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Hypertension — Diagnosis & Management

Registrar quick reference · 2024 ESC vs Australian NHFA
Compiled Jun 2026
Verify locally
Confirm out-of-office
Decision support only — not a substitute for the 2024 ESC guideline, the NHFA, or eTG. The guidelines genuinely disagree here: ESC 2024 keeps hypertension at ≥140/90 but pushes an on-treatment target of 120–129 systolic, while the Australian NHFA target is <140/90 (lower if high-risk). Both rest on standardised, validated measurement and out-of-office confirmation — a casual clinic reading is not the same number. Verify all doses.
1 Treatment — step up to target
Foundationeveryone, always
From "elevated BP" upward.
Lifestyle: sodium <2 g/day (salt <5 g), increase potassium (diet/substitute), DASH-style diet, weight loss, ≥150 min/week activity, limit alcohol, stop smoking.
Step 1 · dualsingle-pill combination
Most patients with hypertension.
ACEi/ARB + CCB (or + thiazide-like diuretic) as one pill. Monotherapy only if ≥85, frail, orthostatic, or high-risk "elevated BP."
Step 2 · tripleA + C + D
Not at target on dual therapy.
ACEi/ARB + CCB + thiazide-like diuretic (indapamide/chlortalidone), single pill where possible.
Step 3 · resistantuncontrolled on triple
≥140/90 on 3 agents incl. a diuretic at max-tolerated dose.
Confirm adherence, exclude white-coat & secondary, then add spironolactone PATHWAY-2; then β-/α-blocker; consider renal denervation (expert centre).
Target SBP 120–129 for most on treatment (ESC 2024, "opt-out", standardised measurement) SPRINT ESPRIT vs <140/90 (NHFA). Individualise: ≥85, frailty, orthostatic symptoms → "as low as reasonably achievable." β-blockers are not first-line unless compelling indication (IHD, HF, AF). Never combine ACEi + ARB.
2 Define it, confirm it, target it

Thresholds & confirmation

Non-elevated
<120/70
Elevated BP
120–139/70–89
Hypertension
≥140/90
  • ConfirmOut-of-office before labelling: ABPM (≥135/85 daytime) or validated HBPM — excludes white-coat, catches masked.
  • DiscordESC 2024 & NHFA define HTN ≥140/90; US ACC/AHA uses ≥130/80. "Elevated BP" is the ESC 2024 addition.
  • TechniqueValidated device, correct cuff, seated & rested, averaged readings.

Targets — and the catch

  • ESC 2024SBP 120–129 for most on treatment (DBP 70–79); "as low as reasonably achievable" if not tolerated.
  • NHFA<140/90 generally; consider <120 SBP in high CV risk if tolerated.
  • The catchThese targets assume standardised/automated measurement — trial BP reads lower than a routine clinic cuff. Don't chase 120 on a casual reading.
  • Elderly≥80: a pragmatic <150/90 is reasonable HYVET; watch the J-curve & orthostasis.
3 Assess risk, organ damage & secondary causes

Risk & target-organ damage

  • CV riskAbsolute risk via the Australian CVD risk calculator (2023) — drives intensity for "elevated"/borderline cases.
  • HMODLVH (ECG/echo), albuminuria + eGFR (uACR), retinopathy, ankle-brachial index.
  • BaselineU&E, glucose/HbA1c, lipids, urinalysis, ECG.

Think secondary

  • AldosteroneScreen for primary aldosteronism (aldosterone:renin ratio) in all confirmed hypertension (ESC 2024) — it's commoner than assumed and under-screened.
  • SuspectAge <40, resistant, abrupt/severe/accelerated, hypokalaemia, or HMOD out of proportion.
  • CausesRenovascular (FMD in young, atherosclerotic), renal parenchymal, phaeo, Cushing's, thyroid, OSA, coarctation; drugs — NSAIDs, COCP, decongestants, alcohol, liquorice, stimulants, VEGF inhibitors.
4 Resistant HTN & the hypertensive crises

Resistant hypertension

  • Define≥140/90 on 3 agents (incl. diuretic) at max-tolerated dose — after confirming adherence & out-of-office readings.
  • FirstAdherence, technique, white-coat, secondary causes, interfering drugs.
  • AddSpironolactone PATHWAY-2; then bisoprolol or doxazosin; renal denervation as an option at expert centres.

Emergency vs urgency

  • EmergencySevere BP + acute organ damage (encephalopathy, ACS, pulmonary oedema, dissection, AKI, eclampsia, papilloedema) → IV, monitored, controlled: ~25% drop in the first hour.
  • SpecialDissection → SBP <120 + HR <60 (β-blocker first). Eclampsia → magnesium + labetalol/hydralazine. Phaeo → α-block before β.
  • UrgencySevere BP, no acute organ damage → oral, gradual. Don't crash the BP in ED — rapid drops cause watershed ischaemia.
Sources. McEvoy et al. "2024 ESC Guidelines for the management of elevated blood pressure and hypertension," Eur Heart J 2024 (non-elevated/elevated/hypertension classification; out-of-office confirmation; target SBP 120–129 "opt-out"; initial dual single-pill combination; β-blockers not first-line; systematic primary-aldosteronism screening; spironolactone for resistant HTN; renal denervation). National Heart Foundation of Australia — Guideline for the diagnosis and management of hypertension in adults (2016); Australian CVD risk calculator (2023); eTG.   Key trials: SPRINT & ESPRIT (intensive SBP lowering reduces CVD); PATHWAY-2 (spironolactone best 4th-line for resistant HTN); HYVET (treating the very elderly); STEP (intensive target in older adults).   Caveats: the intensive ESC target depends on standardised/automated measurement and is individualised for frailty, age ≥85, and orthostasis — NICE and others still treat to ≥140/90, so know which framework you're applying. Spironolactone's resistant-HTN role rests on surrogate BP outcomes, not CVD endpoints. Verify all doses. Companion to the cardiac & CKD sheets.