2018 practice guidelines for the management of arterial hypertension of the European society of cardiology and the European society of hypertension ESC/ESH task force for the management of arterial hypertension

© 2018 Wolters Kluwer Health, Inc. All rights reserved. Blood pressure, epidemiology and risk. Globally, over 1 billion people have hypertension. As populations age and adopt more sedentary lifestyles, the worldwide prevalence of hypertension will continue to rise towards 1.5 billion by 2025. Elevated blood pressure (BP) is the leading global contributor to premature death, accounting for almost 10 million deaths in 2015, 4.9 million due to ischaemic heart disease and 3.5 million due to stroke. Hypertension is also a major risk factor for heart failure, atrial fibrillation, chronic kidney disease (CKD), peripheral artery disease (PAD) and cognitive decline. 2. Definition of hypertension. The classification of BP and the definition of hypertension is unchanged from previous European guidelines, and is defined as an office SBP at least 140 mmHg and/or DBP at least 90 mmHg, which is equivalent to a 24-h ABPM average of at least 130/80 mmHg, or a home blood pressure monitoring (HBPM) average at least 135/ 85 mmHg. 3. Screening and diagnosis of hypertension. Hypertension is usually asymptomatic (hence the term 'silent killer'). Because of its high prevalence, screening programmes should be established to ensure that BP is measured in all adults, at least every 5 years and more frequently in people with a high-normal BP. When hypertension is suspected because of an elevated screening BP, the diagnosis of hypertension should be confirmed either by repeated office BP measurements, over a number of visits, or by out-of-office BP measurement using 24-h ABPM or by HBPM. 4. The importance of cardiovascular risk assessment and detection of HMOD. Other cardiovascular risk factors such as dyslipidaemia and metabolic syndrome frequently cluster with hypertension. Thus, unless the patient is already at high or very high risk due to established CVD, formal cardiovascular risk assessment is recommended using the SCORE system. It is important to recognize, however, that the presence of HMOD, especially left ventricular hypertrophy (LVH), chronic kidney disease (CKD) or advanced retinopathy, further increases the risk of cardiovascular morbidity and mortality, and should be screened for as part of risk assessment in hypertensive patients because the SCORE system alone may underestimate their risk. 5. Think - could this patient have secondary hypertension? For most people with hypertension, no underlying cause will be detected. Secondary (and potentially remediable) causes of hypertension are more likely to be present in people with young onset of hypertension (< 40 years), people with severe or treatment-resistant hypertension, or people who suddenly develop significant hypertension in midlife on a background of previously normal BP. Such patients should be referred for specialist evaluation. 6. Treatment of hypertension - importance of lifestyle interventions. The treatment of hypertension involves lifestyle interventions and drug therapy. Many patients with hypertension will require drug therapy, but lifestyle interventions are important because they can delay the need for drug treatment or complement the BP-lowering effect of drug treatment. Moreover, lifestyle interventions such as sodium restriction, alcohol moderation, healthy eating, regular exercise, weight control and smoking cessation, all have health benefits beyond their impact on BP. 7. When to consider drug treatment of hypertension. The treatment thresholds for hypertension are now less conservative than they were in previous guidelines. We now recommend that patients with lowmoderate risk grade 1 hypertension (office BP 140-159/90-99 mmHg), even if they do not have HMOD, should now receive drug treatment if their BP is not controlled after a period of lifestyle intervention alone. For higher risk patients with grade 1hypertension, including those with HMOD, or patients with higher grades of hypertension (e.g. grade 2 hypertension, 160/100 mmHg), we recommend initiating drug treatment alongside lifestyle interventions. These recommendations apply to all adults up to the age of 80 years. 8. Special considerations in frail and older patients. It is increasingly recognized that biological rather than chronological age, as well as consideration of frailty and independence, are important determinants of the tolerability of and likely benefit from BP-lowering medications. It is important to note that even in the very old (i.e. > 80 years), BP-lowering therapy reduces mortality, stroke and heart failure. Thus, these patients should not be denied treatment, or have treatment withdrawn simply on the basis of age. For people more than 80 years of age who have not yet received treatment for their BP, treatment is recommended when their office SBP is at least 160 mmHg, provided that the treatment is well tolerated. 9. How low should SBP be lowered? This has been a hotly debated topic. A key discussion point is the balance of potential benefits versus potential harm or adverse effects. This is especially important whenever BP targets are lowered, as there is a greater potential for harm to exceed benefit. Thus, in this guideline, we recommend a target range. The evidence strongly suggests that lowering office SBP to less than 140 mmHg is beneficial for all patient groups, including independent older patients. There is also evidence to support targeting SBP to 130 mmHg for most patients, if tolerated. Even lower SBP levels (<130 mmHg) will be tolerated and potentially beneficial for some patients, especially to further reduce the risk of stroke. SBP should not be targeted to below 120 mmHg because the balance of benefit versus harm becomes concerning at these levels of treated SBP. 10. Blood pressure targets in old and very old patient. As discussed above, independence, frailty and comorbidities will all influence treatment decisions, especially in older ( 65 years) and very old (> 80 years) patients. The desired SBP target range for all patients aged more than 65 years is less than 140 mmHg but not less than 130 mmHg. This is lower than in previous guidelines and may not be achievable in all older patients, but any BP lowering towards this target is likely to be beneficial provided that the treatment is well tolerated. 11. Blood pressure targets in patients with diabetes and/or chronic kidney disease. The BP-treatment targets for patients with diabetes or kidney disease have been a moving target in previous guidelines because of seemingly contradictory results from major outcome trials and meta-analyses. For diabetes, targeting the SBP to less than 140 mmHg and towards 130 mmHg, as recommended for all other patient groups, is beneficial on major outcomes. Moreover, targeting SBP to less than 130 mmHg, for those who will tolerate it, may further reduce the risk of stroke but not other major outcomes. SBP should not be lowered below 120 mmHg. For patients with CKD, the evidence suggests that the target BP range should be less than 140 mmHg but not less than 130 mmHg. 12. How low should DBP be lowered? The optimal DBP target has been less well defined, but a DBP target of less than 80 mmHg is recommended. Some patients with stiff arteries and isolated systolic hypertension will already have DBP levels below this target. These are high-risk patients and the low DBP should not discourage treatment of their elevated SBP to the recommended target, provided that treatment is well tolerated. 13. The need to do better on blood pressure control. A key message in this guideline is the need to do better at improving BP control rates. Despite the overwhelming evidence of treatment benefit, on average, less than 50% of patients with treated hypertension achieve a SBP target of less than 140 mmHg. Physician inertia (inadequate up-titration of treatment, especially from monotherapy) and poor patient adherence to treatment (especially when based on multiple pills) are now recognized as the major factors contributing to poor BP control. 14. Start treatment in most patients with two drugs, not one. Monotherapy is usually inadequate therapy for most people with hypertension; this will be especially true now that the BP-treatment targets for many patients are lower than in previous guidelines. This guideline sets out to normalize the concept that initial therapy for the majority of patients with hypertension should be with a combination of two drugs, not a single drug. The only exception would be in a limited number of patients with a lower baseline BP close to their recommended target, who might achieve that target with a single drug, or in some frailer old or very old patients, in whom more gentle reduction of BP may be desirable. Evidence suggests that this approach will improve the speed, efficiency and consistency of initial BP lowering and BP control, and is well tolerated by patients. 15. A single pill strategy to treat hypertension. Poor adherence to longer-term BP lowering medication is now recognized as a major factor contributing to poor BP control rates. Research has shown a direct correlation between the number of BP-lowering pills and poor adherence to medications. Moreover, SPC therapy has been shown to improve adherence to treatment. SPC therapy is now the preferred strategy for initial two-drug combination treatment of hypertension and for three-drug combination therapy when required. This will control the BP in most patients with a single pill and could transform BP control rates. 16. A simplified drug-treatment algorithm. We have simplified the treatment strategy so that patients with uncomplicated hypertension and many patients with a variety of comorbidities (e.g. HMOD, diabetes, PAD or cerebrovascular disease) receive similar medication. We recommend a combination of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) with a CCB or thiazide/thiazide-like diuretic as initial therapy for most patients. For those requiring three drugs, we recommend a combination of an ACE inhibitor or ARB with a CCB and a thiazide/ thiazide-like diuretic. We recommend beta-blockers be used when there is a specific indication for their use (e.g. angina, postmyocardial infarction, HFrEF or when heart-rate control is required). 17. Hypertension in women and in pregnancy. In women with hypertension who are planning pregnancy, ACE inhibitors or ARBs and diuretics should be avoided and the preferred medications to lower BP, if required, include alpha-methyl dopa, labetalol or CCBs. The same drugs are suitable if BP lowering is required in pregnant women. ACE inhibitors or ARBs should not be used be used in pregnant women. 18. Is there a role for device-based therapy for the treatment of hypertension? A number of device-based interventions have been developed and studied for the treatment of hypertension. To date, the results from these studies have not provided sufficient evidence to recommend their routine use. Consequently, the use of device-based therapies is not recommended for the treatment of hypertension, unless in the context of clinical studies and randomized controlled trials, until further evidence regarding their safety and efficacy becomes available. 19. Managing cardiovascular disease risk in hypertensive patients, beyond BPS statins. For hypertensive patients at moderate CVD risk or higher, or those with established CVD, BP lowering alone will not optimally reduce their risk. These patients would also benefit from statin therapy, which further reduces the risk of a myocardial infarction by approximately one-third and stroke by approximately one-quarter, even when BP is controlled. Similar benefits have been seen in hypertensive patients at the border between low and moderate risk. Thus, many more hypertensive patients would benefit from statin therapy than are currently receiving this treatment. 20. Managing cardiovascular disease risk in hypertensive patients, beyond BP - antiplatelet therapy. Antiplatelet therapy, especially low-dose aspirin, is recommended for secondary prevention in hypertensive patients, but is not recommended for primary prevention (i.e. in patients without CVD).