Guidelines for the management of elevated blood pressure and hypertension

The 2024 ESC Guidelines on blood pressure (BP) and hypertension include a vast scope of novelties and revisions. Among the most important are a new BP classification, new treatment targets, and pharmacological and non-pharmacological management.

The new guidelines issued 57 new and 43 revised recommendations on different aspects of hypertension management [1–3]. “We have a lot of work to do,” stated Prof. John William McEvoy (National University of Ireland, Galway, Ireland), considering the still poor implementation of effective BP treatment worldwide.

For measuring BP, new recommendations do not only include the use of calibrated devices to enforce correct measurement technique (class I) but also highlight out-of-office measuring for diagnosis and patient-centred care:

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  • It is recommended to measure BP using a validated and calibrated device, to enforce the correct measurement technique, and to apply a consistent approach to BP measurement for each patient (class I).
  • Out-of-office BP measurement is recommended for diagnostic purposes, particularly because it can detect both white-coat hypertension and masked hypertension. Where out-of-office measurements are not logistically or economically feasible, it is recommended to confirm the diagnosis with a repeat office BP measurement using the correct standardised measurement technique (class I).
  • Home BP measurement for managing hypertension by using self-monitored BP is recommended to achieve better BP control (class I).
  • Self-measurement, when properly performed, is recommended due to its positive effects on the acceptance of a diagnosis of hypertension, patient empowerment, and adherence to treatment (class I).

A new blood pressure classification

Instead of the former 7 categories for BP, the new Guidelines now define 3 categories. They illustrate that the cardiovascular disease (CVD) risk augmentation through BP is incremental:

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  • non-elevated BP (office BP <20/70 mmHg);
  • elevated BP (120–139/70–89 mmHg);
  • hypertension (≥140/≥90 mmHg).

For the confirmation of elevated BP and hypertension, out-of-office measurement is required. Further management is tailored according to categories. “Hypertensive individuals, regardless of age, regardless of risk, deserve a drug treatment immediately and, of course, this does not apply to the elevated BP subgroup,” Prof. Rosa Maria Bruno (Hôpital Européen Georges Pompidou, France) indicated. Persons with elevated BP are subject to a stepwise risk assessment that includes the prediction of the 10-year risk of CVD, the evaluation of risk modifiers, and the consideration of further CVD testing, to determine the adequate measures indicated.

Two new class I recommendations particularly elaborate on the CVD risk assessment in elevated BP:

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  • It is recommended to use a risk-based approach in the treatment of elevated BP, and individuals with moderate or severe chronic kidney disease, established CVD, hypertension-mediated organ damage, diabetes mellitus, or familial hypercholesterolaemia are considered at increased risk for CVD events (class I).
  • It is recommended that, irrespective of age, individuals with elevated BP and a SCORE2 or SCORE2-OP CVD risk of ≥10% are considered at increased risk for CVD for the purpose of risk-based management of their elevated BP (class I).

As there is an important focus on patient-centred care within the new guideline, a class I recommendation includes an informed discussion about CVD risk and treatment benefits tailored to the needs of a patient as part of hypertension management.

Non-pharmacological interventions

Lifestyle and non-drug measures to lower BP play an important role in the management of elevated BP. “Highlighted in our recommendations is an increase in potassium intake and there's now a lot of evidence to indicate indeed that increasing potassium intake, particularly in patients with hypertension without moderate-to-advanced kidney disease is really what should be focused upon,” Prof. Rhian Touyz (McGill University, Canada) emphasised.

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  • In patients with hypertension without moderate-to-advanced CKD and with high daily sodium intake, an increase of potassium intake of 0.5–1.0 g/day —for example through sodium substitution with potassium-enriched salt (comprising 75% sodium chloride and 25% potassium chloride) or through diets rich in fruits and vegetables— should be considered (class IIa).
  • It is recommended to restrict sugar consumption, in particular sugar-sweetened beverages, to a maximum of 10% of energy intake (class I).

Treatment targets and pharmacological management

Guidance on when to start BP treatment is given in various new recommendations:

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  • In adults with elevated BP and low/medium CVD risk (<10% over 10 years), BP lowering with lifestyle measures is recommended and can reduce the risk of CVD (class I).
  • In adults with elevated BP and sufficiently high CVD risk, after 3 months of lifestyle intervention, BP lowering with pharmacological treatment is recommended for those with confirmed BP ≥130/80 mmHg to reduce CVD risk (class I).
  • It is recommended that in hypertensive patients with confirmed BP ≥140/90 mmHg, irrespective of CVD risk, lifestyle measures and pharmacological BP-lowering treatment are initiated promptly to reduce CVD risk (class I).

As for the treatment target, the committee implemented a simplified, yet intensified approach with a target of 120–129 mmHg in systolic BP. “This applies to most patients indeed, including patients with diabetes, patients with CKD, with previous stroke, and with cardiac disease,” Prof. Bruno informed adding that “the lower the better.” In patients with poor tolerance of this target, one should aim at going as low as possible (i.e. ALARA principle).

“We suggest that when patients have been diagnosed with hypertension, they start with a low dose of double combination therapy, and if BP has still not reached the target, low-dose triple combination therapy is suggested,” said Prof. Touyz (see Figure). An initial monotherapy is, for example, recommended for elevated BP, frailty, and orthostatic hypotension. Finally, when performed in medium-to-high volume centres, renal denervation may also be considered in consenting adults with resistant hypertension on 3 drugs, or with a combination of increased CVD risk and uncontrolled BP on fewer than 3 drugs (class IIb).

Figure: Algorithm for pharmacological BP lowering. Modified from [3]


ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; MI, myocardial infarction.

1. 
   
   1. Presentations in Session ‘2024 ESC Guidelines Overview,’ ESC Congress 2024, 30 Aug–02 Sept, London, UK.
   2. Presentations in Session ‘2024 ESC Guidelines for the Management of Elevated Blood Pressure and Hypertension,’ ESC Congress 2024, 30 Aug–02 Sept, London, UK.
   3. McEvoy JW, et al. Eur Heart J. 2024; Aug 30. DOI: 10.1093/eurheartj/ehae178.

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Posted on 7 November 20247 November 2024