Arterial hypertension is the most prevalent chronic disease in the world and the leading modifiable cause of cardiovascular disease. In 2026, European and American scientific societies have updated their clinical practice guidelines with significant changes to diagnostic thresholds, control targets, and the treatment algorithm. This article reviews the key points that every physician and patient should know.
New diagnostic thresholds and classification
The European Society of Hypertension (ESH) maintains the diagnostic threshold at 140/90 mmHg for office measurement, but reinforces the role of ambulatory blood pressure monitoring (ABPM) as the reference standard. Masked hypertension — normal office readings but ABPM above 130/80 mmHg — affects 15-20% of patients and carries a cardiovascular risk equivalent to overt hypertension.
The current classification distinguishes three grades: grade 1 (140-159/90-99 mmHg), grade 2 (160-179/100-109 mmHg), and grade 3 (≥180/≥110 mmHg). High-normal blood pressure (130-139/85-89 mmHg) is no longer considered benign: in patients with diabetes or chronic kidney disease, pharmacological treatment is now recommended in this range.
Updated control targets
The general target for adults under 65 is a systolic pressure of 120-129 mmHg — a tightening from the previous 130 mmHg. The SPRINT and STEP trials demonstrated that this stricter target reduces major cardiovascular events by 25%, albeit with higher rates of orthostatic hypotension and hypokalemia.
- Adults <65 years: target 120-129/70-79 mmHg
- Adults 65-79 years: target 130-139/70-79 mmHg
- Over 80 years: systolic target 140-149 mmHg if well tolerated
- Diabetes mellitus: systolic 120-130 mmHg
- CKD with proteinuria: systolic <130 mmHg
Treatment algorithm: the polypill era
The main therapeutic update in the 2026 guidelines is the recommendation to initiate combination therapy in grade 1 hypertension with high or very high cardiovascular risk, skipping the monoterapy step. The preferred first-line combination remains an ACE inhibitor or angiotensin receptor blocker (ARB) plus a calcium channel blocker or thiazide diuretic.
The antihypertensive polypill — a single capsule containing three active agents at fixed doses — has shown a 30-40% improvement in therapeutic adherence versus separate tablets. Trials including TRIUMPH and TripleA showed superior blood pressure control at 6 months with the polypill in high-risk patients.
Resistant hypertension and new options
Resistant hypertension is defined as blood pressure remaining above target on three antihypertensive drugs at full doses, including a diuretic. It affects 10-15% of treated hypertensives and carries a fourfold higher cardiovascular risk than controlled hypertension.
In this subgroup, catheter-based renal denervation received FDA and EMA approval in 2025 as an adjunctive treatment. The SPYRAL HTN-ON MED and RADIANCE-HTN TRIO trials demonstrated 8-12 mmHg reductions in ambulatory systolic pressure, with an acceptable safety profile. The technique involves radiofrequency or ultrasound ablation of renal sympathetic nerves from within the renal arteries.
Non-pharmacological measures: updated evidence
Lifestyle interventions are not complementary but central to treatment. Sodium restriction to under 5 g/day reduces systolic pressure by 5-6 mmHg. The DASH diet combined with moderate aerobic exercise (150 minutes per week) can reduce systolic pressure by up to 11 mmHg — equivalent to a single antihypertensive drug.
Weight reduction (1 mmHg per kg lost), alcohol moderation (maximum 14 units per week in men, 8 in women), and smoking cessation complete the evidence-based non-pharmacological recommendations.
