Treatment of hypertension in Norway in relation to new European hypertension guidelines

Abstract

New guidelines for high blood pressure (BP) by the European Society of Cardiology (ESC) now consider BP of 120–140/70–90 mmHg to be elevated (“high”) BP and recommend pharmacotherapy for BP > 130/80 mmHg if the estimated 10-year risk of cardiovascular events exceeds 10%, regardless of age. These recommendations are given with reference to two meta-analyses, but the studies included in the referred meta-analyses lack direct relevance, as patients in the first meta-analysis had established hypertension and several cardiovascular risk conditions. Further, the estimation of risk levels in the second meta-analysis was not done a priori with the recommended SCORE2 risk tool, but through a post hoc analysis of cardiovascular death in the placebo group. We argue that no randomized study has provided BP treatment based on such risk algorithms, nor from healthy participants with “elevated BP” (120–139/70–89 mmHg). A further problem is the use of a fixed risk threshold of 10% regardless of age, which will shift treatment to older patients without any major risk factors, while younger individuals with early onset of high BP and other metabolic syndrome characteristics usually will have a 10-year estimated cardiovascular risk far below this threshold, thus treatment may be delayed. This concept of the 2024 ESC hypertension guidelines is not evidence-based and should, in our opinion, not be implemented in Norway or in any other country. Norwegian doctors should follow the National Directorate of Health’s guidelines with age-adjusted intervention thresholds and consult European Society of Hypertension guidelines if they need to consider more extensive patient recommendations.

Keywords

blood pressure / European Society of Cardiology / European Society of Hypertension / guidelines / hypertension

References

[1] Hjerte- og karsykdommer i Norge [Internet]. Folkehelseinstituttet; [cited 2025 Nov 10]. Available from: https://www.fhi.no/he/fr/folkehelserapporten/ikke-smittsomme/Hjerte-kar/

[2] Desai T, Clarke R, Ross S, Grimsgaard S, Njølstad I, Lewington S. Trends in prevalence, treatment and control of hypertension in 38,825 adults over 36 years in Tromsø prospective study. Scand J Public Health. 2023; 51: 1033-41.

[3] Holmen J, Holmen TL, Tverdal A, Holmen OL, Sund ER, Midthjell K. Blood pressure changes during 22-year of follow-up in large general population - the HUNT Study, Norway. BMC Cardiovasc Disord. 2016; 16: 94.

[4] Forebygging av hjerte- og karsykdom [Internet]. Helsedirektoratet; [cited 2025 Nov 10]. Available from: https://www.helsedirektoratet.no/retningslinjer/forebygging-av-hjerte-og-karsykdom

[5] Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, 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.

[6] McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, et al.; ESC Scientific Document Group. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024; 45: 3912-4018.

[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] Blood Pressure Lowering Treatment Trialists’ Collaboration. Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis. Lancet. 2021; 397: 1625-36.

[10] Thomopoulos C, Parati G, Zanchetti A. Effects of blood-pressure-lowering treatment on outcome incidence. 12. Effects in individuals with high-normal and normal blood pressure: overview and meta-analyses of randomized trials. J Hypertens. 2017; 35: 2150-60.

[11] Selmer R, Igland J, Ariansen I, Tverdal A, Njølstad I, Furu K, et al. NORRISK 2: A Norwegian risk model for acute cerebral stroke and myocardial infarction. Eur J Prev Cardiol. 2017; 24: 773-82.

[12] Navar-Boggan AM, Peterson ED, D’Agostino RB Sr, Pencina MJ, Sniderman AD. Using age- and sex-specific risk thresholds to guide statin therapy: one size may not fit all. J Am Coll Cardiol. 2015; 65: 1633-9.

[13] Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, et al.; ESC Scientific Document Group. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021; 42: 3227-337.

[14] Lonn EM, Bosch J, López-Jaramillo P, Zhu J, Liu L, Pais P, et al.; HOPE-3 Investigators. Blood-Pressure Lowering in Intermediate-Risk Persons without Cardiovascular Disease. N Engl J Med. 2016; 374: 2009-20.

[15] Kjeldsen SE, Brunström M, Burnier M, Egan B, Narkiewicz K, Kreutz R, et al. Management of ‘Elevated’ blood pressure according to the 2024 European Society of Cardiology Guidelines: lack of supportive evidence and high risk of excessive treatment. Blood Press. 2025; 34: 2480608.

[16] Klemsdal TO, Gjelsvik B, Elling I, Johansen S, Kjeldsen SE, Kristensen Ø, et al. New guidelines for the prevention of cardiovascular disease. Tidsskr Laegeforen. 2017; 137.

[17] Chen H, Zhang X, Cai S, Li J, Tang S, Hocher C, et al. Even high normal blood pressure affects live birth rate in women undergoing fresh embryo transfer. Hum Reprod. 2022; 37: 2578-88.

[18] Ma S, Hu L, Chen H, Liu Y, Hocher J, Xu X, et al. Inverse association of prepregnancy systolic blood pressure and live birth rate in normotensive women undergoing in vitro fertilization/intracytoplasmic sperm injection. Fertil Steril. 2024; 122: 667-77.

[19] Kjeldsen SE, Gjelsvik B, Klemsdal TO. Hypertensjonsbehandling i lys av nye internasjonale retningslinjer. Tidsskr Nor Laegeforen. 2025; 145. Norwegian.