The following are key points to remember about the European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines for the Management of Arterial Hypertension:

1. This excellent and comprehensive 2018 hypertension guideline, written by European experts, differs in some areas with the US 2017 guideline for the prevention, detection, evaluation, and management of high blood pressure (BP) in adults. The definitions of classes of recommendation (I, IIa, IIb, III) and levels of evidence (A, B, C) are the same as the US guideline.
2. It emphasizes use of evidence-based properly conducted studies, with the highest priority given to randomized controlled trials (RCTs) and meta-analyses of RCTs. Questions related to diagnosis, risk stratification, and treatment of hypertension are addressed by observational or registry-based studies, and when evidence is lacking but the question is important to clinical practice, the recommendation is based on consensus of pragmatic expert opinion.
3. The ESC/ESH and US guidelines both suggest regular use of home BP monitoring and ambulatory BP monitoring as an option to confirm the diagnosis of hypertension, detect white-coat and masked hypertension, and monitor BP control for medication adjustment.
4. Each encourages monitoring nonadherence as a cause of poor BP control, and more aggressive treatment of BP in the older and very old with emphasis on the biologic, not chronological age including concern for frailty, independence, and tolerance of medication. Lower BP target ranges are provided for treated patients based on age and specific comorbidities. Each emphasizes a similar role for nurses and pharmacists for education, support, and follow-up. The recommendations for evaluation of secondary causes of hypertension and resistant hypertension, and suggested drug approaches are very similar.
5. The European recommendations are generally more conservative regarding definitions, treatment thresholds, and treatment targets. The Europeans express concern with the randomized clinical trial data, suggesting the threshold for beginning drug therapy in high-risk patients at 130 mm Hg had a significant percentage of patients on antihypertensive therapy that was begun at higher pressures. And this would be a higher risk group who would prejudice to further benefit if the trial systolic BP (sBP) was <140 mm Hg.
6. In the US guideline, Stage 1 hypertension is defined as office sBP 130-139 or diastolic BP (dBP) 80-89 mm Hg. In contrast, ESC/ESH defines Stage 1 hypertension as office sBP values 140-159 and/or dBP 90-99 mm Hg, with a similar definition in adults of any age. The European higher threshold is based on evidence from multiple RCTs that there is a clearer treatment benefit using the higher thresholds.
7. Similar lifestyle interventions are recommended in each guideline. In the US, BP-lowering medication is recommended for secondary prevention of recurrent cardiovascular disease (CVD) events in patients with CVD and Stage 1 hypertension or threshold of sBP 130 mm Hg or dBP of 80 mm Hg, and the same threshold for primary prevention in adults whose 10-year atherosclerotic CVD (ASCVD) risk is estimated at 10% or higher. In the absence of CVD and estimated 10-year ASCVD risk <10%, the threshold is a sBP of 140 or dBP of 90 mm Hg.
8. The more conservative European guideline suggests considering drug treatment in only very high-risk patients with CVD (especially coronary artery disease [CAD]) with BP 130-139/85-89 mm Hg. However, drug treatment is suggested at that threshold in low to moderate risk without CVD, renal disease, or target organ damage if after 3-6 months of lifestyle intervention BP is not controlled.
9. The European guideline threshold for treatment of office sBP is 140 mm Hg and dBP 90 mm Hg for 18-79 year olds. For those ≥80 years, sBP is 160 mm Hg and diastolic 90 mm Hg. Recommendations are similar in patients with diabetes, chronic kidney disease (CKD), CAD, and stroke/transient ischemic attack (TIA). The European target in hypertension, diabetes, CAD, and stroke/TIA is sBP 120-130/70-79 mm Hg for 18-65 year olds, and 130-139/70-79 for 65 to >80 year olds. In CKD, the target is <140 to 130 mm Hg, if tolerated. In the US, BP goal for hypertension, diabetes, CAD, and CKD is <130/80 mm Hg, as tolerated.
10. As with the US, the Europeans emphasize that the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver, as appropriate.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Hypertension

Keywords: Antihypertensive Agents, Atherosclerosis, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Consensus, Coronary Artery Disease, Diabetes Mellitus, Frail Elderly, Geriatrics, Hypertension, Ischemic Attack, Transient, Life Style, Masked Hypertension, Primary Prevention, Renal Insufficiency, Chronic, Secondary Prevention, Stroke, Vascular Diseases, White Coat Hypertension

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