The 2024 European Society of Cardiology (ESC) guidelines on managing elevated blood pressure (BP) and hypertension were created by a multidisciplinary group, including patient representatives. Their key messages are summarized as “ten commandments” (Figure 1):
- Blood pressure classification: New categories—non-elevated (<120/70 mmHg), elevated (120–139/70–89 mmHg), and hypertension (≥140/90 mmHg).
- Diagnosis: Prefer out-of-office BP measurements for diagnosis and follow-up, when feasible.
- Risk assessment: Evaluate cardiovascular disease (CVD) risk through (i) identifying established CVD, (ii) estimating 10-year CVD risk, (iii) considering sex-specific/shared risk modifiers, and (iv) using additional risk tools if needed.
- Elevated BP + low CVD risk: Recommend lifestyle changes only, if CVD risk is <5% or borderline (5–<10%) without modifiers or abnormal results.
- Elevated BP + high CVD risk: Begin with lifestyle measures; if after 3 months BP remains ≥130/80 mmHg, add drug therapy.
- Hypertension: Use both lifestyle interventions and medication. Most patients should start with a single-pill, two-drug combination.
- Lifestyle management: Updated advice includes regular aerobic/resistance exercise, more potassium, less sodium (<2 g/day), balanced diet, healthy BMI, quitting smoking, and limiting alcohol.
- Treatment targets: Aim for systolic BP 120–129 mmHg in most patients, including those <85 years without frailty. In patients ≥85 years, or with frailty, orthostatic symptoms, or limited life expectancy, lower BP as much as safely achievable (ALARA).
- Resistant hypertension: Treat with spironolactone (or eplerenone), then beta blockers, then other options (e.g. alpha blockers). Renal denervation may be considered.
- Multidisciplinary care: Strongly encourage team-based approaches and task-shifting beyond physicians to optimize BP control.
Figure 1: Summarizing the ‘ten commandments’ of the 2024 ESC Clinical Practice Guidelines for the Management of Elevated Blood Pressure and Hypertension. N.B., for the 5th commandment, drug treatment is only for persons with high CVD risk and a repeat confirmed BP of 130/80 mmHg or more after 3 months of lifestyle measures. ALARA, as low as reasonably achievable; CVD, cardiovascular disease; SBP, systolic blood pressure
