The 2024 ESC Guidelines outline conditions for BP measurement in both office and ambulatory settings, establish different diagnostic thresholds (table 1), and, compared with the previous guidelines, describe the measurement process in a more systematic manner. They also stress the importance of out-of-office BP measurements (ambulatory [ABPM] and home [HBPM]) for diagnosis and follow-up purposes. The prominence given to out-of-office measurements is driven by the strong evidence showing that ambulatory monitoring can predict cardiovascular events and confirm white-coat and masked hypertension. Finally, the guidelines emphasize the need to use validated BP devices with confirmed accuracy and refer readers to a universal standard1 for validating these devices that was not yet available when the 2018 guidelines were published.

The 2024 ESC Guidelines introduce a new systolic BP treatment target of 120-129mmHg but maintain the threshold for diagnosing hypertension at 140/90mmHg. They also clearly define orthostatic hypotension and interarm BP differences and specify that BP should be measured using an auscultatory not an automated method in pregnant women and patients with atrial fibrillation.

The new guidelines recommend opportunistic screening for elevated BP and hypertension at least every 3 years in adults younger than 40 years and at least once a year in those aged 40 years or older. For individuals with elevated BP who do not meet the threshold for BP-lowering medication, a repeat BP measurement and risk assessment within 1 year is advised.

To diagnose hypertension in patients with an office BP of 140-159/90-99mmHg, the guidelines recommend confirmation with out-of-office measurements, or, if this is not possible, repeated office measurements on separate visits. For BP levels of 160-179/100-109mmHg, diagnosis should be confirmed as soon as possible (within no more than 1 month), preferably with ABPM or HBPM. A hypertensive emergency must be ruled out in patients with BP ≥180/110mmHg.

As noted, a key change in the 2024 ESC Guidelines is the introduction of the elevated BP category (SBP 120-139mmHg or DBP 70-89mmHg). This represents a significant departure from the 2018 guidelines, which focused primarily on hypertension, defined as BP ≥140/90mmHg. This traditional threshold of 140/90mmHg was maintained in the 2023 guidelines published by the European Society of Hypertension (ESH). While the ESH did not include an elevated BP category, it did emphasize the importance of risk assessment in individuals with high to normal BP (130-139mmHg).2 The addition of the elevated BP category in the 2024 ESC guidelines is based on evidence suggesting that lowering BP to within this range benefits patients with cardiovascular disease (atherosclerotic or heart failure), moderate or severe kidney disease, hypertension-mediated vascular or cardiac damage, diabetes, or familial hypercholesterolemia.

The guidelines discuss the use of predictive models such as Systematic Coronary Risk Evaluation 2 (SCORE2) and SCORE-Older Persons for risk stratification. A 10-year risk of a cardiovascular event of 10% or higher would indicate high risk and support treatment initiation, even in patients with elevated BP. The 2023 ESH guidelines also recommend using prediction models for risk stratification, although they do not explicitly endorse their use in guiding treatment decisions in patients with elevated BP (figure 1).

Figure 1.

Central illustration. ABPM, ambulatory blood pressure measurement; ACE, angiotensin-converting enzyme; ARBs, angiotensin receptor blockers; CCBs, calcium channel blockers; DBP, diastolic blood pressure; HBPM, home blood pressure measurement; LV, left ventricular; OH, orthostatic hypertension; SBPM, systolic blood pressure measurement; SCORE2, Systematic Coronary Risk Evaluation 2; SCORE-OP, SCORE-Older Persons.

(0.95MB).

The components of the initial assessment remain unchanged, and include medical history, medication history, physical examination, an electrocardiogram (ECG), and routine tests, such as basic blood and urine analyses (albumin-creatinine ratio). Additional tests should be based on clinical suspicion. An echocardiogram, for example, is recommended for patients with hypertension and ECG abnormalities or signs or symptoms of heart disease. This test may also be considered for patients with elevated BP, particularly if it is likely to influence clinical decisions. Coronary artery calcium scoring is an option for patients with elevated BP or hypertension when results are likely to lead to treatment changes, as are carotid or femoral ultrasound imaging and pulse wave velocity (table 2).

With a prevalence of 15%-30% in young hypertensive adults, secondary hypertension is now believed to be common than previously thought. The 2024 ESC Guidelines recommend appropriate screening for this condition in individuals with suggestive signs, symptoms, or medical history. Given the prevalence of secondary hypertension, early screening for primary hyperaldosteronism by renin and aldosterone measurements should be considered.

For the first time ever, the ESC Guidelines recommend opportunistic screening to improve the prediction of adult hypertension in older children and adolescents with a family history of hypertension.

Lifestyle measures for BP control, and in most cases, cardiovascular risk reduction, continue to be strongly recommended (IA) and include sodium restriction (maximum intake of 2g/d), regular physical activity, weight loss, smoking cessation, and adherence to the DASH (Dietary Approaches to Stop Hypertension) diet. The alcohol consumption limit of 100 g/wk for both men and women also remains unchanged (IB). New recommendations include restricted consumption of sugar-sweetened beverages (sugar intake limited to 10% of energy intake) (IB), potassium supplementation for patients without chronic kidney disease, and monitoring of potassium levels in patients with kidney disease or on potassium-sparing medication (IIaC).

Recommended pharmacological treatments remain largely unchanged. Angiotensin-converting enzyme inhibitors, angiotensin 2 receptor blockers, calcium antagonists, and diuretics continue to be recommended as first-line treatments for BP control and cardiovascular risk reduction. Beta-blockers should be added when patients have angina, heart failure, or myocardial infarction, or need heart rate control.

Combination therapy should be prescribed from the outset, except in patients older than 85 years, frail patients, and those with symptomatic orthostatic hypotension. The addition of spironolactone should be considered when triple combination therapy does not achieve BP control. The guidelines provide a practical algorithm to guide decisions on drug combinations and timing.

Pharmacological treatment should be initiated at BP >140/90mmHg, regardless of risk. Lifestyle changes should be the first step in high-risk patients with BP >130/80mmHg. If control is not achieved within 3 months, BP-lowering medication should be introduced.

The 2024 ESC Guidelines recommend targeting a BP of 120-129/70-79mmHg (IA) provided the medication is well tolerated. This recommendation is based on the latest studies and meta-analyses evaluating hypertension and its impact on cardiovascular risk.

Guidance on blood-lowering devices in the 2024 ESC guidelines mainly focuses on catheter-based renal denervation, which is recommended for patients with resistant hypertension (IIbB) and patients with high cardiovascular risk and poor BP control (IIbA). This procedure, however, must be performed only in experienced centers and only in appropriately informed patients following evaluation by a multidisciplinary team. These recommendations mark a significant shift from the 2018 guidelines,3 which recommended renal denervation exclusively for research purposes.

The 2024 ESC guidelines have expanded the definition of preeclampsia to include gestational hypertension accompanied by proteinuria, maternal organ dysfunction (including kidney injury), liver dysfunction, neurological complications, or uteroplacental dysfunction. Proteinuria is no longer mandatory for diagnosis. Low- to moderate-intensity exercise during the first trimester of pregnancy is recommended to reduce the risk of preeclampsia. In addition, the BP threshold for pregnant women has been tightened to 140/90mmHg.

The 2024 ESC Guidelines introduce new groups and recommendations for isolated systolic and diastolic hypertension and orthostatic hypotension with supine hypertension. Clinicians are advised to test for orthostatic hypotension with supine hypertension before initiating or intensifying treatment. Newly diagnosed patients should be encouraged to adopt lifestyle changes and switched to BP-lowering drugs with less impact on orthostatic hypertension.

Young adults (<40 years) and very old adults (≥85 years) have been reclassified in the 2024 ESC guidelines. For older patients aged <85 years without significant frailty or comorbidities, the guidelines recommend using the same treatment targets and strategies as those used in younger patients.

Stricter BP targets have also been introduced for patients with diabetes. The guidelines now recommend starting treatment at BP >130/80mmHg and question the increased risk attributed to BP values <120/70mmHg in the 2018 guidelines.

Renin-angiotensin-aldosterone system (RAAS) inhibitors (IIaC) are recommended for patients with aortic valve stenosis or moderate to severe mitral regurgitation.

The definition and recommended management of resistant hypertension remain largely unchanged, although the new guidelines now advise referral to a specialized center. Treatment continues to require at least 3 BP-lowering drugs, including a diuretic, with the addition of spironolactone (or eplerenone if this is not tolerated) and beta-blockers if not already indicated. This recommendation has been upgraded from IIaB to IB. Catheter-based renal denervation is also mentioned as a treatment option for resistant hypertension. Renal artery angioplasty should be considered for patients with renovascular hypertension (class IIaC recommendation for patients with renal artery stenosis due to fibromuscular dysplasia), but should not be performed if significant stenosis is absent. Finally, the recommendation for using a calcium channel blocker combined with a diuretic or RAAS inhibitor in individuals from sub-Saharan Africa has been downgraded from IB to IIaB.

The 2024 ESC Guidelines contain a new section on managing acute hypertension in specific settings, such as intracerebral hemorrhage, ischemic stroke, hypertensive emergencies, pregnancy, and perioperative periods. BP-lowering treatment before hospital discharge is strongly recommended for patients with ischemic stroke. For those with intracerebral hemorrhage and a starting SBP >220mmHg, the guidelines advise against lowering BP by >70mmHg within the first hour of treatment. To prevent hematoma expansion, the recommended target is an SPB of 140-160mmHg within the first few hours. After a stroke, the target should be 120-129mmHg.

The 2024 ESC Guidelines emphasize patient-centered care and highlight the importance of involving patients in decision-making and their own care. The guidelines stress the need to consider sociodemographic differences and use effective communication strategies to help patients understand the risks of hypertension and the benefits of treatment. Readers are also reminded that a multidisciplinary care approach involving physicians, nurses, pharmacists, dietitians, and physiotherapists can improve BP control in patients with hypertension.