What’s New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension?

Abstract

In 2024, the European Society of Cardiology (ESC) released a new guideline for the management of elevated blood pressure (BP) and hypertension. The guideline introduced a new BP categorization: i) non-elevated (office BP <120/70 mm Hg) for which drug treatment is not recommended, ii) elevated (120–139/70–89 mm Hg) for which drug treatment is recommended based on cardiovascular disease risk and follow-up BP level, and iii) hypertension (≥ 140/90 mm Hg) for which prompt confirmation and drug treatment is recommended in all individuals. The initial default systolic BP treatment target is 120–129 mmHg for most; however, relaxed targets (BP as low as reasonably achievable) are recommended in case of treatment intolerance, adults ≥85 years, symptomatic orthostasis, moderate-to-severe frailty, or limited life expectancy. Here, we summarize what is new and different in the 2024 ESC guideline, relative to other major international hypertension guidelines in Europe and America. Our aim is to reconcile any uncertainty clinicians may have about implementing these various guidelines in patient care.

Introduction

Cardiovascular disease (CVD) research has grown exponentially over the past several decades,^{1, 2} making it increasingly challenging for clinicians to stay up-to-date on advancements in CVD. Accordingly, clinical practice guidelines serve as an important resource to assist clinicians in patient management. These guidelines summarise current knowledge, weigh the benefits and harms of diagnostic and therapeutic approaches, and provide evidence-based recommendations provided by experts.

While some have criticized guidelines for being too long, too academic, poorly implemented, subject to bias and influence, and at times contrary to individualized clinician-patient care;^{3, 4} there is also no doubt that guidelines are an important resource to many individuals. Engagement with guidelines by clinicians, scientists, patients, the public, and policy makers is enormous. To take one example, the 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guideline for the management of arterial hypertension has to date been viewed almost 2 million times and has over 14 thousand citations.⁵

Beyond their utility as an educational and management resource, guidelines are often used by policy-makers to inform important regulatory decisions at a health system level. However, numerous guidelines for the same clinical condition often co-exist, emanating from different international and national societies. For blood pressure (BP) management, European,^{6, 7} North American,^{8, 9} Asian,^10–14 and global guidelines co-exist.^{15, 16} Furthermore, guidelines are often updated based on developments and advances in the field. Accordingly, clinicians have an extensive choice of guidelines to consider, though this may also be an obstacle for implementation and optimal patient care.

While regional and international collaboration among professional learned societies to develop joint guidelines is to be encouraged and sometimes occurs, there are also circumstances that may hinder such efforts. For example, geographical differences in clinical care can complicate a ‘one size fits all’ approach with respect to globalized guideline harmonization efforts. In addition, due to substantial clinician engagement with guidelines, release of separate guidelines may appeal to individual societies in the hopes of increasing attendance at their own societal annual congress meetings or increasing readership and citations at their associated medical journals. Furthermore, not all guidelines are created equal and societies often differ starkly on their philosophy around guideline generation. For instance, in an effort to align with 2013 recommendations from the Institute of Medicine for trustworthy guideline development,¹⁷ the ESC has standardized policies for all of its guidelines relating to temporal rotation of guideline chairs, diversity of task-force members, limits on the number of times an individual can coauthor a guideline, management of financial disclosures and conflicts of interest, anonymous voting procedures, and external review processes. Recently, the ESC further strengthened the financial disclosure policies for its entire suite of clinical practice guidelines. To be eligible to sit on an ESC guideline task force, members (and their spouse) can not receive more than 10,000 Euro per annum in personal payments from industry, direct or indirect and in aggregate. Indirect payments are intended as payments to a department or institution or any other body that effects a member’s (or his/her spouse) remuneration. These financial disclosure policies, together with other ESC-specific processes for guideline generation, may differ from other organisations. When other societies do not agree with implementing ESC processes and policies, joint guidelines (such as those for hypertension in Europe) are regrettably not possible.

The availability of several guidelines for a specific topic has pros and cons. There is risk in this situation. For example, conflicting messages between guidelines may result in confusion and decision paralysis. Multiple guidelines may also place additional time constraints on clinicians which could result in unrealistic expectations, increased stress, and decreased job satisfaction.^{18, 19} On the other hand, there is also potential for benefit. For example, choice is healthy in the market and competition can drive improved quality. Having a range of guideline products for clinicians to choose from may allow the clinician to implement the guideline (or guidelines) that best suit their own needs and preferences. For example, a clinician may prioritize geographical criteria, or the lack of real or perceived industry influence, or guideline generation policies, or the length and ease of use of guidelines, or other factors, in their choice of which guideline to follow. In addition, the existence of various guidelines, with their similarities and differences, serves as an important reminder that guidelines are a set of recommendations that the end-user may or may not choose to use. They are not directives and are not legally-binding. Differences in guideline recommendations can also highlight areas of uncertainty and instigate future research.

In this context, the ESC, which has been producing CVD guidelines for 30 years, has released a new, updated, guideline on the management of elevated BP and hypertension in 2024.⁷ Here, we summarize what is new and different in the 2024 ESC guidelines for the management of elevated BP and hypertension. In so doing, we also compare and contrast the 2024 ESC guidelines with other major international guidelines. While numerous guidelines exist, our focus is on comparisons with the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline for the management of high BP and the 2023 ESH guideline for the management of arterial hypertension.^{6, 8}

Guideline Development Process

The 2024 ESC guideline Task Force members were selected by the Task Force chairs and clinical practice guideline committee chair after an open call for applications with consideration of gender and country of origin. The task force comprised 24 members including a methodologist, two patient representatives, and experts in cardiology, general practice medicine, nephrology, geriatrics, neurology, clinical psychology, and epidemiology.⁷ All members had to comply with ESC financial disclosure policies. All draft recommendations were subject to at least 2 rounds of anonymous votes and required at least 75% agreement by voting members. The guideline underwent three rounds of peer review with over 50 peer reviewers in addition to several rounds of quality control.⁷ The 107-page full guideline was supplemented with a brief summary ‘pocket guideline’ and an interactive smart phone App. A brief comparison of the guideline writing processes of the 2024 ESC, 2023 ESH, and 2017 ACC/AHA guidelines are outlined in Table 1.

Table 1:

Blood Pressure Clinical Practice Guidelines Development Processes

	2017 ACC/AHA Guidelines	2023 ESH Guidelines	2024 ESC Guidelines
Task Force Members	21 members consisting of clinicians, cardiologists, epidemiologists, internists, an endocrinologist, a geriatrician, a nephrologist, a neurologist, a nurse, a pharmacist, a physician assistant, and 2 lay/patient representative	59 experts appointed by ESH representing internal medicine, cardiology, nephrology, endocrinology, geriatrics, general medicine, pharmacology, and epidemiology.	24 Task Force members including a methodologist, two patient representatives, and experts in cardiology, general medicine, nephrology, geriatrics, neurology, and epidemiologist.
Financial Disclosures	Members reported relationships with industry (RWI). These disclosures were reviewed to ascertain the candidate’s RWI status, and assess eligibility to serve in various capacities in the production of ACC/AHA guidelines. Employees of industry, part-time or full-time, are prohibited. The Chair(s) and at least half the writing committee members must be free of relevant RWI.	No documented requirements for reporting and no limits	Members were limited to 10,000 euro in personal payments (direct or indirect) per annum in aggregate from a healthcare company and members with declared interests on specific topics abstained from voting on related recommendations.
Peer review and Voting Process	Anonymous voting on recommendations. Guideline was reviewed by 2 official reviewers nominated by ACC and AHA; 1 reviewer each of the endorsement societies; and 38 individual content reviewers	Disagreements regarding recommendations were not resolved by voting but rather by non-anonymized consensus of a shared text. The manuscript was sent for external peer review and the final version was approved by all Task Force members	All recommendations were subject to an anonymous vote and required at least 75% agreement by voting members. The guideline underwent three rounds of peer review with over 50 peer reviewers in addition to several rounds of quality control.
Class of Recommendations	Class I: Is recommended Class IIa: Is reasonable Class IIb: May be reasonable Class III: Not recommended/may be harmful	Class I: Is useful/beneficial and benefits outweigh risks Class II: Conflicting evidence/uncertain benefit-risk balance Class III: Not beneficial or risks outweigh potential benefits	Class I: Is recommended Class IIa: Should be considered Class IIb: May be considered Class III: Is not recommended
Level of Evidence	A: Multiple high quality randomized clinical trials or meta-analyses of high quality randomized clinical trials or one randomized trial combined with high-quality registry studies B-R: Moderate quality evidence from 1 or more randomized clinical trials or meta-analyses of moderate quality randomized clinical trials B-NR: Moderate quality evidence from 1 or more observational studies or registries or meta-analyses of these study types C-LD: Randomized or non-randomized observational or registry studies with limitations of design or execution or meta-analyses of such studies or mechanistic studies C-EO: Expert opinion	A: Randomized clinical trial or meta-analysis of randomized clinical trials. Single trial sufficient if powered appropriately and without important limitations B: Randomized clinical trial with surrogate endpoints, observational studies without significant limitations, or meta-analyses of these types of studies C: Observational studies with surrogate endponts, other study type with limitations, and expert opinion	A. Multiple randomized clinical trials or meta-analyses B: Single randomized clinical trial or large non-randomized studies C: Small observational studies or expert opinion
Endorsement	American Academy of Physician Assistants, Association of Black Cardiologists, American College of Preventive Medicine, American Geriatric Society, American Pharmacists Association, American Society of Hypertension, American Society of Preventive Cardiology, National Medical Association, and Preventive Cardiovascular Nurses association	European Renal Association and the International Society of Hypertension	European Society of Endocrinology and European Stroke Organization.

Abbreviations: ACC= American College of Cardiology; AHA=American Heart Association; BP= blood pressure; ESC= European Society of Cardiology; ESH= European Society of Hypertension; EO= expert opinion; LD= limited data; NR= non-randomized; R= randomized; RWI= relationships with industry

Definition of Hypertension and Classifications of Blood Pressure

The 2024 ESC guideline introduced a new simplified and more user-friendly classification of BP to aid pharmacological treatment decisions.⁷ The guideline classifies BP as non-elevated (<120/70 mm Hg) for which drug treatment is not recommended, elevated (120–139/70–89 mm Hg) for which drug treatment is recommended in select individuals depending on CVD risk and follow-up BP, and hypertension (≥ 140/90 mm Hg) for which prompt confirmation and treatment recommended in all individuals. The guideline acknowledges that there is a continuous increased risk of CVD with increments in BP,^20–22 such that the diagnosis of hypertension and, accordingly, any hypertension diagnostic threshold, is to a degree arbitrary. However, and in contrast to the 2017 ACC/AHA guideline, the 2024 ESC guideline chose to maintain the traditional definition of hypertension (≥ 140/90 mm Hg) because this is the BP threshold above which treatment to lower BP results in net benefit for most adults. Furthermore, as the updated title of the 2024 ESC guideline suggests, the new category of elevated BP was introduced with the consideration that, within this BP range and mostly among higher CVD risk individuals, randomized clinical trials have demonstrated a relative benefit of BP reduction for the prevention of cardiovascular events.^23–28 Of note, the ESC guideline task force decided against using terms such as “normal” or “optimal” when categorizing BP as CVD risk is still increasing per unit increase in BP even within the lowest category and therefore felt such terms may be misleading.²⁹

The 2023 ESH guideline recommends BP values be classified as: optimal, normal, high-normal, grade 1 hypertension, grade 2 hypertension, and grade 3 hypertension (Class I).^{5, 6} In addition to providing a BP-based classification, the ESH guideline is the only guideline that recommends hypertension also to be staged as stage 1 (uncomplicated hypertension), stage 2 [presence of hypertension mediated organ damage (HMOD), diabetes mellitus, or chronic kidney disease (CKD) stage 3], or stage 3 (presence of CVD or stage 4 or 5 CKD).⁶ In contrast, the 2017 ACC/AHA guideline classify BP levels as normal, elevated, hypertension stage 1 and hypertension stage 2.⁸ The 2017 ACC/AHA guideline chose to define hypertension as a BP of 130/80 mmHg or higher as a clinical trial demonstrating benefit of BP lowering began enrolling high-risk individuals at that threshold.³⁰ A comparison of the BP categories of all three guidelines is provided in Figure 1.

Figure 1: Comparison of Classifications of Blood Pressure in the 2017 ACC/AHA, 2023 ESH and 2024 ESC Guidelines.

Figure Illustrating categorization of blood pressure in the 2017 American College of Cardiology/American Heart Association, 2023 European Society of Hypertension, and 2024 European Sociaty of Cardiology hypertension guidelines. Abbreviations: ACC= American College of Cardiology; AHA=American Heart Association; BP= blood pressure; ESC= European Society of Cardiology; ESH= European Society of Hypertension.

Ultimately, and diverging from the 2023 ESH and 2017 ACC/AHA guidelines, the 2024 ESC guideline decided to simplify the classification of BP and utilize it for the purposes of treatment allocation rather than using somewhat arbitrary prognostic BP stages.

Risk Assessment

A new aspect of the 2024 ESC guideline is the introduction of CVD risk assessment among those with elevated BP for the purpose of identifying individuals for pharmacological treatment, specifically when the BP remains ≥130/80 mmHg despite 3 months of lifestyle intervention.⁷ With accumulating clinical trials demonstrating a benefit of BP reduction when enrolling high-risk individuals beginning at a BP of 130/80 mmHg,^{25, 26, 30} the 2024 ESC guideline placed a strong emphasis on a CVD risk assessment when identifying individuals with elevated BP for treatment. Recognizing that eligibility criteria for CVD risk varies across these trials making matching of patients to trial eligibility criteria is impractical, a systematic approach to CVD risk assessment was developed. The 2024 ESC guideline recommends using a 4-step approach to identifying individuals for treatment initiation. First, the guideline recommends that individuals with elevated BP and established CVD, moderate or severe chronic kidney disease (CKD), hypertension mediated organ damage (HMOD), diabetes mellitus, or familial hypercholesterolemia be considered at sufficiently high- risk for CVD events to warrant consideration of drug treatment. Second, in the absence of these high-risk conditions, the guideline recommends using the Systematic COronary Risk Evaluation 2 (SCORE2) or Systematic COronary Risk Evaluation 2 Older Persons (SCORE2-OP) to predict 10-year risk CVD events.^{31, 32} The 2024 ESC guideline recommends that a 10-year risk of 10% or higher be considered sufficiently high risk for CVD events among persons in the elevated BP category. This risk threshold was selected when considering average CVD risk of the control group of contempory clinical trials. ³³ Third, for individuals with borderline 10-year risk defined as a risk between 5% and 10%, the 2024 ESC guidelines advise that specific non-traditional risk modifiers should be considered to up classify individuals to high risk, recognizing CVD risk is often underestimated among these individuals. Finally, in the absence of such risk modifiers, for individuals with elevated BP and borderline risk, the 2024 ESC guideline states that specific risk assessment tests (measurement of coronary artery calcium (CAC) score, cardiac biomarkers, carotid or femoral plaque, or pulse wave velocity) may be considered to up-classify the risk of these patients if testing is abnormal.

The 2017 ACC/AHA guideline also advises the use of risk to guide BP-lowering treatment specifically for individuals with a BP of 130–139/80–89 mmHg.⁸ The guideline recommends that, for individuals with established atherosclerotic CVD, heart failure, diabetes mellitus, CKD, or with a pooled cohort equation 10-year risk of CVD that is at or above 10%, BP lowering lifestyle and pharmacological treatment should be initiated.

The 2023 ESH guideline also recommends cardiovascular risk stratification in hypertensive patients, giving priority on associated conditions such as established CVD, CKD, long-standing or complicated diabetes, severe HMOD, or marked elevation of a single risk factor such as cholesterol as major risk reclassification criteria. Risk assessment using SCORE2³¹ and SCORE2-OP³² 10-year CVD risk prediction models is also mentioned for those who are not already deemed high or very high risk, but it is not specified how to utilize these risk assessment results to guide BP-lowering treatment (Table 2).

Table 2:

Role of Risk Assessment in Blood Pressure Clinical Practice Guidelines

	2017 ACC/AHA Guidelines	2023 ESH Guidelines	2024 ESC Guidelines
Application of risk assessment	Stage 1 Hypertension (SBP 130 – 139 or 80–89 mmHg)	Hypertension (≥140/90 mmHg)	Elevated blood pressure (SBP 120–139 or DBP 70–89 mmHg)
Approach to risk assessment	Assess for clinical ASCVD, HF, CKD, DM and calculate 10-year risk of CVD using ACC/AHA Pooled Cohort Equations (no formal recommendation)	Calculation of 10-year CVD risk using SCORE2 or SCORE2-OP is recommended (Class I, LOE B) in absence of established CVD, CKD, long-standing or complicated diabetes, severe HMOD, or marked elevation of a single risk factor	4-step approach to risk assessment: 1) Moderate/severe CKD, established CVD, HMOD, DM, and FH are considered high risk (Class I, LOE B) 2) In absence, calculation of 10-year CVD risk using SCORE2/OP is recommended (Class I, LOE B) 3) Risk modifiers should be considered (Class IIa, LOE B) if 10-year risk is borderline (5%- <10%) 4) Risk tools (CAC, cardiac biomarkers, carotid/femoral plaque, and PWV) may be considered (Class IIb, LOE B) if risk remains uncertain
Application to BP treatment	Lifestyle and pharmacological therapy recommended for individuals with BP 130–139/80–89 mmHg and clinical ASCVD, HF, CKD, DM, or 10-year CVD risk of ≥10% estimated by the Pooled Cohort equation (Class I, LOE A for SBP and C-EO for DBP)	No formal recommendation provided on how exactly to use risk assessment in allocating BP treatment	BP-lowering treatment is recommended (Class I, LOE A) for BP ≥130/80 mmHg despite 3 months of lifestyle measures if 1) high-risk CVD conditions, 2) SCORE2/OP risk ≥10%, or 3) SCORE/OP risk 5 - <10% + risk modifiers or abnormal risk testing.

Abbreviations: ACC= American College of Cardiology; AHA=American Heart Association; BP= blood pressure; ASCVD = atherosclerotic cardiovascular disease; CAC= coronary artery calcium scoring; CKD= chronic kidney disease; CVD= cardiovascular disease; DBP = diastolic blood pressure; DM= diabetes mellitus; EO= expert opinion; ESC= European Society of Cardiology; ESH= European Society of Hypertension; FH= familial hypercholesterolemia; HF= heart failure; HMOD= hypertension mediated organ damage; LOE= level of evidence; PWV= pulse wave velocity; SBP = systolic blood pressure; SCORE2= Systematic Coronary Risk Evaluation 2; SCORE2-OP= Systematic Coronary Risk Evaluation 2 – Older Persons

Measurement of Blood Pressure

The 2024 ESC guideline places increased emphasis on and a Class I recommendation for out-of-office BP measurement in both the diagnosis and subsequent management of elevated BP and hypertension, with repeat office measurement usage only recommended if out-of-office measurement is not logistically/economically feasible.⁷ The 2017 ACC/AHA guideline also specifically recommends out-of-office BP measurement for these purposes but without specifying any role for repeat office measurement if out-of-office BP measurement cannot be done.⁸ In contrast, the 2023 ESH guideline recommends that the diagnosis of hypertension be made using repeated office BP measurement (at least two), though out-of-office measurement is recommended to supplement office measurement in diagnosis if available (Class I) and for the purposes of diagnosing white-coat hypertension, masked hypertension and true resistant hypertension (Class I).⁶ For the long-term management of hypertension, all guidelines recommend out-of-office measurement, with a unique recommendation in the ESH guideline for home-based (HBPM) rather than ambulatory BP measurement for this purpose (Table 3).^{6, 8}

Table 3:

Guideline Recommendations for Blood Pressure Measurement

	2017 ACC/AHA Guidelines	2023 ESH Guidelines	2024 ESC Guidelines
Measurement device and technique	• No specific device type recommended. • Validated and calibrated devices advised. • Standardized approach recommended (Class I, LOE C-EO) • Cuffless BP devices not discussed. • No specific device recommended for individuals with atrial fibrillation.	• Automated electronic devices are recommended for office and out-of-office BP measurement (Class I, LOE B). • Validated devices recommended (Class I, LOE B). • Standardized approach recommended (Class I, LOE C). • Cuffless BP devices should not be used in clinical practice (Class III, LOE C). • Favors automated oscillometric devices for patients with atrial fibrillation.	• No specific device type recommended. • Validated and calibrated devices recommended (Class I, LOE B). • Standardized approach recommended (Class I, LOE B). • Cuffless devices not recommended. • Favors manual auscultation for individuals with atrial fibrillation (Class IIa, LOE C).
Diagnosing Hypertension	• Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension (Class I, LOE A).	• Office BP is recommended for diagnosis of hypertension (Class I, LOE A). • Out-of-office measurement is recommended to provide additional information on BP values if available (Class I, LOE C). • HBPM or ABPM are recommended for diagnosing white coat hypertension or masked hypertension (Class I, LOE B). • ABPM is recommended to diagnose true resistant hypertension (Class I, LOE C).	• Out-of-office BP measurement is recommended for diagnostic purposes but use of repeat office measurement if out-of-office BP measurement is not available (Class I, LOE B).
Subsequent follow-up/long-term management of hypertension	• Out-of-office BP measurements are recommended for the titration of BP medications (Class I, LOE A).	• HBPM is recommended for long-term follow-up of treated hypertension (Class I, LOE B).	• Out-of-office BP measurement is recommended for ongoing management of hypertension with use of office measurement when out-of-office measurement is not logistically/economically feasible (Class I, LOE B).

Abbreviations: ABPM= ambulatory blood pressure monitoring; ACC= American College of Cardiology; AHA=American Heart Association; BP= blood pressure; ESC= European Society of Cardiology; ESH= European Society of Hypertension; EO= expert opinion; LOE= level of evidence; HBPM= home blood pressure monitoring

The stronger emphasis on out-of-office BP measurement for diagnostic purposes in the 2024 ESC and 2017 ACC/AHA guidelines as compared to the 2023 ESH guideline may reflect data demonstrating that out-of-office BP measurement is generally more accurate than office BP measurement,³⁴ better predicts CVD events,³⁵ and correlates better with left ventricular mass.³⁶

Diagnostic Work-up

Evaluation for hypertension-mediated organ damage (HMOD)

The 2024 ESC guideline specifically recommends measurement of serum creatinine, eGFR, and urine albumin/creatinine ratio (Class I) in all patients with hypertension (and at least annually if moderate-to-severe CKD is diagnosed), a 12-lead ECG in all patients with hypertension (Class I), an echocardiogram in patients with hypertension and ECG abnormalities or signs/symptoms of cardiac disease (Class I), and fundoscopy for individuals with hypertensive emergency, malignant hypertension, or hypertension and diabetes (Class I).⁷ The 2024 ESC guideline also advises that renal ultrasound should be considered for hypertensive patients with CKD (Class IIa).⁷ The guideline notes that echocardiogram, coronary artery calcium scoring, measurement of pulse wave velocity, fundoscopy, and carotid or femoral ultrasound may be considered for patients with elevated BP or hypertension when it is likely to change patient management (Class IIb).⁷ As SCORE2 is not validated in young adults (< 40 years), the 2024 ESC guideline advises screening for HMOD be considered for these young individuals with elevated BP who do not have high-risk CVD conditions (Class IIb).⁷ HMOD assessment may also help overcoming patient and physician inertia.

The 2023 ESH guideline advises (without providing a formal recommendation) that a basic screening for HMOD be performed in all hypertensive patients.⁶ The guideline advises a 12-lead ECG should be obtained in all hypertensive patients.⁶ The guideline discusses the value of several tests to evaluate for HMOD including ankle-brachial index, coronary artery calcium score, carotid ultrasound, renal ultrasound, echocardiogram, and pulse wave velocity but without providing any formal recommendations on when to perform these tests.⁶

The 2017 ACC/AHA guideline advises (without formal recommendation) an electrocardiogram be performed in all patients with hypertension while additional tests for HMOD such as an echocardiogram and urine albumin/creatinine ratio are considered to be optional.⁸

Evaluation for secondary hypertension

The 2024 ESC guideline recommends that patients with hypertension presenting with suggestive signs, symptoms or medical history of secondary hypertension are appropriately screened (Class I). In a major departure from other guidelines, the ESC guideline also advises that screening for primary aldosteronism by renin and aldosterone measurements should be considered in all adults with confirmed hypertension (Class IIa). This recommendation was motivated by accumulating data suggesting that primary aldosteronism has a prevalence of between approximately 5% - 20 % among individuals with hypertension,^37–39 that most individuals do not have hypokalemia or diuretic-induced hypokalemia that might prompt testing,³⁸ and that adrenalectomy or targeted drug treatment are effective for reducing CVD risk among individuals with aldosterone producing adenomas- even when considered over and above the effect of adrenalectomy or targeted drug therapy on reducing BP level.⁴⁰ For young adults (< 40 years of age), comprehensive screening for the main causes of secondary hypertension is recommended by the 2024 ESC guideline (Class I), except for obese young adults where it is recommended to simply start with an obstructive sleep apnoea evaluation.⁷

The 2023 ESH guideline do not provide any formal recommendations for evaluating for secondary hypertension. They note that screening all hypertensive patients is not feasible or cost-effective but they note in the text that diagnostic suspicion for secondary hypertension should prompt referral to specialized hypertension centers for further diagnostic work-up and treatment.⁶

The 2017 ACC/AHA guideline recommends screening for secondary hypertension when there is suggestive clinical findings, which include drug-resistant hypertension, abrupt onset hypertension, hypertension among individuals < 30 years, exacerbation of previously controlled hypertension, disproportionate target organ damage, malignant hypertension, late onset diastolic hypertension, and unprovoked or excessive hypokalemia (Class I).⁸ The 2017 ACC/AHA guideline specifically recommends screening for primary aldosteronism but only for selected individuals with resistant hypertension, hypokalemia, incidental adrenal mass, family history of early-onset hypertension, or stoke at a young age (Class I).⁸

Evaluation for resistant hypertension

The 2024 ESC guidelines advises that patients with resistant hypertension should be considered for referral to specialist centres and, in another departure from other guidelines, that adherence testing with either direct observed therapy or drug level measurement be considered (Class IIa). The 2023 ESH and 2017 ACC/AHA guidelines note that resistant hypertension requires the exclusion of secondary hypertension (Class I in both guidelines).^{6, 8}

Management of Non-resistant Hypertension

Non-pharmacological interventions

The 2024 ESC, 2023 ESH, and 2017 ACC/AHA guidelines provide overall similar recommendations for non-pharmacological interventions for patients with hypertension.^{6, 8} All three guidelines recommend minimization of alcohol intake (Class I in all guidelines) and maintenance or weight loss to achieve a normal BMI (Class I in all guidelines).^{6, 8} The 2023 ESH and 2024 ESC guidelines also specifically recommend smoking cessation (Class I) for the purposes of CVD health. While all three guidelines recommend exercise, sodium restriction, and potassium supplementation, they differ slightly in their guidance. The 2024 ESC and 2023 ESH guidelines recommend a 2 gram sodium restriction (Class I) while the 2017 ACC/AHA guideline does not provide a formal recommendation for target daily sodium restriction. All guidelines recommend exercise but the 2024 ESC guideline specifically recommends further supplementing at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic exercise per week with low- or moderate-intensity dynamic or isometric resistance training two to three times per week. This latter suggestion by the 2024 ESC guideline for resistance training reflects data demonstrating BP reductions with strength training.⁴¹ All guidelines advise that patients with hypertension without advanced chronic kidney disease increase their potassium intake or replace sodium with potassium-enriched salts, however, 2023 ESH and 2017 ACC/AHA guidelines provide a Class I recommendation while 2024 ESC guideline provides a Class IIa recommendation. The lower Class of recommendation in the 2024 ESC guideline was in consideration of the availability of just one CVD outcomes trial demonstrating benefit of potassium supplementation or substitution to date in a homogenous population of Asian adults.⁴²

When to initiate pharmacological therapy

The 2024 ESC, 2023 ESH, and 2017 ACC/AHA guidelines differ significantly in their thresholds to initiate BP-lowering pharmacological therapy (Table 4). The 2024 ESC guideline recommends prompt initiation of both lifestyle and BP-lowering pharmacological therapy for individuals with confirmed hypertension (≥140/90 mmHg) irrespective of age and CVD risk (Class I).⁷ Similarly, the 2017 ACC/AHA guideline also recommends lifestyle and BP-lowering pharmacological therapy for all individuals with a BP ≥140/90 mmHg (defined as stage II hypertension).⁸ In contrast, while the 2023 ESH guideline also recommends (Class I) initiation of both lifestyle and BP-lowering pharmacological therapy for most adults with confirmed hypertension (≥140/90 mmHg), it recommends pharmacological therapy be initiated at a higher SBP threshold of 160 mmHg for patients aged 80 years or older (Class I) with the caveat that initiation may be considered at a lower threshold of 140–160 mmHg (Class II).⁶ While no formal recommendation is provided, the 2023 ESH guideline also differs for individuals with grade 1 hypertension (140–159 mmHg/90–99 mmHg) and low CVD risk and an absence of HMOD, lifestyle interventions may be initiated for several months before starting drug treatment.⁶ Age stratified thresholds for treatment initiation were not used by the 2024 ESC guideline as 1) meta-analyses of clinical trials have not found age to be an effect modifier for treatment efficacy at least up to 85 years,⁴³ and 2) contemporary trials including older individuals have shown a benefit in CVD event reduction.^{25, 33, 44}

Table 4:

Blood Pressure Lowering Treatment Thresholds

	2017 ACC/AHA Guidelines	2023 ESH Guidelines	2024 ESC Guidelines
Threshold for Pharmacological Treatment Initiation	1. BP ≥ 140/90 irrespective of age (Class I, LOE for A for SBP and C-EO for DBP if high-risk and Class I, LOE C-LD if low risk) 2. SBP 130 – 139 or DBP 80 – 89 plus one of the following (Class I, LOE A for SBP and C-EO for DBP):  • Clinical atherosclerotic CVD, HF, CKD, or DM  • Pooled cohort equation 10-year CVD risk ≥10%	1. SBP ≥ 160 if age ≥ 80 years (Class I, LOE B) 2. BP ≥ 140/90 if age 18 – 79 years (Class I, LOE A) 3. BP ≥ 130/80 if history of CVD, predominantly CAD (Class I, LOE A)	1. BP ≥ 140/90 irrespective of age (Class I, LOE A) 2. SBP 130 – 139 or DBP 80 – 89 despite 3 months of lifestyle treatment plus one of the following (Class I, LOE A) ‡: • High-risk conditions (established CVD, HMOD, DM, FH, or moderate or severe CKD) • SCORE2/SCORE2-OP 10-year CVD risk ≥10% • SCORE2/SCORE2-OP 10-year CVD risk 5% - <10% + abnormal risk modifiers or risk tool tests
First line medications	• ACEi, ARB, dihydropyridine CCB, and thiazide or thiazide-like diuretics (Class I, LOE A)	• ACEi, ARB, dihydropyridine CCB, beta blockers, and thiazide or thiazide-like diuretics (Class I, LOE A)	• ACEi, ARB, dihydropyridine CCB, and thiazide or thiazide-like diuretics (Class I, LOE A)
BP Treatment Targets	• BP <130/80 mmHg irrespective of age; recommended (Class I, LOE B-R for SBP and C-EO for DBP) if established CVD, DM, CKD, HF or 10-year risk of CVD ≥ 10% and may be reasonable (Class IIb, LOE B-NR for SBP and C-EO for DBP) in absence of high CVD risk or high risk conditions	• BP <130/80 mmHg if age <65 years (Class I, LOE A) • BP <140/80 if age 65 – 79 years * (140–150 mmHg if isolated systolic hypertension) (Class I, LOE A) • SBP of 140–150 and DBP < 80 mmHg if age ≥80 years † (Class I, LOE A)	• SBP target 120 – 130 mmHg in all adults if tolerated § (Class I, LOE A) • If standard target is not tolerable due to side effects, target SBP level “as low as reasonably achievable” (Class I, LOE A) • DBP target 70 – 79 mmHg (Class IIb, LOE C)

Abbreviations: ACC= American College of Cardiology; ACEi = Angiotensin converting enzyme inhibitors; ARB= angiotensin receptor blockers; AHA=American Heart Association; BP= blood pressure; CAD= coronary artery disease; calcium channel blockers = CCB; CKD= chronic kidney disease; CVD= cardiovascular disease; DBP= diastolic blood pressure; DM= diabetes mellitus; ESC= European Society of Cardiology; ESH= European Society of Hypertension; EO= expert opinion; FH= familial hypercholesterolemia; HF= heart failure; HMOD= hypertension mediated organ damage; LD= limited data; LOE= level of evidence; NR= non-randomized; R= randomized; SBP= systolic blood pressure; SCORE2= Systematic Coronary Risk Evaluation 2; SCORE2-OP= Systematic Coronary Risk Evaluation 2 – Older Persons.

^*BP <130/80 can be considered if treatment well tolerated (Class II, LOE B)

^†SBP 130 – 139 can be considered if treatment well tolerated (Class II, LOE B)

^‡Exceptions: moderate-to-severe frailty, symptomatic orthostatic hypotension, age ≥ 85 years

^§More lenient target (BP <140/90 mmHg) should be considered for individuals with symptomatic orthostatic hypotension or age ≥85 years (Class IIa, LOE C) and may be considered among individuals with moderate-to-severe frailty or limited life expectancy (Class IIb, LOE C).

The guidelines also differ regarding patient populations to treat when the BP is below 140/90 mmHg. The 2024 ESC guideline recommends lifestyle therapy for all individuals with elevated BP defined as SBP 120–139 mmHg or DBP 70–89 mmHg and initiation of pharmacological therapy for those with SBP 130–139 or DBP 80–89 mmHg after 3 months of lifestyle therapy in a broader population with high-risk CVD conditions (established CVD, HMOD, diabetes mellitus, moderate or severe CKD, and familial hypercholesterolemia), individuals with a 10-year predicted CVD risk of 10% or greater, or individuals with a borderline 10-year CVD risk of 5% - <10% combined with risk modifiers and/or abnormal risk tools (Class 1). In contrast, the 2023 ESH guideline recommends pharmacological therapy to lower BP for individuals with SBP 130–139 or DBP 80–89 mmHg (defined as high-normal BP) but only if there is a history of CVD, predominantly coronary artery disease (Class I).⁶ The 2017 ACC/AHA guideline recommends the initiation of both lifestyle and pharmacological BP-lowering therapy for those with SBP 130– 139 or DBP 80–89 mmHg (defined as stage 1 hypertension) and either clinical atherosclerotic CVD, heart failure, CKD, diabetes mellitus, or a 10-year risk of CVD of 10% or higher as determined by the pooled cohort equation.⁸

The expanded emphasis on high CVD risk individuals recommended for treatment with an SBP 130–139 or DBP 80–89 mmHg in the 2024 ESC guideline reflects several recent trials demonstrating benefit of BP lowering when enrolling high risk individuals within this BP range published since the 2017 ACC/AHA guideline,²⁵ and even the 2023 ESH guideline.²⁶

BP-lowering treatment selection

The 2024 ESC guideline recommends angiotensin converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), dihydropyridine calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics as the first line BP-lowering agents (Class I).⁷ These medications are also first line agents recommended by 2017 ACC/AHA guideline (Class I).⁸ The 2023 ESH guideline differs substantially, with the inclusion of beta blockers as first line medications (Class 1).⁶ In contrast, the 2024 ESC guideline recommends (Class I) beta blockers are combined with one of these other major classes when there is a compelling indication (e.g. heart failure with reduced ejection fraction).⁷ The 2017 ACC/AHA guideline states that beta blockers are secondary agents without a formal recommendation.⁸ Beta blockers were not considered 1^st line in the 2024 ESC guideline due in large part to inferior stroke prevention in comparison with other classes of BP lowering treatments.^{45, 46}

The 2024 ESC and 2023 ESH guidelines recommend initial two-drug fixed dose combination therapy in most patients with hypertension (Class I in both guidelines) with similar exceptions.^{6, 7} Both guidelines recommend a three-drug combination if a two-drug combination is not sufficient to control BP and use of fixed-dose single pill combinations when two or more drug combinations are required (Class I in both guidelines).^{6, 7} The 2017 ACC/AHA guideline also recommends initiation of two agents for individuals with BP ≥140/90 mmHg, but as either separate or fixed-dose combination and with the prerequisite that the average BP is more than 20/10 mmHg above target (Class I).⁸ The 2017 ACC/AHA guideline however does note that use of combination pills can be useful to improve adherence (Class IIa). Nevertheless, since the publication of the 2017 ACC/AHA guideline, several additional trials have been published showing benefit of single pill combinations in BP reduction supporting the higher Class of recommendation used by the 2024 ESC and 2023 ESH guidelines.^{47, 48}

The 2023 ESH guideline states that renal denervation can be considered for patients with eGFR > 40 ml/min/1.73m² who have uncontrolled BP despite BP-lowering combination therapy or if drug treatment elicits serious side effects (Class II).⁶ Likewise, the 2024 ESC guideline states that renal denervation may be considered for uncontrolled hypertension among patients with increased CVD risk on fewer than three agents provided they express a preference to undergo renal denervation after a shared risk-benefit discussion (Class IIb).⁷ Notably, the 2024 ESC guideline states that renal denervation is not recommended as a first-line treatment for hypertension (Class III).⁷ As the 2017 ACC/AHA guideline was released before randomized clinical trials demonstrating efficacy of renal denervation for BP reduction, this treatment was not discussed. An updated ACC/AHA guideline is expected in 2025.

Blood pressure targets

The 2024 ESC guideline recommends an initial default SBP target of 120–129 mmHg in most adults (Class I) if tolerated.⁷ Importantly, the 2024 ESC guideline notes that an SBP target of 120 mmHg is the optimal point in the target range. Among individuals who cannot achieve this target range due to tolerability, the guideline recommends targeting a SBP level “as low as reasonably achievable” (Class I).⁷ However, the 2024 ESC guideline does also note that a more lenient target (e.g. BP <140/90 mmHg) should be considered among individuals with pre-treatment symptomatic orthostatic hypotension and/or age of 85 years or older (Class IIa) and may be considered among individuals with moderate-to-severe frailty or limited life expectancy (Class IIb).⁷

The 2017 ACC/AHA guideline recommends a similar but less exact BP target, albeit with differing strength of recommendation dependent on the patient’s risk. For adults with known CVD or 10-year risk of CVD of 10% or higher, a BP target of <130/80 mmHg is recommended (Class I).⁸ However, in the absence of CVD or high CVD risk, this same target, <130/80 mmHg may be reasonable (Class IIb).⁸

In contrast to the both of these guidelines, the 2023 ESH guideline stratifies BP targets according in particular to age (Figure 2). The guideline recommends a target of <130/80 mmHg for individuals <65 years, a target of <140/80 for individuals aged 65 to 79 years of age (increasing to 140–150 mmHg for individuals with isolated systolic hypertension), and a target SBP of 140–150 with a diastolic BP < 80 mmHg for individuals aged 80 years or older (Class I).⁶ On the basis of post-hoc observational data suggestive of a BP J-curve, the 2023 ESH guideline specifically recommends against targeting a BP below 120/70 mmHg (Class III, harm).

Figure 2: Comparison of Blood Pressure Treatment Thresholds and Targets for Older Adults across Major Hypertension Guidelines.

Figure illustrating differing treatment thresholds and targets for older adults (65 years and older) in clinical practice guidelines. Abbreviations: ACC= American College of Cardiology; AHA=American Heart Association; ALARA= as low as reasonably achievable; BP= blood pressure; CVD=cardiovascular disease; ESC= European Society of Cardiology; ESH= European Society of Hypertension.

Several contemporary clinical trials informed the lower targets endorsed by the 2024 ESC guideline, specifically Systolic Blood Pressure Intervention Trial (SPRINT),²⁴ Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP),²⁵ and Effects of intensive Systolic blood Pressure lowering treatment in reducing RIsk of vascular evenTs (ESPRIT).²⁶ Furthermore, since meta-analyses have not demonstrated that age is an effect modifier of the efficacy of BP lowering treatment at least up to 85 years,⁴³ age-stratified targets were not endorsed by ESC.

Management of Resistant Hypertension

The 2024 ESC and 2023 ESH guidelines favor spironolactone (if not contraindicated) as the first line agent for resistant hypertension (Class IIa in ESC 2024 and Class II in ESH 2023).^{6, 7} The 2017 ACC/AHA guideline also favors spironolactone as the agent of choice for resistant hypertension but does not provide a formal recommendation.⁸

The 2023 ESH guideline states renal denervation can be considered as an additional treatment option in patients with resistant hypertension if eGFR is > 40 ml/min/1.73m² (Class II).⁶ Similarly, the 2024 ESC guideline advises that renal denervation may be considered for resistant hypertension patients with uncontrolled BP if performed at a medium-to-high volume center and if the patient expresses a preference to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment (Class IIb).⁷ The 2024 ESC guideline also advises against renal denervation if the eGFR is < 40 ml/min/1.73m² (Class III).⁷ As previously stated, trials demonstrating benefit of renal denervation emerged after the publication of the 2017 ACC/AHA guideline.

Guideline Implementation

In response to recent trials and studies strongly confirming the efficacy of multidisciplinary care,^{28, 49–51} and acknowledging that prior guideline recommendations have been poorly implemented,⁵² the 2024 ESC guideline takes a provocative departure from prior ESC guidelines by providing a Class I recommendation for multidisciplinary approaches in the management of patients with elevated BP and hypertension, including appropriate and safe task-shifting away from physicians. A strong position in favor of patient-centered care is also taken in 2024 ESC guideline. This approach is not unique to the 2024 ESC guideline, both the 2023 ESH and the 2017 ACC/AHA guidelines recommend a multi-dimensional team-based care approach to hypertension (Class I in both guidelines).^{6, 8} The 2017 ACC/AHA and 2023 ESH additional outline additional strategies that may improve implementation. The 2023 ESH guideline, recommends the use of novel telehealth technologies and virtual care to improve BP management (Class I).⁶ The 2017 ACC/AHA guideline recommends use of the electronic health record and registries for quality improvement initiatives to improve BP control (Class I) and provides support for telehealth strategies (Class IIa).⁸ The 2017 ACC/AHA guideline also states that performance measures and financial incentives to clinicians may be reasonable for improving hypertension control (Class IIa).⁸

In order to identify barriers to implementation, the 2024 ESC guideline task force undertook a novel pilot initiative to survey the national cardiac societies in Europe during the peer review process of the guideline, in order to understand the feasibility of implementing key areas of the guideline. This survey revealed that most national societies thought that out-of-office BP measurement is realistic and feasible in their countries, that most patients would be able to take an active role in BP self-monitoring and management, that there are no major barriers to accessing BP-lowering medications for all patients who need them, and that implementing the lifestyle recommendations of the guideline is feasible. However, the surveyed societies were less confident that clinicians would utilize risk scores for management of elevated BP.

Conclusions

In summary, there are many similarities between the new 2024 ESC guideline, the 2023 ESH guideline, and the 2017 ACC/AHA guideline for the management of hypertension. However, there are also some important differences. More high CVD risk individuals are likely to be treated with BP-lowering medication by the 2024 ESC guideline than the 2017 ACC/AHA and 2023 ESH guidelines. In addition, and informed by the most recent intensive treat-to-target trials, the ESC 2024 guideline have the most intensive initial default treatment targets, albeit specifying this intensive treatment approach has to be well tolerated and is not applicable in all conditions. Finally, the 2024 ESC recommendations tackle historically poor hypertension guideline implementation by providing provocative guidance on multi-disciplinary care, including appropriate and safe task-shifting away from physicians.