Blood pressure Based on 2025 ESC Guideline for Summary

1. Definition & Classification

The ESC has refined its classification system into three distinct categories based on standardized office blood pressure (BP) measurements.

Category	Office Systolic BP (mmHg)	Office Diastolic BP (mmHg)	Key Implication
Non-elevated BP	< 120	and < 70	Normal range; drug treatment is not recommended.
Elevated BP (NEW)	120–139	or 70–89	A new “pre-hypertensive” state that identifies individuals at risk. Management depends on overall cardiovascular risk.
Hypertension	≥ 140	or ≥ 90	The definition of hypertension remains unchanged. Confirmation requires out-of-office measurements.

2. Diagnosis

The guidelines strongly emphasize the importance of accurate diagnosis, moving away from reliance on single in-clinic readings.

• Out-of-Office Measurement is Preferred: For diagnosing and managing hypertension, ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) is recommended whenever feasible.
• Detecting Phenotypes: Out-of-office measurements are crucial for identifying:
  • White-coat hypertension: High BP in the clinic but normal outside.
  • Masked hypertension: Normal BP in the clinic but high outside.
• In-Clinic Measurement: If out-of-office readings are not possible, standardized office measurements can be used. It is important to note that routine office BP may be 5–10 mmHg higher than standardized readings.
• Special Circumstance: In patients with atrial fibrillation, manual BP measurements are recommended as most automated devices are not validated for this condition.

3. Initial Investigation & Risk Assessment

Upon diagnosis, a comprehensive assessment is vital to guide management. This involves evaluating:

• Causative and Contributory Factors: Lifestyle, medications, and potential secondary causes.
• Cardiovascular Disease (CVD) Risk: A stepwise approach is recommended for all individuals with elevated BP:
  1. Assess for high-risk conditions (e.g., established CVD, diabetes, chronic kidney disease).
  2. Predict 10-year CVD risk using tools like SCORE2 or SCORE2-OP (for older persons).
  3. Evaluate for risk modifiers (e.g., family history of premature CVD, specific conditions in women like gestational diabetes or pre-eclampsia).
  4. Consider additional testing (e.g., for hypertension-mediated organ damage).
• Hypertension-Mediated Organ Damage (HMOD): Screening for subclinical damage to the heart, brain, kidneys, and eyes is a key part of the initial workup.

4. Primary and Secondary Causes

Understanding the underlying cause is crucial for effective management.

• Primary (Essential) Hypertension: This is the most common form, accounting for the vast majority of cases, where no single identifiable cause can be found.
• Secondary Hypertension: Accounts for approximately 10% of cases and has a discernible underlying cause.

Screening for Secondary Causes: The guidelines recommend comprehensive screening for secondary hypertension in specific groups:

• All adults diagnosed with hypertension before the age of 40.
• Exception: For obese young adults, screening for obstructive sleep apnoea should be the first step.
• Other common causes to consider include renal disease, primary aldosteronism, and drug-induced hypertension.

5. Management

The 2024 guidelines advocate for a proactive and intensive, yet personalized, management strategy.

A. Lifestyle Modifications

Lifestyle interventions are the cornerstone of management for all patients and should be initiated simultaneously with pharmacological treatment when indicated.

• Diet: Adopt a healthy diet (e.g., DASH-like), reduce sodium intake to <2 g/day, and increase potassium intake.
• Exercise: Engage in regular aerobic and resistance training.
• Weight Management: Maintain a normal body-mass index.
• Other: Smoking cessation and limiting alcohol consumption.

B. Pharmacological Treatment: A Risk-Based Approach

The decision to start medication is no longer based on BP alone but is integrated with overall CVD risk.

Category	CVD Risk	Management Strategy
Elevated BP (120-139/70-89)	Low (10-year risk <5% or borderline 5-<10% without modifiers)	Lifestyle measures are recommended.
Elevated BP (120-139/70-89)	High (10-year risk ≥10%, or borderline with modifiers)	Lifestyle measures plus pharmacological treatment if BP remains ≥130/80 mmHg after 3 months.
Hypertension (≥140/90)	Any	Lifestyle and pharmacological treatment are recommended.

Key Treatment Principles:

• Initial Therapy: For most patients, treatment should be initiated with a single-pill combination of two drugs.
• First-Line Agents: Recommended classes include ACE inhibitors (ACEis), Angiotensin Receptor Blockers (ARBs), Dihydropyridine Calcium Channel Blockers (CCBs), and Diuretics.
• Treatment Target: The new target systolic BP for most adults on medication is 120-129 mmHg, provided it is well tolerated.
• The “ALARA” Principle: For patients who cannot tolerate the intensive target (e.g., those >85 years, frail, or with limited life expectancy), the goal is to achieve a BP that is ‘As Low as Reasonably Achievable’ (ALARA).

C. Managing Resistant Hypertension

For patients with resistant hypertension, the guidelines recommend:

• Confirming true resistant hypertension and excluding secondary causes.
• Optimizing therapy and adding spironolactone as the preferred fourth-line agent.
• Referring to specialist centers and considering renal denervation (RDN) as a specialized, shared-decision option after thorough evaluation.