The European Society of Cardiology (ESC) has presented new recommendations to improve the screening of high blood pressure (hypertension) and its drug management.
The ESC experts first pointed out problems with the quality of blood pressure (BP) measurement, the criteria of which are rarely respected in practice: use of a validated device, measurement after five minutes in a seated position in an environment calm, cuff positioned at the level of the arm which must be supported at desk height (and not resting on the patient’s leg), average of three measurements. Once again, measurements outside the doctor’s office are strongly recommended for diagnosis because they allow the detection of both “white coat” hypertension and masked hypertension.
In 2023, Public Health France (SPF) estimated the incidence of hypertension in the territory at nearly one in three adults, affecting 17 million French people. This chronic pathology is the leading cause of cardiovascular death but still remains underdiagnosed and undertreated. One in two patients in France do not know that they are hypertensive. And only half of diagnosed patients are treated pharmacologically, with 25% having BP control below 140/90 mmHg.
High BP stage
A new classification is proposed. If hypertension remains defined by a BP ≥ 140/90 mmHg at the doctor’s office (≥ 135/85 mmHg when self-measured at home), the recommendations differentiate, for values below these thresholds, from non-elevated BP (< 120/70 mmHg in the office and at home) and high BP (SBP between 120 and 139 mmHg and DBP between 70 and 89 mmHg in the office and between 120 and 134 mmHg and 70 and 84 mmHg at home).
As soon as hypertension is proven, experts recommend prescribing dual therapy as first-line therapy for patients under 85 years of age. Combinations comprising an enzyme-converting enzyme inhibitor or an angiotensin 2 receptor antagonist + a calcium channel blocker or a diuretic should be preferred. The goal is to reach a blood pressure around 120-129/70-79 mmHg.
Monotherapy is indicated in the elderly, those with moderate to severe frailty, or in cases of orthostatic hypotension (systematically looked for during the initial evaluation), as well as in patients with high BP (between 120 and 139 mmHg ) and at high cardiovascular risk (chronic kidney failure, cardiovascular disease, heart failure, etc.) and failure to achieve blood pressure goals with healthy and dietary rules alone.
Soon any recommendations for triple therapy?
Triple therapies in a single tablet are currently indicated for patients in whom dual therapy is insufficient, and for those with three treatments in several tablets, in order to improve compliance. A clinical study (1) demonstrated better effectiveness of a new triple therapy of low-dose antihypertensive drugs (telmisartan, amlodipine and indapamide) in a single tablet to achieve a BP lower than 130/80 mmHg and maintain it over time, without more adverse effects than dual therapy.
The blood pressure control rate below 140/90 mmHg is also better with triple therapy: 74% of patients remain there, compared to 53 to 61% of patients for dual therapies. Therapy combining these three classes of antihypertensive drugs is an interesting option which could substantially improve blood pressure control.
(1) A. Rodgers et al., The Lancet, 2024,
vol 404, 10462, p1536-1546
