Harmonization of ACC/AHA and ESC/ESH BP/Hypertension Guidelines

Whelton PK, Carey RM, Mancia G, Kreutz R, Bundy JD, Williams B.
Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines: Comparisons, Reflections, and Recommendations. Eur Heart J 2022;Aug 11:[Epub ahead of print.]

The following are key points to remember from this article on the harmonization of the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/European Society of Hypertension (ESC/ESH) blood pressure/hypertension guidelines:

  1. In 2017, the ACC/AHA guideline provided 106 formal recommendations for the prevention and management of elevated blood pressure (BP). In 2018, the ESC/ESH published a related guideline with 122 recommendations. While the guidelines provide similar recommendations in many respects, areas of difference exist.
  2. A major source of BP misclassification is due to measurement errors. Both guidelines emphasize the accurate measurement of BP using validated devices and multiple readings. ACC/AHA recommends averaging office reading for ≥2 readings using the same device on ≥2 occasions. ESC/ESH recommends three office measures with an additional reading if two of the readings differ by >10 mm Hg. Both guidelines recommend home BP monitoring or ambulatory BP monitoring (ABPM) measures to confirm elevated BP and diagnosis of masked or white-coat hypertension.
  3. BP targets are somewhat lower in ACC/AHA than ESC/ESH guidelines, especially in older adults and those with chronic kidney disease (CKD). The ACC/AHA includes categories for normal BP (<120/80 mm Hg), elevated BP (120-129/<80 mm Hg), and two stages of hypertension, stage 1 (130-139/80-90 mm Hg) and stage 2 (≥140/≥90 mm Hg). The ESC/ESH classifies BP into optimal BP (<120/<80 mm Hg), normal BP (120-29/80-84 mm Hg), high normal BP (130-39/85-89 mm Hg), three grades of systolic/diastolic hypertension (starting at 140/90 mm Hg), and isolated systolic hypertension. It retains the same systolic BP (SBP) ≥140 mm Hg and/or diastolic BP (DBP) ≥90 mm Hg cut points for diagnosis of hypertension recommended in the preceding 2013 ESH/ESC guidelines. Additional cut points exist for home BP and ABPM in both guidelines.
  4. The ESC/ESH takes a more stepped approach, first recommending achievement of an SBP/DBP <140/90 mm Hg before targeting a lower BP. The ESC/ESH identified a SBP of 120 mm Hg and a DBP 70 mm Hg as the lower safety boundary for BP reduction in adults 18-65 years of age, with 130 mm Hg in those with CKD. On the other hand, the ACC/AHA recommends a single SBP/DBP target of <130/80 mm Hg in most adults, but SBP <130 mm Hg in older well adults if tolerated.
  5. Both guidelines recommend cardiovascular disease (CVD) risk assessment to aid in decisions for BP management and initiation of antihypertensive medications. The ACC/AHA recommends assessment of atherosclerotic CVD (ASCVD) risk using the Pooled Cohort Equations with >10% risk considered high risk. For adults <40 years of age, the ACC/AHA recommends the estimation of lifetime CVD risk. In the ESC/ESH guidelines, adults with existing CVD, including asymptomatic atheromatous disease on imaging, type 1 or 2 diabetes mellitus, very high levels of individual CVD risk factors, or CKD are considered to be at high or very high risk (10-year CVD mortality of 5–10% and ≥10%, respectively). For all others, 10-year CVD mortality risk should be estimated using the Systematic Coronary Risk Evaluation (SCORE) risk estimator. The SCORE risk is estimated using a patient’s age, sex, total cholesterol or total and high-density lipoprotein cholesterol, smoking status, and level of SBP.
  6. The ACC/AHA guideline recommends antihypertensive medication for SPB ≥140 mm Hg or DPB ≥90 mm Hg irrespective of ASCVD risk. Drug therapy is also recommended for adults at high risk for ASCVD and SBP 130-30 mm Hg or DBP 80-89 mm Hg. ESC/ESH recommends target ranges but recognizes that the optimal and tolerated targets for individuals will differ. The initial SBP/DBP target is <140/90 mm Hg for all adults with hypertension. Provided the treatment is well tolerated, targeting 130/80 mm Hg is recommended, with subsequent efforts to achieve a lower BP in those 18-65 years of age. The ESC/ESH recommends 3 months of lifestyle modification for patients with a low or moderate risk for CVD, only then if BP is not controlled (i.e., SPB ≥140 or DPB ≥90 mm Hg) to start antihypertensive medication. The exception for these cut points in the ESC/ESH guidelines is for adults >80 years; medications are recommended when office SBP is ≥160 mm Hg.
  7. Both guidelines emphasize lifestyle modification for the prevention and treatment of elevated BP. In a high percentage of adults, elevated BP is related to an unhealthy diet, lack of physical activity, and/or use of alcohol. Both guidelines address adherence and recommend single-pill combinations to improve adherence and reduce therapeutic inertia. However, no specific class of antihypertensive is recommended. The ACC/AHA recommends combination therapy for most patients and specifically African Americans. Simultaneous use of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker is potentially harmful.
  8. Treatment of other CVD risk factors is recommended in both guidelines, but ACC/AHA references other ACC/AHA guidelines for specific details, whereas ESC/ESH includes details for statin and aspirin therapy.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Geriatric Cardiology, Prevention, Vascular Medicine, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Hypertension, Smoking

Keywords: Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Atherosclerosis, Antihypertensive Agents, Aspirin, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Cholesterol, Diabetes Mellitus, Geriatrics, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Life Style, Lipoproteins, HDL, Primary Prevention, Renal Insufficiency, Chronic, Risk Assessment, Risk Factors, Sedentary Behavior, Smoking, White Coat Hypertension

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