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2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension

Mancia, Giuseppe (Chairperson) (Italy)a; Fagard, Robert (Chairperson) (Belgium)b; Narkiewicz, Krzysztof (Section co-ordinator) (Poland)c; Redán, Josep (Section co-ordinator) (Spain)d; Zanchetti, Alberto (Section co-ordinator) (Italy)e; Böhm, Michael (Germany)f; Christiaens, Thierry (Belgium)g; Cifkova, Renata (Czech Republic)h; De Backer, Guy (Belgium)i; Dominiczak, Anna (UK)j; Galderisi, Maurizio (Italy)k; Grobbee, Diederick E. (Netherlands)l; Jaarsma, Tiny (Sweden)m; Kirchof, Paulus (Germany/UK)n,o; Kjeldsen, Sverre E. (Norway)p; Laurent, Stéphane (France)q; Manolis, Athanasios J. (Greece)r; Nilsson, Peter M. (Sweden)s; Ruilope, Luis Miguel (Spain)t; Schmieder, Roland E. (Germany)u; Sirnes, Per Anton (Norway)v; Sleight, Peter (UK)w; Viigimaa, Margus (Estonia)x; Waeber, Bernard (Switzerland)y; Zannad, Faiez (France)z; List of authorsTask Force members:

doi: 10.1097/HJH.0b013e328364ca4c

aCentro di Fisiologia Clinica e Ipertensione, Università Milano-Bicocca; IRCSS, Istituto Auxologico Italiano, Milano, Italy

bHypertension and Cardiovascular Rehabilitation Unit, KU Leuven University, Leuven, Belgium

cDepartment of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland

dUniversity of Valencia INCLIVA Research Institute and CIBERobn, Madrid, Spain

eUniversity of Milan, Istituto Auxologico Italiano, Milan, Italy

fKlinik fur Innere Medizin III, Universitaetsklinikum des Saarlandes, Homburg/Saar, Germany

gGeneral Practice and Family Healthcare, Ghent University, Ghent, Belgium

hCentre for Cardiovascular Prevention, Charles University Medical School I and Thomayer Hospital, Prague, Czech Republic

iDepartment of Public Health, University Hospital, Ghent, Belgium

jCollege of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK

kCardioangiology with CCU, Department of Translational Medical Science, Federico II University Hospital, Naples, Italy

lUniversity Medical Centre Utrecht, Utrecht, Netherlands

mDepartment of Social and Welfare Studies, Faculty of Health Sciences, University of Linkoping, Linkoping, Sweden

nCentre for Cardiovascular Sciences, University of Birmingham and SWBH NHS Trust, Birmingham, UK

oDepartment of Cardiovascular Medicine, University of Munster, Germany

pDepartment of Cardiology, University of Oslo, Ullevaal Hospital, Oslo, Norway

qDepartment of Pharmacology and INSERM U970, European Hospital Georges Pompidou, Paris, France

rCardiology Department, Asklepeion General Hospital, Athens, Greece

sDepartment of Clinical Sciences, Lund University, Scania University Hospital, Malmo, Sweden

tHypertension Unit, Hospital 12 de Octubre, Madrid, Spain

uNephrology and Hypertension, University Hospital, Erlangen, Germany

vCardiology Practice, Ostlandske Hjertesenter, Moss, Norway

wNuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK

xHeart Health Centre, North Estonia Medical Centre, Tallinn University of Technology, Tallinn, Estonia

yPhysiopathologie Clinique, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

zINSERM, Centre d’Investigation Clinique 9501 and U 1116, Universite de Lorraine and CHU, Nancy, France

Correspondence to Professor Giuseppe Mancia, Centro di Fisiologia Clinica e, Ipertensione, Via F. Sforza, 35, 20122, Milano, Italy. Tel: +39 039 233 3357; fax: +39 039 322 274; e-mail: giuseppe.mancia@unimib.itandProfessorRobertFagard,Hypertension&CardiovascularRehab.Unit,KULeuvenUniversity,Herestraat49,3000Leuven,Belgium.Tel+3216348707;fax+3216343766;

Document Reviewers: Denis L. Clement (ESH Review Co-ordinator) (Belgium), Antonio Coca (ESH Review Co-ordinator) (Spain), Thierry C. Gillebert (ESC Review Co-ordinator) (Belgium), Michal Tendera (ESC Review Co-ordinator) (Poland), Enrico Agabiti Rosei (Italy), Ettore Ambrosioni (Italy), Stefan D. Anker (Germany), Johann Bauersachs (Germany), Jana Brguljan Hitij (Slovenia), Mark Caulfield (UK), Marc De Buyzere (Belgium), Sabina De Geest (Switzerland), Genevieve Anne Derumeaux (France), Serap Erdine (Turkey), Csaba Farsang (Hungary), Christian Funck-Brentano (France), Vjekoslav Gerc (Bosnia & Herzegovina), Giuseppe Germano (Italy), Stephan Gielen (Germany), Herman Haller (Germany), Arno W. Hoes (Netherlands), Jens Jordan (Germany), Thomas Kahan (Sweden), Michel Komajda (France), Dragan Lovic (Serbia), Heiko Mahrholdt (Germany), Michael Hecht Olsen (Denmark), Jan Ostergren (Sweden), Gianfranco Parati (Italy), Joep Perk (Sweden), Jorge Polonia (Portugal), Bogdan A. Popescu (Romania), Zeljko Reiner (Croatia), Lars Ryden (Sweden), Yuriy Sirenko (Ukraine), Alice Stanton (Ireland), Harry Struijker-Boudier (Netherlands), Costas Tsioufis (Greece), Philippe van de Borne (Belgium), Charalambos Vlachopoulos (Greece), Massimo Volpe (Italy), David A. Wood (UK).

Adapted from the 2013 ESH and ESC extended guidelines which were published in the Journal of Hypertension 2013; 31:1281–1357; European Heart Journal 2013; 34:2159–2219; Blood Pressure 2013; 22:193–278. Entities that participated in the development of the ESH/ESC Guidelines are listed in the extended version of the guidelines.

© The European Society of Hypertension (ESH). For permissions please e-mail:

The disclosure forms of the authors and reviewers are available on the respective Society websites: and

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1.1 Principles

The 2013 European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines continue to adhere to some fundamental principles that inspired the 2003 and 2007 guidelines, namely to base recommendations on properly conducted studies identified from an extensive review of the literature; to consider, as the highest priority, data from randomized, controlled trials and their meta-analyses, but not to disregard the results of observational and other studies of appropriate scientific calibre; and to grade the level of scientific evidence and the strength of recommendations in order to more effectively alert physicians on recommendations that are based on the opinions of the experts rather than on evidence (Tables 1 and 2). When appropriately recognized, this can avoid guidelines being perceived as prescriptive and favour the performance of studies wherein opinion prevails and evidence is lacking.

This shortened version of the ESH/ESC guidelines is for the practicing physician who often requires simplified information. However, whenever the physicians would like to know the source of the data upon which the recommendations are based, they are encouraged to consult the extensive version of the ESH/ESC guidelines wherein adequate references are given. These guidelines, however, do not override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient.

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1.2 New aspects

Because of new evidence on several diagnostic and therapeutic aspects of hypertension, the present guidelines differ from the 2007 ones in several points:

1. Re-emphasis on integration of blood pressure (BP), cardiovascular risk factors, asymptomatic organ damage and clinical complications for total cardiovascular risk assessment.

2. Update of the prognostic significance of out-of-office BP (both ambulatory and home BP), white-coat hypertension and masked hypertension.

3. Initiation of antihypertensive drug treatment only in patients with SBP or DBP values at least 140 or 90 mmHg, independent of level of total cardiovascular risk.

4. Unified target SBP (<140 mmHg) in both higher and lower cardiovascular risk patients.

5. Revised recommendations on treatment of hypertension in young people and in the elderly.

6. Liberal approach to initial monotherapy, without any all-ranking purpose scheme.

7. Revised therapeutic algorithm for achieving target BP.

8. Revised attention to resistant hypertension.

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The continuous relationship between BP and cardiovascular and renal events make the distinction between normotension and hypertension difficult. In practice, however, cut-off BP values are universally used to facilitate the decision about treatment (Table 3).

In order to help prognosis, total cardiovascular risk should be stratified in different categories (low, moderate, high and very high risk referred to the 10-year risk of cardiovascular mortality), based on BP category, cardiovascular risk factors, asymptomatic organ damage and presence of diabetes, and symptomatic cardiovascular disease or chronic kidney disease (CKD), as summarized in Fig. 1.

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The initial evaluation of a patient with hypertension should confirm the diagnosis of hypertension; detect causes of secondary hypertension; and assess cardiovascular risk, organ damage and concomitant clinical conditions. This calls for BP measurement, medical history including family history, physical examination, laboratory investigation and further diagnostic tests. Some of the investigations are needed in all patients; others only in specific patient groups.

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3.1 Blood pressure measurement

3.1.1 Office and out-of-office blood pressure

Although conventional office BP measurement currently remains the ‘gold standard’ for screening, diagnosis and management of hypertension, it is generally accepted that out-of-office BP provides important adjunct information.

At present, BP can no longer be estimated using a mercury manometer in many – although not all – European countries. Auscultatory or oscillometric semiautomatic sphygmomanometers are used instead, but these devices should be validated according to standardized protocols and their accuracy checked periodically. Table 4 gives instructions for correct office BP measurements, and Table 5 provides clinical indications for out-of-office BP measurement, namely measurements at home or over the 24 h.

Office BP is usually higher than ambulatory and home BP and the difference increases as office BP increases. Cut-off values for the definition of hypertension by home and ambulatory BP are reported in Table 6.

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3.1.2 White-coat and masked hypertension

The term ‘white-coat’ or ‘isolated office’ hypertension refers to a condition in which BP is elevated in the office at repeated visits and normal out of the office either on ambulatory blood pressure monitoring or on home blood pressure monitoring. Conversely, BP may be normal in the office and abnormally high out of the medical environment, which is termed ‘masked’ or ‘isolated ambulatory’ hypertension. Cut-off values to be used are those in Table 6.

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3.1.3 Central blood pressure

Owing to the variable superposition of incoming and reflected pressure waves along the arterial tree, aortic BP (central BP) may be different from brachial BP. Central BP can be estimated indirectly by various methods. The current guidelines consider that, despite the growing interest in these methods, more investigation is needed before recommending the routine measurement of central BP for clinical use.

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3.2 Medical history

The information to be obtained at the time of the first diagnosis of hypertension is indicated in Table 7.

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3.3 Physical examination

Physical examination aims to establish or verify the diagnosis of hypertension, establish current BP, screen for secondary causes of hypertension and refine global cardiovascular risk. Procedures for BP measurement are indicated in Tables 4 and 5. Other information to be obtained by physical examination is in Table 8.

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3.4 Laboratory investigations

Laboratory investigations are directed at providing evidence for additional risk factors, searching for secondary hypertension and looking for organ damage. Investigations should proceed from the most simple to the more complicated ones, as summarized in Table 9.

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3.5 Searching for asymptomatic organ damage

Owing to the importance of asymptomatic organ damage as an intermediate stage in the continuum of cardiovascular disease, and as a determinant of overall cardiovascular disease, signs of organ involvement should be sought carefully by appropriate techniques as indicated below.

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3.6 Searching for secondary forms of hypertension

A specific, potentially reversible cause of BP elevation can be identified in a relatively small number of adult patients with hypertension. However if basal work-up leads to the suspicion of a secondary form of hypertension, the patient should be referred to a specialized centre where specific diagnostic procedures may be performed.

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4.1 Recommendations of previous guidelines revised

The 2007 ESH/ESC Guidelines, like many other scientific guidelines, recommended the use of antihypertensive drugs in patients with Grade 1 hypertension even in the absence of other risk factors or organ damage after nonpharmacological treatment had proved unsuccessful. This recommendation also specifically included the elderly hypertensive patient. The 2007 Guidelines also suggested drug treatment of patients with diabetes, previous cardiovascular disease (CVD) or CKD even when their BP was in the high normal range (130–139/85–89 mmHg). Furthermore, a lower BP target was recommended for these high or very high risk patients (<130/80 mmHg) than in patients at low–moderate risk (<140/90 mmHg). These recommendations were reappraised in a 2009 ESH Task Force document on the basis of an extensive critical review of the evidence. The following now summarizes the conclusions for the current guidelines: attention should be directed to the Class of recommendation and the Level of evidence, in order to distinguish what is considered compelling and what simply prudent.

Figure 2 also summarizes recommendations and suggestions for treatment initiation and BP targets in the context of total risk stratification of hypertensive individuals.

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4.2 When to initiate antihypertensive drug treatment

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4.3 Blood pressure treatment targets

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5.1 Lifestyle changes

Appropriate lifestyle changes are the cornerstone for the prevention of hypertension. They are also important for its treatment, although they should never delay the initiation of drug therapy in patients at high level of risk. In addition to the BP-lowering effect, lifestyle changes contribute to the control of other cardiovascular risk factors and clinical conditions.

The lifestyle measures that have been shown to be capable of reducing BP and therefore recommended are as follows:

1. salt restriction to 5–6 g/day;

2. moderation of alcohol consumption to no more than 20–30 g of ethanol per day in men and 10–20 g/day in women;

3. high consumption of vegetables and fruits and low-fat dairy products;

4. reduction of weight to a BMI of 25 kg/m2 and waist circumference to less than 102 cm in men and less than 88 cm in women;

5. at least 30 min of moderate dynamic exercise on 5 to 7 days per week.

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5.2 Pharmacological therapy

5.2.1 Choice of antihypertensive drugs

The current guidelines reconfirm that all major classes of antihypertensive agents are suitable for the initiation and maintenance of antihypertensive treatment either in monotherapy or in some combinations, and that no all-purpose ranking of drugs for general antihypertensive usage is evidence based. All classes have their advantages but also contraindications, and may be preferentially used or avoided in specific conditions. Contraindications and preferred indications are listed in Tables 10 and 11.

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5.2.2 Monotherapy and combination therapy

The current guidelines share the 2007 Guidelines’ opinion that monotherapy can reduce BP to target only in a limited number of patients and that most patients require the combination of at least two drugs, and they reconfirm that initiation with a drug combination can be considered in patients at high cardiovascular risk or with markedly high BP. The algorithm of Fig. 3, however, is a modification of the 2007 one, to emphasize that adding drugs to drugs should be done with attention to results and any compound overtly ineffective or minimally effective should be replaced, rather than retained in an automatic step-up multiple-drug approach. Combinations to be preferred or avoided are illustrated in Fig. 4.

Strengths of recommendations about choice of drugs and combinations of antihypertensive agents are given in the summary table below.

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Summary recommendations for antihypertensive treatment strategies in various conditions are listed below.

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6.1 White-coat and masked hypertension

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6.2 Elderly

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6.3 Young adults

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6.4 Women

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6.5 Diabetes mellitus

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6.6 Metabolic syndrome

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6.7 Diabetic and nondiabetic nephropathy

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6.8 Cerebrovascular disease

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6.9 Heart disease

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6.10 Atherosclerosis, arteriosclerosis and peripheral artery disease

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6.11 Resistant hypertension

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8.1 Follow-up visits

After initiation of antihypertensive drug therapy, it is important to see the patient at 2-week to 4-week intervals to evaluate the effects on BP and to assess possible side-effects. Some medications will have an effect within days or weeks but a continued delayed response may occur during the first 2 months. Once the target is reached, a visit interval of a few months is reasonable.

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8.2 Elevated blood pressure at control visits

Patients and physicians have a tendency to interpret an uncontrolled BP at a given visit as due to occasional factors and thus to downplay its clinical significance. Due attention should be given to poor adherence or irregular consumption of drugs (sometimes because of adverse effects), to the white-coat effect and to substances or drugs opposing the antihypertensive effect of treatment.

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8.3 Can antihypertensive medication be stopped?

In some patients, in whom treatment is accompanied by an effective BP control for an extended period, it may be possible to reduce the number and dosage of drugs. This may be particularly the case if BP control is accompanied by healthy lifestyle changes. Reduction of medications should be made gradually and the patient should frequently be checked because of the risk of reappearance of hypertension.

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Despite overwhelming evidence that hypertension is a major cardiovascular risk factor and that BP-lowering substantially reduce the risk, there is evidence that all over the world a noticeable proportion of hypertensive individuals are unaware of this condition or, if aware, do not undergo treatment; target BP values are seldom achieved; failure to achieve BP control is associated with persistence of an elevated cardiovascular risk; and the rate of awareness of hypertension and BP control is improving slowly or not at all. As a consequence, high BP remains a leading cause of death and cardiovascular morbidity in Europe, as elsewhere in the world. Overall, three main causes of the low rate of BP control in real life have been identified: physician inertia; patient low adherence to treatment; and deficiencies of healthcare systems in their approach to chronic diseases. Methods to improve adherence to physicians’ recommendations are listed in Table 12.


antihypertensive treatment; blood pressure; cardiovascular complications; cardiovascular risk; device therapy; guidelines; hypertension; lifestyle; organ damage

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