Managing the patient with hypertension and elevated heart rate in the routine care setting: expert opinion and narrative review

Increased resting heart rate (RHR) due to overactivity of the sympathetic nervous system (SNS) increases the risk of adverse cardiovascular outcomes in hypertension by promoting multiple aspects of hypertension-mediated organ damage (HMOD) such as endothelial dysfunction, arterial stiffness, left ventricular hypertrophy and renal damage. A vicious cycle of SNS overactivity and adverse cardiovascular remodelling leads ultimately to increased risk of adverse clinical cardiovascular outcomes and heart failure with either reduced or preserved left ventricular ejection fraction. Epidemiological studies show that elevated RHR (>80 bpm) provides a straightforward means of identifying people with hypertension likely to be complicated by SNS overactivity who may benefit from therapy that reduces HR and/or the activity of the SNS, such as beta-blockers. The current (2023/2024) guideline from the European Society of Hypertension (ESH) provides detailed guidance on the management of arterial hypertension. Like other guidelines, this document is long and complex. An expert group of cardiologists from Europe, the Middle East, Africa, and Russia, with experience in the clinical handling of such patients, have summarised the key elements of the 2023 ESH guideline, for the identification and management of patients with hypertension driven by an overactive sympathetic nervous system. These recommendations are based on a detailed review of clinical evidence. They are intended to propose a straightforward, pragmatic approach aimed at supporting physicians’ clinical practice in primary care and other routine care settings, including in higher-, medium-, and lower-income countries, and in rural and urban environments.