22/02/2024, 14:59 2023 ESH Hypertension Guideline Update: Bringing Us Closer Together Across the Pond - American College

n College of Cardiology

2023 ESH Hypertension Guideline Update:

Bringing Us Closer Together Across the Pond
Feb 05, 2024 | Prasantha L Vemu, MD; Eugene Yang, MD, FACC; Joseph Ebinger, MD, FACC
Expert Analysis

Quick Takes
The 2023 European Society of Hypertension (ESH) and 2017 American College of
Cardiology/American Heart Association (ACC/AHA) hypertension guidelines both
emphasize proper blood pressure (BP) measurement, cardiovascular (CV) risk
assessment, optimal lifestyle interventions, and specific pharmacotherapy
management.

Both guidelines recommend a lower BP target (<130/80 mm Hg) for adults at high
risk to reduce the risk of CV events.

Key differences include a lower diagnostic threshold by ACC/AHA criteria (<130/80

mm Hg) than by ESH criteria (<140/90 mm Hg) and age-based treatment targets
(ESH criteria).

Introduction
Hypertension represents a major modifiable risk factor for coronary artery disease (CAD),
heart failure (HF), stroke, chronic kidney disease (CKD), and dementia.1 Two well-established
clinical practice guidelines on hypertension include the 2017 American College of
Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood Pressure in Adults and the recently published
2023 European Society of Hypertension (ESH) Guidelines for the Management of Arterial
Hypertension.2,3 This analysis reviews key similarities and differences between these
guidelines.
Importance of Accurate Blood Pressure Measurement
Both guidelines stress the importance of standardized, accurate measurement of blood
pressure (BP) and recommend office-based measurements for diagnosis. Although both
agree that validated, cuffed devices should be used for BP measurements, the ESH
guidelines explicitly recommend against use of cuffless measurement devices. The ESH
guidelines point to a lack of standardized validation protocols to test the accuracy of these
devices and list concerns about the need for periodic calibration and use of novel predictive
technologies to estimate BP.4,5 There is consensus that multiple office BP measurements
and BP tracking with either home BP monitoring or ambulatory BP monitoring should be
performed before diagnosing hypertension. Compared with the 2018 European Society of
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Cardiology (ESC)/ESH Guidelines for the Management of Arterial Hypertension, the 2023 ESH
guidelines emphasize using out-of-office BP monitoring in addition to traditional in-office
measurements to diagnose hypertension.6
Cardiovascular Risk Stratification
Both guidelines recommend cardiovascular disease (CVD) risk assessment. The ESH
guidelines recommend using the updated Systematic Coronary Risk Evaluation 2 (SCORE2)
tool for CVD risk stratification.7 This risk-estimation model is derived from data from a large
cohort of Europeans without clinical CVD or diabetes mellitus (DM).7 Whereas the original
Systematic Coronary Risk Evaluation (SCORE) tool included only fatal CVD events, the
SCORE2 tool estimates 10-year risk of both fatal and nonfatal CVD events in adults 40-69
years of age, which aligns with the CVD risk assessment tool recommended by the ACC/AHA
guideline.2 The ACC/AHA guideline recommends using the Pooled Cohort Equation (PCE) to
estimate 10-year risk of fatal and nonfatal CVD events in adults 40-79 years of age.2 Unlike
the ACC/AHA guideline, the ESH guidelines recommend using a separate risk assessment
tool for adults ≥70 years of age, derived from a large Norwegian cohort: the Systematic
Coronary Risk Evaluation 2–Older Persons (SCORE2-OP).8 Whereas the PCE is used to guide
treatment decisions of hypertension, the SCORE2 is not. The ACC/AHA guideline
recommends calculating risk in primary-prevention patients and starting medical therapy at
a lower BP threshold for patients at high risk.
Blood Pressure Categories and Hypertension Diagnosis
The 2023 ESH guidelines maintain the same BP grade classifications as the 2018 ESC/ESH
guidelines.6 The ESH recommends a threshold of >140/90 mm Hg (grade 1) for the diagnosis
of hypertension, whereas the ACC/AHA guideline recommends a lower threshold of >130/80
mm Hg (stage 1). Systolic blood pressure (SBP) ranging between 130 and 139 mm Hg or
diastolic blood pressure (DBP) ranging between 80 and 89 mm Hg represent stage 1
hypertension in the ACC/AHA guideline, whereas the ESH guidelines classify these ranges as
"normal" or "high-normal" (130-139/85-89 mm Hg). Whereas the ACC/AHA guideline
categorizes BP ≥140/90 mm Hg as stage 2 hypertension, the ESH guidelines subdivide BP
levels ≥140/90 mm Hg into grades 1, 2, and 3 hypertension (Table 1).
Table 1: Similarities and Differences Between ACC/AHA and ESH Guidelines on
Hypertension

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22/02/2024, 14:59 2023 ESH Hypertension Guideline Update: Bringing Us Closer Together Across the Pond - American College of Cardiology

Table 1: Similarities and Differences Between ACC/AHA and ESH Guidelines on Hypertension. Courtesy of
Vemu PL, Yang E, Ebinger J.
ACC = American College of Cardiology; ACE = angiotensin-converting enzyme; AHA = American Heart
Association; BP = blood pressure; ESH = European Society of Hypertension; SCORE2 = Systematic Coronary
Risk Evaluation 2; SCORE2-OP = Systematic Coronary Risk Evaluation 2–Older Persons.

Blood Pressure Treatment Targets

The ACC/AHA guideline recommends treatment to a BP target of <130/80 mm Hg for many
patients. The ESH guidelines recommend BP treatment targets that differ on the basis of
age. Although the ESH guidelines recommend the same BP treatment target as the ACC/AHA
guideline for many adults, the ESH guidelines recommend higher BP treatment thresholds
for adults >65 years of age. The ESH guidelines target BP <140/80 mm Hg for patients 65-79
years of age. For patients in this age group with isolated systolic hypertension and for adults
≥80 years of age, the threshold is even more lenient, targeting SBP between 140 and 150
mm Hg. The ESH guidelines also recommend a higher BP target (<140/90 mm Hg) for
patients with hypertension and CKD than does the ACC/AHA guideline (<130/80 mm Hg), but
recommend the same BP target (<130/80 mm Hg) for patients with hypertension and
coexisting CAD, DM, and cerebrovascular disease.

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Recommendations for Drug Therapy Initiation

Promotion of lifestyle interventions to prevent, treat, and delay onset of hypertension
feature prominently in both guidelines.2,3 Both guidelines recommend treatment initiation
with antihypertensive agents for patients who have established CVD and BP ≥130/80 mm
Hg. The ACC/AHA guideline further specifies that patients who have an estimated 10-year
risk of atherosclerotic CVD of >10% should also be started on treatment. Both guidelines
recommend treatment initiation at higher BP thresholds of SBP ≥140 mm Hg and/or DBP
≥90 mm Hg regardless of calculated cardiovascular (CV) risk or established CVD. For older
adults (>80 years of age), the ESH guidelines explicitly recommend drug therapy when SBP is
>160 mm Hg, whereas the ACC/AHA guideline does not make this distinction.
Pharmacotherapy
Both guidelines recommend that initial therapies include at least one of four major classes:
angiotensin-converting enzyme inhibitors (ACEIs), angiotensin-receptor blockers (ARBs),
thiazide or thiazide-like diuretics, and calcium channel blockers (CCBs). The ESH guidelines
continue to include beta-blockers (BBs) as an optional first-line therapy on the basis of
randomized controlled trial evidence, whereas the ACC/AHA guideline does not. The
guidelines both emphasize use of BBs for patients with a history of ischemic heart disease
or HF. The ESH guidelines also recommend consideration of BBs in the treatment of other
CV and non-CV conditions, such as atrial fibrillation, hypertension in pregnancy, and
hyperthyroidism.9
Both guidelines recommend single-pill combination therapy to reduce pill burden and
improve adherence. The ESH guidelines recommend the preferred combination of ACEIs or
ARBs with either CCBs or thiazide/thiazide-like diuretics. Whereas the ESH guidelines
strongly emphasize initial treatment with a two-drug combination for most patients with
hypertension, the ACC/AHA guideline recommends this approach for patients with stage 2
hypertension, those with BP >20/10 mm Hg above their target BP, and Black patients.
Renal Denervation Therapy
The updated ESH guidelines now recommend consideration of renal denervation therapy as
an additional or alternative therapy in patients who have uncontrolled resistant
hypertension or adverse effects to medications, which is a change from the 2018 ESC/ESH
guidelines.3
Conclusions
The 2023 ESH guidelines did not endorse major changes to their primary recommendations;
however, the guidelines now align more closely with the 2017 ACC/AHA guideline. Although
these guidelines represent a step toward guideline harmonization, key differences remain,
including when to initiate therapy.
References
1. Fuchs FD, Whelton PK. High blood pressure and cardiovascular disease. Hypertension
2020;75:285-92.

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22/02/2024, 14:59 2023 ESH Hypertension Guideline Update: Bringing Us Closer Together Across the Pond - American College of Cardiology

2. Whelton PK, Carey RM, Aronow WS, et al. 2017

ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA guideline for the
prevention, detection, evaluation, and management of high blood pressure in adults: a
report of the American College of Cardiology/American Heart Association Task Force on
Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.
3. Mancia G, Kreutz R, Brunström M, et al. 2023 ESH guidelines for the management of
arterial hypertension the Task Force for the management of arterial hypertension of
the European Society of Hypertension: endorsed by the International Society of
Hypertension (ISH) and the European Renal Association (ERA). J Hypertens
2023;41:1874-2071.
4. Stergiou GS, Mukkamala R, Avolio A, et al.; European Society of Hypertension Working
Group on Blood Pressure Monitoring and Cardiovascular Variability. Cuffless blood
pressure measuring devices: review and statement by the European Society of
Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular
Variability. J Hypertens 2022;40:1449-60.
5. Mukkamala R, Yavarimanesh M, Natarajan K, et al. (2021). Evaluation of the accuracy of
cuffless blood pressure measurement devices: challenges and proposals. Hypertension
2021;78:1161-7.
6. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management
of arterial hypertension: the Task Force for the management of arterial hypertension of
the European Society of Cardiology and the European Society of Hypertension: the Task
Force for the management of arterial hypertension of the European Society of
Cardiology and the European Society of Hypertension. J Hypertens 2018;36:1953-2041.
7. SCORE2 Working Group and ESC Cardiovascular Risk Collaboration. SCORE2 risk
prediction algorithms: new models to estimate 10-year risk of cardiovascular disease in
Europe. Eur Heart J 2021;42:2439-54.
8. SCORE2-OP Working Group and ESC Cardiovascular Risk Collaboration. SCORE2-OP risk
prediction algorithms: estimating incident cardiovascular event risk in older persons in
four geographical risk regions. Eur Heart J 2021;42:2455-67.
9. Mancia G, Kjeldsen SE, Kreutz R, Pathak A, Grassi G, Esler M. Individualized beta-blocker
treatment for high blood pressure dictated by medical comorbidities: indications
beyond the 2018 European Society of Cardiology/European Society of Hypertension
guidelines. Hypertension 2022;79:1153-66.

Clinical Topics: Prevention, Hypertension

Keywords: Blood Pressure, Blood Pressure Monitors, Hypertension, Primary Prevention, Secondary
Prevention, Cardiovascular Diseases

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