The 2024 ESC guidelines on hypertension, announced at ESC2024, maintain the diagnostic threshold of 140/90 mmHg but simplify blood pressure classification. Out-of-office measurements are emphasized, and drug therapy targets an SBP of 120–129 mmHg.
The 2024 ESC hypertension guidelines were unveiled at ESC2024, marking the first update since 2018.
★The blood pressure classification was streamlined from six to three stages, maintaining the threshold of 140/90 mmHg for hypertension.
- The guidelines emphasize the role of out-of-office blood pressure monitoring in diagnosing hypertension.
- A systematic four-step risk assessment is recommended for patients with elevated blood pressure.
- Potassium intake is newly recommended for hypertensive patients with high sodium intake and no moderate or severe CKD.
- The drug treatment goal for elevated blood pressure is an SBP of 120–129 mmHg, starting with a single drug if lifestyle interventions fail.
- No specific higher targets are set for older adults, and renal denervation may be considered for resistant hypertension.
On August 30, the first day of the European Society of Cardiology Congress (ESC2024) held in London, UK, the “2024 ESC Guidelines for the Management of Elevated Blood Pressure and Hypertension” were announced. The previous guidelines were released in 2018, making this the first revision in six years. Unlike the 2018 edition, which was co-edited with the European Society of Hypertension (ESH), the 2024 edition was solely edited by the ESC. The threshold for diagnosing hypertension remains at 140/90 mmHg; however, the classification of blood pressure levels has been consolidated from six stages in the 2018 edition to three stages, with a recommended target systolic blood pressure (SBP) of 120–129 mmHg for a wide range of patients during pharmacological treatment. Additionally, the guidelines have enhanced the role of out-of-office blood pressure monitoring and considered renal sympathetic denervation via catheter as an option for resistant hypertension.
The 2024 guidelines feature 136 recommendations, 57 of which are new. John William McEvoy, the lead editor from the University of Galway in Ireland, summarized, “More than half of the Class 1 recommendations are supported by evidence levels A or B, demonstrating the high quality of the research involved.”
Blood Pressure Classification Consolidated into Three Stages
The diagnostic threshold for hypertension remains unchanged from the 2018 edition, with an SBP of 140 mmHg or higher or a diastolic blood pressure (DBP) of 90 mmHg or higher in the clinic. On the other hand, the classification of blood pressure levels has been consolidated into three stages: “non-elevated blood pressure” (SBP <120 mmHg and DBP <70 mmHg), “elevated blood pressure” (SBP 120–139 mmHg or DBP 70–89 mmHg), and “hypertension” (SBP ≥140 mmHg or DBP ≥90 mmHg) (Table 1).
Table 1 shows the classification of blood pressure levels and the corresponding thresholds under different measurement conditions (unit: mmHg, ABPM: ambulatory blood pressure monitoring). Although the upper limit of elevated blood pressure is indicated as “up to 139 mmHg” for SBP in the clinic in the guidelines text, Table 1 follows the notation in Table 5 of the guidelines.
In the 2018 edition, blood pressure was classified into six stages: optimal blood pressure (<120/80 mmHg), normal blood pressure (120–129/80–84 mmHg), high-normal blood pressure (130–139/85–89 mmHg), grade 1 hypertension (140–159/90–99 mmHg), grade 2 hypertension (160–179/100–109 mmHg), and grade 3 hypertension (≥180/110 mmHg).
The guidelines recommend multiple blood pressure measurements, including out-of-office measurements, for diagnosing non-elevated blood pressure or hypertension, with a higher emphasis placed on out-of-office measurements than in the 2018 edition.
Systematic Risk Assessment from Non-Elevated Blood Pressure
The guidelines recommend lifestyle modification advice as necessary for patients with non-elevated blood pressure, along with reassessment of risk, including blood pressure, every three years for those under 40 and annually for those 40 and over.
For elevated blood pressure, a four-step, staged risk assessment is recommended. The first step is to check for comorbidities that increase cardiovascular disease (CVD) risk, such as a history of CVD, moderate or more severe chronic kidney disease (CKD), diabetes, hypertensive organ damage, or familial hypercholesterolemia. If any of these comorbidities are present, the following steps can be skipped, and treatment interventions focused on lifestyle modifications should begin.
If none of these comorbidities are present, the second step involves assessing the 10-year CVD risk using SCORE2 (SCORE2-OP for those over 70). SCORE2 is a CVD risk assessment tool developed for Europeans, and if the 10-year CVD risk is found to be 10% or higher, further risk assessment can be skipped, and treatment interventions, including lifestyle modifications, should begin.
If SCORE2 is less than 5%, the patient is placed under observation. If SCORE2 is between 5% and 10%, step 3 involves checking for more detailed CVD risk factors. If any are identified, treatment intervention should begin. If no risk factors are found, step 4 involves checking for coronary artery calcium scores or blood markers like BNP as necessary. If these are abnormal, treatment intervention should begin, and if they are within the normal range, the patient should be observed, with an annual reassessment.
The guidelines emphasize a four-stage assessment due to the diverse range of hypertension risk factors, allowing for a weighted evaluation according to the degree of risk. However, since elevated blood pressure is not yet classified as hypertension, there may be debate on how extensively this detailed risk assessment can be implemented in routine clinical practice.
Regarding lifestyle improvements, a new recommendation for potassium intake was added. For hypertensive patients without moderate or more severe CKD and with high sodium intake, it is recommended to increase potassium intake by 0.5–1.0 g/day through methods such as substituting potassium chloride-containing salt.
Target Blood Pressure for Antihypertensive Drug Treatment: 120–129 mmHg SBP
For patients with elevated blood pressure who are identified as high-risk for CVD and targeted for lifestyle modification, if their blood pressure exceeds 130/80 mmHg after three months of intervention, it is recommended to start treatment with a single antihypertensive drug. For patients diagnosed with hypertension, it is recommended to begin drug treatment alongside lifestyle modifications.
There are no significant changes from the 2018 edition in the structure of drug therapy. Initial drug therapy consists of a combination of two low-dose antihypertensive drugs, and if the target is not reached within 1–3 months, a combination of three low-dose drugs should be used. If blood pressure control remains inadequate, the dosage should be increased to the maximum tolerated dose. The selection criteria for combination therapy are also consistent with the 2018 edition, with the combination of a renin-angiotensin system inhibitor (ACE inhibitor or ARB) with a calcium channel blocker or diuretic recommended for dual therapy, and the combination of all three drugs recommended for triple therapy. However, the combination of an ACE inhibitor and an ARB is contraindicated. The target blood pressure for treatment is set at 120–129 mmHg SBP.
No higher treatment targets were set for older adults, and for those under 85 without moderate or more severe frailty who are tolerating antihypertensive treatment, treatment equivalent to that for younger adults is recommended. In connection with this, it is recommended that frailty assessment be performed for older adults as needed.
For resistant hypertension, if patients fully understand the risks and benefits and wish to proceed, renal sympathetic denervation via catheter at a high-volume facility may be considered.
