AMSTERDAM—The European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) released new guidelines for managing arterial hypertension at this year's ESC meeting.¹ The recommendations differ in a number of ways from previous editions (2003 and 2007).

Despite previous iterations, the 2013 guidelines committee found "limited or no evidence of <130/80 (mm Hg) targets in specific high-risk groups; indeed, there was evidence of some harm," according to Byron Williams, MD, London, who presented highlights of the annual meeting. "The new guidelines have simplified a blood pressure goal of <140/90 mm Hg for all."

Well, almost all. The guidelines suggest a target systolic blood pressure (SBP) of <140 mm Hg in both higher- and lower-risk patients, implying that high-normal SBP (130-139 mm Hg) shouldn't be lowered, not even in patients with diabetes or chronic kidney disease. However, in individuals older than 80 years, the target SBP is 140-150 mm Hg. As for diastolic blood pressure (DBP) the target is <90 mm Hg except in patients with diabetes, where evidence supports lower values (80-85 mm Hg).

Home Monitoring Comes of Age

The 2007 guidelines recognized the prognostic significance of ambulatory BP; now, the 2013 guidelines acknowledge evidence supporting home BP monitoring. Guidelines committee co-chair Professor Robert Fagard, Leuven University, Belgium, said, "Home blood pressure monitoring has come of age and that's important for (detecting) white coat hypertension, masked hypertension, etc."

Still, his co-chair Professor Giuseppie Mancia added that despite the fact that out-of-office BP may be important in several conditions to classify patients, "the gold standard for diagnosis of hypertension remains office blood pressure because a large amount of data is available and because the protective effect of treatment that has been documented in trials is entirely based on office blood pressure changes." (Note: The guidelines indicate different definitions of hypertension based on how and where the measurements are taken. See Table 1.)

While there may be arguments as to whether the guidelines are strict enough, particularly in the high-normal range and in patients at high risk, Dr. Mancia said, "The attitude is to be guided by evidence because if we overstate a case, we can make future studies more difficult. Once a concept is in the guidelines, then ethical committees may argue against doing a study. And so it's extremely important not to make recommendations when the evidence is not there."

Indeed, unlike previous iterations, Dr. Fagard—who represented the ESC—insisted that the 2013 guidelines follow ESC protocol and categorize recommendations by class and indicate level of evidence. He said he welcomes the change because previously the guidelines made some recommendations that were not as well-supported by evidence as others. For example, the 2007 guidelines recommended a target of 130/80 mm Hg for individuals with diabetes. "If we had said, 'may be considered' [as a target], there would be no problem," said Dr. Fagard, instead they made it a recommendation and now "we are in a little bit of a problem because we have to say, that's not true; 140 over 85 is enough."

While acknowledging the collegiality of the overall guidelines development process, his co-chair, Dr. Mancia, admitted that one discussion got a little heated, perhaps even raising BPs: attributing the class and the level of evidence. "And this tells you how difficult it is sometimes to grade evidence," said Dr. Mancia.

Guidelines are not only based on evidence, but also on the interpretation and extrapolation of evidence. As an example, Dr. Mancia said, "We base our recommendations on trials that last 5 years and extrapolate [the results] to a lifetime. That's why guidelines can make mistakes and that's why they are not orders. They are just recommendations done by a group of experts who should be humble enough just to recognize that, in quite a large number of issues, consensus is the word, not just evidence."

Abandoning First-line/Second-line?

In terms of therapy, while the US guidelines for managing patients with hypertension indicate a preference for diuretic therapy first, the new ESH/ESC guidelines continue to show no preference among the five major classes of antihypertensive therapies: diuretics (thiazides, chlorthalidone, and indapamide), beta-blockers, calcium antagonists, ACE inhibitors, and ARBs. "All are appropriate initial therapy," said Dr. Fagard. It's the decrease in BP that matters and "most of the drugs bring about similar changes in blood pressure. There are some differences; our position is that all of them can be used as first-line but it should be individualized."

Dr. Mancia doesn't even care much for that term: "It's probably time to abandon the old all-purpose ranking of drugs into first choice, second choice, which refers to an average patient who does not exist in clinical practice. I think it is much better to try to help physicians tailor treatment to give the proper drug in the proper clinical circumstance." Thus, the guidelines address comorbidities, target organ damage, contraindications, and possible adverse effects of specific drugs, assisting clinicians to individualize therapy.

The guidelines also acknowledge that in high-risk patients, it may be appropriate to forgo monotherapy and initiate combination therapy from the start. Besides reducing risk more quickly by lowering blood pressure faster, there may be an additional benefit. "We know that starting treatment with combination (therapy) is accompanied by a lower rate of treatment discontinuation later on," said Dr. Fagard. Given that nonadherent patients have a greater incidence of cardiovascular events, anything that favors adherence to treatment should be supported and there is evidence, he said, that starting treatment with combination therapy may help perhaps because early success has a positive psychological impact.

Dr. Mancia had the final word, recommending close follow-up of patients and "not taking lightly" uncontrolled BP at any given office visit. Such "one-off" results may not be exceptions at all, he said, yet physicians and patients alike often downplay them, postponing any decision to alter therapy until the next visit. "This is called 'clinical inertia,'" he said, "and it is one of the major factors for the poor rate of blood pressure control worldwide. This is discussed by the guidelines and of course some advice—good common-sense advice—is given to improve on this." (Table 2)

Just how much do we need these long-awaited revisions? We just found out how European clinicians have their work cut out for them. At ESC 2013, new EUROASPIRE data were presented showing the rate of uncontrolled hypertension is 45% in high-risk populations.

Reference

1. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension. Eur Heart J. 2013 June 14. [Epub ahead of print]

Keywords: Diuretics, Blood Pressure Monitoring, Ambulatory, White Coat Hypertension, Masked Hypertension, Diabetes Mellitus