New guidelines call for intensified BP targets, add blood pressure category to pinpoint heart attack, stroke risk

Updated European Society of Cardiology (ESC) Guidelines on the management of elevated blood pressure and hypertension include a new elevated blood pressure category, more ambitious and intensive treatment targets, and for the first time, recommendations on the use of renal denervation to treat various forms of hypertension. The Guidelines, published in the European Heart Journal, have been produced by an international panel of experts that include co-Chairpersons Professor Bill McEvoy of the University of Galway, Ireland, and Professor Rhian Touyz of McGill University, Canada.

Elevated blood pressure and hypertension are by far the most common and important risk factors for heart attack and stroke (otherwise known as cardiovascular disease). As many as 45% of European adults have hypertension.

The new guidelines are designed to get more patients to an evidence-based blood pressure treatment target and to increase the eligibility for blood pressure lowering medications to match the best current evidence from clinical trials. The ESC Guidelines also provide numerous pragmatic recommendations to avoid patients becoming symptomatic from overtreatment.

The 2024 Guidelines maintain the existing definition of "hypertension" as a BP ≥140/90 mmHg. However, they introduce a new category of "elevated BP" which is defined as a BP 120-139/70-89 mmHg. This new "elevated BP" category is introduced to facilitate consideration of more intensive blood pressure treatment targets among persons at increased risk for cardiovascular disease.

"This new category of elevated blood pressure recognizes that people do not go from normal BP to hypertensive overnight," says Prof. McEvoy. "It is in most cases a steady gradient of change, and different subgroups of patients—for example those at a higher risk of developing cardiovascular disease (e.g., people living with diabetes)—could benefit from more intensive treatment before their BP reaches the traditional threshold of hypertension."

Moreover, adds Prof. Touyz, "The risks associated with increased blood pressure start at systolic blood pressure levels even below 120 mmHg."

In another major change, the 2024 ESC Guidelines introduce a new systolic BP treatment target range of 120-129 mmHg for most patients receiving BP-lowering medication, with the important proviso that the new target requires that treatment is well tolerated. The 2024 ESC Guidelines also provide pragmatic recommendations on a systolic BP target "as low as reasonably achievable" (known as the ALARA principle) in frail and older persons and in those not tolerating the primary treatment target of 120-129 mmHg. The guidelines focus more on frailty of individuals rather than chronological age.

This new systolic BP treatment target of 120-129 represents a paradigm shift from prior European guidelines, including the 2018 ESC/ESH Hypertension Guidelines, the 2021 ESC Prevention Guidelines, and the 2023 ESH Hypertension Guidelines.

Specifically, whereas prior guidelines generally recommended patients be treated for a BP <140/90 mmHg in the first instance and only thereafter be considered for treatment for <130/80 mmHg (a 2-step approach), the new 2024 guidelines recommend that most patients be treated for a systolic BP of 120-129 mmHg in the first instance (those who cannot tolerate this target can have it relaxed).

"This change is driven by new trial evidence confirming that more intensive BP treatment targets reduce CVD outcomes across a broad spectrum of eligible patients," says Prof. McEvoy.

In part to accommodate this new more intensive systolic BP treatment target range, the 2024 ESC Guidelines provide stronger recommendations than prior guidelines for the use of out-of-office BP measurements (including ambulatory BP monitors and validated home BP monitors).

Additionally, the 2024 Guidelines, for the first time, make recommendations on the use of renal denervation for treatment of hypertension. Due to lack of evidence regarding cardiovascular outcomes benefit, the guidelines do not recommend this medical procedure as first line treatment, and nor is it recommended for patients with highly impaired renal function, (eGFR <40 mL/min/1.73 m²) or secondary causes of hypertension.

On renal denervation, the guidelines say, "To reduce BP, and if performed at a medium-to-high volume center, catheter-based renal denervation may be considered for patients with resistant hypertension who have BP that is uncontrolled despite a three BP-lowering drug combination (including a thiazide or thiazide-like diuretic), and who express a preference to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment."

Prof Touyz explains, "These evidence-based recommendations provide guidance for clinicians and their patients on the use of this important new technology. However, it must be stressed that this procedure needs to be undertaken in a center where there is expertise and experience."

These new ESC Guidelines also update dietary advice on sodium and potassium intake, and further emphasize the importance of lifestyle modifications for patients in a range of different circumstances and stages of CVD and chronic kidney disease. They also highlight the importance of sex and gender differences in hypertension and integrate this throughout the document, rather than as a separate section, as in most other guidelines.