Key points
- New blood pressure thresholds for diagnosing hypertension
- A personalized approach to choosing antihypertensive therapy
- The role of non-pharmacological measures in treatment
- Why home blood pressure monitoring matters
- Preventing complications through a combined approach
Definition and classification
Under the 2023 guidelines of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH), hypertension is defined as a persistent systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg.
Blood pressure classification (ESC/ESH 2023)
| Category | SBP (mmHg) | DBP (mmHg) |
|---|---|---|
| Optimal | <120 | <80 |
| Normal | 120-129 | 80-84 |
| High normal | 130-139 | 85-89 |
| Grade 1 hypertension | 140-159 | 90-99 |
| Grade 2 hypertension | 160-179 | 100-109 |
| Grade 3 hypertension | ≥180 | ≥110 |
Current approaches to diagnosis
1. Office blood pressure measurement
Still the diagnostic gold standard, but only when the protocol is followed strictly:
- The patient must rest for at least 5 minutes
- Use validated automatic monitors
- At least 2–3 readings, 1–2 minutes apart
- Correct patient position and cuff size
2. Ambulatory blood pressure monitoring (ABPM)
Recommended for:
- Confirming the diagnosis in patients with BP 140–179/90–109 mmHg
- Identifying white-coat hypertension
- Diagnosing masked hypertension
- Assessing how well treatment is working
"Ambulatory monitoring detects up to 30% of masked hypertension cases that office measurement misses." — ESC/ESH Guidelines 2023
3. Home self-monitoring
An essential part of the modern approach to treating hypertension:
- Improves adherence to treatment
- Allows the effect of therapy to be judged
- Helps identify episodes of hypotension
- Reduces how often visits are needed
A personalized approach to treatment
Cardiovascular risk assessment
The modern approach stratifies patients by risk using the SCORE2 and SCORE2-OP charts (the latter for patients ≥70). That determines both the target blood pressure and how intensively to treat.
Worth remembering
Target blood pressure is individual and depends on age, comorbidity and how well treatment is tolerated. For most patients the target is <140/90 mmHg; for high-risk patients, <130/80 mmHg.
The drug therapy algorithm
First-line therapy:
- ACE inhibitors or angiotensin II receptor blockers
- Calcium channel blockers
- Thiazide diuretics
Most patients need combination therapy. Fixed-dose combinations are preferred because they improve adherence.
Recommended combinations:
- ACEi/ARB + calcium channel blocker
- ACEi/ARB + diuretic
- Calcium channel blocker + diuretic
Non-pharmacological treatment
Lifestyle change remains the foundation of hypertension treatment and can lower blood pressure by 5–15 mmHg:
The DASH diet
Lowers BP by 5–11 mmHg. Rich in fruit, vegetables, whole grains and lean protein.
Weight loss
Each kilogram lost lowers BP by about 1 mmHg. Target: BMI 20–25 kg/m².
Physical activity
150 minutes of moderate activity per week. Lowers BP by 4–9 mmHg.
Limiting alcohol
Men: ≤2 drinks/day, women: ≤1 drink/day. Lowers BP by 2–4 mmHg.
Stress Management
Meditation, yoga and breathing exercises can lower BP by 3–5 mmHg.
Stopping smoking
Vascular function improves immediately, and the risk of complications falls by 50%.
Monitoring and treatment review
How often to review
- Starting treatment: every 2–4 weeks until the target BP is reached
- Stable course: every 3–6 months
- With comorbidity: an individual schedule
Laboratory monitoring
Check regularly:
- Creatinine and eGFR
- Electrolytes (K+, Na+)
- Lipid panel
- Glucose / HbA1c
- Albuminuria
What good treatment achieves
With blood pressure adequately controlled, stroke risk falls by 35–40%, myocardial infarction by 20–25% and heart failure by 50%.
Special patient groups
Older patients (≥65)
- Target: <140/90 mmHg, or <130/80 if well tolerated
- Lower blood pressure cautiously to avoid hypotension
- Watch particularly for orthostatic hypotension
Diabetes
- Target: <130/80 mmHg
- Drugs of choice: ACEi/ARB
- Albuminuria must be monitored
CKD
- Target: <130/80 mmHg
- ACEi/ARB where proteinuria >300 mg/day
- Monitor creatinine and potassium
Resistant hypertension
Diagnosed when optimal triple therapy, including a diuretic, at maximum tolerated doses fails to control blood pressure.
Causes of pseudo-resistance:
- Non-adherence to treatment (40–50% of cases)
- Incorrect measurement technique
- The white-coat effect
- Suboptimal therapy
Additional treatment options:
- Spironolactone 25–50 mg/day
- Amiloride 5–10 mg/day
- Bisoprolol or doxazosin
- Interventional approaches, on strict indications
Practical advice for patients
Tips for daily blood pressure control
- Measure regularly: morning and evening, at the same times
- Keep a diary: record your readings and how you feel
- Correct technique: five minutes of rest, correct position
- Adherence: take your medication consistently
- Lifestyle changes: diet, exercise, giving up harmful habits
Conclusion
Treating hypertension well requires a personalized approach that accounts for the individual patient, their comorbidities and their risk factors. Combining drug therapy with non-pharmacological measures brings most patients to target and substantially reduces the risk of cardiovascular complications.
The decisive factor is the patient's own participation: self-monitoring, following lifestyle advice, and staying on the prescribed medication.