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New ESH/ESC Hypertension Guidelines Liberalize BP Goals
The revised guidelines relax some BP targets, incorporate daytime ambulatory and nocturnal BP measures, and recommend that the decision to treat be based on a patient's overall cardiovascular health.
A new iteration of guidelines, released jointly in July 2013 by the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC), has attempted to simplify blood pressure (BP) targets for patients with hypertension. The ESH/ESC sets the new SBP goal for all patients at <140 mm Hg, even “high-risk” patients (ie, patients with type 2 diabetes and those with chronic kidney disease), in whom more stringent BP goals were previously targeted (<130 mm Hg).* In elderly patients (>80 years of age), the target SBP should be liberalized to 140-150 mm Hg. The goal for DBP for most patients remains <90 mm Hg with more strict targets (80 to 85 mm Hg) for patients with diabetes
In addition to BP targets, the guidelines emphasize the importance of quality measures, such as ambulatory BP monitoring and improvement in medication compliance. The definition of hypertension, which has always been an office BP of ≥140/90 mm Hg, now also includes daytime ambulatory measurements of ≥135/85 m Hg or nocturnal measurements of ≥120/70 mm Hg. The office measurement remains the gold standard, however, because most of the studies on hypertension have used this definition. The European guidelines also suggest, when deciding whether or not to treat, that clinicians avoid strict cutoffs to define hypertension and instead place the blood pressure value within context of the patient’s overall cardiovascular risk.
After ruling out causes of secondary hypertension when indicated, the European guidelines outline that any of the 5 available classes of antihypertensive medication can be used to initiate therapy (ie, diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, or angiotensin receptor blockers). In some instances committee chairperson Dr. Giuseppe Mancia even recommends dual therapy as first-line treatment, as it is associated with a lower rate of discontinuation and a higher rate of therapeutic success. Initial combination therapy may be appropriate if the pre-treatment blood pressure is very high and monotherapy is unlikely to be successful or if blood pressure control is needed rapidly in a high-risk patient.
Most importantly, however, the European guideline writing committee emphasizes the burden of untreated or under-treated hypertension and its associated morbidity and mortality.
*SBP <130 mm Hg is now a recommendation rather than a target.
References:
Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension. Eur Heart J. 2013;34:2158-2219. (Full text)
