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2023 ESH Hypertension Guideline Update - Bringing Us Closer Together Across The Pond - American College of Cardiology
2023 ESH Hypertension Guideline Update - Bringing Us Closer Together Across The Pond - American College of Cardiology
n College of Cardiology
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.
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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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.
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Keywords: Blood Pressure, Blood Pressure Monitors, Hypertension, Primary Prevention, Secondary
Prevention, Cardiovascular Diseases
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Last Updated February 2024
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