What are the latest European Society of Cardiology (ESC) hypertension guidelines for managing hypertension?

2024 ESC Hypertension Guidelines Summary

The 2024 European Society of Cardiology (ESC) guidelines recommend a target blood pressure of 120-129/70-79 mmHg for most adults with hypertension if tolerated, with more lenient targets for specific populations including those aged ≥85 years, patients with symptomatic orthostatic hypotension, or moderate-to-severe frailty. 1, 2

Diagnosis and Risk Assessment

• Diagnosis requires repeated office BP readings ≥140/90 mmHg, preferably confirmed by home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg
• A basic screening for hypertension-mediated organ damage (HMOD) should be performed in all hypertensive patients, including a 12-lead ECG 1
• Cardiovascular risk assessment is essential using SCORE2/SCORE2-OP risk calculation tools 1
• In a major departure from previous guidelines, screening for primary aldosteronism by renin and aldosterone measurements should be considered in all adults with confirmed hypertension (Class IIa) 1
• For young adults (<40 years), comprehensive screening for secondary hypertension is recommended (Class I) 1

Treatment Thresholds

BP-lowering treatment is recommended (Class I, LOE A) for:

• All patients with BP ≥140/90 mmHg
• Patients with BP ≥130/80 mmHg despite 3 months of lifestyle measures if:
  1. High-risk CVD conditions (established CVD, HMOD, diabetes, moderate/severe CKD, familial hypercholesterolemia)
  2. SCORE2/OP risk ≥10%
  3. SCORE2/OP risk 5%-<10% with risk modifiers or abnormal risk testing 1

Lifestyle Interventions

All guidelines recommend:

• Weight loss or maintenance of healthy body weight (Class I)
• Regular physical activity: 90-150 minutes/week of aerobic exercise plus resistance training 2-3 times/week 1, 2
• Sodium restriction to approximately 2g per day (5g salt)
• Increased potassium intake through diet or potassium-enriched salt substitutes
• Alcohol moderation
• Smoking cessation (Class I) 1, 2, 3

Pharmacological Treatment

First-line Medications

• ACE inhibitors
• Angiotensin receptor blockers (ARBs)
• Dihydropyridine calcium channel blockers
• Thiazide or thiazide-like diuretics 1, 2

Treatment Strategy

• Initial combination therapy is recommended for most patients with BP ≥140/90 mmHg, preferably as a single-pill combination 1
• Beta-blockers are not first-line agents unless there are compelling indications (e.g., heart failure with reduced ejection fraction) 1
• The 2024 ESC guidelines differ from the 2023 ESH guidelines, which include beta-blockers as first-line medications 1

Special Populations

• For patients aged ≥85 years, those with symptomatic orthostatic hypotension, or moderate-to-severe frailty, a more lenient target (BP <140/90 mmHg) should be considered (Class IIa, LOE C) 1
• For patients with resistant hypertension:
  • Reinforcement of lifestyle measures, especially sodium restriction
  • Addition of low-dose spironolactone to existing treatment
  • Consider referral to specialist centers
  • Adherence testing with either direct observed therapy or drug level measurement should be considered (Class IIa) 1, 2

Key Differences from Previous Guidelines

1. Expanded emphasis on treating patients with SBP 130-139 or DBP 80-89 mmHg who have high cardiovascular risk
2. Recommendation for screening for primary aldosteronism in all adults with confirmed hypertension
3. Comprehensive screening for secondary hypertension in young adults (<40 years)
4. Beta-blockers not included as first-line therapy unless specifically indicated
5. Emphasis on single-pill combinations to improve adherence 1

Implementation Pitfalls to Avoid

• Failing to confirm hypertension diagnosis with out-of-office measurements before starting treatment
• Using beta-blockers as first-line therapy in uncomplicated hypertension
• Combining ACE inhibitors and ARBs (increases risk of end-stage renal disease and stroke)
• Neglecting to screen for primary aldosteronism in adults with confirmed hypertension
• Not adjusting targets for elderly patients (≥85 years) or those with frailty or orthostatic hypotension 1, 2

The 2024 ESC guidelines represent a significant update from previous versions, with greater emphasis on early intervention for high-risk patients, comprehensive screening for secondary causes, and optimized treatment strategies to improve blood pressure control and reduce cardiovascular risk.