Disclosure: Kevin Fernando, MBChB, MSc, has disclosed the following relevant financial relationships: Received speaker fees from: Amarin; Amgen; AstraZeneca; Bayer; Boehringer Ingelheim; Dexcom; Daiichi Sankyo; Lilly; Menarini; Novartis; Novo Nordisk; Roche Diagnostics; Embecta; Roche Diabetes Care

Received honoraria for participation in advisory boards from: Amarin; Amgen; AstraZeneca; Bayer; Boehringer Ingelheim; Lilly; Menarini; Novartis; Roche Diabetes Care; Roche Diagnostics; Sanofi

Received funding for conference registration and subsistence from: Menarini; Daiichi Sankyo

Hypertension remains one of the most important preventable risk factors for cardiovascular, cerebrovascular, and kidney disease globally and contributes significantly to my daily clinical workload in primary care.

I therefore eagerly (and somewhat apprehensively) awaited the updated European Society of Cardiology (ESC) guidance for the management of hypertension that was unveiled during the organization's 2024 congress in London, which I was fortunate to attend.

The guideline contains many significant and pragmatic additions with important implications for clinicians, with respect to diagnosis, management, and, indeed, workload. Many of these recommendations now also align ESC guidance with US guidance on the management of hypertension. The guidance does not make any significant changes to treatment algorithms -- initial low-dose double combination therapy is still recommended for most patients -- and instead focuses efforts on intervention thresholds.

Notably, and as its title reflects, the updated guideline introduces a new blood pressure (BP) category called "elevated BP." This is in essence what some previously called "prehypertension." My recently retired senior partner, who worked for nearly 35 years in my practice, was always skeptical about the increasing number of "pre-" conditions in our medical lexicon. He preferred to group them together as "preposterous" and saw them as leading to overmedicalization. So, what would he make of this new ESC BP category?

The ESC guidance defines elevated BP as a clinic BP of 120/70-139/89 mm Hg or home BP of 120/70-134/84 mm Hg. Note that the same lower BP threshold is used for diagnosing elevated BP with both clinic and home measurements. The guideline task force tells us that this category reflects the steady slope of change in BP over time and that certain at-risk patients may benefit from earlier antihypertensive treatment than others.

The threshold for diagnosing hypertension, thankfully, remains unchanged at ≥ 140/90 mm Hg (home BP ≥ 135/85 mm Hg), which is consistent with other global hypertension guidance.

This new elevated BP category also reflects the expansive evidence base demonstrating a continuum of risk between BP and adverse cardiovascular outcomes even at a systolic BP < 120 mm Hg. Consequently, a BP < 120/70 mm Hg is now termed "nonelevated BP" rather than "normal BP" to signify that these categories are to guide treatment rather than prognosis.

The guideline task force assures us that within this elevated BP category, the efficacy of antihypertensive therapy and prevention of cardiovascular events has been robustly demonstrated with high-quality evidence from randomized clinical trials. Moreover, the benefits of a specified BP reduction are largely independent of pretreatment BP. The task force does acknowledge, however, that cardiovascular risk varies among patients in this new category, and not all will require pharmacologic intervention. And indeed, no pharmacologic intervention is without harm or financial cost.

We are asked to stratify individuals within the elevated BP category by risk to help identify those who would benefit from medication. The guidance recommends the SCORE2 or SCORE2-OP (for those aged ≥ 70 years) risk tools for estimating 10-year cardiovascular risk; if the risk is 10% or greater, then relevant lifestyle interventions should be recommended for 3 months to reduce BP. After this time, medication should be initiated (initially monotherapy) for those with BP that is still ≥ 130/80 mm Hg. If 10-year cardiovascular risk is < 10%, then lifestyle interventions alone are recommended with annual monitoring of BP and cardiovascular risk.

A tighter systolic BP target of 120-129 mm Hg is now recommended for most patients, if tolerated. We must, of course, use our clinical judgement regarding patients with frailty or limited predicted lifespan. A helpful and pragmatic infographic on frailty assessment in the management of BP is included within the guidance.

The guidance also provides sex-specific risk modifiers (eg, gestational diabetes and recurrent miscarriage) and shared risk modifiers (eg, high-risk ethnicity, family history of premature atherosclerotic cardiovascular disease [ASCVD], and severe mental illness) that may tip patients with nontraditional cardiovascular risk factors over the 10% treatment threshold.

Furthermore, the following comorbid conditions warrant prompt antihypertensive therapy for patients with elevated BP without further risk stratification: established clinical ASCVD or heart failure (all subtypes), moderate or severe chronic kidney disease (estimated glomerular filtration rate < 60 mL/min or albuminuria ≥ 3 mg/mmol), type 1 diabetes, type 2 diabetes, and familial hypercholesterolemia. For patients with type 2 diabetes, the task force reminds us that certain patients younger than 60 years with elevated BP may have a 10-year cardiovascular risk < 10%, so in this group, the diabetes-specific risk tool SCORE2-Diabetes should be considered to ensure that cardiovascular disease risk is > 10% before initiating pharmacologic therapy.

This new elevated BP category has significant implications for my primary care workload. At present, UK NICE hypertension guidance prompts further investigation, risk stratification, and consideration of treatment if home BP is 135/85-149/94 mm Hg (ie, stage 1 hypertension) and only repeating BP measurement at least every 5 years if below this BP range. The wider use of home BP monitoring and remote monitoring or telemedicine will facilitate the implementation of this ESC guidance in my clinical practice, as the guidance itself points out.

I also echo my senior partner's concerns that this new category will lead to the overmedicalization of blood pressure; lifestyle intervention should take place pari passu with pharmacologic intervention, and this principle should be communicated clearly with all patients who are considering treatment.

I was therefore pleased to see the hierarchy of lifestyle intervention in the guidance; the first step in healthcare is self-care, and as clinicians, we must educate before we medicate. Moreover, a recent network meta-analysis suggested that the systolic BP-lowering effect of exercise interventions among hypertensive populations appears similar to that of commonly used antihypertensive medications. Lifestyle intervention remains the cornerstone of management of all long-term conditions, not just hypertension.

However, the tighter systolic BP target worries me; this target will lead to polypharmacy and challenges with adherence, as well as harm from adverse drug effects such as postural hypotension and acute kidney injury.

In regard to adherence, past database studies have suggested that after 1 year, almost half of patients stop taking their medication. Single-pill fixed-dose drug combinations will help mitigate nonadherence but are expensive and not widely available in the UK. They thus are underused. The guidance reinforces these ideas.

I am grateful for these evidence-based recommendations for the management of elevated BP and hypertension. But as my senior partner always reminded me, guidelines should be considered handrails rather than train tracks. We should have the confidence to deviate from guidelines when we judge that it is in our patients' best interests. This is the art of modern medicine. Instead of practicing evidence-based medicine, I prefer to deliver evidence-informed yet person-centered care. In this context, that means striving for lower but well-tolerated BP targets.

I acknowledge, however, that hypertension is undertreated globally and has catastrophic consequences. This updated ESC guidance, and specifically the new category of elevated BP, is a significant step forward in addressing this therapeutic gap. It gives clinicians evidence-informed BP targets to aspire to and will help narrow this therapeutic gap, if not completely close it.