2024 ESC Guidelines for the Management of Elevated Blood Pressure and Hypertension

Authors, Journal, Affiliations, Type, DOI

• Chairpersons: John William McEvoy (University of Galway, Ireland), Rhian M. Touyz (McGill University, Canada)
• Task Force Co-ordinators: Cian P. McCarthy (USA), Rosa Maria Bruno (France)
• Large multinational task force (25 members) representing ESC, European Stroke Organisation, European Society of Endocrinology
• Journal: European Heart Journal, 2024; 45(38):3912–4018
• Type: Clinical Practice Guideline — replaces the 2018 ESC/ESH hypertension guidelines
• DOI: https://doi.org/10.1093/eurheartj/ehae178

Overview

The 2024 ESC Guidelines represent a major update from the 2018 version, fundamentally changing how blood pressure is classified and treated across the cardiovascular risk spectrum. The headline change is a new universal systolic BP treatment target of 120–129 mmHg (Class I, Level A), substantially more aggressive than the prior 130/80 mmHg goal. A new intermediate "Elevated BP" category (office SBP 120–139 or DBP 70–89 mmHg) is introduced, requiring formal CVD risk stratification (SCORE2/SCORE2-OP) to determine who warrants pharmacotherapy in this range. The guidelines also mandate out-of-office BP measurement for diagnosis and monitoring, expand primary aldosteronism screening to all confirmed hypertensive patients, and upgrade catheter-based renal denervation from not recommended (Class III, 2018) to Class IIb for resistant hypertension.

Keywords

Blood pressure, hypertension, elevated blood pressure, hypertension-mediated organ damage, ambulatory blood pressure monitoring, home blood pressure monitoring, antihypertensive medication, treatment targets, secondary hypertension, cardiovascular disease risk, resistant hypertension, renal denervation, primary aldosteronism, SCORE2

Key Takeaways

Blood Pressure Classification (New 2024 System)

• Three categories replace the prior 4-grade system:
  • Non-elevated BP: office SBP <120 mmHg AND DBP <70 mmHg
  • Elevated BP (NEW): office SBP 120–139 mmHg OR DBP 70–89 mmHg
  • Hypertension: office SBP ≥140 mmHg OR DBP ≥90 mmHg
• Hypertension definition unchanged at ≥140/90 mmHg; old "Normal", "High-Normal", "Grade 1/2/3" categories retired
• Out-of-office equivalents: HBPM hypertension ≥135/85 mmHg; ABPM 24h ≥130/80 mmHg; ABPM daytime ≥135/85 mmHg; ABPM night-time ≥120/70 mmHg
• Non-elevated BP threshold: same lower limit (120/70 mmHg) applies across office, HBPM, and daytime ABPM

BP Measurement

• Validated device + standardised technique mandatory for all BP measurements (Class I, B)
• Out-of-office measurement (HBPM or ABPM) recommended for diagnosis and ongoing management (Class I, B)
• Office BP measurement protocol: 5-min seated rest → 3 readings 1–2 min apart → average last 2; both arms at first visit; >10 mmHg inter-arm difference warrants investigation
• HBPM: twice daily (morning + evening), ≥3 days (ideally 7), two readings per session, average all readings; morning readings before medication/breakfast
• ABPM: 15–30 min intervals daytime, 30–60 min at night; ≥70% valid recordings; minimum ≥27 readings/24h
• Oscillometric devices NOT validated for AF measurement; manual auscultatory preferred in AF (Class IIa, C)
• Orthostatic hypotension (≥20/10 mmHg drop at 1 or 3 min after standing from lying/sitting 5 min) should be assessed at initial diagnosis and when symptoms arise (Class IIa, C)
• Cuffless devices not yet recommended for routine clinical use

Risk-Based Approach for Elevated BP

• Patients with confirmed hypertension (≥140/90 mmHg): no further risk stratification needed — treat with lifestyle + pharmacotherapy promptly (Class I, A)
• Patients with elevated BP (120–139/70–89 mmHg): risk stratification required
  • Automatic high-risk (no calculator needed): moderate/severe CKD, established CVD, HMOD, diabetes mellitus, familial hypercholesterolaemia → treat if confirmed BP ≥130/80 mmHg after 3 months lifestyle (Class I, A)
  • Use SCORE2 (age 40–69) or SCORE2-OP (age ≥70): ≥10% 10-year CVD risk = sufficiently high risk → treat (Class I, B)
  • Borderline 5–<10% risk: consider sex-specific risk modifiers (gestational diabetes, gestational HT, preeclampsia, preterm delivery, stillbirth, recurrent miscarriage) and shared risk modifiers (South Asian ethnicity, premature ASCVD family history, socioeconomic deprivation, autoimmune disorders, HIV, severe mental illness) (Class IIa, B)
  • If still uncertain after risk modifiers: CAC score, carotid/femoral plaque, high-sensitivity troponin/BNP, or pulse wave velocity (Class IIb, B)
  • <5% predicted CVD risk OR elevated BP 120–129/70–79 mmHg: lifestyle only + reassess at 1 year (Class IIa, C)
  • SCORE2 not validated in patients <40 years; HMOD screening preferred in this group (Class IIb, B)

Non-Pharmacological Interventions (Class I, A unless noted)

• Sodium: <2300 mg/day (5.8 g NaCl); potassium-enriched salt substitutes (75% NaCl + 25% KCl) should be considered to increase potassium 0.5–1.0 g/day (Class IIa, A); caution with potassium in CKD or on K-sparing agents
• Sugar: Restrict free sugar ≤10% of energy intake; discourage sugar-sweetened beverages (Class I, B)
• Exercise: ≥150 min/week moderate aerobic exercise or 75 min/week vigorous, PLUS resistance training (isometric or dynamic) 2–3×/week (Class I, A)
• Diet: Mediterranean or DASH diet recommended (Class I, A)
• Weight: Target BMI 20–25 kg/m² and waist circumference <94 cm men / <80 cm women (Class I, A)
• Alcohol: Less than ~100 g/week pure alcohol; abstinence preferred for optimal outcomes (Class I, B)
• Smoking: Cessation recommended

Pharmacological Treatment — Initiation

• Hypertension (≥140/90 mmHg): initiate lifestyle + pharmacotherapy promptly regardless of CVD risk (Class I, A)
• Elevated BP + sufficiently high CVD risk: after ≤3 months lifestyle, add pharmacotherapy if confirmed BP ≥130/80 mmHg (Class I, A)
• Elevated BP + low/medium CVD risk (<10%): lifestyle only (Class I, B)
• Elevated BP + special populations (defer drug to ≥140/90 mmHg): pre-treatment symptomatic orthostatic hypotension, age ≥85 years, moderate-to-severe frailty, limited predicted lifespan <3 years (Class IIa, B)
• Maintain BP-lowering treatment lifelong, including beyond age 85, if well tolerated (Class I, A)
• Timing of medications: take at most convenient time of day to establish a habit (Class I, B)

Pharmacological Treatment — Drug Classes

• First-line (Class I, A): ACE inhibitors, ARBs, dihydropyridine CCBs, thiazide/thiazide-like diuretics (chlorthalidone, indapamide) — beta-blockers are NOT first-line for uncomplicated hypertension
• Beta-blockers excluded from first-line because of inferior CVD event reduction (particularly stroke) vs other drug classes, despite similar BP lowering
• Combination therapy preferred: two-drug SPC (RAS blocker + CCB or RAS blocker + diuretic); three-drug SPC (RAS blocker + CCB + diuretic) for resistant/difficult-to-control HT
• Resistant hypertension add-on: spironolactone (Class IIa, B); if not tolerated: eplerenone, beta-blocker (if not already used), centrally-acting agents, alpha-blockers, hydralazine, potassium-sparing diuretics (Class IIa, B)
• In HFrEF/HFmrEF: ACEi/ARB or ARNi + beta-blocker + MRA + SGLT2i recommended (Class I, A)
• In HFpEF with hypertension: SGLT2i (Class I, A); ARBs and/or MRAs may be considered (Class IIb, B)
• In CKD + eGFR >20: SGLT2i recommended for outcomes improvement (Class I, A)
• RAS blockers (ACEi/ARB): should be considered for microalbuminuria/proteinuria in hypertension (Class IIa, B — downgraded from Class I in 2018); for aortic valve stenosis/regurgitation and moderate-to-severe mitral regurgitation (Class IIa, C)

Blood Pressure Treatment Targets

• Universal target (Class I, A): treated systolic BP 120–129 mmHg in most adults, if well tolerated
• SBP 120 mmHg is the optimal point within the 120–129 mmHg range if tolerated
• Diastolic target: achieving 70–79 mmHg on treatment with systolic at goal — may be considered to reduce CVD risk (Class IIb, C)
• ALARA principle (Class I, A): if 120–129 mmHg target not tolerated, aim for systolic "as low as reasonably achievable"
• Lenient target warranted — consider <140 mmHg (Class IIa, C): pre-treatment symptomatic orthostatic hypotension OR age ≥85 years
• Lenient target warranted — consider <140/90 mmHg (Class IIb, C): moderate-to-severe frailty OR limited predicted lifespan (<3 years)
• Note: 2021 ESC Prevention Guidelines endorsed 130–139 mmHg as first step; this 2024 update supersedes that with a single 120–129 mmHg target to counter therapeutic inertia
• Pregnancy: target <140/90 mmHg but not <80 mmHg diastolic (evidence for 120-129 target does not apply in pregnancy)
• Confirm target achievement with out-of-office BP ("trust but verify" approach)

Hypertension-Mediated Organ Damage (HMOD)

HMOD indicates long-standing elevated BP and confers incremental CVD risk. Key assessment thresholds:

• Kidney: eGFR <60 mL/min/1.73 m² OR albuminuria ≥30 mg/g (routine for all, at least annually if CKD)
• Heart (ECG): LVH by Sokolow-Lyon (SV1+RV5 >35 mm), RaVL ≥11 mm, Cornell voltage (SV3+RaVL >28 mm men, >20 mm women)
• Heart (echo): LV mass/height²·⁷ >50 (men) / >47 (women) g/m²·⁷; LV mass/BSA >115 (men) / >95 (women) g/m²; RWT ≥0.43 (concentric); LA volume/height² >18.5 (men) / >16.5 (women) mL/m²; diastolic dysfunction; e' <7 cm/s; E/e' >14
• Cardiac biomarkers: hs-cTnT/I >99th percentile; NT-proBNP >125 pg/mL (age <75) or >450 pg/mL (age ≥75)
• Arteries: carotid/femoral plaque (focal wall thickness >1.5 mm); PWV >10 m/s (carotid-femoral) or >14 m/s (brachial-ankle); CAC score >100 Agatston units
• Fundoscopy: recommended if BP >180/110 mmHg or in hypertensive diabetes; may be considered in elevated BP (Class IIb, B)
• 12-lead ECG mandatory for all hypertensive patients (Class I, B); echocardiography if ECG abnormal or cardiac symptoms (Class I, B)

Secondary Hypertension

• Prevalence 10–35% of hypertensive patients; up to 50% of resistant hypertension
• Screen all patients with suggestive signs/symptoms/history (Class I, B)
• Primary aldosteronism: Screen with aldosterone-to-renin ratio (ARR) in ALL adults with confirmed hypertension (Class IIa, B) — not just resistant cases; hypokalaemia absent in majority; ARR interpretation varies with concurrent medications (Table 12 in guidelines)
• Renovascular HT: renal Doppler ultrasound ± CT/MRI angiography; FMD-related — renal angioplasty without stenting preferred (Class IIa, C); atherosclerotic — stenting may be considered in specific high-risk scenarios (flash pulmonary oedema, resistant HT, unexplained small kidney) (Class IIb, C)
• OSA: Screen all resistant HT; polysomnogram if suspected (AHI >5 confirms; >30 = severe)
• Phaeochromocytoma/paraganglioma: 24h urinary and/or plasma metanephrines/normetanephrines
• Genetic testing should be considered for suspected monogenic/phaeochromocytoma cases (Class IIa, B); routine genetic testing not recommended (Class III, C)

Resistant Hypertension

• Definition: BP ≥140/90 mmHg (confirmed out-of-office) on ≥3 drugs at maximally tolerated doses including a thiazide/thiazide-like diuretic + RAS blocker + CCB, after excluding pseudo-resistance (non-adherence, white-coat effect, poor measurement, interfering drugs)
• In CKD with eGFR <30: loop diuretic required to define resistant HT
• Refer to specialist hypertension centres (Class IIa, B)
• Treatment: spironolactone (Class IIa, B); if not tolerated/effective: eplerenone, beta-blocker, centrally-acting agent, alpha-blocker, hydralazine, potassium-sparing diuretic (Class IIa, B)
• Renal denervation: may be considered (Class IIb, B) — see renal denervation section below

Device-Based Therapy — Renal Denervation

• Major upgrade from 2018 (Class III) to 2024 (Class IIb):
  • For resistant hypertension on 3-drug combination: Class IIb, B (medium-to-high volume centre; patient preference; multidisciplinary assessment)
  • For increased CVD risk + uncontrolled HT on <3 drugs: Class IIb, A
• Remains Class III (not recommended): as first-line BP intervention (Class III, C); eGFR <40 mL/min/1.73 m² or secondary hypertension causes (Class III, C)
• Concerns: modest effect (~6 mmHg placebo-corrected office SBP; ~4 mmHg on 24h ABPM = equivalent to 1 drug); no CVD outcomes trial; cost-effectiveness not established; 0.25–0.5% rate of renal artery stenosis/dissection requiring stenting; "always on" effect limits reversibility

Specific Populations

Young Adults (18–40 years):

• Secondary hypertension more frequent (15–30%); screen comprehensively if HT diagnosed <40 years (Class I, B); in obese young adults, start with OSA evaluation
• SCORE2 not validated <40 years; use HMOD to stratify elevated BP in this age group (Class IIb, B)
• Adherence particularly poor (<50%); communication and follow-up critical

Pregnancy:

• Hypertension in pregnancy: second leading cause of maternal mortality; affects ~7% of pregnancies
• Treat all confirmed BP ≥140/90 mmHg in gestational hypertension and chronic hypertension (Class I, B) — threshold lowered from ≥150/95 mmHg in 2018 guidelines
• Target BP <140/90 mmHg but not below 80 mmHg diastolic (Class I, C)
• First-line: dihydropyridine CCBs (extended-release nifedipine preferred), labetalol, methyldopa (Class I, C)
• RAS blockers are absolutely contraindicated in pregnancy (Class III, B)
• SBP ≥160/DBP ≥110 mmHg — consider immediate hospitalization (Class IIa, C)
• Low-to-moderate exercise recommended to prevent gestational HT and preeclampsia (Class I, B)
• HBPM and ABPM should be considered to exclude white-coat and masked HT (Class IIa, C)
• Pre-eclampsia prevention: aspirin 100–150 mg/day at bedtime from weeks 12–36 in high-risk women; calcium 0.5–2 g/day if low dietary calcium
• Post-partum: BP check within 6h of delivery; daily for ≥1 week; follow-up at 6–12 weeks, 6 months, 12 months, then annually

Very Old/Frail Patients (≥85 years and/or moderate-to-severe frailty):

• Age <85 + not frail: follow same guidelines as younger patients (Class I, A)
• Maintain treatment lifelong if well tolerated, even >85 years (Class I, A)
• If symptomatic orthostatic hypotension/age ≥85: consider treatment only from ≥140/90 mmHg (Class IIa, B)
• If moderate-to-severe frailty or limited lifespan <3 years: consider treatment only from ≥140/90 mmHg (Class IIb, C)
• Preferred agents when initiating in ≥85 years or frail: long-acting dihydropyridine CCBs or RAS inhibitors → low-dose diuretic; avoid beta-blockers (unless compelling indication) and alpha-blockers (Class IIa, B)
• Screen for frailty using Clinical Frailty Scale; deprescription if BP drops with progressive frailty (Class IIb, C)

Diabetes:

• All T2DM + elevated BP: pharmacotherapy recommended if BP ≥130/80 mmHg after ≤3 months lifestyle (Class I, A)
• Target SBP 120–129 mmHg if tolerated (Class I, A)
• SCORE2-Diabetes for risk estimation in T2DM <60 years (Class IIa, B)

Chronic Kidney Disease:

• Moderate-to-severe CKD + confirmed BP ≥130/80 mmHg: lifestyle + pharmacotherapy (Class I, A)
• eGFR >30 mL/min/1.73 m²: target SBP 120–129 mmHg if tolerated (Class I, A); individualized targets for lower eGFR
• SGLT2i recommended if eGFR >20 mL/min/1.73 m² (Class I, A)
• ACEi/ARB considered if microalbuminuria/proteinuria (Class IIa, B)

Atrial Fibrillation:

• Manual auscultatory BP measurement preferred in AF (oscillometric devices not validated) (Class IIa, C)

Orthostatic Hypotension:

• Test before starting or intensifying BP medications (Class I, B)
• Non-pharmacological first-line for orthostatic hypotension + supine hypertension; switch to agents less likely to cause orthostasis rather than de-intensifying overall therapy (Class I, A)

Acute Blood Pressure Management

• Hypertensive emergency: target organ damage present; parenteral IV therapy with controlled reduction
• Intracerebral haemorrhage (acute): immediate BP lowering to SBP 140–160 mmHg within 6h considered (Class IIa, A); SBP ≥220 mmHg — do not reduce >70 mmHg within 1h (Class III, B)
• Ischaemic stroke: BP-lowering therapy before hospital discharge recommended if indication exists (Class I, B); target SBP 120–129 mmHg in history of TIA/stroke if BP ≥130/80 mmHg (Class I, A)
• Pre-eclampsia/severe pregnancy hypertension: IV labetalol, oral methyldopa, oral nifedipine (Class I, C); IV hydralazine as second-line

Patient-Centred Care

• Informed CVD risk discussion tailored to patient needs (Class I, C)
• Motivational interviewing at hospitals/community centres (Class IIa, B)
• Home BP self-monitoring recommended for better control (Class I, B)
• Multidisciplinary approaches including appropriate task-shifting from physicians (Class I, A)
• Follow-up: at least yearly once BP controlled (Class IIa, C)

Limitations of the Document

• Outcomes requirement for Class I drug recommendations: a strength but also a limitation — excludes some evidence-based lifestyle strategies from the highest recommendation class
• Generalizability: many key trials (SPRINT, STEP, ESPRIT) enrolled populations that were less frail and less multimorbid than real-world patients; evidence for frail/very old poorly represented
• BP target of 120–129 mmHg: validated in trials that started with baseline SBP ≥130 mmHg; evidence for treating patients already near 130 mmHg to lower targets extrapolated
• Primary aldosteronism screening in all HT: aspirational recommendation; testing rates currently ~2% of eligible patients; implementation barriers not fully addressed
• No CVD outcomes data for renal denervation: Class IIb based on BP-lowering trials only; CVD outcomes extrapolated
• Out-of-office BP monitoring: strongly promoted but resource/cost barriers in many healthcare systems
• Sex and gender: considered throughout (strength), but many trials still under-represented women and sex-specific thresholds for HMOD not uniformly validated

Key Concepts Mentioned

• concepts/Hypertension-HMOD — hypertension-mediated organ damage assessment framework
• concepts/Renal-Denervation — upgraded from Class III (2018) to Class IIb (2024) for resistant HT
• concepts/Blood-Pressure-Target-T2DM — new ESC target of 120–129 mmHg aligns with BPROAD evidence
• concepts/Aldosterone-Synthase-Inhibitors — not yet incorporated but complement ESC primary aldosteronism focus
• concepts/Hypertensive-Disorders-of-Pregnancy — ESC 2024 updates treatment threshold to ≥140/90 mmHg for all types
• concepts/Cuffless-BP-Monitoring — not recommended for routine clinical use (consistent with AHA 2026)

Key Entities Mentioned

• entities/Hypertension — primary disease entity; ESC 2024 updates classification, targets, risk stratification, and treatment algorithm
• entities/Atrial-Fibrillation — hypertension as leading modifiable AF risk factor; specific measurement considerations
• entities/Heart-Failure — HFrEF/HFmrEF: ARNi/ACEi/ARB + BB + MRA + SGLT2i; HFpEF: SGLT2i Class I; ARBs/MRAs Class IIb

Wiki Pages Updated

• wiki/sources/ht-esc-2024.md — created (this file)
• wiki/entities/Hypertension.md — added ESC 2024 classification, 120–129 mmHg target, risk stratification algorithm, primary aldosteronism screening update, renal denervation upgrade, frailty thresholds, ESC–AHA comparison; updated source_count 8→9
• wiki/concepts/Renal-Denervation.md — added ESC 2024 Class IIb recommendations and comparison with AHA 2025 COR 2b; updated source_count 2→3
• wiki/concepts/Blood-Pressure-Target-T2DM.md — added ESC 2024 guideline section; updated source_count 1→2
• wiki/concepts/Hypertensive-Disorders-of-Pregnancy.md — added ESC 2024 specific recommendations (treatment threshold, agents, aspirin, calcium); updated source_count 3→4
• wiki/concepts/Hypertension-HMOD.md — created new concept page
• wiki/wikiindex.md — updated Hypertension entity description; added Hypertension-HMOD concept
• wiki/sourceindex.md — added ht-esc-2024 entry