What are the updated recommendations in the European Society of Cardiology (ESC) 2025 Madrid guideline for managing cardiovascular conditions?

Updated Recommendations in the European Society of Cardiology (ESC) 2025 Madrid Guidelines

The 2024-2025 European Society of Cardiology guidelines introduce significant changes in blood pressure management, chronic coronary syndromes, and ischemia with non-obstructive coronary arteries, with new blood pressure categories and treatment targets being the most impactful changes for reducing cardiovascular morbidity and mortality.

Blood Pressure Management - Major Updates

New BP Classification System

• Three new categories 1:
  1. Non-elevated BP: <120/70 mmHg (drug treatment not recommended)
  2. Elevated BP: 120-139/70-89 mmHg (drug treatment recommended based on CV risk and follow-up BP)
  3. Hypertension: ≥140/90 mmHg (prompt confirmation and treatment recommended for most individuals)

New Treatment Targets

• Default systolic BP target: 120-129 mmHg for most adults receiving BP medications 1
• More lenient targets (BP as low as reasonably achievable - ALARA principle) recommended for 1:
  • Treatment intolerance
  • Adults ≥85 years
  • Symptomatic orthostatic hypotension (≥20 mmHg systolic drop)
  • Moderate-to-severe frailty
  • Limited life expectancy

Risk-Based Treatment Approach

• Treatment decisions for elevated BP (120-139/70-89 mmHg) now based on cardiovascular risk assessment 1
• Out-of-office BP measurement strongly emphasized for diagnosis and monitoring 1

Chronic Coronary Syndromes (CCS) Updates

Diagnostic Approach

• First-line anatomic imaging recommended for initial evaluation 1
• Coronary computed tomography angiography (CCTA) receives Class I recommendation for initial diagnostic assessment 1

Management of Ischemia with Non-Obstructive Coronary Arteries (INOCA/ANOCA)

• New Class I recommendation for invasive coronary function testing (CFT) when 1:
  • Mechanisms of chest pain are uncertain after non-invasive testing
  • Patients have persistent symptoms despite medical therapy
  • At time of initial coronary angiography when appropriate

Targeted Treatment for INOCA/ANOCA

• Mechanism-based approach to medical treatment based on CFT results 1:
  • For coronary microvascular dysfunction (CMD): Beta-blockers, calcium channel blockers, ranolazine, trimetazidine, or ivabradine (Class IIa, B)
  • For endothelial dysfunction: ACE inhibitors (Class IIa, B)
  • For vasospastic angina: Calcium channel blockers (Class I, A) and nitrates (Class IIa, B)

Peripheral Arterial and Aortic Diseases Updates

Blood Pressure Management

• Target systolic BP of 120-129 mmHg if tolerated (Class I, A) 1
• ACEIs or ARBs recommended as first-line therapy (Class IIa, B) 1
• More lenient BP goals (<140/90 mmHg) for specific populations:
  • Age ≥85 years (Class IIa, C)
  • Residential care (Class IIa, C)
  • Symptomatic orthostatic hypotension (Class IIa, C)
  • Severe frailty or limited life expectancy (Class IIb, C)

Atherosclerotic Aortic Disease Management

• Intensive statin therapy to achieve LDL-C <1.4 mmol/L (55 mg/dL) with >50% reduction from baseline 2
• Beta-blockers as first-line therapy for patients with aortic disease and hypertension 2

Implementation Considerations

Measurement Technique

• Validated and calibrated devices required for BP measurement (Class I, B) 1
• Manual auscultatory method recommended for patients with atrial fibrillation (Class IIa, C) 1

Lifestyle Modifications

• Mediterranean diet rich in legumes, fiber, nuts, fruits, and vegetables 2
• Regular aerobic exercise appropriate to functional capacity 2
• Smoking cessation mandatory with pharmacotherapy and behavioral support 2

Clinical Impact

The 2025 ESC guidelines represent a significant shift in cardiovascular disease management, particularly in:

1. Earlier intervention for elevated BP based on risk assessment
2. Lower BP targets (120-129 mmHg) for most patients
3. Recognition of INOCA/ANOCA as important clinical entities requiring specific diagnostic and treatment approaches
4. Personalized approach for special populations (elderly, frail)

These changes aim to reduce cardiovascular morbidity and mortality through more aggressive risk factor management while recognizing the need for individualization in specific patient populations.