The 2024 European Society of Cardiology (ESC) Guidelines on elevated blood pressure (BP) and hypertension reflect a shift from binary thresholds towards a risk-based management approach that aims to reflect the continuous relationship between BP and cardiovascular disease (CVD).1 2 Specifically, rather than providing treatment recommendations based solely on a binary hypertension threshold of BP ≥140/90 mm Hg, the 2024 ESC Guidelines expand treatment recommendations to a broader range of adults who benefit from BP lowering. To this end, the ESC endorses the following categorisation of BP: (1) Non-elevated (office BP <120/70 mm Hg) for which drug treatment is not recommended; (2) Elevated (120–139/70–89 mm Hg) for which drug treatment is recommended based on high CVD risk and follow-up systolic BP level ≥130 mm Hg after 3 months of lifestyle intervention; and (3) Hypertension (≥140/90 mm Hg) for which prompt confirmation and drug treatment are recommended in most individuals.1
It is important to note at the outset that this new BP categorisation and the related recommendations for BP lowering in the 2024 ESC Guidelines are based on a consistent body of evidence from multiple contemporary randomised clinical trials.3–8 In other words, the 2024 ESC treatment recommendations draw on causal knowledge from multiple trials demonstrating reductions in fatal and non-fatal CVD and all-cause mortality.4 A common theme of these trials was the enrolment of high CVD risk adults with systolic BP ≥130 mm Hg and randomising them to a target systolic BP of <130 mm Hg (indeed many randomised to <120 mm Hg). These trials cannot be …
