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Year:2018
2018PracticeGuidelinesforthemanagementofarterialhypertensionofthe
EuropeanSocietyofHypertensionandtheEuropeanSocietyofCardiology:
ESH/ESCTaskForcefortheManagementofArterialHypertension
Williams,Bryan;Mancia,Giuseppe;Spiering,Wilko;etal;Burnier,Michel;Ruschitzka,Frank
DOI:https://doi.org/10.1097/HJH.0000000000001961
PostedattheZurichOpenRepositoryandArchive,UniversityofZurich
ZORAURL:https://doi.org/10.5167/uzh-161736
JournalArticle
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Originallypublishedat:
Williams,Bryan;Mancia,Giuseppe;Spiering,Wilko;etal;Burnier,Michel;Ruschitzka,Frank(2018).
2018PracticeGuidelinesforthemanagementofarterialhypertensionoftheEuropeanSocietyofHyper-
tensionandtheEuropeanSocietyofCardiology:ESH/ESCTaskForcefortheManagementofArterial
Hypertension.JournalofHypertension,36(12):2284-2309.
DOI:https://doi.org/10.1097/HJH.0000000000001961
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
2018 Practice Guidelines for the management of
arterial hypert ension of the E ur opean S ocie ty of
Cardiology and the European Society of H ypertension
ESC/ESHTask Forcefor the Management of Arterial Hypertension
List of authors/Task Force members:
Bryan Williams (ESC Chairperson) (UK), Giuseppe Mancia (ESH Chairperson) (Italy),
Wilko Spiering (The Netherlands), Enrico Agabiti Rosei (Italy), Michel Azizi (France),
Michel Burnier (Switzerland), Denis Clement (Belgium), Antonio Coca (Spain),
Giovanni De Simone (Italy), Anna Dominiczak (UK), Thomas Kahan (Sweden),
Felix Mahfoud (Germany), Josep Redon (Spain), Luis Ruilope (Spain), Alberto Zanchetti
y
,
Mary Kerins (Ireland), Sverre Kjeldsen (Norway), Reinhold Kreutz (Germany),
Stephane Laurent (France), Gregory Y.H. Lip (UK), Richard McManus (UK),
Krzysztof Narkiewicz (Poland), Frank Ruschitzka (Switzerland), Roland Schmieder (Germany),
Evgeny Shlyakhto (Russia), Konstantinos Tsioufis (Greece), Victor Aboyans (France), and
Ileana Desormais (France)
Keywords: adherence, blood pressure measurement,
blood pressure treatment thresholds and targets, blood
pressure, combination therapy, device therapy, drug
therapy, hypertension-mediated organ damage, lifestyle
interventions, secondary hypertension, special conditions
Abbreviations: ABI, ankle–brachial index; ABPM,
ambulatory blood pressure monitoring; ACE, angiotensin-
converting enzyme; ACEi, angiotensin-converting enzyme
inhibitor; ACR, albumin:creatinine ratio; ARB, angiotensin
receptor blocker; BP, blood pressure; bpm, beats per
minute; BSA, body surface area; CAD, coronary artery
disease; CKD, chronic kidney disease; CVD, cardiovascular
disease; DHP, dihydropyridine; eGFR, estimated glomerular
filtration rate; ESC, European Society of Cardiology; ESH,
European Society of Hypertension; HbA1c, Haemoglobin
A1c; HBPM, home blood pressure monitoring; HDL-C,
HDL-cholesterol; HFpEF, heart failure with preserved
ejection fraction; HFrEF, heart failure with reduced ejection
fraction; HMOD, hypertension-mediated organ damage;
IMT, intima–media thickness; LDLC, LDL cholesterol; LEAD,
lower extremity artery disease; LVH, left ventricular
hypertrophy; MAP, mean arterial pressure; MI, myocardial
infarction; MR, magnetic resonance; MRA,
mineralocorticoid receptor antagonist; MUCH, masked
uncontrolled hypertension; NTproBNP, N-terminal pro-B
natriuretic peptide; o.d., omni die (every day); PAC, plasma
aldosterone concentration; PAD, peripheral artery disease;
PRA, plasma renin activity; PRC, plasma renin
concentration; PWV, pulse wave velocity; RAS, renin–
angiotensin system; RCT, randomized controlled trial; RWT,
relative wall thickness; SPC, single-pill combination; SUCH,
sustained uncontrolled hypertension; TIA, transient ischaemic
attack; WUCH, white-coat uncontrolled hypertension
Summary
The key messages in 20 points
1. Blood pressure, epidemiology and risk. Glob-
ally, over 1 billion people have hypertension. As
populations age and adopt more sedentary lifestyles,
the worldwide prevalence of hypertension will con-
tinue to rise towards 1.5 billion by 2025. Elevated
blood pressure (BP) is the leading global contributor
to premature death, accounting for almost 10 million
deaths in 2015, 4.9 million due to ischaemic heart
disease and 3.5 million due to stroke. Hypertension is
also a major risk factor for heart failure, atrial fibrilla-
tion, chronic kidney disease (CKD), peripheral artery
disease (PAD) and cognitive decline.
2. Definition of hypertension. The classification of
BP and the definition of hypertension is unchanged
from previous European guidelines, and is defined
as an office SBP at least 140 mmHg and/or DBP at
Journal of Hypertension 2018, 36:2284–2309
Correspondence to Professor Michel Burnier, Service of Nephrology and Hyperten-
sion, Rue du Bugnon 17, Lausanne 1011, Switzerland.
E-mail: michel.burnier@chuv.ch
y
Professor Zanchetti died during the development of these Guidelines, in March 2018.
He contributed fully to the redaction of these Guidelines, as a member of the
Guidelines’ Task Force and as a section co-ordinator. He will be sadly missed by
colleagues and friends.
ESH Practice Guidelines Writing Task Force: Michel Burnier, Sverre E. Kjel dsen,
Guido Grassi, Krzysztof Narkiewicz, Gianfranco Parati, Reinhold Kreutz, Enrico Agabiti
Rosei, Konstantinos Tsioufis, Bryan Williams, Giuseppe Mancia.
Received 5 September 2018 Accepted 11 September 2018
J Hypertens 36:2284–2309 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/HJH.0000000000001961
2284 www.jhypertension.com Volume 36 Number 12 December 2018
Practice Guidelines
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
least 90 mmHg, which is equivalent to a 24-h ABPM
average of at least 130/80 mmHg, or a home blood
pressure monitoring (HBPM) average at least 135/
85 mmHg.
3. Screening and diagnosis of hypertension.
Hypertension is usually asymptomatic (hence the
term ‘silent killer’). Because of its high prevalence,
screening programmes should be established to
ensure that BP is measur ed in all adults, at least
every 5 years and more frequently in people with a
high-normal BP. When hypertension is suspected
because of an elevated screening BP, the diagnosis
of hypertension should be confirmed either by
repeated office BP measurements, over a number
of visits, or by out-of-office BP measurement using
24-h ABPM or by HBPM.
4. The importance of cardiovascular risk assess-
ment and detection of HMOD. Other cardiovas-
cular risk factors such as dyslipidaemia and
metabolic syndrome frequently cluster with hyper-
tension. Thus, unless the patient is already at high or
very high risk due to established CVD, formal car-
diovascular risk assessment is recommended using
the SCORE system. It is important to recognize,
however, that the presence of HMOD, especially
left ventricular hypertrophy (LVH), chronic kidney
disease (CKD) or advanced retinopathy, further
increases the risk of cardiovascular morbidity and
mortality, and should be screened for as part of risk
assessment in hypertensive patients because the
SCORE system alone may underestimate their risk.
5. Think – could this patient have secondary
hypertension? For most people with hyperten-
sion, no underlying cause wil l be detected. Second-
ary (and potentially remediable) causes of
hypertension are more likely to be present in people
with young onset of hypertension (< 40 years),
people with severe or treatment-resistant hyperten-
sion, or people who suddenly develop significant
hypertension in midlife on a background of previ-
ously normal BP. Such patients should be referred
for specialist evaluation.
6. Treatment of hypertension – importance of
lifestyle interventions. The treatment of hyper-
tension involves lifestyle interventions and drug
therapy. Many patients with hypertension will
require drug therapy, but lifestyle interventions
are important because they can delay the need for
drug treatment or complement the BP-lowering
effect of drug treatment. Moreover, lifestyle inter-
ventions such as sodium restriction, alcohol moder-
ation, healthy eating, regular exercise, weight
control and smoking cessation, all have health ben-
efits beyond their impact on BP.
7. When to consider drug treatment of hyperten-
sion. The treatment thresholds for hypertension are
now less conservative than they were in previous
guidelines. We now recommend that patients with
lowmoderate risk grade 1 hypertension (o ffice BP
140–159/90–99 mmHg), even if they do not have
HMOD, should now receive drug treatment if their
BP is not controlled after a period of lifestyle inter-
vention alone. For higher risk patients with grade
1hypertension, including those with HMOD, or
patients with higher grades of hypertension (e.g.
grade 2 hypertension, 160/100 mmHg), we recom-
mend initiating drug treatment alongside lifestyle
interventions. These recommendations apply to all
adults up to the age of 80 years.
8. Special considerations in frail and older
patients. It is increasingly recognized that biologi-
cal rather than chronological age, as well as con-
sideration of frailty and independence, are
important determinants of the tolerability of and
likely benefit from BP-lowering medications. It is
important to note that even in the very old (i.e. > 80
years), BP-lowering therapy reduces mor tality,
stroke and heart failure. Thus, these patients should
not be denied treatment, or have treatment with-
drawn simply on the basis of age. For people more
than 80 years of age who have not yet received
treatment for their BP, treatment is recommended
when their office SBP is at least 160 mmHg, provided
that the treatment is well tolerated.
9. How low should SBP be lowered? This has been a
hotly debated topic. A key discussion point is the
balance of potential benefits versus potential harm
or adverse effects. This is especially important
whenever BP targets are lowered, as there is a
greater potential for harm to exceed benefit. Thus,
in this guideline, we recommend a target range. The
evidence strongly sugges ts that lowering office SBP
to less than 140 mmHg is beneficial for all patient
groups, including independent older patients. There
is also evidence to support targeting SBP to
130 mmHg for most patients, if tolerated. Even lower
SBP levels (<130 mmHg) will be tolerated and
potentially beneficial for some patients, especially
to further reduce the risk of stroke. SBP should not
be targeted to below 120 mmHg because the bal-
ance of benefit versus harm becomes concerning at
these levels of treated SBP.
10. Blood pressure targets in old and very old
patient. As discussed above, independence, frailty
and comorbidities will all influence treatment deci-
sions, especially in older ( 65 years) and very old
(> 80 years) patients. The desired SBP target range
for all patients aged more than 65 years is less than
140 mmHg but not less than 130 mmHg. This is
lower than in previous guidelines and may not be
achievable in all older pa tients, but any BP lowering
towards this target is likely to be beneficial provided
that the treatment is well tolerated.
11. Blood pressure targets in patients with diabe-
tes and/or chronic kidney disease. The BP-treat-
ment targets for patients with diabetes o r kidney
disease have been a moving target in previous
guidelines because of seemingly contradictory
results from major outcome trials and meta-analyses.
For diabetes, targeting the SBP to less than
140 mmHg and towards 130 mmHg, as recom-
mended for all other patient groups, is beneficial
2018 Practice Guidelines for the management of hypertension
Journal of Hypertens ion www.jhypertension.com 2285
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
on major outcomes. Moreover, targeting SBP to less
than 130 mmHg, for those who will tolerate it, may
further reduce the risk of stroke but not other major
outcomes. SBP should not be lowered below
120 mmHg. For patients with CKD, the evidence
suggests that the target BP range should be less
than 140 mmHg but not less than 130 mmHg.
12. How low should DBP be lowered? The optimal
DBP target has been less well defined, but a DBP
target of less than 80 mmHg is recommended. Some
patients with stiff arteries and isolated systolic
hypertension will already have DBP levels below
this target. These are high-risk patients and the low
DBP should not discourage treatment of their ele-
vated SBP to the recommended target, provided that
treatment is well tolerated.
13. The need to do better on blood pressure con-
trol. A key message in this guideline is the need to
do better at improving BP control rates. Despite the
overwhelming evidence of treatment benefit, on
average, less than 50% of patients with treated
hypertension achieve a SBP target of less than
140 mmHg. Physician inertia (inadequate up-titra-
tion of treatm ent, especially from monother apy) and
poor patient adherence to treatment (especially
when based on multiple pills) are now recognized
as the major factors contributing to poor BP control.
14. Start treatment in most patients with two
drugs, not one. Monotherapy is usually inadequate
therapy for most people with hypertension; this will
be especially true now that the BP-treatment targets
for many patients are lower than in previous guide-
lines. This guideline sets out to normalize the con-
cept that initial therapy for the majority of patients
with hypertension should be with a combination of
two drugs, not a single drug. The only exception
would be in a limited number of patients with a
lower baseline BP close to their recommended
target, who might achieve that target with a single
drug, or in some frailer old or very old patients, in
whom more gentle reduction of BP may be desir-
able. Evidence suggests that this approach will
improve the speed, efficiency and consistency of
initial BP lowering and BP control, and is well
tolerated by patients.
15. A single pill strategy to treat hypertension.
Poor adherence to longer-term BP lowering medi-
cation is now recognized as a major fac tor contrib-
uting to poor BP control rates. Research has shown a
direct correlation between the number of BP-low-
ering pills and poor adherence to medications.
Moreover, SPC therapy has been shown to improve
adherence to treatment. SPC therapy is now the
preferred strategy for initial two-drug combination
treatment of hypertension and for three-drug com-
bination therapy when required. This will control
the BP in most patients with a single pill and could
transform BP control rates.
16. A simplified drug-treatment algorithm. We
have simplified the treatment strategy so that
patients with uncomplicated hypertension and
many patients with a variety of comorbidities (e.g.
HMOD, diabetes, PAD or cerebrovascular disease)
receive similar medication. We recommend a com-
bination of an angiotensin-converting enzyme
(ACE) inhibitor or angiotensin receptor blocker
(ARB) with a CCB or thiazide/thiazide-like diuretic
as initial therapy for most patients. For those requir-
ing three drugs, we recommend a combination of an
ACE inhibitor or ARB with a CCB and a thiazide/
thiazide-like diuretic. We recommend beta-blockers
be used when there is a specific indication for their
use (e.g. angina, postmyocardial infarction, HFrEF
or when heart-rate control is required).
17. Hypertension in women and in pregnancy. In
women with hypertension who are planning preg-
nancy, ACE inhibitors or ARBs and diuretics should
be avoided and the preferred medications to lower
BP, if required, include alpha-methyl dopa, labetalol
or CCBs. The same drugs are suitable if BP lowering is
required in pregnant women. ACE inhibitors or ARBs
should not be used be used in pregnant women.
18. Is there a role for device-based therapy for the
treatment of hypertension? A number of device-
based interventions have been developed and stud-
ied for the treatment of hypertension. To date, the
results from these studies have not provided sufficient
evidence to recommend their routine use. Conse-
quently, the use of device-based therapies is not
recommended for the treatment of hypertension,
unless in the context of clinical studies and random-
ized controlled trials, until further evidence regarding
their safety and efficacy becomes available.
19. Managing cardiovascular disease risk in hyper-
tensive patients, beyond BPS statins. For hyper-
tensive patients at moderate CVD risk or higher, or
those with established CVD, BP lowering alone will
not optimally reduce their risk. These patients
would also benefit from statin therapy, which fur-
ther reduces the risk of a myocardial infarction by
approximately one-third and stroke by approxi-
mately one-quarter, even when BP is controlled.
Similar benefits have been seen in hypertensive
patients at the border between low and moderate
risk. Thus, many more hypertensive patients would
benefit from statin therapy than are currently receiv-
ing this treatment.
20. Managing cardiovascular disease risk in hyper-
tensive patients, beyo nd BP – antipla telet ther-
apy. Antiplatelet therapy, especially low-dose
aspirin, is recommended for secondary prevention
in hypertensive patients, but is not recommended for
primary prevention (i.e. in patients without CVD).
INTRODUCTION
These 2018 European Society of Cardiology/European
Society of Hypertension (ESC/ESH) guidelines for the man-
agement of arterial hypertension are designed for adults
with hypertension, that is aged at least 18 years. The
purpose of the review and update of these guidelines
was to evaluate and incorporate new evidence into the
Williams et al.
2286 www.jhypertension.com
Volume 36 Number 12 December 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
guideline recommendations. The specific aims of these
guidelines were to produce pragmatic recommendations
to improve the detection and treatment of hypertension,
and to improve the poor rates of BP control by promoting
simple and effective treatment strategies.
Principles
These fundamental principles are to base recommendations
on properly conducted studies, identified from an extensive
review of the literature; to give the highest priority to data
from randomized controlled trials (RCTs); and to also con-
sider well conducted meta-analyses of RCTs as strong evi-
dence. This contrasts with network meta-analyses, which we
do not consider to have the same level of evidence because
many of the comparisons are nonrandomized; to recognize
that RCTs cannot address many important questions related
to the diagnosis, risk stratification and treatment of hyper-
tension, which can be addressed by observational or registry-
based studies of appropriate scientific calibre; to grade the
level of scientific evidence and the strength of recommen-
dations according to ESC recommendations; to recognize
that opinions may differ on key recommendations, which are
resolved by voting; and to recognize that there are circum-
stances in which there is inadequate or no evidence, but the
question is important for clinical practice and cannot be
ignored. In these circumstances, we resort to pragmatic
expert opinion and endeavour to explain its rationale.
What is new and what is changed in the 2018
European Society of Cardiology/European
Society of Hypertension hypertension
guidelines?
Because of new evidence on several diagnostic and therapeu-
tic aspects of hypertension, the present guidelines differ from
the 2013 ones in several points indicated as follows (Fig. 1).
New concepts
Blood pressure measurement
1. Wider use of out-of-office BP measurement with ABPM
and/or HBPM, especially HBPM, as an option to con-
firm the diagnosis of hypertension, detect white coat
and masked hypertension and monitor BP control.
Less conservative treatment of blood pressure in
older and very old patients
1. Lower BP thresholds and treatment targets for older
patients, with an emphas is on considerations of bio-
logical rather than chronological age (i.e. the impor-
tance of frailty, independence and the tolerability of
treatment).
2. Recommendation that treatment should never be
denied or withdrawn on the basis of age, provided
that treatment is tolerated.
A SPC treatment strategy to improve blood pressure
control
1. Preferred use of two-drug combination therapy for the
initial treatment of most people with hypertension.
2. A single-pill treatment strategy for hypertension with
the preferred use SPC therapy for most patients.
3. Simplified drug-treatment algorithms with the pre-
ferred use of an ACE inhibitor or ARB combined with
a CCB or/and a thiazide/thiazide-like diuretic as the
core treatment strategy for most patients, with beta-
blockers used for specific indications.
New target ranges for blood pressure in treated patients
1. Target BP ranges for treated patients to better identify
the recommended BP target and lower safety bound-
aries for treated BP, according to a patient’s age and
specific comorbidities.
Detecting poor adherence to drug therapy
1. A strong emphasis on the importance of eva luating
treatment adherence as a major cause of poor
BP control.
A key role for nurses, pharmacists in the longer-term
management of hypertension
1. The important role of nurses and pharmacists in the
education, support and follow-up of
2. Treated hypertensive patients are emphasized as part
of the overall strategy to improve BP control.
DEFINITIONS AND C LASSIF ICATIONS
The relationship between BP and cardiovascular and renal
events is continuous, making the distinction between nor-
motension and hypertensionbased on cut-off BP val-
uessomewhat arbitrary. ‘Hypertension’ is defined as the
level of BP at which the benefits of treatment (either with
lifestyle interventions or drugs), unequivocally outweigh
the risks of treatment, as documented by clinical trials. This
evidence has been reviewed and provides the basis for the
recommendation that the classification of BP and definition
of hypertension rem ain unchanged from previous ESH/ESC
guidelines (Fig. 2).
DIAGNOSTIC EVA LUA TION
Evaluation of the cardiovascular risk
Quantification of total cardiovascular risk (i.e. the likelihood
of a person developing a cardiovascular event over a defined
period) is an important part of the risk-stratification process
for patients with hypertension. Many cardiovascular risk-
assessment systems are available and most project 10-year
risk. Since 2003, the European guidelines on CVD prevention
have recommended use of the Systematic COronary Risk
Evaluation (SCORE) system (Figs. 3–5) because it is based on
large, representative European cohort datasets (http://
www.escardio.org/Guidelines-&-Education/Practice-tools/
CVD-prevention-toolbox/SCORE-Risk-Charts). The SCORE
system only estimates the risk of fatal cardiovascular events.
Measurement of blood pressure
Auscultatory or oscillometric semiautomatic or automatic
sphygmomanometers are the preferred method for
2018 Practice Guidelines for the management of hypertension
Journal of Hypertens ion www.jhypertension.com 2287
