The European Society of Hypertension (ESH) has released refreshed guidelines for the management of hypertension, which have been endorsed by the European Renal Association and the International Society of Hypertension, and which provide updated and simplified advice and recommendations.
The guidelines were presented during the 32nd Annual European Meeting on Hypertension and Cardiovascular Protection in Italy last month.
Co-chairs of the task force that created the document were Dr Giuseppe Mancia, professor emeritus of medicine, University Milano-Bicocca, Italy, and Professor Reinhold Kreutz, Charité-University Medicine Berlin, Germany.
“We have tried to provide a simplified message to key topics with these new guidelines,” Kreutz said. “We have confirmed the definition of hypertension and provide clear guidance for blood pressure monitoring and a simplified general strategy targeting similar blood pressure goals for most patients, although the treatment algorithms of how you get there may be different for different groups.”
While there are no major surprises in the guidelines, there are multiple advances and added-value changes, including clear advice on how to measure blood pressure, an upgrade for beta-blockers in the treatment algorithms, and a new definition and treatment recommendations for “true resistant hypertension”, reports Medscape.
Definition remains unchanged
The definition of hypertension remains unchanged from the previous guidelines – repeated office systolic blood pressure values of ≥140 mm Hg and/or diastolic blood pressure values of ≥90 mm Hg.
Kreutz said the correct measurement of blood pressure is of key importance, and the new guidelines include a detailed algorithm on how to measure blood pressure. The preferred method is automated cuff-based blood pressure measurement.
They have upgraded the use of out-of-office blood pressure measurement, particularly home measurement, as useful in long-term management. “In future, there should be more emphasis on follow-up using technology with remote control and virtual care.”
Thresholds for starting treatment
On thresholds for initiating anti-hypertensive therapy, the guidelines recommend treatment be initiated when systolic blood pressure is ≥140 mm Hg or diastolic blood pressure is ≥90 mm Hg.
The same recommendation is given for patients with grade 1 hypertension (systolic, 140–159 mmHg; and/or diastolic, 90–99 mm Hg) irrespective of cardiovascular risk, although they add that for patients in the lower blood pressure range who have no hypertension-mediated organ damage and who are at low cardiovascular risk, consideration may be given to starting treatment with lifestyle changes only.
If, however, blood pressure control is not achieved within a few months of a lifestyle-based approach alone, drug treatment is necessary.
For older patients (80 or older), the task force recommends initiation of drug treatment at 160 mm Hg systolic, although a lower systolic threshold of 140–160 mm Hg may be considered. Thresholds for the initiation of drug treatment for very frail patients should be individualised.
Blood pressure targets
The blood pressure target is the same as before, for the general population of patients with hypertension: <140/80 mm Hg for most patients. This accounts for the major portion of the protective effect of blood pressure lowering.
However, the consensus document notes that despite the smaller incremental benefit, an effort should be made to reach a range of 120–129/70–79 mm Hg, but only if treatment is well tolerated to avoid the risk of treatment discontinuation because of adverse events, which might offset, in part or completely, the incremental reduction in cardiovascular outcomes.
The guidelines do allow slightly higher targets for older and very frail patients.
A new feature is the upgrading of beta-blockers in the treatment algorithms. “These may not have previously been considered as a first choice of anti-hypertensive medication, but we see that in clinical practice, many patients are actually treated with these drugs because there are so many conditions in which beta-blockers have a compelling evidence-based indication or are believed to be favourable.”
The guidelines also recommend that all drugs be given as once-daily preparations and be taken preferably in the morning.
“The new TIME study has established there is no difference in outcome with morning or evening dosing, but we know adherence is often better when drugs are taken in the morning, and it is not advisable to take diuretics in the evening,” Kreutz said.
The guidelines have introduced a new term, “true resistant hypertension”, defined as systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg in the presence of the following conditions: the maximum recommended and tolerated doses of a three-drug combination comprising a renin-angiotensin system blocker (either an ACE inhibitor or an ARB), a calcium blocker, and a thiazide/thiazide-like diuretic were used; inadequate blood pressure control has been confirmed by ambulatory (preferable) or home blood pressure measurement; and various causes of pseudo-resistant hypertension (especially poor medication adherence) and secondary hypertension have been excluded.
“Many patients appear to have resistant hypertension, but we need to screen them carefully to ensure they are adherent to treatment – and most are found not to be truly resistant,” Kreutz said.
“We estimate only about 5% of them have true resistant-hypertension.” For these patients, two treatment approaches are recommended. For those who do not have advanced kidney disease (glomerular filtration rate >40 mL/min), renal denervation can be considered.
This is a new II B recommendation.
Kreutz noted that studies of renal denervation excluded patients with advanced kidney disease, so there are no data for this group.
For these patients, the guidelines suggest a combination diuretic approach (chlorthalidone with a loop diuretic) could be considered in light of the results of the recent CLICK study.
Dr Paul Whelton, chair of the most recent American College of Cardiology/American Heart Association hypertension guidelines committee, and president of the World Hypertension League, said: “I would say the changes are incremental rather than major, but that is probably appropriate."
He welcomed the greater emphasis on out-of-office blood pressure measurement. “That’s where we should be headed.”
He said both the US and European guidelines aim for a target blood pressure of 130/80 mm Hg for most patients but have different ways of issuing that advice.
“The Europeans recommend a minimum goal of 140/90 mm Hg, and if there are no issues, then press on to get to under 130/80 mm Hg. In the US, we’ve gone for a more direct approach of recommending less than 130/80 mm Hg.
“My fear with the European approach is that by saying, get to 140/90 mm Hg first, then move on to 130/80 mmHg, is that you’re likely to lose people. And doctors could feel that 140/90 is fine.”
More effort needed on implementation
Whelton said where all hypertension guidelines were lacking was in the implementation of the recommendations.
“We have a huge burden of illness, and it is a very cost-effective area for management, but still, rates of blood pressure control are bad. Generally speaking, even with a conservative target of 140/90, the best countries only have control rates of around 30%, and this can be as low as 8% in some low/middle-income countries.”
The approach to blood pressure management needed to change, he said.
“We are doing these things really badly. In routine care, blood pressure is measured horribly. Nobody would accept a pilot of a plane saying he should be doing all these procedures but he’s too busy and it’s probably okay, but that’s how blood pressure is often measured in clinical practice. And we can’t do a good job if we’re not measuring the key variable properly on which the diagnosis is based.”
ACC article – Treatment in Morning versus Evening – TIME (Open access)
Medscape article – New ESH Hypertension Guidelines Aim for Simplified Message (Open access)
See more from MedicalBrief archives:
New NICE hypertension guidelines a ‘pragmatic compromise’ — The Lancet
Traditional methods for testing BP no longer adequate — study
Home BP monitoring significantly improves hypertension control, cuts costs