2024 ESC Guidelines: Essential Ten Commandments for Managing Elevated Blood Pressure and Hypertension

The guidelines were published online in the European Heart Journal on October 16, 2024.

Blood Pressure Classification

A notable change in the guidelines is the introduction of a new classification system. Blood pressure is categorized as:

• Non-elevated: Office BP < 120/70 mmHg
• Elevated BP: Office BP 120–139/70–89 mmHg
• Hypertension: Office BP ≥ 140/90 mmHg

This clear classification helps clinicians better understand and manage their patients' conditions.

Diagnosis Recommendations

The guidelines recommend out-of-office BP measurements, such as home monitoring, as the preferred method for diagnosing elevated BP and hypertension. This approach allows for more accurate readings than traditional office measurements, which can be influenced by "white coat syndrome."

Risk Assessment Protocols

Effective risk assessment is crucial for individuals with elevated BP. The guidelines outline a step-wise approach:

1. Identify individuals with high cardiovascular disease (CVD) risk conditions.
2. Predict the 10-year risk of CVD.
3. Evaluate sex-specific and shared risk modifiers.
4. Consider additional testing using various risk assessment tools.

This comprehensive risk assessment helps identify high-risk patients who may benefit from more aggressive management.

Management Strategies

For individuals with elevated BP and low CVD risk, lifestyle changes are recommended. These may include increased physical activity, dietary modifications, and weight management. For those with elevated BP and high CVD risk, initial lifestyle measures are also recommended, followed by pharmacological treatment if BP remains elevated after three months.

In cases of established hypertension, the guidelines advocate for both lifestyle modifications and medication. An initial approach using single-pill double combination therapy is suggested for most patients, facilitating better adherence and control.

Lifestyle Management Recommendations

The updated lifestyle recommendations encourage:

• Aerobic and resistance training
• Increased potassium and reduced sodium intake (less than 2g/day)
• A balanced diet
• Maintenance of a normal body mass index
• Smoking cessation and limited alcohol consumption

These lifestyle changes are crucial for managing blood pressure and improving overall health.

Target Blood Pressure Goals

For patients undergoing treatment, the guidelines recommend a target systolic BP of 120–129 mmHg. In older individuals, particularly those over 85, or those with specific health challenges, a more flexible target is advised—aiming for the lowest BP achievable without causing adverse effects.

Addressing Resistant Hypertension

For patients with resistant hypertension, the guidelines recommend the use of spironolactone or eplerenone as first-line treatments, followed by beta blockers and other medications as needed. Renal denervation is also an option for some patients.

Multidisciplinary Approach

Finally, the guidelines stress the importance of a multidisciplinary team approach in managing BP. This includes delegating responsibilities away from physicians to improve overall care and control elevated blood pressure.

In summary, the 2024 ESC guidelines for managing elevated blood pressure and hypertension provide a comprehensive framework aimed at improving patient outcomes through a combination of lifestyle changes, personalized treatment plans, and a collaborative healthcare approach.

Reference:

McCarthy, C. P., Touyz, R. M., & McEvoy, J. W. The ‘ten commandments’ for the 2024 European Society of Cardiology guidelines on elevated blood pressure and hypertension. European Heart Journal. https://doi.org/10.1093/eurheartj/ehae646