions are indicated for all patients with high-normal BP or HT because they can delay the need for drug treatment or complement the BP-lowering effect of drug treatment. Moreover, most lifestyle interventions have health benefits beyond their effect on BP. The decision to start a BP-lowering drug treatment depends on the BP level and on the total CVD risk of the patient.

Drug treatment of grade 1 HT has level A evidence for reducing CVD risk. In younger patients, however, the absolute 10-year CVD risk is often low and therefore drug treatment initiation should be discussed with the patient only if BP remains elevated despite lifestyle adaptations. The presence of hypertension-mediated organ damage mandates in most cases drug treatment. For grade 2 HT or higher drug treatment is recommended.

Targets

In table 3, recommended BP targets are given based on the 2021 ESC guidelines on CVD prevention [1] in two age groups and in subgroups with co-morbidities.

In younger patients (< 70 yrs old) the SBP target is 120-130 mmHg. In patients aged >=70 yrs the SBP target is < 140 mmHg and down to 130 mmHg if tolerated. These changes in BP targets compared to previous guidelines are supported by evidence that these treatment targets are safely achieved in many patients and are associated with significant reductions in the risk of major stroke, heart failure and CVD death (11). It is however recognized that the evidence supporting more strict targets is less strong for the very old (> 80 yrs) and for frail patients.

Table 3: Recommended office blood pressure target ranges.

Office SBP treatment target ranges (mmHg)

CAD = coronary artery disease; CKD = chronic kidney disease; DBP = diastolic blood pressure; DM = diabetes mellitus; SBP = systolic blood pressure; TIA = transient ischaemic attack.

Control through lifestyle changes

Lifestyle changes are always the key initial stage in BP control. The most important measures are summarized in table 4. More details can be found in the recommended references [1-2].

Table 4: Lifestyle measures to control BP

Control through drug therapy

Benefits of pharmacological treatment are mainly driven by BP reduction per se, not by drug type. The choice of the drugs will, therefore, depend on the efficacy of the drug, adverse effects, co-morbidities, contra-indications, suitability, and economic issues.

Renin-angiotensin- aldosterone system (RAS) blockers are especially recommended for BP control in patients with diabetes, particularly if they are suffering from proteinuria or micro-albuminuria. It is recommended to initiate antihypertensive treatment with a two-drug combination in most patients, preferably as a single-pill combination. Exceptions are frail older patients and those with low-risk, grade 1 hypertension (particularly if SBP <150 mmHg).

It is recommended that the preferred combinations include combinations of the five major classes (angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics. Recommended treatment combinations are based on best available evidence, pragmatic considerations (e.g. combination pill availability), and pathophysiological reasoning. A combination of an ACE inhibitor or ARB with a CCB or thiazide/thiazide-like diuretic is the preferred initial therapy for most patients with hypertension.

It is recommended, if BP remains uncontrolled with a two-drug combination, that treatment be increased to a three-drug combination, usually a RAS blocker with a CCB and a diuretic, preferably as a single-pill combination. Single-pill strategy to treat HT is useful to prevent poor adherence to BP-lowering medications.
Beta-blockers should be used when there is a specific indication (e.g. angina, post myocardial infarction, arrythmia, HFrEF, or as an alternative to an ACE inhibitor or ARB in women of child-bearing potential). Combinations of an ACE inhibitor and an ARB are not recommended because of no added benefit on outcomes and increased risk of harm.

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. Different antihypertensive drug classes are available and allow effective and safe BP control in most patients to be achieved.