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Hypertension

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Updated 2024 ESC guidelines for the evaluation and management of hypertension.

Background

Overview

Definition
According to the 2018 ACC/AHA guidelines, elevated BP is defined as systolic pressure of 120-129 mmHg and diastolic pressure < 80 mmHg, stage 1 HTN is defined as SBP of 130-139 mmHg or DBP of 80-89 mmHg, and stage 2 HTN is defined as SBP of ≥ 140 mmHg or DBP of ≥ 90 mmHg. According to the 2024 ESC guidelines, elevated BP is defined as an office SBP of 120-139 mmHg or DBP of 70-89 mmHg, and HTN is defined as an office SBP of ≥ 140 mmHg and DBP of ≥ 90 mmHg.
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Pathophysiology
Primary HTN etiology is multifactorial and most frequently associated with a combination of environmental (unhealthy diet, increased sodium intake, insufficient potassium intake, inadequate physical activity, overweight/obesity) and genetic factors (multiple risk alleles, gene-gene interactions, fetal programming, epigenetic mechanisms). Secondary HTN etiology includes primary aldosteronism, renal HTN, renal parenchymal disease, pheochromocytoma/paraganglioma, Cushing's syndrome, hypothyroidism, hyperthyroidism, hypercalcemia and primary hyperparathyroidism, congenital adrenal hyperplasia, acromegaly, coarctation of the aorta, and medication or recreational drug use (amphetamines, cocaine, phencyclidine). White-coat HTN and isolated systolic HTN are essential subtypes.
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Epidemiology
HTN is highly prevalent worldwide. The prevalence of HTN in the US is estimated at 31,900 per 100,000 adults based on the 140/90 mmHg cutoff. Rates are highest in African Americans and increase with age.
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Risk factors
Risk factors for primary HTN include nonmodifiable factors, such as advancing age, African and Hispanic ancestry, and family history, and modifiable factors, include an unhealthy diet, high sodium intake, low potassium intake, physical inactivity, overweight or obesity, low socioeconomic status, and limited access to healthcare.
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Disease course
HTN is mostly asymptomatic until an acute hypertensive crisis or end-organ complications occur. Manifestations of end-organ damage in HTN include motor or sensory deficit (brain); hypertensive retinopathy (retina); and AF, arrhythmias, pulmonary congestion and peripheral edema (heart). Secondary HTN presents with symptoms of the causal condition, for example, abdominal bruit in renal artery stenosis or abdominal masses in polycystic kidney disease. A fourth heart sound is often the earliest sign of hypertensive heart disease. HTN decreases health-related QoL.
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Prognosis and risk of recurrence
Prognosis is highly dependant on the BP and end-organ damage. Higher BP and more severe retinopathy or organ damage are associated with a worse prognosis. Untreated or treatment-resistant HTN leads to lower survival rates. However, effective BP control raises 10-year survival rates to 70%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hypertension are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2023,2022), the American Diabetes Association (ADA 2024), the American Society of Addiction Medicine (ASAM/AAAP 2024), the Canadian Cardiovascular Society (CCS/CAIC 2024), the European Reference Network on Rare Endocrine Conditions (Endo-ERN 2024), the ...
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Screening and diagnosis

Indications for screening, adults: as per ESC 2024 guidelines, obtain office and/or out-of-office BP measurements in all adults (≥ 18 years) on an opportunistic basis, record measurements in their medical file, and inform patients of their current BP.
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  • Indications for screening (pregnancy)

  • Indications for screening (children)

Classification and risk stratification

Staging: as per ESC 2024 guidelines, classify BP as non-elevated BP, elevated BP, or HTN to aid treatment decisions.
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  • Cardiovascular risk stratification

Diagnostic investigations

Office BP measurement: as per ESC 2024 guidelines, measure office BP in both arms at least at the first visit, as a between-arm SBP difference of >10 mmHg is associated with increased CVD risk and may indicate arterial stenosis.
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  • Out-of-office BP measurement

  • Choice of measurement device

  • Initial investigations

  • Echocardiography

  • Fundoscopy

  • Evaluation for modifiable risk factors

  • Evaluation for drug or alcohol use

  • Evaluation for obstructive sleep apnea

  • Evaluation for renovascular and renal parenchymal disease

  • Evaluation for primary hyperaldosteronism

  • Evaluation for pheochromocytoma

  • Evaluation for aortic coarctation

  • Evaluation for thyroid disease

  • Evaluation for hyperparathyroidism

  • Evaluation for congenital adrenal hyperplasia

  • Evaluation for acromegaly

  • Genetic testing

Medical management

Multidisciplinary care: as per ESC 2024 guidelines, implement multidisciplinary approaches in the management of patients with elevated BP and HTN, including appropriate and safe task-shifting away from physicians, to improve BP control.
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  • Indications for treatment (general population)

  • Indications for treatment (elderly)

  • Indications for treatment (high CVD risk)

  • Goals of treatment (BP targets, general population)

  • Goals of treatment (BP targets, elderly)

  • Goals of treatment (BP targets, high CVD risk)

  • Goals of treatment (clinical targets)

  • Goals of treatment (safety measures)

  • Choice of antihypertensives (general principles)

  • Choice of antihypertensives (initial therapy)

  • Choice of antihypertensives (subsequent therapy)

  • Management of resistant HTN (diagnosis)

  • Management of resistant HTN (general principles)

  • Management of resistant HTN (pharmacotherapy)

  • Management of resistant HTN (renal denervation)

  • Management of resistant HTN (monitoring)

  • Management of hypertensive urgency

  • Management of hypertensive emergency

  • Lipid-lowering therapy (statins)

  • Lipid-lowering therapy (non-statins)

  • Antiplatelet therapy

Inpatient care

Management of hospitalized patients: as per AAFP 2024 guidelines, avoid administering acute management of severe asymptomatic HTN in hospitalized patients, as it increases the risk of adverse composite outcomes, AKI, and myocardial infarction.
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Nonpharmacologic interventions

Lifestyle modifications: as per ESC 2024 guidelines, offer lifestyle modifications to reduce the risk of CVD in adult patients with elevated BP and low/medium CVD risk (< 10% over 10 years).
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  • Dietary modifications

  • Salt restriction

  • Potassium supplementation

  • Alcohol restriction

  • Weight loss

  • Exercising

  • Smoking cessation

  • Stress management

  • Supplements

  • Telehealth interventions

  • Adjuncts to controlling HTN

Therapeutic procedures

Renal denervation: as per ESC 2024 guidelines, consider performing catheter-based renal denervation at a medium-to-high volume center to reduce BP in patients with resistant HTN having uncontrolled BP despite a combination of three BP-lowering drugs (including a thiazide or thiazide-like diuretic), if they want to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment.
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  • Renal artery revascularization

Perioperative care

Timing of surgery: as per ESH 2023 guidelines, do not defer noncardiac surgery routinely in patients with grade 1 or 2 HTN (BP < 180/110 mmHg).
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  • Preoperative assessment

  • Perioperative management of antihypertensives

Specific circumstances

Pediatric and adolescent patients: as per ESC 2024 guidelines, obtaining opportunistic screening with office BP measurements to monitor the development of BP during late childhood and adolescence, especially if one or both parents have HTN, to better predict the development of adult HTN and associated CVD risk.
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  • Young adult patients

  • Elderly patients

  • Pregnant patients (BP measurement)

  • Pregnant patients (exercise)

  • Pregnant patients (low-dose aspirin)

  • Pregnant patients (BP targets)

  • Pregnant patients (choice of antihypertensives)

  • Pregnant patients (management of severe HTN)

  • Black patients

  • Patients with stage 1 HTN

  • Patients with white coat HTN (screening and evaluation)

  • Patients with white coat HTN (management)

  • Patients with masked HTN

  • Patients with isolated systolic HTN

  • Patients with isolated diastolic HTN

  • Patients with night-time HTN

  • Patients with afferent baroreflex failure

  • Patients with efferent autonomic failure

  • Patients with obesity (weight loss)

  • Patients with obesity (weight loss medications)

  • Patients with obesity (bariatric surgery)

  • Patients with obesity (antihypertensive therapy)

  • Patients with diabetes mellitus (screening)

  • Patients with diabetes mellitus (lifestyle modifications)

  • Patients with diabetes mellitus (BP targets)

  • Patients with diabetes mellitus (pharmacotherapy)

  • Patients with diabetes mellitus (pediatric patients)

  • Patients with CKD (lifestyle modifications)

  • Patients with CKD (BP targets)

  • Patients with CKD (antihypertensives)

  • Patients with CKD (renal transplant recipients)

  • Patients with coronary artery disease

  • Patients with HF (reduced ejection fraction)

  • Patients with HF (preserved ejection fraction)

  • Patients with myocardial infarction

  • Patients with AIS (acute treatment, indications and BP targets)

  • Patients with AIS (acute treatment, induced HTN)

  • Patients with AIS (secondary prevention)

  • Patients with hemorrhagic stroke (general principles)

  • Patients with hemorrhagic stroke (subarachnoid hemorrhage)

  • Patients with hemorrhagic stroke (intracerebral hemorrhage)

  • Patients with valvular heart disease

  • Patients with thoracic aortic disease

  • Patients with PAD

  • Patients with AF (evaluation)

  • Patients with AF (antihypertensive therapy)

  • Patients with AF (rate control)

  • Patients with AF (anticoagulation)

  • Patients with obstructive sleep apnea

  • Patients with cancer (evaluation)

  • Patients with cancer (management)

  • Patients with cancer treatment-induced HTN

  • Patients with stimulant intoxication

  • Patients with glaucoma

Preventative measures

Body weight control: as per ESC 2024 guidelines, counsel patients to aim for a stable and healthy BMI (20-25 kg/m²) and waist circumference values (< 94 cm for males and < 80 cm for females) to reduce BP and CVD risk.
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  • Antiplatelet therapy

  • Statin therapy

Follow-up and surveillance

Indications for specialist referral
As per AAPA/ABC/ACC/…/PCNA 2018 guidelines:
Refer adults with HTN and a positive screening test for primary aldosteronism to a HTN specialist or endocrinologist for further evaluation and treatment.
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Consider referring patients with secondary HTN to a HTN specialist with relevant expertise.
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  • Assessment of treatment response

  • Assessment of treatment adherence

  • Self-monitoring