What’s New in the ESH/ESC Guidelines on Hypertension?
Editor's Note: Commentary based on Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013;31:1281-357.
The new aspects of the 2013 guidelines on hypertension of the European Society of Hypertension and the European Society of Cardiology1 are listed in an initial subsection. They concern both the diagnostic and the therapeutic approach to this condition. With regards to diagnosis, the guidelines acknowledge the growing evidence in favour of a more frequent use of home and/or ambulatory blood pressure (BP), but continue to consider office BP values as the diagnostic reference, and still the only measurement by which the protective effects of antihypertensive treatment have been documented. They also assign major importance to the assessment of asymptomatic organ damage in quantification of total cardiovascular risk, with a comprehensive Table that scores the various measures of altered organ structure or function in terms of prognostic value, cost and availability in clinical practice.
With regard to treatment, the 2013 European guidelines confirm that antihypertensive drugs should be promptly employed in patients with grade 2 or 3 hypertension as well as in those with grade 1 hypertension and a high or very high cardiovascular risk because of diabetes, a history of cardiovascular disease or renal damage. They adopt a more conservative position than in the past on initiation of drug treatment in patients with grade 1 hypertension if elderly or with a low-to-moderate cardiovascular risk because of limitations of supporting data from randomized controlled trials. In these patients the advice is to rely on lifestyle interventions and to consider drugs mainly in presence of some aggravating conditions such as an elevated ambulatory BP. Lifestyle interventions, rather than antihypertensive drugs, are also regarded as the most appropriate therapeutic approach to individuals with a high normal BP (regardless whether their cardiovascular risk is in the low-to-moderate or high range), and a more conservative view is taken on the BP values to be pursued with treatment as well. Based on randomized trial data, the European guidelines recommend to lower BP to < 140/90 mmHg in both low-to-moderate and high risk hypertensive patients, thereby failing to confirm the previous recommendation to be more aggressive (BP target < 130/80 mmHg) when the 10 year chance of a cardiovascular event is greater than 20%. Because of the favourable results of two trials, diastolic BP target (< 85 mmHg) is advised for diabetic patients, but tighter systolic target values (140-150 mmHg) are recommended in individuals aged ≥ 65 years. Newly emerging BP targets for treatment, such as a reduced BP variability between visits, are mentioned without any recommendation because of the post-hoc (and thus scientifically weaker) nature of the supporting evidence.
As to the drugs to use to control BP, the European guidelines confirm the liberal attitude previously adopted on first-choice agents. That is, they recommend diuretics, beta-blockers, ACE inhibitors, angiotensin receptor antagonists and calcium channel blockers as suitable for initiation of antihypertensive treatment. As shown by the largest available meta-analyses of randomized trials, these drugs exhibit a similar ability to lower BP as well as to protect patients from cardiovascular morbid or fatal events. All-purpose ranking of antihypertensive drugs is believed to be of limited help to practising physicians, because it refers to an average patient which hardly exists in real life. Accordingly, the European guidelines discuss in depth the criteria that may help to tailor treatment in different demographic and clinical conditions, an issue to which they devote several Tables and separate subsections. One of these subsections concerns treatment of resistant hypertension, in which renal denervation is defined as a "promising" approach. However, this approach needs to demonstrate that the resulting BP reduction translates into cardiovascular and renal protection.
Finally, the 2013 European guidelines strongly support combination treatment as a fundamental strategy to achieve BP control. Given the limited number of trials in which combinations were compared by a randomized design, the Guidelines recommend two drug combinations largely used in trials proving the protective effect of antihypertensive treatment: A blocker of the renin-angiotensin system with a calcium channel blocker, a blocker of the renin-angiotensin system with a diuretic and also a calcium channel blocker with a diuretic. Because of the adverse effects exhibited in trials, combinations that lead to double-blockade of the renin-angiotensin system are not recommended, whereas the preferred non-drug combinations are also advised as a possible initial treatment step in patients with grade 2 or 3 hypertension or an otherwise high cardiovascular risk profile. It is recognized that this may carry some inconveniences (e.g. administration of a useless drug in patients in whom BP control can be achieved by monotherapy), but it is also emphasized that when an event can potentially occur within a short time interval, achieving fast BP control is desirable. Consideration is also given to recent evidence that, for psychological or other reasons, fast BP control may lead to a lesser incidence of treatment discontinuation at a later time. This is important because discontinuation of treatment is a problem of devastating dimensions, and is responsible for poor BP control in hypertensive populations and for persistence of high BP as the number one cause of death worldwide.
- Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013;31:1281-357.
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