ACC/AHA vs. ESC/ESH on Hypertension Guidelines

Bakris G, Ali W, Parati G.
ACC/AHA Versus ESC/ESH on Hypertension Guidelines: JACC Guideline Comparison. J Am Coll Cardiol 2019;73:3018-3026.

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

  1. The authors compared the recommendations of the most recent ACC/AHA and ESC/ESH blood pressure guidelines, each of which represented updates and reinforced concepts of prevention regarding elevated blood pressure (BP).
  2. Both guidelines provide general recommendations of a low-sodium diet (<2300 mg of sodium), exercise, body weight reduction, low to moderate alcohol intake, and adequate potassium intake.
  3. The guidelines agree on the importance of proper methods of BP measurement, the use of home BP monitoring and ambulatory monitoring, focusing on detecting and improving adherence, and both support the use of BP telemonitoring and digital health solutions for follow-up.
  4. Both recommend use of absolute cardiovascular (CV) risk estimates computed with risk calculators and that a >10% 10-year risk of atherosclerotic CV disease should be treated more aggressively. And both provide a concise definition of organ damage assessment. The ACC/AHA guideline details guidance for ethnic/racial groups. ESC/ESH emphasizes the importance of environmental and altitude effects on BP.
  5. There are major disagreements with the level of BP defining hypertension, the specific BP targets for treatment, and the use of initial combination therapy. ACC/AHA does not address isolated systolic hypertension, which is detailed in the ESC/ESH guideline, with target systolic BP to <140 mm Hg. ESC/ESH limits BP reduction to no lower than 120/70 mm Hg regardless of baseline, age, and target organ damage.
  6. The initial single-pill combination is strongly recommended in both guidelines with angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker + thiazide or calcium channel blocker. However, ESC/ESH recommends it as initial therapy in patients at ≥140/90 mm Hg and the ACC/AHA recommends a single-pill combination in patients with >20/10 mm Hg above BP goal.
  7. The most important distinction is that ACC/AHA maintains that all people with a BP >130/80 mm Hg have hypertension and BP should be targeted to <130/80 mm Hg. While this implies increased cost, the ACC/AHA guideline stresses lifestyle change for BP for the first 6 months except for those at high risk or with target organ damage.
  8. The ESC/ESH guideline defines hypertension as >140/90 mm Hg with the goal being 130 to <140/70-79 mm Hg for all but targeting to <130/70-79 mm Hg or lower only in those at high cardiovascular risk defined as diabetes, post-stroke, and coronary artery disease.
  9. The authors suggest that a more evidence-based statement for the guideline would be to set the lower BP target for treatment at >15% 10-year CV risk, because all trials had cohorts with >15% CV risk.

Keywords: Altitude, Angiotensin-Converting Enzyme Inhibitors, Angiotensin Receptor Antagonists, Blood Pressure, Blood Pressure Determination, Blood Pressure Monitoring, Ambulatory, Calcium Channel Blockers, Coronary Artery Disease, Diabetes Mellitus, Diet, Sodium-Restricted, Exercise, Hypertension, Life Style, Metabolic Syndrome, Potassium, Practice Guidelines as Topic, Primary Prevention, Risk Factors, Stroke, Thiazides, Weight Loss

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