Cardiology · ESC

Hypertension in adults

ESC

Source:2024 ESC Guidelines for the management of elevated blood pressure and hypertension

Verified Apr 2026

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Red Flags

BP ≥180/120 mmHg with new neurological deficit, dyspnoea, chest pain, or AKI — hypertensive emergency, immediate IV therapy^[1]
Severe hypertension in pregnancy ≥20 weeks gestation — preeclampsia or eclampsia^[2]
BP elevation with hypokalaemia and metabolic alkalosis — screen for primary aldosteronism^[1]
Resistant hypertension — uncontrolled despite three agents at maximally tolerated doses including a diuretic^[1]

First-line treatment

Interventions

Lifestyle modification^[1]
Sodium <2 g/day, plant-based diet, ≥150 min/week moderate aerobic activity, weight reduction if BMI ≥25, alcohol limitation, smoking cessation

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Amlodipine + perindopril (single-pill combination)^[1]	CCB + ACE inhibitor SPC	5/4 mg once daily, up-titrate to 10/8 mg as needed	—	ESC 2024 strongly recommends starting with single-pill combinations to improve adherence
Telmisartan + amlodipine^[1]	ARB + CCB SPC	40/5 mg once daily, up-titrate to 80/10 mg	—	Alternative SPC, especially with diabetes or microalbuminuria
Indapamide^[1]	Thiazide-like diuretic	1.5 mg sustained-release once daily	—	Add as third agent if dual SPC inadequate; preferred over hydrochlorothiazide for cardiovascular outcomes
Empagliflozin^[1]	SGLT2 inhibitor	10–25 mg once daily	—	ESC 2024 recommends in hypertension with diabetes, heart failure, or CKD — modest BP reduction plus organ protection

Amlodipine + perindopril (single-pill combination)^[1]

CCB + ACE inhibitor SPC

Adult: 5/4 mg once daily, up-titrate to 10/8 mg as needed
Paediatric: —

ESC 2024 strongly recommends starting with single-pill combinations to improve adherence

Telmisartan + amlodipine^[1]

ARB + CCB SPC

Adult: 40/5 mg once daily, up-titrate to 80/10 mg
Paediatric: —

Alternative SPC, especially with diabetes or microalbuminuria

Indapamide^[1]

Thiazide-like diuretic

Adult: 1.5 mg sustained-release once daily
Paediatric: —

Add as third agent if dual SPC inadequate; preferred over hydrochlorothiazide for cardiovascular outcomes

Empagliflozin^[1]

SGLT2 inhibitor

Adult: 10–25 mg once daily
Paediatric: —

ESC 2024 recommends in hypertension with diabetes, heart failure, or CKD — modest BP reduction plus organ protection

Safety-net

Take medication daily even when feeling well — hypertension causes no symptoms until target organs are damaged^[1]
Sudden severe headache, chest pain, vision changes, slurred speech, or one-sided weakness — call emergency services immediately^[1]
Avoid NSAIDs (ibuprofen, diclofenac, naproxen) — they raise BP and worsen kidney function. Use paracetamol for pain^[1]

Referral criteria

BP ≥180/120 with neurological deficit, chest pain, dyspnoea, or AKIEmergency department for IV antihypertensive and end-organ workup^[1]
Resistant hypertension despite three agents including diuretic at maximum tolerated dosesHypertension clinic; consider renal denervation evaluation^[1]
Stage 2 hypertension with positive primary aldosteronism screen (high ARR)Endocrinology for confirmatory testing and adrenal imaging^[1]
Pregnancy with BP ≥140/90 mmHgObstetric medicine same-day^[2]

Clinical summary

Diagnosis and management of elevated blood pressure and hypertension in adults, including a new 'elevated BP' category for SBP 120–139 or DBP 70–89 mmHg.

References

1.2024 ESC Guidelines for the management of elevated blood pressure and hypertension (2024)
2.Gestational Hypertension and Preeclampsia. Obstetrics & Gynecology (2020)

Drug

Class

Adult

Paediatric

Notes