A comparative analysis on the latest international and local guidelines for the management of hypertension

INTRODUCTION Hypertension is the leading modifiable risk factor for cardiovascular diseases (CVDs) and mortality globally. Therefore, effective management of high blood pressure (BP) is critical in improving overall population health.[1,2] In Singapore, the prevalence of hypertension rose from 19.8% in 2010 to 37.0% in 2021–2022.[3,4] The 2024 European Society of Cardiology (ESC) guidelines for hypertension introduced several new recommendations based on best available current evidence.[5] In December 2023, the Agency for Care Effectiveness (ACE) in Singapore also promulgated guidelines with an evidence-based and value-driven approach to hypertension management to guide primary care providers.[6] This commentary highlights and compares the updates from these guidelines, with recommendations from the Singapore Hypertension Society (SHS). UPDATES AND RECOMMENDATIONS New blood pressure target recommendations While both ESC and ACE maintain the current definition of hypertension as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, they recognise that cardiovascular risk is already increased in individuals with BP values below the threshold. The ESC highlighted office BP readings of 120–139/70–89 mmHg as ‘elevated BP’, while ACE defined ‘high-normal BP’ as BP of 130–139/85–89 mmHg. Patients with BP within this BP range who are at high risk for CVD based on risk stratification tools can benefit from the initiation of antihypertensive medications.[7] Another ESC update recommends targeting a systolic BP of 120–129 mmHg among patients on antihypertensive medications. This update signals a shift towards more intensive BP control based on contemporary evidence, which suggests that a lower BP target optimally decreases CVD risk.[7,8,9,10] Furthermore, in cases whereby pharmacotherapy is not well tolerated, ESC recommends a systolic BP target that is ‘as low as reasonably achievable’ (ALARA principle). In contrast, ACE recommended BP targets based on cardiovascular risk stratification and overall health status, with the more stringent BP target of <130/80 mmHg recommended for patients at high to very high CVD risk. The SHS advocates applying the ALARA principle to personalise BP targets. It recognises that a lower achieved BP benefits patients, provided that such targets can be achieved safely. Avoiding beta-blockers for first-line hypertension treatment Both the ESC and ACE guidelines recommend angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and dihydropyridine calcium channel blockers as first-line treatment options for hypertension. The SHS highlights that beta-blockers should be avoided as first-line monotherapy due to their lower efficacy and higher side effect profile.[11,12] However, beta-blockers may be considered as the first-line therapy or used in certain subgroups, such as those with chronic coronary syndromes or heart failure with reduced ejection fraction (specifically cardioselective beta-blockers), or for heart rate control in atrial fibrillation.[13] Combination therapy to improve adherence and control The ESC recommends combination BP-lowering treatment, especially a fixed-dose, single-pill combination regimen, for more effective BP control, instead of monotherapy. Similarly, ACE recognises the potential benefit of intensive BP control in reducing major cardiovascular events, with recommendations to start low-dose dual therapy in patients with BP ≥20/10 mmHg above the target, Grade 2 hypertension or higher, or comorbidities that increase CVD risks, such as diabetes mellitus or chronic kidney disease (CKD).[17,18] Additionally, it cautions against lowering BP excessively below 120/70 mmHg, as evidence of clinical benefit is inconsistent and it may promote side effects and treatment discontinuation. The ACE guidelines show that only one single-pill combination drug is subsidised. The SHS advocates increasing the number of single-pill combinations available to improve hypertension control nationally. Special populations: the elderly Given the rapidly ageing Singapore population, specific recommendations for the management of hypertension in elderly persons are highlighted by ACE. For patients aged >80 years, frail patients, or those having limited life expectancy, ACE recommends less-stringent BP targets (e.g. <150/90 mmHg), weighing against the potential harms of intensive BP control, such as increased adverse effects, impaired organ function or limited tolerability. In contrast, ESC does not provide a specific BP target for patients with moderate or worse fraility, but instead suggested a shared decision approach to determine appropriate BP targets.[19,20] Universal screening for primary aldosteronism One new ESC recommendation is to perform universal screening for primary aldosteronism in all adults with hypertension. Primary aldosteronism affects 5%–20% of all individuals with hypertension, of whom[21,22] about 50% have unilateral adrenal disease (Conn’s syndrome), which can be successfully treated with laparoscopic adrenalectomy.[23,24] Due to the deleterious effects of hyperaldosteronism, patients with primary aldosteronism are at greater risk of cardiovascular events and renal failure compared to those with essential hypertension.[25,26,27,28] In Singapore, about half of the patients with primary aldosteronism had prolonged hypokalaemia for more than a year before specialist evaluation.[29] Patients with primary aldosteronism may also have normokalaemia.[21,22] Ultimately, primary care physicians should refer patients at high-risk for primary aldosteronism to specialists — those with hypertension and hypokalaemia, resistant or severe hypertension. With the emergence of newer aldosterone synthase inhibitors,[30,31] aldosterone-directed pharmacotherapy may become commonplace in the treatment of hypertension. The SHS recommends further research on the potential barriers to screening for hyperaldosteronism in hypertensive patients, pursuing a cost-effective threshold and an urgent implementation of screening programmes. Potassium supplementation Another new ESC recommendation suggests increasing dietary potassium intake in hypertensive patients (without moderate-to-advanced CKD). This can be achieved through sodium substitution with potassium-enriched salt, or diets rich in fruits, vegetable and beans, as recently promoted by the Singapore Health Promotion Board.[32] In a large open-label trial in rural China,[33] residents randomly assigned to the intervention group using a salt substitute (75% sodium chloride, 25% potassium chloride) had lower rates of stroke, cardiovascular events and all-cause mortality, as compared to the control group using regular salt (100% sodium chloride). A lower urinary sodium-to-potassium ratio is associated with a greater reduction in BP and lower CVD risk.[34,35,36] Other studies have shown that potassium supplementation alone improves BP.[37] This non-pharmacological approach may be particularly important in Singapore, where dietary sodium intake is high and potassium intake is well below the World Health Organization recommendation of 3.5 g daily.[38,39,40] Thus, increasing the intake of potassium may improve BP at the population level. Managing hyperkalaemia in patients with chronic kidney disease While increasing potassium intake is beneficial, patients with CKD may be at higher risk of hyperkalaemia. This can be managed by the regular use of potassium binders. The SHS advocates improving access to potassium binders.[41] This requires updating protocols for managing chronic hyperkalaemia and educating primary care doctors on assessing potassium levels in patients with CKD who need potassium binders. Of note, sodium polystyrene sulfonate is a subsidised medication, while patiromer is unavailable in Singapore and sodium zirconium cyclosilicate, though available, is costly. Enhancing adherence to blood pressure treatment Adherence to hypertensive medications is often suboptimal,[42,43] confering a higher CVD risk.[44,45] In addition to single-pill combinations, ESC also recommends the objective evaluation of adherence (either directly observed treatment or detecting the prescribed drugs in blood or urine sample). This is more accurate than subjective measurements through pharmacy records, pill counting or patient recall. It is particularly useful in patients with apparent resistant hypertension[46] and may prompt interventions to improve adherence, such as motivational counselling and drug regimen simplification. The use of drug adherence testing is currently being evaluated in Singapore (Clinicaltrials.gov NCT: 06938633). Separately, a primary care clinic intervention trial in Singapore demonstrated improved BP control relative to usual care using a cost-effective approach.[47] This multifaceted intervention included clinician training in hypertension management, subsidised single-pill combination medications, nurse-delivered motivational conversations and telephone follow-ups. The SHS advocates effective funding and reimbursement strategies to enable nation-wide access in all primary care facilities. Box 1 summarises the recommendations issued by the SHS.Box 1: Singapore Hypertension Society recommendations.Use of technology Leveraging recent technological advancement brought about by the coronavirus disease 2019 pandemic,[48] the ESC recommends physician–patient web communications as an effective tool in primary care, whereby patients can report home BP readings via the Internet with low incremental costs.[49] Locally, this was implemented in the form of the Primary Tech-Enhanced Care Home Blood Pressure Monitoring Programme, a collaborative effort by the Ministry of Health’s Office of Healthcare Transformation and all three polyclinic clusters, supported by the national IT server, Synapxe.[50,51] Under this programme, patients are provided with a Bluetooth-enabled BP machine to share their BP readings automatically with their care team via telesupport (e.g. medical advice for abnormal BP readings, in-app reminders, nurse-led check-in) and teleconsultations to adjust medications. Patients enrolled in this programme have shown reduction and maintenance of BP, demonstrating its efficacy. Ideally, this programme should be scaled beyond the polyclinic setting, to support patients managed by all primary care physicians. CONCLUSION The 2024 ESC guidelines introduced new concepts for the management of hypertension, emphasising more stringent BP targets through pharmacological and non-pharmacological measures and the integration of various tools to enhance patient adherence. The ACE guidelines considered local practices and patient demographics to provide pointers tailored to the Singaporean population. Overall, both guidelines underscore the importance of individualised patient care, balancing the benefits of intensive BP control with patient-specific factors to optimise outcomes. Acknowledgement This manuscript was written with the valuable guidance and support of members of the Singapore Hypertension Society. It is co-authored by Leow AST and his mentor (Puar TH) as part of the SMJ Editorial Fellowship programme 2025. Financial support and sponsorship Nil. Conflicts of interest Sia CH, Poh KK and Puar TH are members of the SMJ Editorial Board and were thus not involved in the peer review and publication decisions of this article.