2024 ESC Clinical Practice Guidelines for the Management of Elevated Blood Pressure and Hypertension
31 Aug 2024
Elevated Blood Pressure and Hypertension For 30 years, ESC Guidelines have been summarising relevant evidence on a given topic to inform healthcare professionals on the benefits and risks of particular diagnostic or therapeutic procedures, with the ultimate aim of improving patient care. This year, four new guidelines have been diligently prepared, incorporating important updates and new recommendations ready for publication and presentation at ESC Congress 2024.
The first of these new guidelines was unveiled yesterday by Professor John William McEvoy (University of Galway School of Medicine and National Institute for Prevention and Cardiovascular Health - Galway, Ireland) and Professor Rhian M. Touyz (McGill University - Montreal, Canada), Chairs of the Guidelines Task Force.
The first main update is the title. “We moved away from ‘arterial hypertension’ to ‘elevated blood pressure (BP) and hypertension’ to reflect that the CVD risk attributable to BP is on a continuous exposure scale and is not a binary scale of normotension versus hypertension,” highlights Prof. McEvoy. Indeed, updated evidence increasingly demonstrates the benefits of BP-lowering medications among persons with high CVD risk and BP levels that are elevated, but who do not meet traditional thresholds used to define hypertension. A new BP category termed ‘elevated BP’ has been introduced – defined as an office systolic BP 120–139 mmHg or diastolic BP 70–89 mmHg – while hypertension remains as defined previously (office systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg).
A new major, evidence-based change is the recommendation to pursue a target systolic BP of 120–129 mmHg among adults receiving BP-lowering medications.
Current research data indicate that achieving an on-treatment BP of 120 mmHg optimally reduces CVD risk,” explains Prof. Touyz. “However, we chose the 120–129 mmHg target range for several reasons, including the fact that contemporary intensive BP trials enrolled patients with baseline systolic BP ≥ 130 mmHg and that BP values recorded under research conditions are not always the same as those recorded in routine practice, which can be 5–10 mmHg higher.” The new target range was also based on patient feedback that lifestyle is preferable to medication unless BP is in the hypertensive range and to provide flexibility for patients and clinicians. Out-of-office BP confirmation is preferred, but office BP measurement is allowed on the grounds of logistical feasibility.
This new systolic BP treatment target of 120–129 mmHg represents a paradigm shift from prior European guidelines. Specifically, whereas prior guidelines generally recommended patients be treated to <140/90 mmHg in the first instance and only thereafter be considered for treatment to <130/80 mmHg (a two-step approach), the new guidelines recommend that most patients should be treated to 120–129 mmHg in the first instance, with a more relaxed target in those where it cannot be tolerated. “Rather than 'opting in' to a more intensive BP treatment target, as recommended in prior European guidelines, the 2024 ESC Guidelines takes an 'opting out' position for more intensive BP treatment targets. This change is motivated by new confirmatory trial evidence for the efficacy of these more intensive BP treatment targets in reducing CVD outcomes,” says Prof. McEvoy.
For selected individual cases where a target systolic BP of 120–129 mmHg is not pursued, either due to intolerance or the existence of conditions that favour leniency, then BP should be treated to as low as reasonably achievable.
For persons with elevated BP, treatment with lifestyle for 3 months is first recommended, prior to considering medications. After 3 months of lifestyle intervention, in adults with elevated BP and sufficiently high CVD risk (≥10% over 10 years), BP lowering with pharmacological treatment is recommended for those with confirmed BP ≥130/80 mmHg to reduce CVD risk.
Given the ageing population in Europe, there is also a focus on tailoring treatment with respect to frailty and into older age, which is addressed in multiple sections. Of note, there is now a Class I recommendation that treatment of elevated BP and hypertension among older patients (aged <85 years) who are not moderately to severely frail follows the same guidelines as for younger people provided that BP–lowering treatment is well tolerated.
The new guidelines place greater emphasis on evidence related to fatal and non-fatal CVD outcomes, requiring that a Class I recommendation for a drug or procedural intervention should be supported by demonstrated benefit on CVD outcomes, not only surrogate outcomes such as BP lowering alone.
With increasing evidence that biological sex and sociocultural gender are modifiers of hypertension, the 2024 guidelines have included ‘sex and gender’ as an integral component throughout the document.
Patient input and their lived experiences have been considered throughout. The guidelines have also been written to make them more ‘user friendly,’ with input from general practitioners.
Want to know more about what’s new? The 2024 ESC Guidelines are now published in the European Heart Journal and are available on the ESC Pocket Guidelines app.
References
- McEvoy JW, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024. doi:10.1093/eurheartj/ehae178.
