ESC 2024 vs. ACC/AHA 2025 Hypertension Guidelines Comparison
The 2024 ESC and 2025 ACC/AHA hypertension guidelines offer updated approaches to blood pressure management, sharing common ground in patient-centered care and lifestyle interventions. However, they diverge significantly in blood pressure categorization, specific treatment targets, and risk stratification tools. Understanding these distinctions is crucial for clinicians to apply the most appropriate diagnostic and therapeutic strategies based on regional practices and patient profiles, aiming to optimize cardiovascular health outcomes.
Key Takeaways
Guidelines share patient-centered care and lifestyle intervention emphasis.
ESC 2024 introduces 'Elevated BP' (120-139/70-89 mmHg) category.
ACC/AHA 2025 uses 'Elevated' (120-129/<80 mmHg) and 'Stage 1' (130-139/80-89 mmHg).
BP targets vary: ESC aims for 120-129/70-79 mmHg, ACC/AHA for <130/80 mmHg.
Risk stratification tools differ: ESC uses SCORE2/SCORE2-OP, ACC/AHA uses PREVENT.
What are the key differences and similarities between the 2024 ESC and 2025 ACC/AHA hypertension guidelines?
The 2024 European Society of Cardiology (ESC) and 2025 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines, while both emphasizing patient-centered care and the critical importance of managing hypertension for cardiovascular health, present notable distinctions. These differences primarily manifest in how blood pressure is categorized, the specific targets for treatment, and the tools employed for risk stratification. Both guidelines advocate for similar first-line drug choices and strongly promote lifestyle interventions, yet their nuanced approaches to diagnosis and management necessitate careful consideration by healthcare professionals to ensure optimal patient outcomes.
- Overall Approach: Both guidelines emphasize patient-centered care and the critical importance of hypertension management for cardiovascular health.
- BP Categorization: ESC 2024 introduces 'Elevated BP' (120-139/70-89 mmHg) and maintains Hypertension (≥140/90 mmHg), with distinct out-of-office thresholds. ACC/AHA 2025 defines 'Elevated' (120-129/<80 mmHg), 'Stage 1 Hypertension' (130-139/80-89 mmHg), and 'Stage 2 Hypertension' (≥140/≥90 mmHg), primarily using office BP thresholds.
- BP Targets: ESC 2024 suggests a general target of 120-129/70-79 mmHg, with individualized flexibility. ACC/AHA 2025 aims for <130/80 mmHg, encouraging <120/<80 mmHg for high-risk individuals.
- Risk Stratification: ESC 2024 utilizes SCORE2/SCORE2-OP, with a ≥10% 10-year CVD risk threshold for treatment consideration. ACC/AHA 2025 employs PREVENT, with a ≥7.5% 10-year CVD risk threshold for treatment initiation at lower BP levels.
- First-line Drug Choices: Both largely agree on ACE inhibitors/ARBs, CCBs, and thiazide-like diuretics as primary options.
- Lifestyle Interventions: Both strongly advocate for similar lifestyle modifications, including diet, exercise, sodium/potassium intake, and cessation of alcohol/smoking. ESC highlights the 'special status' of lifestyle interventions.
- Special Populations Management: Both address specific considerations for diabetes, chronic kidney disease, and pregnancy with individualized approaches.
- Resistant Hypertension & RDN: Both share similar definitions, consider MRA as a key addition, and emphasize multidisciplinary team evaluation for renal denervation.
- Implementation: Both guidelines emphasize multidisciplinary team-based care and the importance of out-of-office blood pressure monitoring.
What are the key aspects of the 2024 ESC Hypertension Guidelines?
The 2024 ESC Guidelines introduce significant updates to the management of elevated blood pressure and hypertension, reflecting a refined understanding of risk and treatment strategies. A notable change is the introduction of a new 'Elevated BP' category, alongside a clear definition for hypertension, emphasizing the importance of out-of-office measurements for accurate diagnosis and ongoing management. The guidelines advocate for a risk-based approach to treatment, utilizing specific tools like SCORE2/SCORE2-OP for comprehensive risk assessment. They also provide detailed recommendations for blood pressure targets, drug choices, and lifestyle interventions, ensuring a holistic and individualized patient care strategy.
- Definitions and Diagnostic Thresholds: The title changed to 'Guidelines on the management of elevated blood pressure and hypertension'. A new 'Elevated BP' category (120-139/70-89 mmHg) is introduced, with hypertension defined as ≥140/90 mmHg. Out-of-office measurement is promoted for diagnosis and management.
- Risk Stratification and Patient Categories: A risk-based approach categorizes BP as non-elevated, elevated, and hypertension. High-risk conditions include CKD, clinical CVD, HMOD, diabetes, and familial hypercholesterolemia. SCORE2/SCORE2-OP is used for risk assessment in different age groups, complemented by additional risk tools like CAC score and arterial stiffness.
- Blood Pressure Targets: The general target is 120-129/70-79 mmHg, with strong emphasis on individualized targets, especially when the systolic target is not tolerated. Specific considerations are given for older patients, those with limited life expectancy, and special populations like pregnant individuals, diabetics, and CKD patients.
- First-line and Second-line Drug Choices: ACE inhibitors, ARBs, CCBs, and diuretics are first-line drug classes. Beta-blockers are added preferentially in certain circumstances. Second-line options for resistant hypertension include spironolactone. Combination therapy is recommended for Stage 1 hypertension.
- Lifestyle Interventions: Comprehensive recommendations cover dietary sodium restriction, potassium intake, physical activity, weight reduction, and moderation of alcohol, coffee, and soft drinks.
- Management in Special Groups: Detailed guidance is provided for elderly/frail patients, individuals with diabetes, chronic kidney disease, pregnant women, and those with resistant hypertension.
- Follow-up, Monitoring, and Treatment Goals: The guidelines emphasize lifelong treatment, regular follow-up, patient-centered care, and multidisciplinary management to achieve defined treatment goals.
What are the core recommendations of the 2025 ACC/AHA Hypertension Guidelines?
The 2025 ACC/AHA Hypertension Guidelines provide a comprehensive framework for diagnosing and managing high blood pressure, building upon previous recommendations with updated insights. These guidelines categorize blood pressure into normal, elevated, Stage 1, and Stage 2, stressing the importance of accurate measurement through multiple readings. They advocate for a risk-based approach, utilizing the PREVENT tool to guide treatment initiation. The overarching blood pressure target is set at less than 130/80 mmHg, with specific considerations for high-risk individuals and special populations. The guidelines also detail first-line drug therapies, combination strategies, and robust lifestyle interventions, promoting a team-based care model for effective long-term management.
- Definitions and Diagnostic Thresholds: BP categorization includes Normal, Elevated, Stage 1, and Stage 2. Diagnosis requires an average of two or more careful readings on two or more occasions. Out-of-office monitoring (ABPM or HBPM) is recommended for confirmation and ongoing monitoring.
- Risk Stratification and Patient Categories: A risk-based approach uses the PREVENT tool for comprehensive risk assessment. Risk thresholds for treatment initiation are defined for increased risk (≥7.5% using PREVENT), lower risk (<7.5% using PREVENT), all adults with hypertension, and those with clinical CVD.
- Blood Pressure Targets: The overarching goal is <130/80 mmHg for all adults, with individualized considerations for special populations. High-risk individuals are encouraged to achieve a systolic BP goal <120 mmHg and diastolic BP goal <80 mmHg. Individualization may be required for patients with intolerance, side effects, limited life expectancy, or frailty. Specific targets are outlined for pregnancy, diabetes, chronic kidney disease, and cerebrovascular conditions.
- First-line and Second-line Drug Choices: First-line therapy includes thiazide-type diuretics, long-acting dihydropyridine CCBs, ACE inhibitors, or ARBs. Combination therapy is recommended for Stage 2 hypertension, while monotherapy is reasonable for Stage 1. Contraindicated combinations, such as simultaneous use of ACEi, ARB, and renin inhibitor, are highlighted. Second-line options for resistant hypertension include MRAs. Labetalol and extended-release nifedipine are preferred in pregnancy.
- Lifestyle Interventions: A comprehensive approach includes weight management, healthy dietary patterns, sodium reduction, adequate potassium intake, regular physical activity, and stress management.
- Management in Special Groups: Specific guidance is provided for elderly/frail patients, individuals with diabetes, chronic kidney disease, pregnant women, and those with resistant hypertension.
- Follow-up, Monitoring, and Treatment Goals: The guidelines emphasize an overarching goal of <130/80 mmHg, team-based care, consistent monitoring, and integrated treatment models, with clear follow-up protocols after therapy changes.
Frequently Asked Questions
What is the primary difference in BP categorization between the ESC and ACC/AHA guidelines?
The ESC 2024 guidelines introduce an 'Elevated BP' category (120-139/70-89 mmHg) and define hypertension as ≥140/90 mmHg. The ACC/AHA 2025 guidelines use 'Elevated' (120-129/<80 mmHg) and 'Stage 1 Hypertension' (130-139/80-89 mmHg).
How do the blood pressure targets compare in the new guidelines?
The ESC 2024 guidelines generally target 120-129/70-79 mmHg. The ACC/AHA 2025 guidelines aim for an overarching goal of <130/80 mmHg, encouraging <120/<80 mmHg for high-risk individuals, with both allowing for individualization.
Which risk stratification tools are recommended by each guideline?
The ESC 2024 guidelines recommend SCORE2/SCORE2-OP for risk assessment. The ACC/AHA 2025 guidelines utilize the PREVENT tool to assess 10-year cardiovascular disease risk and guide treatment initiation.
