What are the new updates from the European Society of Cardiology (ESC) 2025?

New Updates from the European Society of Cardiology (ESC) 2025

The 2024-2025 ESC guidelines introduce significant changes in the management of elevated blood pressure and chronic coronary syndromes, with a new emphasis on INOCA/ANOCA diagnosis and treatment, and a revised blood pressure classification system with more aggressive treatment targets.

Blood Pressure Management Updates

New BP Classification System

• The 2024 ESC guidelines introduce a simplified, user-friendly classification of blood pressure 1:
  • Non-elevated BP: <120/70 mmHg (drug treatment not recommended)
  • Elevated BP: 120-139/70-89 mmHg (drug treatment recommended in select high-risk individuals)
  • Hypertension: ≥140/90 mmHg (prompt confirmation and treatment recommended for most)

New Treatment Approach

• For patients with hypertension (≥140/90 mmHg), the guidelines now recommend initiating lifestyle modifications and antihypertensive medication concurrently 2
• For elevated BP (120-139/70-89 mmHg), all patients should implement lifestyle modifications 2
• Drug treatment is recommended for elevated BP when:
  • BP remains ≥130/80 mmHg despite 3 months of lifestyle modifications
  • Patient has moderate to high cardiovascular risk 2

New BP Target

• The default systolic BP target is now 120-129 mmHg for most adults receiving BP medications 3
• More lenient targets are recommended for:
  • Patients with treatment intolerance
  • Adults ≥85 years
  • Those with symptomatic orthostatic hypotension
  • Patients with moderate-to-severe frailty
  • Those with limited life expectancy 3

Risk Assessment

• A new 4-step approach to CVD risk assessment has been introduced for individuals with elevated BP 1:
  1. Identify high-risk conditions (established CVD, moderate/severe CKD, HMOD, diabetes, familial hypercholesterolemia)
  2. Use SCORE2 or SCORE2-OP to predict 10-year CVD risk (≥10% considered high risk)
  3. Consider risk modifiers for those with borderline risk (5-10%)
  4. Make treatment decisions based on comprehensive risk assessment

Chronic Coronary Syndromes Management Updates

INOCA/ANOCA Recognition and Management

• The 2024 ESC guidelines for chronic coronary syndromes place new emphasis on ischemia with non-obstructive coronary arteries (INOCA) and angina with non-obstructive coronary arteries (ANOCA) 1
• There is a new Class I recommendation for the availability of invasive coronary function testing (CFT) in three scenarios:
  1. At the time of initial coronary angiography
  2. When mechanisms of chest pain are uncertain after non-invasive testing
  3. In patients with established INOCA/ANOCA who have persistent symptoms and poor quality of life despite medical therapy 1

Diagnostic Approach

• INOCA/ANOCA should be considered early during cardiovascular risk stratification and initial diagnostic workup for chest pain 1
• The guidelines recognize that nearly half of stable patients referred for coronary angiography for chronic chest pain do not have ≥50% stenosis of a major epicardial coronary artery 1
• INOCA/ANOCA may be caused by:
  • Coronary microvascular disease (CMD)
  • Coronary artery spasm
  • Myocardial bridging
  • Diffuse non-obstructive atherosclerosis
  • Combinations of these pathways 1

Treatment Recommendations

• Once underlying disorders are identified through invasive CFT, the guidelines recommend a patient-centered, mechanism-based approach to medical treatment 1
• Targeted medical treatment should be guided by CFT results to improve symptoms and quality of life 1
• The guidelines emphasize that multiple mechanisms may contribute to ischemia, and the presence of a severe coronary stenosis does not preclude other considerations 1

Implementation Considerations

Diagnostic Testing

• Out-of-office BP measurement is strongly emphasized for diagnosis and monitoring 3
• First-line anatomic imaging is recommended for initial evaluation of suspected coronary syndromes 3
• Coronary computed tomography angiography (CCTA) receives a Class I recommendation for initial diagnostic assessment 3

Potential Challenges

• Limited access to invasive coronary function testing may impede implementation of the new INOCA/ANOCA recommendations
• The more aggressive BP targets may be challenging to achieve in some patient populations
• Implementation of risk assessment tools and the new BP classification system will require education of healthcare providers

These updated guidelines represent a significant shift toward earlier intervention for elevated BP and a more comprehensive approach to diagnosing and treating coronary syndromes, particularly recognizing the importance of non-obstructive mechanisms of ischemia.