Reevaluate hypertension in athletes based on the latest ESC guideline

Introduction Hypertension (HT) is the most prevalent cardiovascular risk factor in athletes, making regular screening essential during pre-participation assessments. The 2024 European Society of Cardiology (ESC) guideline revised the blood pressure (BP) classification, defining new thresholds for normal, elevated (E), and high (H) BP. However, current sports cardiology recommendations for athletes continue to follow the 2018 ESC guidelines, which may influence the clinical management of hypertensive athletes. Purpose We aimed to reevaluate BP data according to the 2024 ESC recommendations to determine how athletes are redistributed across categories and to assess the characteristics of each group. Methods Based on office resting BP values recorded during sports cardiology screening between 2014–2024, athletes were originally categorised according to the 2018 ESC guideline (optimal/normal: <129/<84; high normal: 130–139/85–89; hypertension: ≥140/90 mmHg). Subsequently, BP values were reclassified according to the 2024 ESC recommendations into elevated (E: 120/70–139/89 mmHg) and high (H: ≥140/90 mmHg) categories. We also analysed the ambulatory BP monitoring (ABPM) results. Athletes with known hypertension were not excluded. Results In total, 2403 examinations were performed (age: 21.3±7.5 years; training history: 12.5±6.3 years; training hours/week: 17.1±6.9) in swimmers, football, basketball, water polo, handball players, and other athletes. Reclassification according to the 2024 ESC guideline resulted in 20% of athletes moving from the 2018 optimal/normal category to the E group (2018 optimal/normal: n=950 vs 2024 normal: n=440; high-normal: n=705 vs E: n=1215), while the high BP category remained unchanged (n=814). Known HT was present in 78 athletes (7%). The H group was older (E: 20.4±7.6 vs. H: 24.3±11.6 years, p<0.01) and had a longer training history (E: 12.4±6.2 vs. H: 16.1±5.3 years, p<0.01), while weekly training hours were similar (E: 17.2±6.9 vs. H: 16.6±7.3h). The proportion of H was significantly higher among water polo players and master athletes (p<0.01). ABPM was performed in 5% of the E group and 35% of the H group. Based on ABPM, 37 athletes belonged to the E and 87 to the H category. HT was present in 34% of the E and 56% of the H group. Newly diagnosed HT occurred in 1% of the E group (n=7) and 8% of the H group (n=36). Most treated athletes received angiotensin receptor blockers (59%), ACE inhibitors (33%), or calcium channel blockers (23%); 9% required combination therapy. Conclusion(s) According to the new ESC guideline, 20% of athletes were reclassified from the normal to the elevated BP category, reflecting stricter thresholds than current sports recommendations. High BP is more prevalent in older age, males, and master athletes. These findings emphasize the importance of hypertension screening and the optimal timing of antihypertensive therapy in athletes to ensure safe sports participation.