The new 2024 ESC Hypertension Guidelines (2024 ESC Guidelines for the management of elevated blood pressure and hypertension) introduce key updates to improve diagnosis, treatment, and prevention of this common condition, which is one of the main cardiovascular risk factors.
The recommendations offer a comprehensive approach for cardiology specialists. They cover accurate blood pressure measurement and tailored management for specific patient groups.
This article summarizes the main points from the 2024 Hypertension Management Guidelines. It aims to help healthcare professionals stay current on this critical topic. We hope this overview provides a clear and efficient summary of the latest updates.
By América Torres
Accurate Blood Pressure Measurement: Core of the 2024 ESC Guidelines
- Clinicians sshould measure blood pressure (BP) with a validated and calibrated device. They should apply the correct technique, and follow a consistent approach for each patient.
- Clinicians should measure BP outside the office for diagnostic purposes. This approach helps detect both white coat hypertension and masked hypertension.
- When out-of-office measurement is not feasible, clinicians should confirm BP with repeated in-office measurements using the correct standardized technique.
- Most automatic oscillometric monitors have not been validated for BP measurement in atrial fibrillation (AF) cases. In these cases, they should consider measuring BP manually via the auscultatory method, when possible.
- Clinicians should assess orthostatic hypotension—defined as a ≥20 mmHg drop in systolic BP and/or a ≥10 mmHg drop in diastolic BP at 1 and/or 3 minutes after standing—at least during the initial diagnosis of elevated BP or hypertension. They should repeat the assessment later if symptoms suggest orthostatic hypotension. Before testing, the patient should lie down or sit for 5 minutes.
Updated Hypertension Classification and Risk Assessment
- The guidelines recommend a risk-based approach. They consider individuals with moderate or severe chronic kidney disease, established cardiovascular disease, hypertension-mediated organ damage, diabetes mellitus, or familial hypercholesterolemia at higher risk for cardiovascular events.
- For patients with type 2 diabetes mellitus and elevated blood pressure, the guidelines recommend considering the SCORE2-Diabetes tool to estimate cardiovascular risk, especially in those <60 years old.
- The guidelines recognize pregnancy complications as sex-specific risk modifiers. They recommend considering these complications to up-classify patients with elevated blood pressure and a borderline 10-year cardiovascular risk (5% to <10%).
- The guidelines identify high-risk ethnicities (such as South Asian), family history of premature atherosclerotic disease, socioeconomic deprivation, inflammatory autoimmune disorders, HIV, and severe mental illness as shared risk modifiers for both sexes. They recommend considering these factors when classifying individuals with elevated BP and a 10-year cardiovascular risk of 5% to <10%.
If treatment decisions to lower BP based on risk remain unclear after evaluating non-traditional cardiovascular risk modifiers and predicted 10-year cardiovascular risk, clinicians can consider additional tools. These include coronary artery calcium (CAC) scoring, carotid or femoral plaque assessment via ultrasound, high-sensitivity cardiac troponin biomarkers, B-type natriuretic peptide, or arterial stiffness measured by pulse wave velocity. These tools can improve risk stratification for patients with borderline 10-year cardiovascular risk (5% to <10%). Clinicians should apply them after shared decision-making and consideration of costs.
Diagnosis and identification of underlying causes
The 2024 ESC Guidelines for the management of hypertension include the following blood pressure measurement best practices:
- Regular BP monitoring with the following frequency:
-Adults <40 years old: at least every 3 years.
–Adults ≥ 40 years old: at least once a year.
- For people with elevated BP who do not meet treatment criteria, the guidelines recommend reassessing blood pressure and reevaluating cardiovascular risk within one year.
- The guidelines suggest considering other forms of hypertension screening, such as systematic detection, self-examinations, and screenings by non-medical personnel. Feasibility may vary across countries and healthcare systems.
- For individuals at higher cardiovascular risk with office BP between 120–139/70–89 mmHg, the guidelines recommend ambulatory BP monitoring (ABPM) and/or home BP monitoring (HBPM). If these are not feasible, clinicians should repeat in-office BP measurements over more than one visit.
- For patients with apparent resistant hypertension, the guidelines recommend assessing treatment adherence (via direct observation or detecting prescribed drugs in blood or urine samples) if resources are available.
- If clinicians diagnose moderate-to-severe chronic kidney disease, the guidelines recommend repeating serum creatinine, estimated glomerular filtration rate (eGFR), and urine albumin-to-creatinine ratio (ACR) measurements at least once a year.
- The guidelines suggest considering coronary artery calcium scoring in patients with elevated blood pressure or hypertension when it is likely to change patient management.
- The guidelines recommend referring patients with resistant hypertension to specialized hypertension centers for further testing.
- Patients with hypertension who show signs, symptoms, or medical history suggesting secondary hypertension should be appropriately screened.
- The guidelines recommend considering primary aldosteronism screening via renin and aldosterone measurements for all adults with confirmed hypertension (BP ≥ 140/90 mmHg).
Lifestyle and pharmacological treatment updates
Here are some key recommendations from the 2024 ESC Guidelines for managing high BP and hypertension and cardiovascular risk assessment in hypertension:
- To better predict adult hypertension and related cardiovascular risk, the guidelines recommend timely BP monitoring during late childhood and adolescence. Monitoring is especially important if one or both parents have hypertension.
- Sugar intake should be restricted, and sugary drinks (e.g., sodas, fruit juices) discouraged from early childhood.
- In individuals with hypertension who are free of moderate-to-severe chronic kidney disease and consume high sodium levels, increasing potassium intake by 0.5 to 1.0 grams per day is recommended. Consider replacing regular salt with potassium-enriched salt or increasing fruit and vegetable consumption.
- For adults with elevated BP and low-to-moderate cardiovascular risk (less than 10% over 10 years), lifestyle changes are recommended to lower BP levels.
- In adults with confirmed elevated BP (≥130/80 mmHg) and high cardiovascular risk, pharmacological treatment is recommended after 3 months of lifestyle changes.
- BP-lowering treatment should only be considered from ≥140/90 mmHg in individuals who meet any of the following criteria:
– Symptomatic orthostatic hypotension (BP drop upon standing) before treatment
– Age 85 or older
– Clinically significant moderate-to-severe frailty
– Limited life expectancy (less than 3 years).
- For patients who cannot tolerate BP-lowering treatment well and cannot achieve a systolic BP of 120–129 mmHg, targeting a systolic BP level “as low as reasonably achievable” (ALARA principle) is recommended
Patient-centered care: The human side of hypertension management
Effective management of hypertension requires a comprehensive approach that includes patient education, technological tools, and multidisciplinary collaboration. Below are several recommendations for improving blood pressure control, from the importance of clear doctor-patient communication to the use of home monitoring devices and the redistribution of responsibilities among healthcare professionals. These approaches not only simplify treatment but also enhance patient adherence to it.
- A clear discussion with patients about cardiovascular risk and treatment benefits, tailored to their needs, is recommended as part of hypertension management.
- Motivational interviewing techniques are suggested to help patients control their BP and improve treatment adherence at hospitals and community health centers.
- Physician-patient online communication is an effective tool that should be considered in primary care, including reporting home BP readings to physicians.
- Home BP monitoring is recommended as it helps better manage hypertension.
- Self-measurement of BP is recommended because, when done correctly, it has positive effects on accepting the hypertension diagnosis, patient empowerment, and treatment adherence.
- To manage hypertension more effectively, a multidisciplinary approach that safely delegates certain tasks from physicians to other healthcare professionals is recommended. This helps improve BP control and ensures more efficient care.
Innovative tools for reliable blood pressure monitoring
- Most vital signs and physical assessment tools are united in one device: NIBP, TEMP, SpO2, 3-lead EKG.
- Large 18” interactive touchscreen with intuitive guidance and easy-to-use interface.
- Highest diagnostic EKG quality with a 32,000 Hz sampling rate (12-lead).
- Bidirectional communication through Wi-Fi and Ethernet connection.
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REFERENCE
John William McEvoy et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. European Heart Journal (2024) 00, 1–107 https://doi.org/10.1093/eurheartj/ehae178
Frequently Asked Questions About the 2024 ESC Hypertension Guidelines
What are the key updates in the 2024 ESC Guidelines for hypertension?
The 2024 ESC Guidelines provide updated recommendations on accurate blood pressure measurement, risk-based classification, lifestyle and pharmacological treatment, and patient-centered care. They emphasize out-of-office monitoring (ABPM and HBPM), use of SCORE2 tools for cardiovascular risk assessment, and individualized treatment thresholds based on patient risk and frailty.
How should blood pressure be measured according to ESC 2024 recommendations?
Blood pressure should be measured using validated and calibrated devices with standardized techniques. Out-of-office measurements, such as home blood pressure monitoring (HBPM) or ambulatory monitoring (ABPM), are recommended for accurate diagnosis and detecting white coat or masked hypertension. Devices like the SCHILLER DS-20 are validated for clinical use and streamline accurate measurements in triage.
When should pharmacological treatment be started for hypertension?
Pharmacological treatment is recommended after 3 months of lifestyle interventions for patients with elevated BP and high cardiovascular risk. For lower-risk adults, treatment starts at ≥140/90 mmHg, considering special circumstances such as frailty, age ≥85, or symptomatic orthostatic hypotension.
What role does the DS-20 Diagnostic Station play in hypertension management?
The DS-20 Diagnostic Station integrates blood pressure, 3-lead EKG, SpO₂, and temperature in one system. It supports adherence to ESC 2024 Guidelines by providing accurate, repeatable measurements, improving workflow efficiency, and enabling better patient monitoring in clinics, triage, and specialized hypertension centers.
How can clinicians assess cardiovascular risk in patients with elevated blood pressure?
Clinicians can use the SCORE2 or SCORE2-Diabetes calculators to estimate 10-year cardiovascular risk. Additional risk modifiers—such as pregnancy complications, ethnicity, family history, chronic kidney disease, or autoimmune disorders—should be considered. Imaging and biomarkers, including coronary artery calcium (CAC) scoring, may further refine risk assessment for borderline cases.