Navigating the 2024 ESC Hypertension Guidelines: What’s New, Context, and Future Directions

What is New

On August 30th, 2024, the European Society of Cardiology (ESC) introduced its latest update to the hypertension guidelines, marking significant shifts in the management of high blood pressure (BP).¹ Prior European guidelines recommended a target BP of <140/90 mmHg, with more intensive treatment reserved for high-risk populations.² However, the 2024 guidelines recommend treating patients with increased cardiovascular risk to a target systolic BP (SBP) of <130 mmHg. A higher target is suggested only for individuals unable to tolerate lower BP levels. This shift reflects a paradigm change towards an “opt-out” strategy for intensive treatment, as opposed to the previous “opt-in” approach, recognizing that lower BP targets can significantly reduce the risk of cardiovascular disease. Additionally, the guidelines introduce a new category of “elevated BP,” defined as office SBP of 120–139 mmHg or diastolic BP (DBP) of 70–89 mmHg. This categorization aligns with U.S. hypertension guidelines³ and is supported by robust clinical trial data, demonstrating the benefits of targeting SBP levels below 120 mmHg.^4–6

The recommendation for home BP monitoring is also emphasized, both for managing hypertension and establishing a diagnosis. This aligns with the recognition that BP measurements can vary, and multiple readings are necessary to confirm a diagnosis.⁷ Home BP monitoring can also promote self-care and empower patients to make choices that support better BP control (e.g., lowering salt; adhering to medication). These updates reflect a growing global consensus to diagnose hypertension earlier in the disease course and to recommend more frequent measurement and treatment at lower levels than previously standard practice.

The 2024 ESC guidelines continue to take a risk-based approach to hypertension treatment. For adults with low-to-moderate cardiovascular risk (a 10-year risk of <10%), the guidelines recommend initiating lifestyle modifications for elevated BP, reserving medication only for those whose BP remains above 140/90 mmHg. In contrast, for high-risk individuals, treatment is recommended once BP exceeds 130/80 mmHg. This stratification is largely based on clinical trials involving patients with increased cardiovascular risk. For example, the Systolic Blood Pressure Intervention Trial (SPRINT),⁴ which included adults over 50 with elevated cardiovascular risk but without diabetes, found that targeting an SBP of <120 mmHg significantly reduced cardiovascular events compared to a target of <140 mmHg. Similarly, the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial, which focused on adults aged 60–80, demonstrated that intensive BP control to a target of 110–130 mmHg was more effective in reducing cardiovascular events than a target range of 130–150 mmHg.⁵ Despite these findings, the 2024 ESC guidelines adopt a more conservative stance. They do not fully endorse initiating or treating to an SBP of <120 mmHg, nor do they mention this target as a potential option for high-risk patients, reflecting a cautious deviation from the SPRINT, STEP, and ACCORD trials’ target levels.^4,5,8 Furthermore, other studies suggest that the ASCVD risk score may not adequately capture the risk of heart failure due to hypertension. For instance, a post-hoc analysis of the SPRINT trial found that intensive BP lowering significantly reduced the incidence of heart failure, although this benefit was observed only in the highest-risk tertile.⁹ Additionally, a study using a unique pooled cohort equation to estimate the 10-year risk of heart failure found that many patients considered at high risk would have a low-to-moderate 10-year ASCVD risk. They, therefore, would not meet the criteria for intensive BP lowering. While more data are needed to guide intensive BP lowering in lower-risk populations, the current evidence supports offering high-risk patients the opportunity for intensive BP treatment to a target of <120 mmHg. Nevertheless, the decision should consider the individual balance of risks and benefits.

Context and Juxtaposition with Reality

Despite numerous hypertension guidelines (Figure) and a general movement to more intensive BP lowering and a global focus on hypertension, hypertension detection, treatment and control remains stubbornly low.¹⁰ According to data from the NCD Risk Factor Collaboration, only 23% of women and 18% of men with hypertension worldwide have their BP under 140/90 mmHg. In many high-income countries (including North American and Western European countries), the control rates are higher but remain suboptimal, with fewer than 50% of patients achieving BP control.

Figure:

Timeline for selected major clinical studies related to blood pressure, clinical practice guidelines, and blood pressure control rate in the United States

This “losing ground” phenomenon is also evident in the United States, where national surveys, such as the National Health and Nutrition Examination Survey (NHANES), have revealed a troubling decline in BP control rates.¹¹ Despite lower SBP treatment targets in guidelines being in place since 2017, fewer than 25% of adults with hypertension achieve the new BP targets (130/80 mmHg) in 2020, and 50% do not even achieve the older targets (140/90 mmHg).¹² In particular, racial and ethnic disparities in hypertension control remain a pressing concern. Black and Hispanic adults have disproportionately lower rates of BP control compared to their White counterparts,¹³ leading to worse hypertension complications and cardiovascular outcomes such as stroke, heart failure, and chronic kidney disease.¹⁴ In other countries such as China, the situation also warrants attention. Recent data suggest that while awareness, treatment, and control of hypertension have improved, 85% patients among those treated remains uncontrolled.¹⁵ The Chinese or Asian guidelines have tailored their recommendations to reflect regional considerations, but the gap between guideline targets and actual BP control remains a challenge.

The juxtaposition between guideline aspirations and the current reality underscores the complexity of managing hypertension in diverse populations. While guidelines advocate for intensive treatment, many patients face structural and socioeconomic barriers that prevent them from accessing care or adhering to treatment plans.¹⁶ Additionally, clinical inertia—where providers are slow to adjust treatment or initiate more aggressive interventions—further contributes to the gap between guidelines and real-world outcomes.

Research and Implementation Needs

Bridging the gap between the ambitious targets of the 2024 ESC guidelines and the current state of hypertension control requires focused research and implementation efforts. First, we need a deeper understanding of the barriers that prevent patients from achieving BP control, especially in underserved populations.¹⁷ While trials like SPRINT and STEP provide strong evidence for the benefits of lower BP targets, more studies are needed to understand how these targets can be achieved in the real world, particularly in low-resource settings.

There is also a clear need for implementation science research to identify strategies to help translate the guidelines into everyday practice.¹⁸ This includes investigating the role of digital health tools, such as remote BP monitoring systems, mobile health apps, and electronic health record integrated decision support tools, in improving adherence and outcomes. Additionally, research should focus on how to effectively engage patients in their care, particularly through lifestyle interventions such as diet, exercise, and stress management, which remain underutilized despite their importance in managing hypertension.

JACC as a Willing Partner

JACC is uniquely positioned to support the dissemination and adoption of these guidelines. As a leading platform for cardiovascular research and clinical practice, JACC can amplify key findings from implementation studies and showcase successful models of guideline adoption. By highlighting innovative approaches to hypertension management, such as the use of artificial intelligence to advance diagnosis and treatment plans¹⁹ or community-based interventions in underserved populations,²⁰ JACC can help bridge the gap between evidence and practice.

Furthermore, JACC can facilitate ongoing dialogue between researchers, clinicians, and public health experts. This is critical as we continue to explore the best ways to integrate these guidelines into diverse healthcare systems and ensure that the benefits of intensive BP control reach all populations, regardless of socioeconomic status or geographic location. The bottom line is that there is a need for concerted action worldwide to address the preventable harm that accrues from elevated BP.

• What is the clinical question being addressed?

  What are the implications of the 2024 ESC hypertension guidelines on clinical practice and population health?

• What is the main finding?

  The 2024 ESC guidelines shift towards more intensive blood pressure management but face challenges in real-world implementation, highlighting the need for focused research and implementation strategies.

Abbreviations:

AAFP

American Academy of Family Physicians

ACC

American College of Cardiology

ACCORD

Action to Control Cardiovascular Risk in Diabetes

ACP

American College of Physicians

AHA

American Heart Association

ALLHAT

Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

ASH

American Society of Hypertension

BHS

British Hypertension Society

CALIBER study

CArdiovascular research using LInked Bespoke studies and Electronic health Records study

DASH sodium trial

Dietary Approaches to Stop Hypertension sodium trial

ESC

European Society of Cardiology

ESPRIT

Effects of Intensive Blood Pressure Lowering Treatment in Reducing Risk of Cardiovascular Events Trial

ESH

European Society of Hypertension

HTN

Hypertension

ISH

International Society of Hypertension

ISHIB

International Society of Hypertension in Blacks

JNC

Joint National Committee

JSH

Japanese Society of Hypertension

MRFIT

Multiple Risk Factor Intervention Trial

NICE

National Institute for Health and Care Excellence

PREVER-Prevention Trial

Prevention of Hypertension in Patients with PreHypertension Prevention Trial

SPRINT

Systolic Blood Pressure Intervention Trial

STEP

Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients trial