2018 European hypertension guidelines include recommendations for single-pill combination therapy to achieve better controla

29 Nov 2018

At the European Society of Cardiology (ESC) Congress 2018, the ESC and the European Society of Hypertension (ESH) presented the latest guidelines for the management of arterial hypertension.1,2 The guidelines now recommend the use of two-drug single-pill therapy instead of single-drug therapy; recommended treatment algorithms; as well as new recommendations for the blood pressure targets in various subgroups of patients.1,2 They also emphasized the importance of maintaining a healthy lifestyle for all patients, including a new recommendation against binge drinking.1,2

"What we're trying to do here is to normalize the concept that starting treatment of hypertension with one drug in the majority is pretty futile, because you won't get control," said Dr. Bryan Williams, University College London, ESC chairperson of the Guidelines Task Force.2

The use of two drugs at the same time, meanwhile, has been adopted by other fields such as antibiotic therapy, HIV management, and asthma treatment, and the ESC/ESH would like to see this implemented in hypertension treatment.2 Dr. Williams further added that the two drugs should be taken as a single pill, “so the patient still sees it as starting treatment with one pill, but actually they’re getting much more effective treatment,” he said.2

When considering the treatment algorithm for the two-drug approach, the new guidelines recommend starting an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) combined with a calcium-channel blocker and/or a thiazide or thiazide-like diuretic.1,2 Beta-blockers should be used for patients with specific indications, such as patients with symptomatic angina, post-myocardial infarction, chronic heart failure, or an alternative drug to ACE inhibitors or ARBs in younger hypertensive women planning pregnancy.1

Furthermore, for patients whose hypertension remain resistant, the addition of low-dose spironolactone to existing treatment, or further diuretic therapy if spironolactone is not tolerated, is recommended.1,2

Apart from suggesting combination treatment, the guidelines also made recommendations regarding the new target ranges and management options in patients. Previously, blood pressure (BP)-lowering therapy was not recommended for patients with high-normal BP, defined as 130-139/85-89mmHg.2,3 However, the current guidelines recommend that drug treatment may be considered in this patient subset if they have high cardiovascular risk associated with cardiovascular diseases.1,2

With regard to various age groups, the 2018 recommendations are as follows: For most patients aged below 65 years, the systolic BP (SBP) target is 120 to 129mmHg, and for patients aged 65 years or above, the target is 130 to 139mmHg.1,2 Fit older patients between the ages of 65 to 80 years can receive BP-lowering treatment (if well-tolerated) along with lifestyle intervention if their SBP is in the range of 140 to 159mmHg.1,2 Moreover, the guidelines note that old age alone is not a sufficient reason to stop treatment in patients.1,2 As such, patients aged 80 or above should be treated to the 130 to 139mmHg range, if tolerated.1,2

The ESC/ESH also stressed on the importance of healthy lifestyle interventions in hypertension management.1 Salt restriction, moderation in alcohol consumption, healthy diet, regular exercise, weight control, and smoking cessation were highlighted as pivotal components of a healthy lifestyle.1,2 Of note, the clinicians also warned against binge drinking, with an added suggestion of alcohol-free days during the week.1,2

  1. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021-3104.
  2. Start with Multiple-Med Single Pill: New European Hypertension Guidelines. Medscape. 2018 (Accessed October 19, 2018, at
  3. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension. Eur Heart J. 2013;34:2159-2219.
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