ESC 2024 2024 ESC Guidelines for the management of elevated blood pressure and hypertension
European Society of Cardiology｜循環器 / 高血圧 / 予防｜107 ページ｜チャンク 1127｜推奨 312 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.9 | I | B | consistent approach to BP measurement for each patient. | Table 3 New recommendations |
| p.9 | IIa | C | Most automated oscillometric monitors have not been validated for BP measurement in AF; BP measurement should be considered using a manual auscultatory method in these circumstances, where possible. | Table 3 New recommendations |
| p.9 | I | B | CVD, HMOD, diabetes mellitus, or familial hypercholesterolaemia are considered at increased risk for CVD events. | Table 3 New recommendations |
| p.9 | I | B | increased risk for CVD for the purposes of risk-based management of their elevated BP. | Table 3 New recommendations |
| p.9 | IIa | B | are <60 years of age. | Table 3 New recommendations |
| p.10 | IIa | C | assessment within 1 year should be considered. | |
| p.10 | IIb | B | depending on their feasibility in different countries and healthcare systems. | |
| p.10 | I | B | office, using ABPM and/or HBPM or, if not logistically feasible, make repeated office BP measurements on more than one visit. | |
| p.10 | IIa | B | considered in the clinical work-up of patients with apparent resistant hypertension, if resources allow. | |
| p.10 | I | C | least annually. | |
| p.10 | IIb | B | Coronary artery calcium scoring may be considered in patients with elevated BP or hypertension when it is likely to change patient management. | |
| p.10 | IIa | B | further testing. | |
| p.10 | I | B | hypertension are appropriately screened for secondary hypertension. | |
| p.10 | IIa | B | hypertension (BP ≥ 140/90 mmHg). | |
| p.10 | IIa | C | serum levels of potassium should be considered if dietary potassium is being increased. | |
| p.10 | I | B | taking to improve adherence. | |
| p.10 | I | B | reduce the risk of CVD. | |
| p.10 | I | A | treatment is recommended for those with confirmed BP ≥130/80 mmHg to reduce CVD risk. | |
| p.10 | I | A | pharmacological BP-lowering treatment is initiated promptly to reduce CVD risk. | |
| p.10 | I | A | It is recommended to maintain BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated. | |
| p.10 | I | A | recommended to target a systolic BP level that is ‘as low as reasonably achievable’ (ALARA principle). | |
| p.10 | IIa | C | be considered. | |
| p.11 | I | B | the age of 40 years, except for obese young adults where it is recommended to start with an obstructive sleep apnoea evaluation. | |
| p.11 | IIb | B | elevated BP without other increased CVD risk conditions to identify additional individuals for possible medical treatment. | |
| p.11 | I | B | to reduce the risk of gestational hypertension and pre-eclampsia. | |
| p.11 | IIa | C | HBPM and ABPM should be considered to exclude white-coat and masked hypertension, which are more common in pregnancy. | |
| p.11 | I | A | It is recommended that treatment of elevated BP and hypertension among older patients aged <85 years who are not moderately to severely frail follows the same guidelines as for younger people, provided BP-lowering treatment is well tolerated. | |
| p.11 | IIb | C | If BP drops with progressing frailty, deprescription of BP-lowering medications (and other drugs that can reduce BP, such as sedatives and prostate-specific alpha-blockers) may be considered. | |
| p.11 | I | B | or lie for 5 min and then measuring BP 1 and/or 3 min after standing. | |
| p.11 | I | A | In hypertensive patients with CKD and eGFR >20 mL/min/1.73 m2, SGLT2 inhibitors are recommended to improve outcomes in the context of their modest BP-lowering properties. | |
| p.11 | IIa | C | In patients with a history of aortic valve stenosis and/or regurgitation who require BP-lowering treatment, RAS blockers should be considered as part of that treatment. | |
| p.11 | IIa | C | In patients with a history of moderate-to-severe mitral valve regurgitation who require BP-lowering treatment, RAS blockers should be considered as part of that treatment. | |
| p.11 | IIa | C | Renal artery angioplasty without stenting should be considered for patients with hypertension and haemodynamically significant renal artery stenosis due to fibromuscular dysplasia. | |
| p.11 | III | A | Renal artery angioplasty is not recommended in patients without confirmed haemodynamically significant renal artery stenosis. | |
| p.11 | III | B | levels within 1 h of commencing treatment is not recommended. | |
| p.12 | I | C | An informed discussion about CVD risk and treatment benefits tailored to the needs of a patient is recommended as part of hypertension management. | |
| p.12 | IIa | B | Motivational interviewing should be considered for patients with hypertension at hospitals and community health centres to assist patients in controlling their BP and to enhance treatment adherence. | |
| p.12 | IIa | C | Physician–patient web communications are an effective tool that should be considered in primary care, including reporting on home BP readings. | |
| p.12 | I | B | Home BP measurement for managing hypertension by using self-monitored BP is recommended to achieve better BP control. | |
| p.12 | I | C | patient empowerment, and adherence to treatment. | |
| p.12 | IIb | B | suggests that this may be no more effective than standard self-monitoring. | |
| p.12 | I | A | Multidisciplinary approaches in the management of patients with elevated BP and hypertension, including appropriate and safe task-shifting away from physicians are recommended to improve BP control. | |
| p.12 | I | C | It is recommended that BP be classified as optimal, normal, high–normal, or grades 1–3 hypertension, according to office BP. CV risk assessment with the SCORE system is recommended for hypertensive patients who are not already at high or very high risk due to established CVD, | Table 4 Revised recommendations |
| p.12 | I | B | renal disease, or diabetes, a markedly elevated single risk factor (e.g. cholesterol), or hypertensive LVH. | Table 4 Revised recommendations |
| p.12 | I | C | It is recommended that the diagnosis of hypertension should be based on: • Repeated office BP measurements on more than one visit, except when hypertension is severe (e.g. grade 3 and especially in high-risk patients). At each visit, three BP measurements should be recorded, 1–2 min apart, and additional measurements should be performed if the first two readings differ by >10 mmHg. The patient’s BP is the average of the last two BP readings. Or • Out-of-office BP measurement with ABPM and/or HBPM, provided that these measurements are logistically and economically feasible. | Table 4 Revised recommendations |
| p.12 | I | B | It is recommended that BP be categorized as non-elevated BP, elevated BP, and hypertension to aid treatment decisions. SCORE2 is recommended for assessing 10-year risk of | Table 4 Revised recommendations |
| p.12 | I | B | fatal and non-fatal CVD among individuals aged 40–69 years with elevated BP who are not already considered at increased risk due to moderate or severe CKD, established CVD, HMOD, diabetes mellitus, or familial hypercholesterolaemia. | Table 4 Revised recommendations |
| p.12 | I | B | SCORE2-OP is recommended for assessing the 10-year risk of fatal and non-fatal CVD among individuals aged ≥70 years with elevated BP who are not already considered at increased risk due to moderate or severe CKD, established CVD, HMOD, diabetes mellitus, or familial hypercholesterolaemia. | Table 4 Revised recommendations |
| p.12 | I | B | Where screening office BP is 140–159/90–99 mmHg, it is recommended that the diagnosis of hypertension should be based on out-of-office BP measurement with ABPM and/or HBPM. If these measurements are not logistically or economically feasible, then diagnosis can be made on repeated office BP measurements on more than one visit. | Table 4 Revised recommendations |
| p.12 | I | C | Where screening office BP is ≥160/100 mmHg: • It is recommended that BP 160–179/100–109 mmHg be confirmed as soon as possible (e.g. within 1 month) preferably by either home or ambulatory BP measurements. • It is recommended when BP ≥180/110 mmHg that hypertensive emergency be excluded. | Table 4 Revised recommendations |
| p.13 | IIb | B | detection of LVH may influence treatment decisions. | |
| p.13 | IIb | B | measuring arterial stiffness. | |
| p.13 | I | A | Mediterranean or DASH diets, is recommended to help reduce BP and CVD risk. | |
| p.13 | I | A | • Less than 8 units/week for women. | |
| p.13 | I | A | systolic BP values in most adults be targeted to 120– 129 mmHg, provided the treatment is well tolerated. | |
| p.13 | I | B | Echocardiography is recommended in hypertensive patients when there are ECG abnormalities or signs or symptoms of LV dysfunction. Echocardiography may be considered when the | |
| p.13 | IIb | B | Ultrasound examination of the carotid arteries may be considered for the detection of asymptomatic atherosclerotic plaques or carotid stenosis in patients with documented vascular disease elsewhere. Measurement of PWV may be considered for | |
| p.13 | I | A | 8 Preventing and treating elevated blood pressure Regular aerobic exercise (e.g. at least 30 min of moderate dynamic exercise on 5–7 days/week) is recommended. | |
| p.13 | I | A | Body-weight control is indicated to avoid obesity (BMI >30 kg/m2 or waist circumference >102 cm in men and >88 cm in women), as is aiming at healthy BMI (about 20–25 kg/m2) and waist circumference values (<94 cm in men and <80 cm in women) to reduce BP and CV risk. | |
| p.13 | I | A | Increased consumption of vegetables, fresh fruits, fish, nuts, and unsaturated fatty acids (olive oil); low consumption of red meat; and consumption of low-fat dairy products are recommended. It is recommended to restrict alcohol consumption to: • Less than 14 units/week for men. | |
| p.13 | I | A | Among all anti-hypertensive drugs, ACE inhibitors, ARBs, beta-blockers, CCBs, and diuretics (thiazides and thiazide-like drugs, such as chlorthalidone and indapamide) have demonstrated effective reduction of BP and CV events in RCTs, and thus are indicated as the basis of anti-hypertensive treatment strategies. | |
| p.13 | I | B | It is recommended that if BP is not controlled with a three-drug combination, treatment should be increased by the addition of spironolactone or, if not tolerated, other diuretics such as amiloride or higher doses of other diuretics, a beta-blocker, or an alpha-blocker. | |
| p.13 | I | A | It is recommended that the first objective of treatment should be to lower BP to <140/90 mmHg in all patients and, provided that the treatment is well tolerated, treated BP values should be targeted to 130/80 mmHg or lower in most patients. | |
| p.13 | I | B | Echocardiography is recommended in patients with hypertension and ECG abnormalities, or signs or symptoms of cardiac disease. | |
| p.13 | IIb | B | Echocardiography may be considered in patients with elevated BP, particularly when it is likely to change patient management. | |
| p.13 | IIb | B | Ultrasound examination of the carotid or femoral arteries for detecting plaque may be considered in patients with elevated BP or hypertension when it is likely to change patient management. | |
| p.13 | IIb | B | Measurement of PWV may be considered in patients with elevated BP or hypertension when it is likely to change patient management. | |
| p.13 | I | A | Moderate intensity aerobic exercise of ≥150 min/week (≥30 min, 5–7 days/week) or alternatively 75 min of vigorous intensity aerobic exercise per week over 3 days are recommended and should be complemented with low- or moderate-intensity dynamic or isometric resistance training (2–3 times/week) to reduce BP and CVD risk. | |
| p.13 | I | A | It is recommended to aim for a stable and healthy BMI (20–25 kg/m2) and waist circumference values (<94 cm in men and <80 cm in women) to reduce BP and CVD risk. Adopting a healthy and balanced diet, such as the | |
| p.13 | I | B | Men and women are recommended to drink less alcohol than the upper limit, which is about 100 g/week of pure alcohol. How this translates into number of drinks depends on portion size (the standards of which differ per country), but most drinks contain 8–14 g of alcohol per drink. Preferably, it is recommended to avoid alcohol to achieve the best health outcomes. | |
| p.13 | I | A | Among all BP-lowering drugs, ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics (thiazides and thiazide-like drugs such as chlorthalidone and indapamide) have demonstrated the most effective reduction of BP and CVD events, and are therefore recommended as first-line treatments to lower BP. | |
| p.13 | IIa | B | If BP is not controlled with a three-drug combination and in whom spironolactone is not effective or tolerated, treatment with eplerenone instead of spironolactone, or the addition of a beta-blocker if not already indicated and, next, a centrally acting BP-lowering medication, an alpha-blocker, hydralazine, or a potassium-sparing diuretic should be considered. To reduce CVD risk, it is recommended that treated | |
| p.14 | IIa | B | the level of risk and comorbidities. | |
| p.14 | I | B | systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg. | |
| p.14 | I | A | A diastolic BP target of <80 mmHg should be considered for all hypertensive patients, independent of In older patients (aged ≥65 years) receiving BP-lowering drugs: • It is recommended that systolic BP should be targeted to a BP range of 130–139 mmHg. Use of device-based therapies is not recommended for the routine treatment of hypertension, unless in the | |
| p.14 | III | B | context of clinical studies and RCTs, until further evidence regarding their safety and efficacy becomes available. | |
| p.14 | I | C | Hypertension in pregnancy In women with gestational hypertension, pre-existing hypertension superimposed by gestational hypertension, or with hypertension and subclinical organ damage or symptoms, initiation of drug treatment is recommended when systolic BP is ≥140 mmHg or diastolic BP ≥90 mmHg. | |
| p.14 | IIb | C | In cases where on-treatment systolic BP is at or below target (120–129 mmHg) but diastolic BP is not at target (≥80 mmHg), intensifying BP-lowering treatment to achieve an on-treatment diastolic BP of 70–79 mmHg may be considered to reduce CVD risk. Because the CVD benefit of an on-treatment systolic BP | |
| p.14 | IIa | C | target of 120–129 mmHg may not generalize to the following specific settings, personalized and more lenient systolic BP targets (e.g. <140 mmHg): should be considered among patients meeting the following criteria: • pre-treatment, symptomatic, orthostatic hypotension; • and/or age ≥85 years. | |
| p.14 | IIb | C | Because the CVD benefit of an on-treatment systolic BP target of 120–129 mmHg may not generalize to the following specific settings, personalized and more lenient BP targets (e.g. <140/90 mmHg) may be considered among patients meeting the following criteria: • clinically significant, moderate to severe frailty at any age; • and/or limited predicted lifespan (<3 years). | |
| p.14 | IIb | B | To reduce BP, and if performed at a medium-to-high volume centre, catheter-based renal denervation may be considered for resistant hypertension patients 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. | |
| p.14 | IIb | A | To reduce BP, and if performed at a medium-to-high volume centre, catheter-based renal denervation may be considered for patients with both increased CVD risk and uncontrolled hypertension on fewer than three drugs, if they express a preference to undergo renal denervation after a shared risk-benefit discussion and | |
| p.14 | III | C | multidisciplinary assessment. Due to a lack of adequately powered outcomes trials demonstrating its safety and CVD benefits, renal denervation is not recommended as a first-line BP-lowering intervention for hypertension. | |
| p.14 | III | C | Renal denervation is not recommended for treating hypertension in patients with moderately to severely impaired renal function (eGFR <40 mL/min/1.73 m2) or secondary causes of hypertension, until further evidence becomes available. In women with gestational hypertension, starting drug treatment is recommended for those with confirmed | |
| p.15 | I | A | 129 mmHg, if tolerated. | |
| p.15 | I | A | 130–139 mmHg. | |
| p.15 | I | C | In all other cases, initiation of drug treatment is recommended when systolic BP is ≥150 mmHg or diastolic BP is ≥95 mmHg. | |
| p.15 | I | C | Systolic BP ≥170 mmHg or diastolic BP ≥110 mmHg in a pregnant woman is an emergency, and admission to hospital is recommended. Diabetes | |
| p.15 | I | A | Antihypertensive drug treatment is recommended for people with diabetes when office BP is ≥140/90 mmHg. | |
| p.15 | I | A | In people with diabetes receiving BP-lowering drugs it is recommended: • To target SBP to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg. • In older people (aged ≥65 years aged), to target to an SBP range of 130–139 mmHg. | |
| p.15 | I | A | Chronic kidney disease In patients with diabetic or non-diabetic CKD, it is recommended that an office BP ≥140/90 mmHg be treated with lifestyle advice and BP-lowering medication. | |
| p.15 | IIa | C | • It is recommended to lower systolic BP to a range of • Individualized treatment should be considered according to its tolerability and impact on renal function and electrolytes. | |
| p.15 | I | A | RAS blockers are more effective at reducing albuminuria than other antihypertensive agents, and are recommended as part of the treatment strategy in hypertensive patients in the presence of microalbuminuria or proteinuria. | |
| p.15 | I | A | Heart failure In patients with HFrEF, it is recommended that BP-lowering treatment comprises an ACE inhibitor or ARB, a beta-blocker and diuretic and/or MRA if required. | |
| p.15 | I | C | In patients with HFpEF, because no specific drug has proven its superiority, all major agents can be used. | |
| p.15 | I | B | In pregnant women with chronic hypertension, starting drug treatment is recommended for those with confirmed office systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg. | |
| p.15 | I | C | In women with chronic and gestational hypertension, it is recommended to lower BP below 140/90 mmHg but not below 80 mmHg for diastolic BP. | |
| p.15 | IIa | C | Systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg in pregnancy can indicate an emergency, and immediate hospitalization should be considered. | |
| p.15 | I | A | In most adults with elevated BP and diabetes, after a maximum of 3 months of lifestyle intervention, BP lowering with pharmacological treatment is recommended for those with confirmed office BP ≥130/80 mmHg to reduce CVD risk. In persons with diabetes who are receiving BP-lowering drugs, it is recommended to target systolic BP to 120– | |
| p.15 | I | A | In patients with diabetic or non-diabetic moderate-to-severe CKD and confirmed BP ≥130/80 mmHg, lifestyle optimization and BP-lowering medication are recommended to reduce CVD risk, provided such treatment is well tolerated. | |
| p.15 | I | A | mL/min/1.73 m2, it is recommended to target systolic BP to 120–129 mmHg, if tolerated. Individualized BP targets are recommended for those with lower eGFR or renal transplantation. | |
| p.15 | IIa | B | ACE inhibitors or ARBs are more effective at reducing albuminuria than other BP-lowering agents and should be considered as part of the treatment strategy for patients with hypertension and microalbuminuria or proteinuria. | |
| p.15 | I | A | In patients with symptomatic HFrEF/HFmrEF, the following treatments with BP-lowering effects are recommended to improve outcomes: ACE inhibitors (or ARBs if ACE inhibitors are not tolerated) or ARNi, beta-blocker, MRA, and SGLT2 inhibitors. | |
| p.15 | I | A | In hypertensive patients with symptomatic HFpEF, SGLT2 inhibitors are recommended to improve outcomes in the context of their modest BP-lowering properties. | |
| p.15 | IIb | B | In patients with symptomatic HFpEF who have BP above target, ARBs and/or MRAs may be considered to reduce heart failure hospitalizations and reduce BP. | |
| p.16 | I | B | combination or with a RAS blocker. | |
| p.16 | I | B | • Or the addition of bisoprolol or doxazosin. | |
| p.16 | III | A | patients with systolic BP <220 mmHg. | |
| p.16 | I | A | I B • Immediately for TIA. | |
| p.16 | I | A | • After several days in ischaemic stroke. | |
| p.16 | I | C | recommended. | |
| p.16 | IIa | B | • Immediate BP lowering is not recommended for • In patients with systolic BP ≥220 mmHg, careful acute BP lowering with i.v. therapy to <180 mmHg should be considered. In severe hypertension, drug treatment with i.v. labetalol, oral methyldopa, or nifedipine is | |
| p.16 | I | A | In patients with confirmed BP ≥130/80 mmHg with a history of TIA or stroke a systolic BP target of 120–129 mmHg is recommended to reduce CVD outcomes, provided treatment is tolerated. | |
| p.16 | IIa | B | In black patients from Sub-Saharan Africa who require BP-lowering treatment, combination therapy including a CCB combined with either a thiazide diuretic or a RAS blocker should be considered. | |
| p.16 | IIa | B | In patients with resistant hypertension and uncontrolled BP despite use of first-line BP-lowering therapies, the addition of spironolactone to existing treatment should be considered. In patients with resistant hypertension in whom | |
| p.16 | IIa | B | spironolactone is not effective or tolerated, treatment with eplerenone instead of spironolactone, or the addition of a beta-blocker if not already indicated, and, next, a centrally acting BP-lowering medication, an alpha-blocker, or hydralazine, or a potassium-sparing diuretic should be considered. | |
| p.16 | IIb | B | To reduce BP, and if performed at a medium-to-high volume centre, catheter-based renal denervation may be considered for resistant hypertension patients who have BP that is uncontrolled despite a three BP-lowering drug combination, and who express a preference to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment. | |
| p.16 | IIa | A | considered to a systolic target 140–160 mmHg to prevent haematoma expansion and improve functional outcome. For patients with ischaemic stroke or TIA and an indication for blood pressure lowering, it is | |
| p.16 | I | C | recommended that BP lowering therapy be commenced before hospital discharge. In severe hypertension in pregnancy, drug treatment with i.v. labetalol, oral methyldopa, or oral nifedipine is recommended. Intravenous hydralazine is a second-line option. | |
| p.24 | I | B | It is recommended to measure BP using a validated and calibrated device, to enforce the correct measurement technique, and to apply a consistent approach to BP measurement for each patient.41,42 | Recommendation Table 1 — Recommendations for measuring blood pressure (see Evidence Tables 1–8) |
| p.24 | I | C | All adult patients (≥18 years) are recommended to have their office and/or out-of-office BP measured on an opportunistic basis and recorded in their medical file, and be told what their current BP is. | Recommendation Table 1 — Recommendations for measuring blood pressure (see Evidence Tables 1–8) |
| p.24 | I | B | Out-of-office BP measurement is recommended for diagnostic purposes, particularly because it can detect both white-coat hypertension and masked hypertension. Where out-of-office measurements are not logistically and/or economically feasible, then it is recommended that the diagnosis be confirmed with a repeat office BP measurement using the correct standardized measurement technique.70 | Recommendation Table 1 — Recommendations for measuring blood pressure (see Evidence Tables 1–8) |
| p.24 | I | B | It is recommended that office BP should be measured in both arms at least at the first visit, because a between-arm systolic BP difference of >10 mmHg is associated with an increased CVD risk and may indicate arterial stenosis.55,110 | Recommendation Table 1 — Recommendations for measuring blood pressure (see Evidence Tables 1–8) |
| p.24 | I | B | If a between-arm difference of >10 mmHg in systolic BP is recorded, then it is recommended that all subsequent BP readings use the arm with the higher BP reading.110 Out-of-office BP measurement is recommended for ongoing management to quantify the effects of | Recommendation Table 1 — Recommendations for measuring blood pressure (see Evidence Tables 1–8) |
| p.24 | I | B | treatment and guide BP-lowering medication titration, and/or identify possible causes of side effects (e.g. symptomatic hypotension). Where out-of-office measurements are not logistically and/ or economically feasible, then ongoing management is recommended to be based on repeated office BP measurements using the correct standardized | Recommendation Table 1 — Recommendations for measuring blood pressure (see Evidence Tables 1–8) |
| p.24 | I | C | measurement technique.74,111,112 It is recommended that all patients undergoing BP measurement also undergo pulse palpation at rest to determine heart rate and arrhythmias such as AF.113 | Recommendation Table 1 — Recommendations for measuring blood pressure (see Evidence Tables 1–8) |
| p.24 | IIa | C | Most automated oscillometric monitors have not been validated for BP measurement in AF; BP measurement should be considered using a manual auscultatory method in these circumstances where possible.47–49 | Recommendation Table 1 — Recommendations for measuring blood pressure (see Evidence Tables 1–8) |
| p.25 | IIa | C | An assessment for orthostatic hypotension (≥20 systolic BP and/or ≥10 diastolic BP mmHg drop at 1 and/or 3 min after standing) should be considered at least at the initial diagnosis of elevated BP or hypertension and thereafter if suggestive symptoms arise. This should be performed after the patient is first lying or sitting for 5 min. | |
| p.25 | IIb | C | Other BP measures and indices (pulse pressure, BP variability, exercise BP) may be considered to provide additional clinical information on CVD risk in some circumstances. | |
| p.25 | I | B | It is recommended that BP be categorized as non-elevated BP, elevated BP, and hypertension to aid treatment decisions.116,121,122,131–138 BP, blood pressure. aClass of recommendation. bLevel of evidence. | Recommendation Table 2 — Recommendations for categorizing blood pressure (see Evidence Table 9) |
| p.28 | I | B | It is recommended to use a risk-based approach in the treatment of elevated BP, and individuals with moderate or severe CKD, established CVD, HMOD, diabetes mellitus, or familial hypercholesterolaemia are considered at increased risk for CVD events.31,153–159,161–163,172 | Recommendation Table 3 — Recommendations for assessing cardiovascular disease risk among individuals with elevated blood pressure (office systolic blood pressure 120–139 mmHg or diastolic blood pressure 70–89 mmHg) (see Evidence Tables 10 and 11) |
| p.28 | I | B | SCORE2 is recommended for assessing 10-year risk of fatal and non-fatal CVD among individuals aged 40–69 years with elevated BP who are not already considered at increased risk due to moderate or severe CKD, established CVD, HMOD, diabetes mellitus, or familial hypercholesterolaemia.143,165,172 | Recommendation Table 3 — Recommendations for assessing cardiovascular disease risk among individuals with elevated blood pressure (office systolic blood pressure 120–139 mmHg or diastolic blood pressure 70–89 mmHg) (see Evidence Tables 10 and 11) |
| p.28 | I | B | SCORE2-OP is recommended for assessing the 10-year risk of fatal and non-fatal CVD among individuals aged ≥70 years with elevated BP who are not already considered at increased risk due to moderate or severe CKD, established CVD, HMOD, diabetes mellitus, or familial hypercholesterolaemia.143,166,172 | Recommendation Table 3 — Recommendations for assessing cardiovascular disease risk among individuals with elevated blood pressure (office systolic blood pressure 120–139 mmHg or diastolic blood pressure 70–89 mmHg) (see Evidence Tables 10 and 11) |
| p.28 | I | B | It is recommended that, irrespective of age, individuals with elevated BP and a SCORE2 or SCORE2-OP CVD risk of ≥10% be considered at increased risk for CVD for the purposes of risk-based management of their elevated BP.143,165,166,172 | Recommendation Table 3 — Recommendations for assessing cardiovascular disease risk among individuals with elevated blood pressure (office systolic blood pressure 120–139 mmHg or diastolic blood pressure 70–89 mmHg) (see Evidence Tables 10 and 11) |
| p.28 | IIa | B | SCORE2-Diabetes should be considered to estimate CVD risk among type 2 diabetes mellitus patients with elevated BP, particularly if they are <60 years of age.164 | Recommendation Table 3 — Recommendations for assessing cardiovascular disease risk among individuals with elevated blood pressure (office systolic blood pressure 120–139 mmHg or diastolic blood pressure 70–89 mmHg) (see Evidence Tables 10 and 11) |
| p.30 | IIa | B | History of pregnancy complications (gestational diabetes, gestational hypertension, pre-term delivery, pre-eclampsia, one or more stillbirths, and recurrent miscarriage) are sex-specific risk modifiers that should be considered to up-classify individuals with elevated BP and borderline increased 10-year CVD risk (5% to <10% risk). 183,184,223,224 | Recommendation Table 4 — Recommendations for refining cardiovascular disease risk (see Evidence Tables 12–14) |
| p.30 | IIa | B | High-risk ethnicity (e.g. South Asian), family history of premature onset atherosclerotic CVD, socio-economic deprivation, auto-immune inflammatory disorders, HIV, and severe mental illness are risk modifiers shared by both sexes that should be considered to up-classify individuals with elevated BP and borderline increased 10-year CVD risk (5% to <10% risk). 186–191,193,198,202,204,208 | Recommendation Table 4 — Recommendations for refining cardiovascular disease risk (see Evidence Tables 12–14) |
| p.30 | IIb | B | After assessing 10-year predicted CVD risk and non-traditional CVD risk modifiers, if a risk-based BP-lowering treatment decision remains uncertain for individuals with elevated BP, measuring CAC score, carotid or femoral plaque using ultrasound, high-sensitivity cardiac troponin or B-type natriuretic peptide biomarkers, or arterial stiffness using pulse wave velocity, may be considered to improve risk stratification among patients with borderline increased 10-year CVD risk (5% to <10% risk) after shared decision-making and considering costs.209–211,215,218,225,226 | |
| p.32 | IIa | C | Opportunistic screening for elevated BP and hypertension should be considered at least every 3 years for adults aged <40 years.236,237 | Recommendation Table 5 — Recommendations for blood pressure screening (see Evidence Table 15) |
| p.32 | IIa | C | In individuals with elevated BP who do not currently meet risk thresholds for BP-lowering treatment, a repeat BP measurement and risk assessment within 1 year should be considered. | Recommendation Table 5 — Recommendations for blood pressure screening (see Evidence Table 15) |
| p.32 | IIb | B | Other forms of screening for hypertension (i.e. systematic screening, self-screening, and non-physician screening) may be considered, depending on their feasibility in different countries and healthcare systems.231–233 BP, blood pressure. aClass of recommendation. bLevel of evidence. | |
| p.32 | I | B | In individuals with increased CVD risk where their screening office BP is 120–139/70–89 mmHg, it is recommended to measure BP out of office, using ABPM and/or HBPM or, if not logistically feasible, by making repeated office BP measurements on more than one visit.70,238–241 | Recommendation Table 6 — Recommendations for confirming hypertension diagnosis |
| p.32 | I | B | Where screening office BP is 140–159/90–99 mmHg, it is recommended that the diagnosis of hypertension should be based on out-of-office BP measurement with ABPM and/or HBPM. If these measurements are not logistically or economically feasible, then diagnosis can be made on repeated office BP measurements on more than one visit.70,238–241 | Recommendation Table 6 — Recommendations for confirming hypertension diagnosis |
| p.32 | I | C | Where screening office BP is ≥160/100 mmHg: • It is recommended that BP 160–179/100–109 mmHg be confirmed as soon as possible (e.g. within 1 month) preferably by either home or ambulatory BP measurements; • It is recommended when BP ≥180/110 mmHg that hypertensive emergency be excluded. Continued | Recommendation Table 6 — Recommendations for confirming hypertension diagnosis |
| p.34 | IIa | B | Objective evaluation of adherence (either directly observed treatment or detecting prescribed drugs in blood or urine samples) should be considered in the clinical work-up of patients with apparent resistant hypertension, if resources allow.261–263 aClass of recommendation. bLevel of evidence. | Recommendation Table 7 — Recommendations for assessing adherence and persistence with treatment (see Evidence Table 16) |
| p.36 | I | B | hypertension.31,281 | Recommendation Table 9 — Recommendations for assessing cardiac hypertension-mediated organ damage |
| p.36 | I | A | It is recommended to measure serum creatinine, eGFR, and urine ACR in all patients with hypertension.170,273 | Recommendation Table 8 — Recommendations for assessing renal hypertension-mediated organ damage |
| p.36 | I | C | If moderate-to-severe CKD is diagnosed, it is recommended to repeat measurements of serum creatinine, eGFR, and urine ACR at least annually.276 | Recommendation Table 8 — Recommendations for assessing renal hypertension-mediated organ damage |
| p.36 | IIa | C | Renal ultrasound and Doppler examination should be considered in hypertensive patients with CKD to assess kidney structure and determine causes of CKD and to exclude renoparenchymal and renovascular hypertension.276,277 CT or magnetic © ESC 2024 resonance renal angiography are alternative testing options. | Recommendation Table 8 — Recommendations for assessing renal hypertension-mediated organ damage |
| p.37 | III | C | recommended. | Recommendation Table 11 — Recommendations for genetic testing in hypertension management |
| p.37 | I | B | Echocardiography is recommended in patients with hypertension and ECG abnormalities, or signs or symptoms of cardiac disease.14,31,292 | |
| p.37 | IIb | B | Echocardiography may be considered in patients with elevated BP, particularly when it is likely to change patient management.31,291 BP, blood pressure; ECG, electrocardiogram. aClass of recommendation. bLevel of evidence. | |
| p.37 | I | C | Fundoscopy is recommended if BP >180/110 mmHg in the work-up of hypertensive emergency and malignant hypertension, as well as in hypertensive patients with diabetes. | Recommendation Table 10 — Recommendations for assessing vascular hypertension-mediated organ damage (see Evidence Table 17) |
| p.37 | IIb | B | Fundoscopy for detecting hypertensive retinopathy may be considered in patients with elevated BP or hypertension.299 | Recommendation Table 10 — Recommendations for assessing vascular hypertension-mediated organ damage (see Evidence Table 17) |
| p.37 | IIb | B | Ultrasound examination of the carotid or femoral arteries for detecting plaque may be considered in patients with elevated BP or hypertension when it is likely to change patient management.211 | Recommendation Table 10 — Recommendations for assessing vascular hypertension-mediated organ damage (see Evidence Table 17) |
| p.37 | IIb | B | Coronary artery calcium scoring may be considered in patients with elevated BP or hypertension when it is likely to change patient management.127,211 | |
| p.37 | IIb | B | © ESC 2024 Measurement of PWV may be considered in patients with elevated BP or hypertension when it is likely to change patient management.28,31,215,216 BP, blood pressure; PWV, pulse wave velocity. aClass of recommendation. bLevel of recommendation. | |
| p.37 | IIa | B | Genetic testing should be considered in specialist centres for patients suspected to have rare monogenic causes of secondary hypertension or for those with phaeochromocytoma/ paraganglioma.302,305 Routine genetic testing for hypertension is not aClass of recommendation. bLevel of evidence. | Recommendation Table 11 — Recommendations for genetic testing in hypertension management |
| p.39 | IIa | B | Patients with resistant hypertension should be considered for referral to clinical centres with expertise in hypertension management for further testing.309,312 aClass of recommendation. bLevel of evidence. | Recommendation Table 12 — Recommendations for resistant hypertension work-up (see Evidence Table 18) |
| p.43 | I | B | It is recommended that patients with hypertension presenting with suggestive signs, symptoms or medical history of secondary hypertension are appropriately screened for secondary hypertension.312,314,315,323,339 | Recommendation Table 13 — Recommendations for screening for secondary hypertension (see Evidence Tables 19 and 20) |
| p.43 | IIa | B | Screening for primary aldosteronism by renin and aldosterone measurements should be considered in all adults with confirmed hypertension (BP ≥140/90 mmHg).313,316,323,339 BP, blood pressure. aClass of recommendation. bLevel of evidence. | Recommendation Table 13 — Recommendations for screening for secondary hypertension (see Evidence Tables 19 and 20) |
| p.43 | IIa | B | Opportunistic screening with office BP measurements to monitor development of BP during late childhood and adolescence, especially if one or both parents have hypertension, should be considered to better predict development of adult hypertension and associated CVD risk.344–346 BP, blood pressure; CVD, cardiovascular disease. aClass of recommendation. bLevel of evidence. | Recommendation Table 14 — Recommendations for screening for hypertension in children and adolescents (see Evidence Table 21) |
| p.47 | I | A | Restriction of sodium to approximately 2 g per day is recommended where possible in all adults with elevated BP and hypertension [this is equivalent to about 5 g of salt (sodium chloride) per day or about a teaspoon or less].353,354 | Recommendation Table 15 — Recommendations for non-pharmacological treatment of blood pressure and cardiovascular risk reduction (see Evidence Tables 22–26) |
| p.47 | I | A | Moderate intensity aerobic exercise of ≥150 min/ week (≥30 min, 5–7 days/week) or alternatively 75 min of vigorous intensity aerobic exercise per week over 3 days are recommended and should be complemented with low- or moderate-intensity dynamic or isometric resistance training (2–3 times/ week) to reduce BP and CVD risk. 1,381,390–393 | Recommendation Table 15 — Recommendations for non-pharmacological treatment of blood pressure and cardiovascular risk reduction (see Evidence Tables 22–26) |
| p.47 | I | A | It is recommended to aim for a stable and healthy BMI (e.g. 20–25 kg/m2) and waist circumference values (e.g. <94 cm in men and <80 cm in women) to reduce BP and CVD risk.399–401 | Recommendation Table 15 — Recommendations for non-pharmacological treatment of blood pressure and cardiovascular risk reduction (see Evidence Tables 22–26) |
| p.47 | I | A | Adopting a healthy and balanced diet, such as the Mediterranean or DASH diets, is recommended to help reduce BP and CVD risk.412,438,439 | Recommendation Table 15 — Recommendations for non-pharmacological treatment of blood pressure and cardiovascular risk reduction (see Evidence Tables 22–26) |
| p.47 | I | B | Men and women are recommended to drink less alcohol than the upper limit, which is about 100 g/week of pure alcohol. How this translates into number of drinks depends on portion size (the standards of which differ per country), but most drinks contain 8–14 g of alcohol per drink. Preferably, it is recommended to avoid alcohol to achieve the best health outcomes.170,419,440,441 | Recommendation Table 15 — Recommendations for non-pharmacological treatment of blood pressure and cardiovascular risk reduction (see Evidence Tables 22–26) |
| p.47 | I | B | It is recommended to restrict free sugar consumption, in particular sugar-sweetened beverages, to a maximum of 10% of energy intake. It is also recommended to discourage consumption of sugar-sweetened beverages, such as soft drinks and fruit juices, starting at a young age.425–427 | Recommendation Table 15 — Recommendations for non-pharmacological treatment of blood pressure and cardiovascular risk reduction (see Evidence Tables 22–26) |
| p.47 | I | A | It is recommended to stop tobacco smoking, initiate supportive care and refer to smoking cessation programmes, as tobacco use strongly and independently causes CVD, CVD events, and all-cause mortality.428,429,431,437 | Recommendation Table 15 — Recommendations for non-pharmacological treatment of blood pressure and cardiovascular risk reduction (see Evidence Tables 22–26) |
| p.47 | IIa | A | In patients with hypertension without moderate to advanced CKD and with high daily sodium intake, an increase of potassium intake by 0.5–1.0 g/day—for example through sodium substitution with potassiumenriched salt (comprising 75% sodium chloride and 25% potassium chloride) or through diets rich in fruits and vegetables—should be considered.348,368,373,374,442 | Recommendation Table 15 — Recommendations for non-pharmacological treatment of blood pressure and cardiovascular risk reduction (see Evidence Tables 22–26) |
| p.47 | IIa | C | In patients with CKD or taking potassium-sparing medication, such as some diuretics, ACE inhibitors, ARBs, or spironolactone, monitoring serum levels of potassium should be considered if dietary potassium is being increased. | Recommendation Table 15 — Recommendations for non-pharmacological treatment of blood pressure and cardiovascular risk reduction (see Evidence Tables 22–26) |
| p.51 | IIa | B | adding spironolactone should be considered.459 | |
| p.51 | III | A | ARB) is not recommended.498–500,517 | |
| p.51 | I | A | Among all BP-lowering drugs, ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics (thiazides and thiazide-like drugs such as chlorthalidone and indapamide) have demonstrated the most effective reduction of BP and CVD events, and are therefore recommended as first-line treatments to lower BP.122,446 | Recommendation Table 16 — Recommendations for pharmacological treatment of hypertension (see Evidence Tables 27, 28, and 29) |
| p.51 | I | A | It is recommended that beta-blockers are combined with any of the other major BP-lowering drug classes when there are other compelling indications for their use, e.g. angina, post-myocardial infarction, heart failure with reduced ejection fraction, or for heart rate control.122,448–450 | Recommendation Table 16 — Recommendations for pharmacological treatment of hypertension (see Evidence Tables 27, 28, and 29) |
| p.51 | I | B | It is recommended to take medications at the most convenient time of day for the patient to establish a habitual pattern of medication taking to improve adherence.246,513 Given trial evidence for more effective BP control vs. | Recommendation Table 16 — Recommendations for pharmacological treatment of hypertension (see Evidence Tables 27, 28, and 29) |
| p.51 | I | B | monotherapy, combination BP-lowering treatment is recommended for most patients with confirmed hypertension (BP ≥140/90 mmHg) as initial therapy. Preferred combinations are a RAS blocker (either an ACE inhibitor or an ARB) with a dihydropyridine CCB or diuretic. Exceptions to consider include patients aged ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or elevated BP (systolic BP 120–139 mmHg or diastolic BP 70–89 mmHg) with a concomitant indication for treatment.131,480,483,484,489 | Recommendation Table 16 — Recommendations for pharmacological treatment of hypertension (see Evidence Tables 27, 28, and 29) |
| p.51 | I | B | In patients receiving combination BP-lowering treatment, fixed-dose single-pill combination treatment is recommended.484,489,501,502,514 | |
| p.51 | I | B | If BP is not controlled with a two-drug combination, increasing to a three-drug combination is recommended, usually a RAS blocker with a dihydropyridine CCB and a thiazide/thiazide-like diuretic, and preferably in a single-pill combination.489 If BP is not controlled with a three-drug combination, | |
| p.51 | IIa | B | If BP is not controlled with a three-drug combination and in whom spironolactone is not effective or tolerated, treatment with eplerenone instead of spironolactone,503 or the addition of a beta-blocker if not already indicated459 and, next, a centrally acting BP-lowering medication,515 an alpha-blocker,515 hydralazine, or a potassium-sparing diuretic should be considered.516 Combining two RAS blockers (ACE inhibitor and an | |
| p.52 | I | B | In adults with elevated BP and low/medium CVD risk (<10% over 10 years), BP lowering with lifestyle measures is recommended and can reduce the risk of CVD.119,120,348,408,411,520,521 | Recommendation Table 17 — Recommendations for initiating blood pressure-lowering treatment (see Evidence Tables 30–32) |
| p.52 | I | A | In adults with elevated BP and sufficiently high CVD riskc, after 3 months of lifestyle intervention, BP lowering with pharmacological treatment is recommended for those with confirmed BP ≥130/ 80 mmHg to reduce CVD risk.116,522 | Recommendation Table 17 — Recommendations for initiating blood pressure-lowering treatment (see Evidence Tables 30–32) |
| p.52 | I | A | It is recommended that in hypertensive patients with confirmed BP ≥140/90 mmHg, irrespective of CVD risk, lifestyle measures and pharmacological BP-lowering treatment are initiated promptly to reduce CVD risk.116,121,122 | Recommendation Table 17 — Recommendations for initiating blood pressure-lowering treatment (see Evidence Tables 30–32) |
| p.52 | I | A | It is recommended to maintain BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated.523–525 | Recommendation Table 17 — Recommendations for initiating blood pressure-lowering treatment (see Evidence Tables 30–32) |
| p.52 | IIa | B | Because the benefit in reducing CVD outcomes is uncertain in these settings, and noting that close monitoring of treatment tolerance is advised, BP-lowering treatment should only be considered from ≥140/90 mmHg among persons meeting the following criteria: pre-treatment symptomatic orthostatic hypotension, age ≥85 years, clinically significant moderate-to-severe frailty, and/or limited predicted lifespan (<3 years).131,524,526,527 | Recommendation Table 17 — Recommendations for initiating blood pressure-lowering treatment (see Evidence Tables 30–32) |
| p.55 | I | A | To reduce CVD risk, it is recommended that treated systolic BP values in most adults be targeted to 120– 129 mmHg, provided the treatment is well tolerated.22,122,131,523,541 | Recommendation Table 18 — Recommendations for blood pressure targets with treatment (see Evidence Table 34) |
| p.55 | I | A | In cases where BP-lowering treatment is poorly tolerated and achieving a systolic of 120–129 mmHg is not possible, it is recommended to target a systolic BP level that is ‘as low as reasonably achievable’ (ALARA principle).22,122,131,523,541 | Recommendation Table 18 — Recommendations for blood pressure targets with treatment (see Evidence Table 34) |
| p.55 | IIa | C | Because the CVD benefit of an on-treatment systolic BP target of 120–129 mmHg may not generalize to the following specific settings, personalized and more lenient BP targets (e.g. <140 mmHg) should be considered among patients meeting the following criteria: pre-treatment symptomatic orthostatic hypotension, and/or age ≥85 years.131 | Recommendation Table 18 — Recommendations for blood pressure targets with treatment (see Evidence Table 34) |
| p.55 | IIb | C | Because the CVD benefit of an on-treatment systolic BP target of 120–129 mmHg may not generalize to the following specific settings, personalized and more lenient BP targets (e.g. <140/90 mmHg) may be considered among patients meeting the following criteria: clinically significant moderate-to-severe frailty at any age, and/or limited predicted lifespan | Recommendation Table 18 — Recommendations for blood pressure targets with treatment (see Evidence Table 34) |
| p.55 | IIb | C | (<3 years). In cases where on-treatment systolic BP is at or below target (120–129 mmHg) but diastolic BP is not at target (≥80 mmHg), intensifying BP-lowering treatment to achieve an on-treatment diastolic BP of 70–79 mmHg may be considered to reduce CVD risk. | Recommendation Table 18 — Recommendations for blood pressure targets with treatment (see Evidence Table 34) |
| p.55 | IIa | C | Once BP is controlled and stable under BP-lowering therapy, at least a yearly follow-up for BP and other CVD risk factors should be considered. BP, blood pressure; CVD, cardiovascular disease. aClass of recommendation. bLevel of evidence. | Recommendation Table 19 — Recommendations for follow-up in patients with treated hypertension (see Evidence Table 33) |
| p.56 | IIb | B | To reduce BP, and if performed at a medium-to-high volume centre, catheter-based renal denervation may be considered for resistant hypertension patients 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.564,566–568,586–590 | Recommendation Table 20 — Recommendations for device-based treatment of hypertension (see Evidence Table 35) |
| p.56 | IIb | A | To reduce BP, and if performed at a medium-to-high volume centre, catheter-based renal denervation may be considered for patients with both increased CVD risk and uncontrolled hypertension on fewer than three drugs, if they express a preference to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment.564,566– | Recommendation Table 20 — Recommendations for device-based treatment of hypertension (see Evidence Table 35) |
| p.56 | III | C | 568,586–590 Due to a lack of adequately powered outcomes trials demonstrating its safety and CVD benefits, renal denervation is not recommended as a first-line BP-lowering intervention for hypertension. | Recommendation Table 20 — Recommendations for device-based treatment of hypertension (see Evidence Table 35) |
| p.56 | III | C | Renal denervation is not recommended for treating hypertension in patients with moderate-to-severely impaired renal function (eGFR <40 mL/min/1.73 m2) or secondary causes of hypertension, until further evidence becomes available. | Recommendation Table 20 — Recommendations for device-based treatment of hypertension (see Evidence Table 35) |
| p.58 | I | B | Comprehensive screening for the main causes of secondary hypertension is recommended in adults diagnosed with hypertension before the age of 40 years, except for obese young adults where it is recommended to start with an obstructive sleep apnoea evaluation.316,626 | Recommendation Table 21 — Recommendations for managing hypertension in young adults (see Evidence Tables 36 and 37) |
| p.58 | IIb | B | Since SCORE2 has not been validated for individuals <40 years, screening for HMOD may be considered in such young individuals with elevated BP without other increased CVD risk conditions to identify additional individuals for possible medical treatment.28,215 | Recommendation Table 21 — Recommendations for managing hypertension in young adults (see Evidence Tables 36 and 37) |
| p.60 | III | B | RAS blockers are not recommended during pregnancy.680,681 | |
| p.60 | I | B | In women with gestational hypertension, starting drug treatment is recommended for those with confirmed office systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg.661 | Recommendation Table 22 — Recommendations for managing hypertension in pregnancy (see Evidence Tables 38–40) |
| p.60 | I | B | In pregnant women with chronic hypertension, starting drug treatment is recommended for those with confirmed office systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg.88,660,661,678 | Recommendation Table 22 — Recommendations for managing hypertension in pregnancy (see Evidence Tables 38–40) |
| p.60 | I | C | In women with chronic and gestational hypertension, it is recommended to lower BP below 140/90 mmHg but not below 80 mmHg for diastolic BP. | |
| p.60 | I | C | Dihydropyridine CCBs (preferably extended-release nifedipine), labetalol, and methyldopa are recommended first-line BP-lowering medications for treating hypertension in pregnancy. | |
| p.60 | I | B | In consultation with an obstetrician, low- to moderate-intensity exercise is recommended in all pregnant women without contraindications to reduce the risk of gestational hypertension and pre-eclampsia.654,655 | |
| p.60 | IIa | C | Systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg in pregnancy can indicate an emergency, and immediate hospitalization should be considered. | |
| p.60 | IIa | C | HBPM and ABPM should be considered to exclude white-coat and masked hypertension, which are more common in pregnancy.679 | |
| p.62 | I | A | It is recommended that treatment of elevated BP and hypertension among older patients aged <85 years who are not moderately to severely frail follows the same guidelines as for younger people, provided BP-lowering treatment is well tolerated.131,523,524 | Recommendation Table 23 — Recommendations for managing hypertension in patients who are very old or frail (see Evidence Table 41) |
| p.62 | I | A | It is recommended to maintain BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated.523–525 Because the benefit in reducing CVD outcomes is | |
| p.62 | IIa | B | uncertain in these settings, and noting that close monitoring of treatment tolerance is advised, BP-lowering treatment should only be considered from ≥140/90 mmHg among persons meeting the following criteria: pre-treatment symptomatic orthostatic hypotension, age ≥85 years, clinically significant moderate-to-severe frailty, and/or limited predicted lifespan (<3 years).131,524,526,527 | |
| p.62 | IIa | C | As the safety and efficacy of BP treatment is less certain in individuals with moderate or severe frailty, clinicians should consider screening older adults for frailty using validated clinical tests; frail patients’ health priorities and a shared-decision approach should be considered when deciding on BP treatments and targets.523,524,613,710 | |
| p.62 | IIa | B | When initiating BP-lowering treatment for patients aged ≥85 years, and/or with moderate-to-severe frailty (at any age), long-acting dihydropyridine CCBs or RAS inhibitors should be considered, followed if necessary by low-dose diuretic if tolerated, but preferably not a beta-blocker (unless compelling | |
| p.62 | IIb | C | indications exist) or an alpha-blocker.711 If BP drops with progressing frailty, deprescription of BP-lowering medications (and other drugs that can reduce BP, such as sedatives and prostate-specific alpha-blockers) may be considered.712 | |
| p.64 | I | B | Before starting or intensifying BP-lowering medication, it is recommended to test for orthostatic hypotension, by first having the patient sit or lie for 5 min and then measuring BP 1 and/or 3 min after standing.97,99 It is recommended to pursue non-pharmacological | Recommendation Table 24 — Recommendations for managing hypertension in patients with orthostatic hypotension |
| p.64 | I | A | approaches as the first-line treatment of orthostatic hypotension among persons with supine hypertension. For such patients, it is also recommended to switch BP-lowering medications that worsen orthostatic hypotension to an alternative BP-lowering therapy and not to simply de-intensify therapy.726,727,729,730 BP, blood pressure. aClass of recommendation. bLevel of evidence. | Recommendation Table 24 — Recommendations for managing hypertension in patients with orthostatic hypotension |
| p.64 | I | A | In most adults with elevated BP and diabetes, after a maximum of 3 months of lifestyle intervention, BP lowering with pharmacological treatment is recommended for those with confirmed office BP ≥130/80 mmHg to reduce CVD risk.445,749 | Recommendation Table 25 — Recommendations for managing hypertension in patients with diabetes |
| p.64 | I | A | BP-lowering drug treatment is recommended for people with pre-diabetes or obesity when confirmed office BP is ≥140/90 mmHg or when office BP is 130–139/80–89 mmHg and the patient is at predicted 10-year risk of CVD ≥10% or with high-risk conditions, despite a maximum of 3 months of lifestyle therapy.445 | Recommendation Table 25 — Recommendations for managing hypertension in patients with diabetes |
| p.64 | I | A | In persons with diabetes who are receiving BP-lowering drugs, it is recommended to target systolic BP to 120–129 mmHg, if tolerated.136,146,445,747,749–752 BP, blood pressure; CVD, cardiovascular disease. aClass of recommendation. bLevel of evidence. | Recommendation Table 25 — Recommendations for managing hypertension in patients with diabetes |
| p.65 | I | A | In patients with diabetic or non-diabetic moderate-to-severe CKD and confirmed BP ≥130/ 80 mmHg, lifestyle optimization and BP-lowering medication are recommended to reduce CVD risk, provided such treatment is well tolerated.275,766 | Recommendation Table 26 — Recommendations for managing hypertension in patients with chronic kidney disease |
| p.65 | I | A | In adults with moderate-to-severe CKD who are receiving BP-lowering drugs and who have eGFR >30 mL/min/1.73 m2, it is recommended to target systolic BP to 120–129 mmHg, if tolerated. Individualized BP targets are recommended for those with lower eGFR or renal transplantation.274,779 | Recommendation Table 26 — Recommendations for managing hypertension in patients with chronic kidney disease |
| p.65 | I | A | In hypertensive patients with CKD and eGFR >20 mL/min/1.73 m2, SGLT2 inhibitors are recommended to improve outcomes in the context of their modest BP-lowering properties.776,777 | Recommendation Table 26 — Recommendations for managing hypertension in patients with chronic kidney disease |
| p.65 | IIa | B | ACE inhibitors or ARBs are more effective at reducing albuminuria than other BP-lowering agents and should be considered as part of the treatment strategy for patients with hypertension and microalbuminuria or proteinuria.780–782 | Recommendation Table 26 — Recommendations for managing hypertension in patients with chronic kidney disease |
| p.67 | I | A | In patients with a history of myocardial infarction who require BP-lowering treatment, beta-blockers and RAS blockers are recommended as part of that treatment.538 | Recommendation Table 27 — Recommendations for managing hypertension in patients with cardiac disease |
| p.67 | I | A | In patients with symptomatic angina who require BP-lowering treatment, beta-blockers and/or CCBs are recommended as part of that treatment.538 In patients with symptomatic HFrEF/HFmrEF, the | Recommendation Table 27 — Recommendations for managing hypertension in patients with cardiac disease |
| p.67 | I | A | following treatments with BP-lowering effects are recommended to improve outcomes: ACE inhibitors (or ARBs if ACE inhibitors are not tolerated) or ARNi, beta-blockers, MRAs, and SGLT2 inhibitors.795 | Recommendation Table 27 — Recommendations for managing hypertension in patients with cardiac disease |
| p.67 | I | A | In hypertensive patients with symptomatic HFpEF, SGLT2 inhibitors are recommended to improve outcomes in addition to their modest BP-lowering properties.795 | Recommendation Table 27 — Recommendations for managing hypertension in patients with cardiac disease |
| p.67 | IIa | C | In patients with a history of aortic valve stenosis and/ or regurgitation who require BP-lowering treatment, RAS blockers should be considered as part of that treatment.794,796 | Recommendation Table 27 — Recommendations for managing hypertension in patients with cardiac disease |
| p.67 | IIa | C | In patients with a history of moderate-to-severe mitral valve regurgitation who require BP-lowering treatment, RAS blockers should be considered as part of that treatment.794 | Recommendation Table 27 — Recommendations for managing hypertension in patients with cardiac disease |
| p.67 | IIb | B | In patients with symptomatic HFpEF who have BP above target, ARBs and/or MRAs may be considered to reduce heart failure hospitalizations and reduce BP.795,799,800 | Recommendation Table 27 — Recommendations for managing hypertension in patients with cardiac disease |
| p.68 | I | A | It is recommended that the BP-lowering drug treatment strategy for preventing recurrent stroke should comprise a RAS blocker plus a CCB or a thiazide-like diuretic.820,823,825,826 | Recommendation Table 28 — Recommendations for managing hypertension in patients with chronic cerebrovascular disease and cognitive impairment |
| p.68 | I | A | In patients with confirmed BP ≥130/80 mmHg with a history of TIA or stroke a systolic BP target of 120– 129 mmHg is recommended to reduce CVD outcomes, provided treatment is tolerated.824,827,828 | Recommendation Table 28 — Recommendations for managing hypertension in patients with chronic cerebrovascular disease and cognitive impairment |
| p.68 | IIa | B | In black patients from Sub-Saharan Africa who require BP-lowering treatment, combination therapy including a CCB combined with either a thiazide diuretic or a RAS blocker should be considered.874 | Recommendation Table 29 — Recommendations for managing hypertension in different ethnic groups |
| p.70 | IIa | B | In patients with resistant hypertension and uncontrolled BP despite use of first-line BP lowering therapies, the addition of spironolactone to existing treatment should be considered.459,515 | Recommendation Table 30 — Recommendations for treating resistant hypertension (see Evidence Tables 42 and 43) |
| p.71 | IIa | B | In patients with resistant hypertension in whom spironolactone is not effective or tolerated, treatment with eplerenone instead of spironolactone,503 or the addition of a beta-blocker if not already indicated459 and, next, a centrally acting BP-lowering medication,515 an alpha-blocker,515 hydralazine, or a potassium-sparing diuretic516 should be considered. | |
| p.71 | IIb | B | To reduce BP, and if performed at a medium-to-high volume centre, catheter-based renal denervation may be considered for resistant hypertension patients who have BP that is uncontrolled despite a three BP-lowering drug combination, and who express a preference to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment.564,566–568,586–590 BP, blood pressure. aClass of recommendation. bLevel of evidence. | |
| p.71 | IIa | C | Renal artery angioplasty without stenting should be considered for patients with hypertension and haemodynamically significant renal artery stenosis due to fibromuscular dysplasia.941 Renal artery angioplasty and stenting may be considered in patients with haemodynamically | Recommendation Table 31 — Recommendations for managing hypertension in patients with renovascular hypertension (see Evidence Tables 44 and 45) |
| p.71 | IIb | C | significant, atherosclerotic, renal artery stenosis (stenosis of 70%–99%, or 50%–69% with post-stenotic dilatation and/or significant trans-stenotic pressure gradient) with: • Recurrent heart failure, unstable angina, or sudden onset flash pulmonary oedema despite maximally tolerated medical therapy; • Resistant hypertension; • Hypertension with unexplained unilaterally small kidney or CKD; • Bilateral renal artery stenosis or unilateral renal artery stenosis in a solitary viable kidney.942,943 | Recommendation Table 31 — Recommendations for managing hypertension in patients with renovascular hypertension (see Evidence Tables 44 and 45) |
| p.72 | IIb | C | In patients with an indication to renal artery revascularization and technically unfeasible, or failed, renal artery angioplasty and stenting, open surgical revascularization may be considered. | |
| p.72 | III | A | Renal artery angioplasty is not recommended in patients without confirmed haemodynamically significant renal artery stenosis.c 938,939 | |
| p.73 | I | B | For patients with ischaemic stroke or TIA and an indication for BP lowering, it is recommended that BP-lowering therapy be commenced before hospital discharge.819,820,823 | Recommendation Table 32 — Recommendations for acutely managing blood pressure in patients with intracerebral haemorrhage or acute ischaemic stroke |
| p.73 | IIa | B | • In patients who are eligible for re-perfusion therapy with intravenous thrombolysis or mechanical thrombectomy, BP should be carefully lowered and maintained at <180/105 mmHg for at least the first 24 h after treatment.956–960 | Recommendation Table 32 — Recommendations for acutely managing blood pressure in patients with intracerebral haemorrhage or acute ischaemic stroke |
| p.74 | IIa | C | stroke onset.956–960 | Recommendation Table 33 — Recommendations for acutely managing blood pressure in patients with severe hypertension in pregnancy and pre-eclampsia (see Evidence Table 46) |
| p.74 | IIa | A | In patients with intracerebral haemorrhage, immediate BP lowering (within 6 h of symptom onset) should be considered to a systolic target 140– 160 mmHg to prevent haematoma expansion and improve functional outcome.948,949 | Recommendation Table 33 — Recommendations for acutely managing blood pressure in patients with severe hypertension in pregnancy and pre-eclampsia (see Evidence Table 46) |
| p.74 | III | B | In patients with intracerebral haemorrhage presenting with systolic BP ≥220 mmHg, acute reduction in systolic BP >70 mmHg from initial levels within 1 h of commencing treatment is not recommended.950,951,960–963 BP, blood pressure; TIA, transient ischaemic attack. aClass of recommendation. bLevel of evidence. | Recommendation Table 33 — Recommendations for acutely managing blood pressure in patients with severe hypertension in pregnancy and pre-eclampsia (see Evidence Table 46) |
| p.74 | I | C | In pre-eclampsia or eclampsia with hypertensive crisis, drug treatment with i.v. labetalol or nicardipine and magnesium is recommended.971 | Recommendation Table 33 — Recommendations for acutely managing blood pressure in patients with severe hypertension in pregnancy and pre-eclampsia (see Evidence Table 46) |
| p.74 | I | C | In pre-eclampsia or eclampsia associated with pulmonary oedema, nitroglycerin given as an i.v. infusion is recommended.242 | Recommendation Table 33 — Recommendations for acutely managing blood pressure in patients with severe hypertension in pregnancy and pre-eclampsia (see Evidence Table 46) |
| p.74 | I | C | In severe hypertension in pregnancy: © ESC 2024 • drug treatment with i.v. labetalol, oral methyldopa, or oral nifedipine is recommended. Intravenous hydralazine is a second-line option.666–668,969,971 i.v., intravenous. aClass of recommendation. bLevel of evidence. | Recommendation Table 33 — Recommendations for acutely managing blood pressure in patients with severe hypertension in pregnancy and pre-eclampsia (see Evidence Table 46) |
| p.76 | I | C | An informed discussion about CVD risk and treatment benefits tailored to the needs of a patient is recommended as part of hypertension management.992 | Recommendation Table 34 — Recommendations for communicating consequences of treatment (see Evidence Table 47) |
| p.76 | IIa | B | Motivational interviewing should be considered for patients with hypertension at hospitals and community health centres to assist patients in controlling their BP and to enhance treatment adherence.993,994 | Recommendation Table 34 — Recommendations for communicating consequences of treatment (see Evidence Table 47) |
| p.76 | IIa | C | Physician–patient web communications are an effective tool that should be considered in primary care, including reporting on home BP readings.995 BP, blood pressure; CVD, cardiovascular disease. aClass of recommendation. bLevel of evidence. | Recommendation Table 34 — Recommendations for communicating consequences of treatment (see Evidence Table 47) |
| p.76 | I | B | Home BP measurement for managing hypertension by using self-monitored BP is recommended to achieve better BP control. | Recommendation Table 35 — Recommendations for self-measuring and monitoring blood pressure (see Evidence Table 48) |
| p.76 | I | C | Self-measurement, when properly performed, is recommended due to positive effects on the acceptance of a diagnosis of hypertension, patient empowerment, and adherence to treatment.1001 | Recommendation Table 35 — Recommendations for self-measuring and monitoring blood pressure (see Evidence Table 48) |
| p.76 | IIb | B | Enhanced self-monitoring of BP using a device paired with a connected smartphone application may be considered, though evidence to date suggests that this may be no more effective than standard self-monitoring.1005,1006 BP, blood pressure. aClass of recommendation. bLevel of evidence. | Recommendation Table 35 — Recommendations for self-measuring and monitoring blood pressure (see Evidence Table 48) |
| p.76 | I | A | Multidisciplinary approaches in the management of patients with elevated BP and hypertension, including © ESC 2024 appropriate and safe task-shifting away from physicians, are recommended to improve BP control.227,229,230,1012–1014,1016 BP, blood pressure. aClass of recommendation. bLevel of evidence. | Recommendation Table 36 — Recommendations for multi/interdisciplinary blood pressure management (see Evidence Table 49) |
| p.78 | I | B | consistent approach to BP measurement for each patient. | |
| p.78 | I | C | recorded in their medical file, and be told what their current BP is. | |
| p.79 | I | B | >10 mmHg is associated with an increased CVD risk and may indicate arterial stenosis. | |
| p.79 | I | B | the higher BP reading. | |
| p.79 | I | B | It is recommended that BP be categorized as non-elevated BP, elevated BP, and hypertension to aid treatment decisions. | |
| p.79 | I | B | It is recommended to use a risk-based approach in the treatment of elevated BP, and individuals with moderate or severe CKD, established CVD, HMOD, diabetes mellitus, or familial hypercholesterolaemia are considered at increased risk for CVD events. | |
| p.79 | I | B | increased risk for CVD for the purposes of risk-based management of their elevated BP. | |
| p.79 | I | B | out-of-office, using ABPM and/or HBPM or, if not logistically feasible, make repeated office BP measurements on more than one visit. | |
| p.79 | I | A | It is recommended to measure serum creatinine, eGFR, and urine ACR in all patients with hypertension. | |
| p.79 | I | B | A 12-lead ECG is recommended for all patients with hypertension. | |
| p.79 | I | B | Echocardiography is recommended in patients with hypertension and ECG abnormalities, or signs or symptoms of cardiac disease. | |
| p.79 | I | C | hypertensive patients with diabetes. | |
| p.79 | III | C | Routine genetic testing for patients with hypertension is not recommended. | |
| p.79 | I | B | are appropriately screened for secondary hypertension. | |
| p.79 | I | A | Restriction of sodium to approximately 2 g per day is recommended where possible in all adults with elevated BP and hypertension [this is equivalent to about 5 g of salt (sodium chloride) per day or about a teaspoon or less]. | |
| p.79 | I | A | to reduce BP and CVD risk. | |
| p.80 | I | A | Adopting a healthy and balanced diet such as the Mediterranean or DASH diets is recommended to help reduce BP and CVD risk. | |
| p.80 | I | B | also recommended to discourage consumption of sugar-sweetened beverages, such as soft drinks and fruit juices, starting at young age. | |
| p.80 | I | A | independently causes CVD, CVD events, and all-cause mortality. | |
| p.80 | I | A | indications for their use, e.g. angina, post-myocardial infarction, HFrEF, or for heart rate control. | |
| p.80 | I | B | to improve adherence. | |
| p.80 | I | B | In patients receiving combination BP-lowering treatment, fixed-dose single-pill combination treatment is recommended. | |
| p.80 | I | B | dihydropyridine CCB and a thiazide/thiazide-like diuretic, and preferably in a single-pill combination. | |
| p.80 | III | A | Combining two RAS blockers (ACE inhibitor and an ARB) is not recommended. | |
| p.80 | I | B | reduce the risk of CVD. | |
| p.80 | I | A | is recommended for those with confirmed BP ≥130/80 mmHg to reduce CVD risk. | |
| p.80 | I | A | pharmacological BP-lowering treatment is initiated promptly to reduce CVD risk. | |
| p.80 | I | A | It is recommended to maintain BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated. | |
| p.80 | I | A | is well tolerated. | |
| p.80 | I | A | to target a systolic BP level that is ‘as low as reasonably achievable’ (ALARA principle). | |
| p.80 | III | C | first-line BP-lowering intervention for hypertension. | |
| p.80 | III | C | mL/min/1.73 m2) or secondary causes of hypertension, until further evidence becomes available. | |
| p.80 | I | B | age of 40 years, except for obese young adults where it is recommended to start with an obstructive sleep apnoea evaluation. | |
| p.80 | I | B | In women with gestational hypertension, starting drug treatment is recommended for those with confirmed office systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg. | |
| p.80 | I | B | In pregnant women with chronic hypertension, starting drug treatment is recommended for those with confirmed office systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg. | |
| p.80 | I | C | In women with chronic and gestational hypertension, it is recommended to lower BP below 140/90 mmHg but not below 80 mmHg for diastolic BP. | |
| p.81 | I | C | medications for treating hypertension in pregnancy. | |
| p.81 | I | B | reduce the risk of gestational hypertension and pre-eclampsia. | |
| p.81 | III | B | RAS blockers are not recommended during pregnancy. | |
| p.81 | I | A | frail follows the same guidelines as for younger people, provided BP-lowering treatment is well tolerated. | |
| p.81 | I | A | It is recommended to maintain BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated. | |
| p.81 | I | B | lie for 5 min and then measuring BP 1 and/or 3 min after standing. | |
| p.81 | I | A | treatment is recommended for those with confirmed BP ≥130/80 mmHg to reduce CVD risk. | |
| p.81 | I | A | In persons with diabetes who are receiving BP-lowering drugs, it is recommended to target systolic BP to 120–129 mmHg, if tolerated. | |
| p.81 | I | A | medication are recommended to reduce CVD risk, provided such treatment is well tolerated. | |
| p.81 | I | A | In hypertensive patients with CKD and eGFR >20 mL/min/1.73 m2, SGLT2 inhibitors are recommended to improve outcomes in the context of their modest BP-lowering properties. | |
| p.81 | I | A | part of that treatment. | |
| p.81 | I | A | ACE inhibitors (or ARBs if ACE inhibitors are not tolerated) or ARNi, beta-blockers, MRAs, and SGLT2 inhibitors. | |
| p.81 | I | A | BP-lowering properties. | |
| p.81 | I | A | thiazide-like diuretic. | |
| p.81 | I | A | CVD outcomes, provided treatment is tolerated. | |
| p.81 | III | A | Renal artery angioplasty is not recommended in patients without confirmed haemodynamically significant renal artery stenosis. | |
| p.81 | I | B | For patients with ischaemic stroke or TIA and an indication for BP lowering, it is recommended that BP lowering therapy should be commenced before hospital discharge. | |
| p.81 | III | B | In patients with intracerebral haemorrhage presenting with systolic BP ≥220 mmHg, acute reduction in systolic BP >70 mmHg from initial levels within 1 h of commencing treatment is not recommended. | |
| p.82 | I | C | In pre-eclampsia or eclampsia with hypertensive crisis, drug treatment with i.v. labetalol or nicardipine and magnesium is recommended. | |
| p.82 | I | C | In pre-eclampsia or eclampsia associated with pulmonary oedema, nitroglycerin given as an i.v. infusion is recommended. | |
| p.82 | I | C | • drug treatment with i.v. labetalol, oral methyldopa, or oral nifedipine is recommended. Intravenous hydralazine is a second-line option. | |
| p.82 | I | B | Home BP measurement for managing hypertension by using self-monitored BP is recommended to achieve better BP control. | |
| p.82 | I | C | Self-measurement, when properly performed, is recommended due to positive effects on the acceptance of a diagnosis of hypertension, patient empowerment, and adherence to treatment. | |
| p.82 | I | A | Multidisciplinary approaches in the management of patients with elevated BP and hypertension, including appropriate and safe task-shifting away from physicians are recommended to improve BP control. |