Page 3 - hypertension_newsletter9

REFLECTIONS
Hypertension
Hypertension Global Newsletter #9 2025

Treatment goals are largely aligned. Both guidelines agree on a target office BP of 120–129/70–79 mmHg, if tolerated. The ESC
2024 guidelines, for the first time, also recommend broader screening for primary aldosteronism in newly diagnosed hypertensive
patients, while ESH 2023 applies a more selective approach, only in patients with indicators of primary aldosteronism or secondary
Hypertension
hypertension to limit laboratory examinations and confusion in appropriate management. Both guidelines advocate for personalised
management, accounting for age, sex, frailty, and other CVD risk modifiers, with lenient targets for older or frail patients.

Both guidelines endorse early use of single-pill combination (SPC) therapy to improve BP control and adherence. They emphasise
starting most patients on dual combination therapy, typically a renin–angiotensin system (RAS) blocker (angiotensin-converting
enzyme [ACE] inhibitor or angiotensin receptor blockers [ARB]) with either a calcium channel blocker (CCB) or thiazide/thiazide-like
diuretic. The ESC guidelines recommend early escalation to low-dose triple combination therapy for patients not achieving target BP
on dual therapy, while the ESH guidelines advise up titrating the dual combination to the maximum tolerated dose before adding a
third agent.

Monotherapy is reserved for specific populations in both guidelines, including those with moderate-to-severe frailty, symptomatic
orthostatic hypotension, or advanced age. Additionally, the ESH guidelines consider monotherapy appropriate in patients with SBP
<150 mmHg and DBP <95 mmHg who are at low CV risk.

Recommendations for β-blockers also differ between the two guidelines. Unlike the ESC guidelines, the ESH guidelines allow for
β-blockers to be used at any treatment step, either as monotherapy as guideline-directed medical therapy in particular cardiac
conditions or in combination with any major drug class. Both societies agree that β-blockers are a cornerstone of therapy and should
be added for patients with angina, heart failure, post myocardial infarction, or when heart rate control is required.

Treatment algorithm for general patients with hypertension

On the topic of device-based BP-lowering, the two guidelines differ slightly in their recommendations on catheter-based renal
denervation. The 2023 ESH guidelines consider renal denervation an option for patients who have uncontrolled BP despite the use
of antihypertensive medications, and even in the absence of these medications if they elicit serious adverse effects. According to the

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