NEW JOINT EUROPEAN SOCIETY OF HYPERTENSION/EUROPEAN SOCIETY OF CARDIOLOGY GUIDELINES FOR THE MANAGEMENT OF ARTERIAL HYPERTENSION
A big event during the 17th European Meeting on Hypertension was the presentation of the new joint European Society of Hypertension/European Society of Cardiology Guidelines for the Management of Arterial Hypertension, introduced to the meeting attendees by Dr. Fagard (chairman), Dr. Filippatos (on behalf of the European Society of Cardiology) and Dr. Kjeldsen (on behalf of the European Society of Hypertension), and briefly reviewed and commented by Dr. Mancia, co-chairperson of the task force, Dr. Laurent and Dr. Schmieder, with the participation of other renowned opinion leaders.
After the initial congratulations to the task force, who made possible the establishment of these new guidelines, by the chair and the representatives of the societies sponsoring these new recommendations, Dr. Mancia emphasized that since 2003 new evidence of diagnosis and treatment advancements made necessary the establishment of new guidelines that could extensively and critically review the available literature, make position statements easy to grasp, and implement the results of randomized clinical studies, as well as other relevant data of high scientific caliber.
Dr. Laurent then stated that the goals of the guidelines are multiple: to establish blood pressure levels, to identify secondary causes of hypertension and to evaluate the overall risk profile. Regarding goals, after describing the still valid risk categorization of blood pressure into optimal, normal, high–normal, stage 1, 2 and 3 hypertension, and isolated systolic hypertension, critical consideration was required for hypotensive episodes in the elderly and individuals with diabetes, as well as hypertension in pregnancy and suspicion of preeclampsia. The inclusion of masked hypertension, or isolated ambulatory hypertension with normal reading in the office, was announced as a new entity. However, Dr. Laurent explained that central blood pressure and augmentation index, which have been identified as independent predictors of cardiovascular events, need further consideration before being included in such generic guidelines.
Specifically, the speakers reviewed the cardiovascular risk categories to state that determining when to start treatment depends on both blood pressure and overall cardiovascular risk. Furthermore, immediate treatment should be based on systolic and diastolic values, as well as on pulse pressure (especially in the elderly), age, total cholesterol, LDL- and HDL-cholesterol levels and other known risk factors. These have been expanded to include fasting blood glucose/abnormal glucose tolerance, visceral obesity/waist circumference/body mass index and metabolic syndrome, and are considered to add moderate risk to persons with optimal blood pressure, but high or very high risk to individuals with even high normal blood pressure. Other factors influencing prognosis and now included in the guidelines for hypertension include subclinical organ damage, carotid intima-media thickness, aortic stiffness and the ankle:brachial index, as well as renal alterations in the form of decreased estimated glomerular filtration rate or decreased creatinine clearance.
However, Dr. Laurent emphasized that half to two-thirds of hypertensive patients are at high or very high risk, and controlling all factors, including blood pressure, is crucial. He recommended including pulse wave velocity, ankle:brachial index and glomerular filtration rate or creatinine clearance among the diagnostic tools given their low cost and high predictive value.
Dr. Mancia briefly reviewed the therapeutic recommendations included in the new guidelines, which are based on the fact that lowering blood pressure markedly reduces cardiovascular morbidity and mortality in all age groups, all racial groups and with direct benefits.
The main factor for treating blood pressure is establishing threshold values from which treatment is required, and establishing target values to reach. In this regard no major changes are included in the new guidelines, as Dr. Mancia suggested threshold values of ³140 mmHg and target values of <140 mmHg for systolic blood pressure, and ³90 and <90 mmHg for diastolic blood pressure, respectively, including the elderly and very elderly persons. However, the new guidelines, like the old, still recommend lower thresholds for treatment and lower on-treatment targets for high-risk patients, including subjects with diabetes, coronary artery disease, history of stroke or renal dysfunction/proteinemia, in which the threshold has been set at ³130/85, and the target at <130/80 mmHg.
Despite these fixed rules, the new guidelines follow a concept of flexible threshold/target levels in relation to each patient’s total cardiovascular risk, so that the same rules apply to subjects with metabolic syndrome, multiple risk factors or subclinical organ damage. Such patients should always receive lifestyle counseling, though the degree of evidence for immediate drug prescription is not enough to formally recommend treatment. As clearly established, the major goals in these patients are to quit smoking, lose weight, reduce excessive alcohol consumption, take exercise, reduce salt and increase fruits and vegetables, while also reducing intake of saturated and total fat. What is new in the current guidelines is that this is not recommended as counseling for the patients, but as something to be instituted with expert support and reinforcement, with close follow-up to start treatment as soon as required and never delaying treatment because of other considerations.
One interesting aspect of the new guidelines, as mentioned by Dr. Mancia, is that despite some concerns, beta-blockers are still considered first-class agents along with diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. This takes into account the common need for more than one drug to successfully control blood pressure, so that combinations, and even fixed-drug combinations to simplify treatment and improve compliance, are recommended as first-line therapies in selected individuals. Specific recommendations based on selected patient populations are included in the guidelines.
Dr. Schmieder continued the presentation of the new guidelines by summarizing considerations and recommendations on specific patient populations and when to use some drugs rather than others. Reviewing all “indications” is not the objective of this report, as they are extensively reviewed in the guidelines publication. Mention was made of drugs to be preferentially used in patients with subclinical organ damage (left ventricular hypertrophy, asymptomatic atherosclerosis, microalbuminuria or renal dysfunction), patients with clinical events (previous stroke, previous myocardial infarction, angina, heart failure, recurrent or permanent atrial fibrillation, end-stage renal disease/proteinuria or peripheral arterial disease), specific conditions (isolated systolic hypertension in the elderly, metabolic syndrome, diabetes, pregnancy or the black population).
After the outlines of the guidelines had been discussed, Dr. Lindholm from the International Society of Hypertension and Dr. Oparil from the American Society of Hypertension congratulated the task force and the European Society of Hypertension for the new guidelines. However, some discrepancies were outlined, such as the lack of systematic classification of strength of evidence by Dr. Oparil, or the confusing role of beta-blockers or implementation measures within the guidelines by Dr. Lindholm. Dr. Zanchetti closed the session by reminding the attendees that new guidelines were indeed required, and that these are largely educative and not prescriptive. “Prescribe, not Proscribe” he used to defend the European Society of Hypertension’s and the European Society of Cardiology’s position in their open philosophy for the new guidelines.
Report prepared by: X. Rabasseda, Prous Science Medical Information Department