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REFLECTIONS
Hypertension
Hypertension Global Newsletter #9 2025

GUIDELINES Hypertension

European guidelines for hypertension in 2024: A comparison of key
recommendations for clinical practice.
Lauder L, et al. Nat Rev Cardio. 2025 Sep;22(9):675-688.

The management of arterial hypertension is a global healthcare management is advised per the 2023 ESH guideline. Out-of-
priority, as elevated blood pressure (BP) is the most prevalent office BP monitoring, including home and 24-hour ambulatory
modifiable risk factor for cardiovascular disease (CVD) morbidity measurements, is advised by both guidelines to confirm
and mortality. Despite effective therapies, limited patient diagnosis and identify masked or white-coat hypertension.
awareness, non-adherence, and inertia among healthcare
professionals hinder BP control, placing a substantial burden on Key differences include classification systems and
healthcare systems. Recognising this public health challenge, pharmacological initiation thresholds; however, both guidelines
the European Society of Hypertension (ESH) and the European specify that the BP threshold targets are based on office BP
Society of Cardiology (ESC) have historically collaborated measurements. The 2023 ESH guidelines retain traditional
on evidence-based guidelines. Following joint publications categories (optimal, normal, high-normal, and three grades
between 2003 and 2018, the two societies released separate of hypertension), while the 2024 ESC guidelines introduce a
guidelines in 2023 (ESH) and 2024 (ESC), prompting the need simplified system emphasising ‘non-elevated BP’ (systolic BP
to understand their points of convergence and divergence. [SBP] <120 / diastolic BP [DBP] <70 mmHg), ‘elevated BP’
(SBP 120–139 / DBP 70–89 mmHg) and ‘hypertension’ (SBP
This Expert Recommendation provides a comparative analysis 140+/DBP 90+ mmHg). Both guidelines recommend initiating
of the 2023 ESH guidelines and the 2024 ESC guidelines, pharmacological treatment in patients with hypertension (BP
highlighting differences in the definition, classification, ≥140/90 mmHg). However, there are some differences between
diagnosis, and treatment of hypertension. For the most part, the guidelines in BP targets for older patients and special
both guidelines are largely similar with only minor differences populations (see figure below). The ESC recommends initiation
in nomenclature and semantics. Both guidelines define in all patients as soon as hypertension is confirmed, as well as
hypertension as office BP ≥140/90 mmHg and emphasise treatment initiation for high/very high CVD risk patients if SBP
comprehensive CVD risk stratification and lifestyle modifications is 130–139 mmHg after three months of lifestyle intervention.
for all patients. Both guidelines also recommend adopting a By contrast, the ESH allows for a 3-month postponement of
Mediterranean or DASH diet with <5 g/day salt, increased pharmacological treatment in asymptomatic patients with a BP
potassium intake, regular physical activity, and maintaining a of <150/95 mmHg, and no evidence of hypertension-mediated
healthy weight (BMI 20–25 kg/m²; waist <94 cm in men, <80 cm organ damage or CVD, with a focus on achieving BP control
in women). Alcohol and tobacco should be avoided, and stress through lifestyle interventions in this patient group.
BP treatment thresholds and targets

b
a A lower threshold in the range 140–159 mmHg can be considered. Preferably ≥140 mmHg if tolerated; more lenient thresholds should be considered in individuals with
moderate-to-severe frailty, symptomatic orthostatic hypotension, or limited lifespan. Despite three months of lifestyle interventions. According to the ESH guideline,
c
d
in patients aged 65–79 years with isolated systolic hypertension, the primary goal is to lower office systolic BP to 140–150 mmHg and, if tolerated, to 130–139 mmHg.
e According to the ESH guideline, in all patients with chronic kidney disease, the primary goal is to lower office BP to <140/90 mmHg and, in most patients, including young
patients and patients with a urinary albumin-to-creatinine ratio ≥300 mg/g or at high risk of CVD, office BP may be lowered to <130/80 mmHg, if tolerated.
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