A review of the 2024 ESC Guidelines on elevated blood pressure and hypertension

Reported from ESC Congress 2024

Introduction

The “2024 ESC Guidelines for the management of elevated blood pressure (BP) and hypertension” were presented at the ESC Congress 2024 in London (UK) and published in the European Heart Journal.¹

The task force included physicians, patient representatives, and methodologists. Although the guidelines build on the “2018 ESC/ESH Guidelines on the management of arterial hypertension,” the European Society of Hypertension (ESH) did not contribute to the current version and published its own guidelines in 2023.² A significant change reflected in the title is the introduction of a new BP category called “elevated BP.” This reflects the continuous relationship between BP and cardiovascular disease (CVD), renal disease, and death³ and aims to raise awareness and emphasize the importance of preventing hypertension through reinforced lifestyle measures.

In some patients with high or very high CVD risk, antihypertensive drug therapy may be indicated even if BP is elevated but does not meet the traditional threshold of ≥140 mmHg systolic or ≥90 mmHg diastolic used to define hypertension. Moreover, the guidelines consider sex and gender as integral components throughout the document and advocate for patient-centred care that employs shared decision-making strategies. In the following, we will summarize important aspects of the guidelines regarding the definition and classification, diagnosis and treatment of hypertension. For more details regarding the underlying evidence and individual patient groups or circumstances, please refer to the full text.

Definition and classification

• Non-elevated BP is defined as an office systolic BP <120 mmHg and diastolic BP <70 mmHg.
• Elevated BP is defined as an office systolic BP of 120-139 mmHg or diastolic BP of 70-89 mmHg.
• Hypertension is still defined as office systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg. However, the 2024 ESC Guidelines did not include a classification of hypertension in stages 1-3.
• Resistant hypertension is defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg despite treatment with appropriate lifestyle measures and a maximum or maximally tolerated doses of a diuretic, a renin-angiotensin-system (RAS) blocker, and a calcium channel blocker. Pseudo-resistant hypertension must be excluded, and out-of-office BP measurements must confirm uncontrolled office BP values.

Measuring BP and diagnosing hypertension

• Opportunistic screening for hypertension is recommended every 3 years in patients <40 years and every year in those ≥40 years or with elevated BP who do not meet thresholds for BP-lowering treatment.
• In patients with elevated BP and high CVD risk, it is recommended to measure BP out-of-office (ambulatory or home BP monitoring [ABPM/HBPM] or, if not logistically feasible, by repeat office BP measurements.
• In patients with office BP ≥140/90 mmHg, it is recommended to confirm the diagnosis of hypertension with out-of-office BP measurements, if logistically feasible.
• Patients with office BP ≥180/110 mmHg should be evaluated for a hypertensive emergency.
• Screening for primary aldosteronism by renin and aldosterone measurements should be considered in all adults with confirmed hypertension.
• Patients with hypertension <40 years or signs or symptoms suggestive of secondary hypertension and patients with resistant hypertension should be screened for secondary hypertension.

Treatment thresholds

In patients with hypertension, pharmacotherapy is recommended in addition to lifestyle measures as CVD risk is considered sufficiently high.

In patients with a systolic BP of 130-139 mmHg after 3 months of lifestyle measures and

• high-risk conditions (e.g., established CVD, diabetes mellitus in adults ≥60 years),
• 10-year estimated CVD risk calculated using SCORE2 or SCORE2-OP >10%,⁴ or
• 10-year estimated CVD risk calculated of 5-10% in the presence of risk modifiers pharmacological treatment is recommended.
• Risk modifiers that should be considered to up-classify individuals with elevated BP and 5-10% 10-year CVD risk include history of pregnancy complications (e.g., gestational diabetes, gestational hypertension, pre-eclampsia), high-risk ethnicity, family history of premature onset atherosclerotic CVD, socio-economic deprivation, auto-immune inflammatory disorders, HIV, and severe mental illness.

Treatment targets

• If well tolerated, it is recommended to target systolic BP values of 120-129 mmHg and ideally 70-79 mmHg for diastolic BP in most patients.
• If achieving a systolic BP of 120-129 mmHg is poorly tolerated, a systolic BP that is “as low as reasonably achievable” (ALARA principle) is recommended.
• In patients ≥85 years of age or with pre-treatment symptomatic orthostatic hypotension, personalized and more lenient BP targets (e.g., <140/90 mmHg) should be considered.

Lifestyle measures

• It is recommended to:
  • normalize weight (BMI 20-25 kg/m² and waist circumference <94 cm in men and <80 cm in women).
  • adopt a healthy and balanced diet, such as the Mediterranean or DASH diet.
  • restrict sodium to <2 g (about 5 g of salt or a teaspoon).
  • restrict consumption of free sugar and avoid alcohol.
  • exercise (≥150 min per week of moderate-intensity aerobic exercise or 75 min per week of vigorous-intensity in addition to dynamic or isometric resistance training 2-3 times per week).
  • In patients with hypertension and high daily sodium intake but who do not have moderate-to-advanced chronic kidney disease, an increase in dietary potassium intake should be considered. This increase should preferably come from potassium-rich fruits and vegetables, such as bananas, avocados, or spinach. Alternatively, potassium-enriched salt can be used.

Pharmacological treatment

• Low-dose two-drug (ideally single-pill) combination therapy with a RAS blocker and a dihydropyridine calcium channel blocker or diuretic is recommended as an initial treatment in most patients.
• If BP remains uncontrolled despite a two-drug combination therapy, increasing to a low-dose three-drug (ideally single-pill) combination with a RAS blocker and a dihydropyridine calcium channel blocker or diuretic is recommended.
• If BP remains uncontrolled despite a low-dose three-drug combination therapy, increasing the doses to maximum or maximally tolerated doses is recommended.
• Beta-blockers are recommended at any step if there are compelling indications (e.g., angina, heart failure with reduced ejection fraction).
• In patients with resistant hypertension, adding spironolactone should be considered. Of note, the addition of spironolactone is no longer a class I recommendation as there are no CVD outcome trials investigating spironolactone in hypertension. However, spironolactone was shown to result in better home systolic BP reductions than bisoprolol and doxazosin, arguably because primary aldosteronism is common among patients with resistant hypertension and resistant hypertension is often associated with sodium retention.⁵

Catheter-based renal denervation

• The guidelines acknowledge that ultrasound and second-generation radiofrequency renal denervation systems have demonstrated a BP-lowering efficacy (placebo-corrected systolic BP lowering of approximately 6 mmHg systolic office BP and 4 mmHg 24-hour systolic BP) in a broad range of patients with and without antihypertensive medication without procedure-related serious safety signals beyond the usual risk of femoral arterial access procedures.
• Therefore, renal denervation may be considered in patients with
  • resistant hypertension if they express a preference to undergo renal denervation after a shared risk-benefit discussion.
  • uncontrolled hypertension on fewer than 3 drugs, if they express a preference to undergo renal denervation after a shared risk-benefit discussion.
• The procedures should be performed at a medium-to-high volume centre and patients should be managed by a multidisciplinary hypertension team, including experts in hypertension and percutaneous cardiovascular interventions.
• In clinical practice, renal denervation is not recommended in patients with an estimated glomerular filtration rate <40 ml/min/1.73 m2, until further evidence becomes available, as these patients were excluded from sham-controlled trials.

Follow-up

• Follow-ups to assess for tolerance/safety and BP control are recommended every 1-3 months (1 month preferred) until BP is controlled, thereafter yearly follow-ups are advised.

References

1. McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, Christodorescu RM, Daskalopoulou SS, Ferro CJ, Gerdts E, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024;45:3912-4018.
2. Parati G, Bilo G, Kollias A, Pengo M, Ochoa JE, Castiglioni P, Stergiou GS, Mancia G, Asayama K, Asmar R, et al. Blood pressure variability: methodological aspects, clinical relevance and practical indications for management - a European Society of Hypertension position paper *. J Hypertens. 2023;41:527-544.
3. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies C. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. The Lancet. 2002;360:1903-1913.
4. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Back M, Benetos A, Biffi A, Boavida JM, Capodanno D, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42:3227-3337.
5. Williams B, MacDonald TM, Morant S, Webb DJ, Sever P, McInnes G, Ford I, Cruickshank JK, Caulfield MJ, Salsbury J, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. The Lancet. 2015;386:2059-2068.

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