Definition and pathophysiology
Blood pressure is a continuous cardiovascular exposure rather than a binary distinction between normotension and hypertension. Its long-term relationship with cardiovascular risk is therefore graded, although practical clinical care requires diagnostic and treatment thresholds.
The 2024 European guideline defines hypertension as an office systolic blood pressure (SBP) of ≥140 mmHg or diastolic blood pressure (DBP) of ≥90 mmHg. It introduces a separate category of elevated blood pressure, defined as office SBP 120–139 mmHg or DBP 70–89 mmHg. This distinction supports a risk-based approach because cardiovascular benefit from blood-pressure reduction may also occur in selected people whose pressure is elevated but below the conventional hypertension threshold.
The traditional diagnostic threshold of 140/90 mmHg derives from epidemiological observations associating pressures above this level with increased mortality. Contemporary management, however, incorporates overall cardiovascular risk, comorbidity and hypertension-mediated organ damage (HMOD), rather than relying exclusively on the office pressure value.
Blood-pressure terminology
Systolic blood pressure: the maximum arterial pulsatile pressure during systole. With auscultatory measurement, it corresponds to the appearance of the first Korotkoff sound.
Diastolic blood pressure: the minimum arterial pulsatile pressure during diastole. It corresponds to disappearance of Korotkoff sounds; if sounds persist, the fourth Korotkoff sound is used.
Office blood pressure: blood pressure measured in a clinical setting, manually or with an automated device.
Home blood-pressure monitoring (HBPM): self-measurement at home, generally with a validated upper-arm oscillometric device.
Ambulatory blood-pressure monitoring (ABPM): automated measurement, usually over 24 hours, at predefined intervals.
Inter-arm difference: a sequential systolic difference of >10 mmHg between the arms.
Orthostatic hypotension: a fall of ≥20 mmHg in SBP and/or ≥10 mmHg in DBP at 1 or 3 minutes after standing, following 5 minutes seated or supine.
White-coat hypertension: office pressure above the hypertension threshold but non-hypertensive home or ambulatory pressure.
Masked hypertension: office pressure below the hypertension threshold but hypertensive home or ambulatory pressure.
Office measurements provide only a limited representation of usual blood pressure and may be biased by the clinical environment. Out-of-office measurement is consequently central to diagnosis and long-term management.
Clinical presentation and symptoms
The source material does not describe the typical symptoms or symptom burden of uncomplicated hypertension. It does, however, identify symptomatic hypotension and symptoms suggestive of orthostatic hypotension as indications for additional postural assessment and as factors influencing treatment targets.
Blood pressure ≥180/110 mmHg requires assessment for hypertensive emergency. In that setting, clinical assessment must determine whether immediate blood-pressure-lowering treatment is required.
Patients with suggestive symptoms, signs or a medical history indicating possible secondary hypertension should undergo appropriate screening for an underlying secondary cause.
Evaluation and physical examination
Standardized office measurement
Accurate technique is essential because inconsistent or incorrect measurement may lead to misclassification. Blood pressure should be measured with a validated and calibrated device using a consistent method for the individual patient.
The recommended procedure is as follows:
The patient should remain seated comfortably in a quiet environment for 5 minutes.
The back and arm should be supported, with the cuff at heart level.
A standard cuff measuring approximately 12–13 cm in width and 35 cm in length is suitable for most patients. Larger or smaller cuffs should be used when arm circumference is >32 cm or <26 cm, respectively.
Three measurements should be obtained, separated by 1–2 minutes.
If the first two readings differ by >10 mmHg, additional measurements should be performed.
The recorded office pressure should be the average of the last two readings.
Both arms should be measured at the first visit. If the systolic inter-arm difference is >10 mmHg, subsequent readings should use the arm with the higher pressure.
Pulse should be palpated at rest to determine heart rate and detect arrhythmias, including atrial fibrillation.
Orthostatic pressure should be measured at 1 and 3 minutes after standing, after 5 minutes seated or supine, at least during the initial assessment and subsequently when symptoms suggest postural hypotension.
In atrial fibrillation, blood-pressure variability may be substantial. Since most automated oscillometric devices have not been validated for measurement during atrial fibrillation, manual auscultatory measurement should be considered where feasible, with additional readings if necessary.
Screening and reassessment
Opportunistic blood-pressure screening should be performed at least every three years in adults younger than 40 years and at least annually in adults aged 40 years or older. Adults should have their blood pressure recorded in the medical record and should be informed of the current value.
A single screening office measurement is generally insufficient to establish hypertension, particularly when the pressure is close to a diagnostic threshold. Confirmation should preferably be obtained outside the office or, if that is not feasible, by repeated standardized office measurements over more than one visit.
Cardiovascular risk assessment
Treatment decisions for elevated blood pressure should be risk-based. Increased cardiovascular risk is recognized in individuals with:
Moderate or severe chronic kidney disease
Established cardiovascular disease
Hypertension-mediated organ damage
Diabetes mellitus
Familial hypercholesterolaemia
SCORE2 is recommended for estimating 10-year fatal and non-fatal cardiovascular risk in people aged 40–69 years with elevated blood pressure who do not already qualify as high risk on the basis of these conditions. SCORE2-OP is recommended for individuals aged ≥70 years in the corresponding situation. Regardless of age, a SCORE2 or SCORE2-OP risk of ≥10% identifies increased cardiovascular risk for purposes of blood-pressure management.
In people with borderline increased 10-year risk of 5% to <10%, risk classification may be refined, after shared decision-making, with selected investigations such as coronary artery calcium scoring, carotid or femoral plaque assessment by ultrasound, high-sensitivity cardiac troponin, B-type natriuretic peptide or pulse-wave velocity. Coronary calcium scoring may also be considered when it is likely to change management.
Diagnostics
Diagnostic thresholds by measurement setting
The European guideline retains an office threshold of ≥140/90 mmHg for hypertension. For HBPM, an average of ≥135/85 mmHg is considered equivalent to an office pressure of ≥140/90 mmHg. Home SBP of 120–134 mmHg or DBP of 70–84 mmHg represents elevated blood pressure in the home setting.
Out-of-office thresholds are particularly important because white-coat and masked hypertension are common. Their estimated prevalence is approximately 15–25% for each condition.
| Clinical situation | Recommended diagnostic approach |
|---|---|
| Office BP 120–139/70–89 mmHg with increased cardiovascular risk | ABPM and/or HBPM; if not feasible, repeated office measurements at more than one visit |
| Office BP 140–159/90–99 mmHg | Confirm with ABPM and/or HBPM; if unavailable, repeated office measurements at more than one visit |
| Office BP 160–179/100–109 mmHg | Confirm promptly, preferably with HBPM or ABPM, for example within 1 month |
| Office BP ≥180/110 mmHg | Exclude hypertensive emergency; if emergency is present, commence treatment immediately |
| Office BP ≥180/110 mmHg without emergency | Prompt confirmation, preferably within approximately one week, may be considered before treatment initiation |
When treatment is being considered for elevated blood pressure, particularly in people with high cardiovascular risk, out-of-office measurement is recommended both to confirm the pressure and to detect masked hypertension.
White-coat and masked hypertension
White-coat hypertension consists of hypertensive office readings with non-hypertensive readings at home or during ambulatory monitoring. The cardiovascular risk profile of affected adults is more similar to that of people without sustained hypertension than to that of people with hypertension both inside and outside the office. Non-pharmacological treatment and careful surveillance are therefore emphasized in the source material, with monitoring for progression to sustained hypertension.
Masked hypertension is characterized by apparently non-hypertensive office pressure but hypertensive home or ambulatory pressure. Its cardiovascular risk profile resembles that of sustained hypertension. It should be suspected particularly when an apparently elevated but non-hypertensive office pressure coexists with HMOD, such as left ventricular hypertrophy or proteinuria. The source material indicates that such patients may require antihypertensive medication in addition to lifestyle intervention.
Electrocardiography and cardiac imaging
A 12-lead electrocardiogram is recommended for all patients with hypertension. Echocardiography is recommended when the ECG is abnormal or when signs or symptoms suggest cardiac disease.
These investigations form part of the evaluation for cardiovascular involvement and HMOD. The source material does not provide further echocardiographic criteria or specific electrocardiographic findings.
Fundoscopy
Fundoscopy is recommended in patients with blood pressure >180/110 mmHg during evaluation for hypertensive emergency or malignant hypertension. It is also recommended in patients with hypertension and diabetes.
Assessment for secondary hypertension
Patients with suggestive signs, symptoms or a relevant medical history should be screened for secondary hypertension. Screening for primary aldosteronism using renin and aldosterone measurements should be considered in all adults with confirmed hypertension, defined here as BP ≥140/90 mmHg.
Routine genetic testing is not recommended for patients with hypertension. Patients with resistant hypertension should be considered for referral to specialist hypertension centres for further investigation. Objective assessment of adherence, either through directly observed therapy or detection of prescribed drugs in blood or urine, may be considered in apparent resistant hypertension when resources permit.
Resistant hypertension is defined as failure to reduce office SBP and DBP below 140 and 90 mmHg, respectively, despite appropriate lifestyle measures and maximally tolerated treatment with a diuretic, a renin–angiotensin-system blocker and a calcium-channel blocker. The uncontrolled office measurements must be confirmed with HBPM or ABPM.
Biomarkers and laboratory findings
Serum creatinine, estimated glomerular filtration rate and urine albumin-to-creatinine ratio should be measured in all patients with hypertension. In moderate-to-severe chronic kidney disease, these measurements should be repeated at least annually.
The source material does not specify additional routine laboratory tests or their interpretation. High-sensitivity cardiac troponin and B-type natriuretic peptide are mentioned as possible tools for cardiovascular risk refinement in selected individuals with borderline increased predicted risk, rather than as universal diagnostic tests.
Treatment and management
Lifestyle intervention
Lifestyle measures are recommended for all adults with elevated blood pressure or hypertension. The specified interventions include:
Sodium restriction to approximately 2 g per day, equivalent to about 5 g of sodium chloride or approximately one teaspoon or less of salt daily.
Moderate-intensity aerobic exercise for at least 150 minutes per week, such as at least 30 minutes on 5–7 days per week. An alternative is 75 minutes of vigorous exercise per week over three days.
Addition of low- or moderate-intensity dynamic or isometric resistance exercise two to three times weekly.
Maintenance of a stable, healthy body mass index of 20–25 kg/m2.
Waist circumference below 94 cm in men and below 80 cm in women.
Restriction of free sugars, particularly sugar-sweetened beverages, to no more than 10% of energy intake.
In patients without moderate-to-advanced chronic kidney disease who have high sodium intake, consideration of increasing potassium intake by 0.5–1.0 g/day, for example through fruit- and vegetable-rich diets or potassium-enriched salt containing 75% sodium chloride and 25% potassium chloride.
When potassium intake is increased in chronic kidney disease or during treatment with potassium-sparing drugs, including some diuretics, ACE inhibitors, angiotensin receptor blockers or spironolactone, serum potassium monitoring should be considered.
Indications for pharmacological treatment
In adults with elevated blood pressure and low or intermediate cardiovascular risk, defined as <10% 10-year risk, lifestyle intervention is recommended and may reduce cardiovascular risk.
In adults with elevated blood pressure and sufficiently high cardiovascular risk, pharmacological treatment is recommended after three months of lifestyle intervention when confirmed BP remains ≥130/80 mmHg.
For confirmed hypertension at ≥140/90 mmHg, pharmacological treatment and lifestyle measures should be initiated promptly, irrespective of cardiovascular risk.
The source material does not provide specific antihypertensive drug names, starting doses, dose-escalation schedules or combination regimens. It does identify the principal classes used in the definition of resistant hypertension: thiazide or thiazide-like diuretics, renin–angiotensin-system blockers and calcium-channel blockers.
Treatment targets
For adults receiving blood-pressure-lowering therapy, the principal target is an SBP of 120–129 mmHg, provided that treatment is well tolerated. Out-of-office measurements are strongly emphasized for confirming attainment of this target.
When this target cannot be achieved because of poor tolerance, the recommended goal is the lowest pressure that is reasonably achievable—the “as low as reasonably achievable” principle.
More lenient treatment targets should be considered in people with:
Symptomatic orthostatic hypotension before treatment
Age ≥85 years
Clinically significant moderate-to-severe frailty
Limited predicted lifespan, defined in the source material as <3 years
In these circumstances, treatment should generally be considered only from an office BP of ≥140/90 mmHg. Treatment tolerance requires close monitoring.
Duration and adherence
Blood-pressure-lowering therapy should generally be continued lifelong, including beyond age 85 years, if it remains well tolerated.
Medication should be taken at the time of day most convenient for the patient, with the aim of establishing a consistent routine and improving adherence. Out-of-office measurements are recommended during ongoing management to quantify treatment response, guide medication titration and identify treatment-related hypotension.
Guideline recommendations
The principal recommendations are summarized below.
| Recommendation | Class | Level |
|---|---|---|
| Use a validated and calibrated device with standardized, consistent technique | I | B |
| Measure and record BP opportunistically in all adults aged ≥18 years | I | C |
| Use out-of-office BP for diagnostic confirmation and detection of white-coat or masked hypertension | I | B |
| Measure BP in both arms at the first visit | I | B |
| Use the arm with the higher pressure for subsequent measurements when the inter-arm systolic difference is >10 mmHg | I | B |
| Use out-of-office BP during ongoing management to assess treatment response and guide titration | I | B |
| Palpate the pulse at rest during BP assessment | I | C |
| Consider manual auscultatory BP measurement in atrial fibrillation | IIa | C |
| Measure creatinine, eGFR and urine ACR in all patients with hypertension | I | A |
| Repeat creatinine, eGFR and urine ACR at least annually in moderate-to-severe CKD | I | C |
| Obtain a 12-lead ECG in all patients with hypertension | I | B |
| Perform echocardiography when ECG abnormalities or signs or symptoms of cardiac disease are present | I | B |
| Perform fundoscopy when BP is >180/110 mmHg in suspected hypertensive emergency or malignant hypertension, and in hypertensive patients with diabetes | I | C |
| Screen for secondary hypertension when clinical features or history are suggestive | I | B |
| Consider renin and aldosterone testing for primary aldosteronism in all adults with confirmed hypertension | IIa | B |
| Restrict sodium to approximately 2 g/day | I | A |
| Undertake at least 150 minutes of moderate aerobic exercise weekly, supplemented by resistance training | I | A |
| Aim for BMI 20–25 kg/m2 and waist circumference <94 cm in men and <80 cm in women | I | A |
| Initiate drug treatment promptly for confirmed BP ≥140/90 mmHg | I | A |
| In higher-risk adults with confirmed BP ≥130/80 mmHg after three months of lifestyle intervention, initiate pharmacological treatment | I | A |
| Continue tolerated BP-lowering treatment lifelong | I | A |
| Consider at least annual follow-up once BP and other cardiovascular risk factors are stable | IIa | C |
Prognosis and follow-up
The source material links white-coat hypertension with a cardiovascular risk profile closer to that of individuals without sustained hypertension, while masked hypertension has a risk profile resembling sustained hypertension. This distinction makes confirmation outside the office important for prognosis as well as diagnosis.
Ambulatory monitoring adds information about nighttime blood pressure. Individuals who do not show the usual pronounced nighttime decline—so-called non-dippers—have higher cardiovascular risk. Nighttime readings may therefore be particularly informative for risk prediction.
After blood pressure is controlled and stable on treatment, follow-up for blood pressure and other cardiovascular risk factors should be performed at least annually. More frequent reassessment is required when treatment is being initiated or adjusted, when orthostatic symptoms occur, when treatment is poorly tolerated, or when out-of-office measurements indicate inadequate control.
The source material does not provide specific mortality estimates, event rates, drug-specific outcome data or detailed follow-up intervals beyond the recommendation for at least yearly review once control is stable.
