Staying up to date with clinical practice guidelines is crucial for health care professionals. This article, the first in a 3-part series, summarizes key 2024 guideline updates relevant to primary care practice. This particular article focuses on recent evidence-based guidance impacting cardiovascular care and management of metabolic conditions, offering a practical overview for busy family physicians.

The European Society of Cardiology (ESC) recommends opportunistic screening for those with elevated blood pressure (BP) every 1 to 3 years (class IIa, level C evidence).1 Hypertension is typically asymptomatic; opportunistic screening assists in early detection. Low-risk adults (<40 years old) should be screened every 3 years, while those aged 40 years or older or with previously elevated BP not requiring treatment should be screened annually.

The ESC recommends classifying management of elevated office BP (120-139/70-89 mm Hg) based on cardiovascular risk level (class I, level B evidence).1 Manage BP with lifestyle interventions alone for the following groups: adults aged 85 years or older, those with moderate to severe frailty, those with symptomatic orthostatic hypotension, or those with a low cardiovascular risk score (Systematic Coronary Risk Evaluation 2 [SCORE2] value <5%) (class I, level B evidence). Initiate pharmacotherapy for high-risk patients—defined as those with cardiovascular disease, moderate-to-severe chronic kidney disease, diabetes, familial hyperlipidemia, hypertension-mediated organ damage, or a SCORE2 risk value of 10% or greater—whose BP remains at 130/80 mm Hg or more after 3 months of lifestyle interventions (class 1, level A evidence). Guide the treatment decision for intermediate-risk patients (SCORE2 value between 5% to 10%) using additional risk modifiers (eg, pregnancy-related disorders, family history, inflammatory disorders). Further tests (ie, coronary artery calcium scan, carotid ultrasound, biomarker testing) may be considered.

The ESC recommends a BP treatment target of 120-129/70-79 mm Hg for most adults receiving antihypertensive medication (class I, level A evidence for systolic BP and class IIb, level C evidence for diastolic BP).1 Intensive BP control reduces average cardiovascular event rates. Confirm the diagnosis with home or ambulatory monitoring if office BP is 140/90 mm Hg or greater, or if BP is 130-139/80-89 mm Hg with risk factors (class I, level A evidence). If BP remains 130/80 mm Hg or more, target a BP of 120-129/70-79 mm Hg using a combination of lifestyle interventions and pharmacotherapy. Aim for a more lenient target—the lowest tolerated BP—for patients aged 85 years or older, those with symptomatic orthostatic hypotension, or those with moderate-to-severe frailty. This aligns with the 2025 Hypertension Canada guidelines, which recommend a systolic blood pressure target of less than 130 mm Hg for most patients, regardless of cardiovascular risk. Diastolic targets are not specified given limited evidence of additional benefit. A higher, individualized target may be appropriate for patients who are frail or symptomatic.2

The ESC recommends a low-dose combination therapy—an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) plus a dihydropyridine calcium channel blocker (CCB) or thiazide–thiazide like diuretic—as initial treatment for uncomplicated hypertension (class I, level B evidence).1 Combining medications has potential synergistic effects by targeting multiple pathophysiological pathways and can potentially decrease side effects by allowing for lower doses. Escalate to low-dose triple therapy, then maximize doses if BP remains uncontrolled after 1 to 3 months. Consider adding spironolactone for resistant hypertension (class IIa, level B evidence). Consider monotherapy initially by using a long-acting dihydropyridine CCB or a renin-angiotensin system (RAS) inhibitor for patients in the elevated BP category (ie, BP 120-139/70-89 mm Hg), those with moderate-to-severe frailty, those with symptomatic orthostatic hypotension, or patients aged 85 years or older (class IIa, level B evidence). These recommendations do not alter established treatments for specific populations, including those with myocardial infarction (β-blockers and RAS blockers), angina (β-blockers and-or CCB), heart failure with reduced ejection fraction (HFrEF), (quadruple therapy), heart failure with preserved ejection fracture (ARB and-or mineralocorticoid receptor antagonists [MRAs]), chronic kidney disease (sodium-glucose cotransporter-2 inhibitors (SGLT2Is) and RAS blockers), stroke (RAS blocker and CCB); patients who are Black (diuretics and-or CCB); and pregnant patients (dihydropyridine CCB or labetalol).

The ESC suggests considering renal denervation for selected patients with uncontrolled hypertension despite taking maximal medication doses, or those at high cardiovascular risk intolerant or not adherent to medications (class IIb, level B evidence).1 This catheter-based procedure disrupts renal sympathetic nerves. It is not recommended for patients with moderate-to-severe kidney impairment (estimated glomerular filtration rate [eGFR] <40 mL/min/1.73 m2) or secondary hypertension (class III, level C).

The ESC recommends lowering systolic BP promptly to a target of 140 to 160 mm Hg within the first 6 hours of acute intracerebral hemorrhage (ICH) onset (class IIa, level A evidence).1 This is a shift from prior guidelines by emphasizing early BP control to reduce hematoma expansion and improve outcomes. Recent high-quality randomized trials support early intensive BP management.3,4 Treatment decisions should consider patient stability, baseline BP, and potential risks associated with rapid BP reduction.

The 2024 American College of Cardiology (ACC) Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction prioritizes angiotensin receptor–neprilysin inhibitors (ARNIs) (ie, sacubitril-valsartan) over ACE inhibitors or ARBs as the preferred first-line therapy for de novo patients with HFrEF (level of evidence not cited).5 This recommendation was supported by the Prospective Study of Biomarkers, Symptom Improvement, and Ventricular Remodeling During Sacubitril/Valsartan Therapy for HF (PROVE-HF) outpatient study, which demonstrated benefits in cardiac remodeling, N-terminal pro–B-type natriuretic peptide reduction, and improved health status. This is a move away from the traditional stepwise approach of starting with an ACE inhibitor or ARB before transitioning to an ARNI. An ACE inhibitor is preferred over an ARNI in patients with a systolic BP less than 100 mm Hg or with severe volume depletion.

The aforementioned 2024 ACC Expert Consensus recommends rapid initiation and titration of all 4 pillars of guideline-directed medical therapy in patients with HFrEF, aiming for target or maximally tolerated doses within 3 months (level of evidence not cited).5 The 4 key medication classes include ARNIs (or ACE inhibitors or ARBs), β-blockers, MRAs, and SGLT2Is. If tolerated, multiple agents can be initiated simultaneously, with more than 1 dose titration at each visit. Frequent adjustments and structured follow-ups are recommended, guided by BP, kidney function, and electrolyte monitoring. The Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies (STRONG-HF) trial supports faster titration within 6 weeks post-discharge, demonstrating reduced heart failure hospitalizations and mortality.

The American Heart Association recommends consideration of a statin in patients with rheumatoid arthritis (weak recommendation, level B-R evidence).6 Due to chronic systemic inflammation accelerating atherosclerosis, patients with rheumatoid arthritis are at increased risk of stroke and cardiovascular events. Treatment with statins in patients with rheumatoid arthritis had an odds ratio of 0.67 (95% CI 0.51 to 0.89) for reducing major adverse cardiovascular events compared with no statin treatment. Rheumatoid arthritis was not listed as a statin-indicated condition in the 2021 Canadian Cardiovascular Society dyslipidemia guideline but was listed as an indication for earlier screening.7

The American Diabetes Association (ADA) recommends ankle-brachial index (ABI) screening for peripheral arterial disease (PAD) in asymptomatic individuals with diabetes aged 50 years and older, or those with microvascular disease, foot complications, or other end-organ damage (grade B evidence).8 Consider screening individuals who had diabetes for 10 years or more. Early PAD detection using ABI testing enables timely intervention, including lifestyle (eg, smoking cessation, structured exercise), pharmacologic (eg, statins, combination aspirin and low-dose rivaroxaban), and foot care strategies, thereby reducing complications and amputations. The Viborg Vascular (VIVA) trial supports PAD screening by showing reduced hospitalizations and mortality with vascular screening, though PAD-specific trials are needed to confirm direct benefits. This recommendation is supported by the Canadian Cardiovascular Society.9

The National Institute for Health and Care Excellence 2024 guideline on diabetic retinopathy recommends ophthalmology assessment both before and after initiating any diabetes treatment likely to result in a rapid, substantial drop in hemoglobin A1c level (no level of evidence provided).10 While long-term glycemic control reduces the progression of diabetic retinopathy, rapid improvements in blood glucose levels can accelerate pre-existing retinopathy and cause transient worsening, including increased macular edema or hemorrhages or other complications such as retinal detachment. During this period of transient worsening, patients are at risk of vision-threatening complications. Identifying pre-existing retinal disease allows for early intervention and monitoring. This recommendation is supported by the ADA.11