New guidelines for the management of elevated blood pressure and hypertension were presented at the European Society of Cardiology (ESC) Congress 2024 and subsequently published in the European Heart Journal.1 The European Society of Hypertension (ESH) had previously published its own updated guidelines 1 year earlier.2,3 Prior guidelines, released in 2018, were the result of a collaborative effort by the ESH and ESC; however, the original agreement for joint guideline development was not upheld.4
The publication of updated recommendations for the diagnosis and treatment of arterial hypertension acknowledges the clinical significance of this risk factor to European health providers, but may raise confusion and uncertainty among physicians and researchers.
The main innovation in the ESC 2024 guidelines is the introduction of two new blood pressure (BP) categories below 140/90 mmHg: elevated (120–139/70–89 mmHg); and non-elevated (<120/70 mmHg). This reclassification abolishes the concept of normotension. When BP is ≥140/90 mmHg, the term hypertension remains applicable. The new elevated BP category, which includes subjects previously classified in the high normal BP range, highlights the continuous relationship between BP levels and cardiovascular (CV) risk. This approach aims to improve BP control at lower BP thresholds.
The ESC 2024 guidelines suggest that the diagnosis of non-elevated BP, elevated BP and hypertension should strongly rely on out-of-office measurements, including ambulatory and home BP measurements, in addition to measurements performed in the clinic. Out-of-office BP measurements are particularly useful for identifying well-known phenotypes, such as masked hypertension and white-coat hypertension. Ambulatory BP monitoring is also recommended to guide deprescription of BP-lowering agents by detecting orthostatic hypotension or highly variable BP, and to assess BP control over 24 hours to account for time-dependent effects of dosing.
Non-pharmacological treatment should be prescribed to all patients, while pharmacological treatment should be considered for hypertensive individuals and those with BP >130/80 mmHg and high CV risk, including chronic kidney disease (CKD), diabetes, hypertension-mediated organ damage (HMOD) or previous CV events.
ESC guidelines recommend assessing CV risk using the Systematic Coronary Risk Evaluation-2 (SCORE2) and SCORE2-Older Persons (SCORE2-OP), as well as evaluating high-risk conditions and previous clinical events. The presence of HMOD, CKD or diabetes indicates high or very high CV risk, eliminating the need to calculate SCORE2 or SCORE2-OP before initiating treatment. For many individuals with elevated BP, the estimated 10-year risk for CV events may be ≥10% according to SCORE2 or SCORE2-OP, indicating a need for BP-lowering drug treatment. According to this threshold, most older individuals, due to the association between age and high CV risk, may be candidates for a more aggressive treatment strategy tempered by the ‘as low as reasonably achievable’ principle. ESC guidelines raise the age threshold for very elderly patients from 80 to 85 years and introduce the concept of frailty, providing a detailed description of clinically useful methods for assessing frail patients. A comprehensive and detailed clinical assessment for comorbidities, HMOD and secondary hypertension, with emphasis on primary aldosteronism diagnosis including renin and aldosterone measurements, is suggested for all patients. However, questions remain about the sustainability of these laboratory and instrumental examinations within European national health systems.
Treatment is based on the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, calcium channel blockers and thiazide or thiazide-like diuretics. β-blockers are considered third-line therapy, although the ESH suggests their inclusion as first-line therapy alongside the other mentioned classes. ESH guidelines also recognise the use of beta blockers for reasons other than hypertension or its complications. All patients should receive lifestyle intervention. Treatment should be initiated early, preferably with a single-pill combination of two drugs. A triple combination therapy is recommended as a second treatment step, encouraging the availability of triple drug combinations. The addition of sodium–glucose cotransporter-2 inhibitors is recommended for patients with CKD or heart failure, with or without diabetes.
In patients with resistant hypertension, renal denervation may be considered. However, it is not recommended as a first-line BP-lowering intervention due to a lack of evidence regarding CV outcomes. Additionally, renal denervation is not advised for patients with moderate to severe renal impairment, as an estimated glomerular filtration rate <40 ml/min/1.73 m2 was an exclusion criterion in randomised clinical trials. In patients with resistant or difficult-to-treat hypertension, adding a fourth drug is a viable option; results from the QUADRO study, presented at the ESC Congress 2024, showed that a quadruple single-pill combination (perindopril, amlodipine, indapamide and bisoprolol) was superior to a triple combination regardless of BP measurement method.
Both the 2023 ESH guidelines, which include a practical version for general practitioners, and the 2024 ESC guidelines focus on the primary care setting. Both guidelines aim to provide clear recommendations for everyday clinical practice and highlight the role of patient follow-up in improving BP control and preventing CV events.5 However, general practitioners have expressed concerns about the application of risk score calculations to determine diagnostic thresholds and treatment goals, as reported in a recent survey included in the supplementary material of the ESC guidelines.
The hope now is that the 2024 ESC and 2023 ESH guidelines will harmonise, reducing confusion and uncertainty, optimising the implementation of their recommendations, and ultimately improving BP control.6