Arterial hypertension remains the single most important risk factor for heart attack and stroke, and in August 2024 the European Society of Cardiology fundamentally revised its guideline on the subject [McEvoy et al., Eur Heart J 2024]. Readings that until recently counted as unremarkable now deserve closer investigation. This article sets out what has actually changed and what the new thresholds mean for you.
What the 2024 ESC guidelines actually change
The 2024 ESC guideline introduces a new three-tier classification of blood pressure measured in the practice: non-elevated (below 120/70 mmHg), elevated (120 to 139 / 70 to 89 mmHg) and hypertension (140/90 mmHg and above) [McEvoy et al., Eur Heart J 2024]. The main novelty is the elevated blood pressure category, which describes a range that was previously usually ticked off as normal. For people with elevated blood pressure and high cardiovascular risk, the guideline recommends drug treatment with a target below 130/80 mmHg once around three months of lifestyle measures have brought no result [ESC 2024, Hypertension 2024]. For most treated adults there is also a new systolic target band of 120 to 129 mmHg, provided you tolerate it well. A one-step approach thus replaces the earlier two-stage procedure, in which treatment first aimed for below 140/90 and only then went lower. Diagnosis relies more heavily on measurements outside the practice, at home or over 24 hours, because these predict cardiovascular events more reliably than a single reading at the doctor's visit.
The three blood pressure categories at a glance
- Non-elevated (below 120/70 mmHg): No drug treatment. Keep readings in this range through exercise, diet and weight.
- Elevated (120 to 139 / 70 to 89 mmHg): New category. At high risk and after three months of lifestyle measures, consider drug therapy.
- Hypertension (140/90 mmHg and above): Confirm with measurements outside the practice, then usually treat promptly.
Why the treatment target was lowered to 120 to 129 mmHg
The most striking element of the new guideline is the systolic target band of 120 to 129 mmHg for most treated adults [McEvoy et al., Eur Heart J 2024]. The ESC bases this recommendation on a large number of randomised trials in which more intensive blood pressure lowering measurably reduced heart attacks and strokes, including in older people who were previously excluded from intensive treatment. The condition of good tolerability matters: anyone who cannot reach the lower target because of dizziness, falls or other complaints is adjusted to a higher target that is acceptable for that individual.
For the very old, from around 85 years of age, and in cases of marked frailty, orthostatic symptoms or limited life expectancy, the guideline expressly provides for exceptions [McEvoy et al., Eur Heart J 2024]. The lower target is a recommendation to be applied with judgement rather than a rigid rule. At Dein Team Herzzentrum we discuss this trade-off with each person individually, because the same number means something different for an athletic person in their mid-50s than for a frail person over 80.
The target of 120 to 129 mmHg applies when treatment is well tolerated. Tolerability and coexisting conditions play a part in the decision, not just the number on the monitor.
Why measuring at home has become so important
A reading taken in the practice can mislead. In some people, blood pressure rises simply because of the situation at the doctor's, so-called white-coat hypertension. In others it is the reverse: practice readings look normal while blood pressure in everyday life is persistently too high, known as masked hypertension. Both patterns can only be detected through measurements outside the practice.
That is why the 2024 ESC guideline recommends confirming hypertension wherever possible with home measurements or 24-hour monitoring [McEvoy et al., Eur Heart J 2024]. For home measurement, the Swiss Heart Foundation gives the slightly lower threshold of 135/85 mmHg, because blood pressure is usually lower without the tension of the practice visit [Schweizerische Herzstiftung 2025]. If you measure regularly at home, you should measure in the morning and in the evening, seated, after a few minutes of rest and with the arm kept still, and note the readings over several days. These records are often more informative than a single practice reading, because they show how blood pressure behaves over the day and over the week. People with demanding jobs benefit particularly from this record, since a single reading at an appointment rarely captures the actual load on the heart. The prerequisite is a validated and tested upper-arm device.
How lifestyle and medication work together
The 2024 guideline clearly rates lifestyle measures as an effective first step [McEvoy et al., Eur Heart J 2024]. It recommends a salt intake of under 2 grams of sodium per day, a potassium intake of at least 3.5 grams per day from vegetables and fruit, and at least 150 minutes of moderate endurance exercise per week, supplemented by light strength training [ESC 2024, Hypertension 2024]. These measures lower blood pressure measurably and at the same time improve the overall cardiovascular risk profile. Many people underestimate the effect of consistent salt reduction and regular exercise, even though in some it lowers the systolic value by several mmHg.
For elevated blood pressure with high risk, the guideline gives these measures around three months. If blood pressure stays above that level, drug therapy begins [McEvoy et al., Eur Heart J 2024]. Which medication and which combination make sense depends on age, coexisting conditions and tolerability. That decision belongs in a conversation with your doctor and cannot be made with an online calculator.
When you should have your blood pressure assessed by a cardiologist
In Switzerland, around one in four adults has high blood pressure, which is roughly 1.5 million people, and about a third of them do not know it, because high blood pressure almost never causes symptoms [Schweizerische Herzstiftung 2025]. Among those over 60, as many as one in two is affected. That is precisely what makes high blood pressure dangerous. A simple decision rule helps you recognise the right moment for an assessment.
- Repeated readings of 140/90 mmHg or above in the practice, or 135/85 mmHg at home: confirmation and assessment.
- Elevated readings plus further risk factors such as raised Lp(a), diabetes, smoking or a family history: a cardiological review.
- Known hypertension that does not reach the target band under treatment: review the therapy.
Frequently asked questions
Do the new ESC values also apply in Switzerland?
The ESC guidelines are the authoritative European reference and are endorsed by the Swiss Society of Cardiology. The thresholds for practice measurement (140/90 mmHg) and for home measurement (135/85 mmHg) match the figures given by the Swiss Heart Foundation [Schweizerische Herzstiftung 2025].
Do I now have to take medication if my reading is 130/80?
Not automatically. A reading in the elevated blood pressure category leads first to a risk assessment and to lifestyle measures over around three months. In this range, the guideline recommends drug treatment mainly for people at high cardiovascular risk [McEvoy et al., Eur Heart J 2024].
How is my cardiovascular risk actually estimated?
For people aged 40 to 69, the 2024 guideline uses the SCORE2 tool, and for people aged 70 and over SCORE2-OP, to estimate the ten-year risk of cardiovascular events [McEvoy et al., Eur Heart J 2024]. This determines how rigorously blood pressure should be lowered.
Why is a reading at the doctor's higher than at home?
In many people, blood pressure rises simply because of the examination situation, so-called white-coat hypertension. That is why the 2024 ESC guideline recommends confirming the diagnosis with home measurements or 24-hour monitoring [McEvoy et al., Eur Heart J 2024].
What does the systolic target of 120 to 129 mmHg mean for older people?
For the very old or frail, the guideline expressly provides for higher targets that are acceptable for the individual [McEvoy et al., Eur Heart J 2024]. Tolerability, fall risk and coexisting conditions all play a part. Treatment is generally adapted to the person's life situation.
How often should I have my blood pressure measured?
The Swiss Heart Foundation recommends that adults from the age of 18 have a measurement at least every five years, and from the age of 40 an annual check [Schweizerische Herzstiftung 2025]. With known risk factors or elevated readings, more frequent checks make sense.
This article is no substitute for medical advice. It puts the 2024 ESC guideline in context and is meant to help you understand your own readings better. Which target and which treatment suit you is best clarified in a personal consultation.