Summary of the 2007 European Society of Hypertension (ESH) and European Society of Cardiology (ESC) Guidelines for the Management of Arterial Hypertension

Figures & data

Figure 1 Stratification of CV risk into four categories.

Low, moderate, high and very high risk refer to 10-year risk of a CV fatal or non-fatal event. The term “added” indicates that in all categories risk is greater than average. The dashed line indicates how definition of hypertension may be variable, depending on the level of total CV risk.

Abbreviations: DBP, diastolic blood pressure; CV, cardiovascular; HT, hypertension; MS, metabolic syndrome; OD, subclinical organ damage; SBP, systolic blood pressure.

Box 1 High/very high-risk subjects

○ BP ≥ 180 mmHg systolic and/or ≥ 110 mmHg diastolic ○ Systolic BP >160 mmHg with low diastolic BP (<70 mmHg) ○ Diabetes mellitus ○ Metabolic syndrome ○ Three CV risk factors ○ One or more of the following subclinical organ damages: – Electrocardiographic (particularly with strain) or echocardio-graphic (particularly concentric) left ventricular hypertrophy – Ultrasound evidence of carotid artery wall thickening or plaque – Increased arterial stiffness – Moderate increase in serum creatinine – Reduced estimated glomerular filtration rate or creatinine clearance – Microalbuminuria or proteinuria ○ Established CV or renal disease

Table 1 Factors influencing prognosis

Risk factors	Subclinical organ damage
■ Systolic and diastolic BP levels ■ Levels of pulse pressure (in the elderly) ■ Age (M >55 years; W >65 years) ■ Smoking ■ Dyslipidemia – TC > 5.0 mmol/L (190 mg/dL) or; – LDL-C > 3.0 mmol/L (115 mg/dL) or; – HDL-C: M < 1.0 mmol/L (40 mg/dL), W < 1.2 mmol/L (46 mg/dL), or; – TG > 1.7 mmol/L (150 mg/dL) or ■ Fasting plasma glucose 5.6–6.9 mmol/L (102–125 mg/dL) ■ Abnormal glucose tolerance test ■ Abdominal obesity (waist circumference >102 cm (M), >88 cm (W)) ■ Family history of premature CV disease (M at age <55 years; W at age <65 years)	■ Electrocardiographic LVH (Sokolow-Lyon >38 mm; Cornell > 2440 mm*ms) or ■ Echocardiographic LVHa (LVMI M ≥ 125 g/m^2, W ≥ 110 g/m^2) ■ Carotid wall thickening (IMT > 0.9 mm) or plaque ■ Carotid-femoral pulse wave velocity >12 m/s ■ Ankle/brachial BP index <0.9 ■ Slight increase in plasma creatinine: M: 115–133 μmol/L (1.3–1.5 mg/dL) W: 107–124 μmol/L (1.2–1.4 mg/dL) ■ Low estimated glomerular filtration rateb (<60 mL/mn/1.73 m^2) or creatine clearancec (<60 mL/min) ■ Microalbuminuria 30–300 mg/24 hr or albumin-creatinine ratio: ≥22(M); or ≥31(W) mg/g creatinine
Diabetes mellitus ■ Fasting plasma glucose ≥7.0 mmol/L (126 mg/dl) on repeated measurement, or ■ Postload plasma glucose >11.0 mmol/L (198 mg/dL)	Established CV or renal disease ■ Cerebrovascular disease: ischemic stroke; cerebral hemorrhage; transient ischemic attack ■ Heart disease: myocardial infarction; angina; coronary revascularization; heart failure ■ Renal disease: diabetic nephropathy; renal impairment (Serum creatinine M > 133 mmol/L, W > 124 mmol/L); proteinuria (>300 mg/24 hr) ■ Peripheral arterial disease ■ Advanced retinopathy: hemorrhages or exudates, papilloedema

a Risk maximal for concentric LVH (left ventricular hypertrophy): increased LVMI (left ventricular mass index) with a wall thickness/radius ratio ≥0.42

b MDRD formula

c Cockroft Gault formula.

Abbreviations: BP, blood pressure; C, cholesterol; CV, cardiovascular disease; IMT, intima-media thickness; M, men; W, women; TG, triglycerides.

Note: the cluster of three out of 5 risk factors among abdominal obesity, altered fasting plasma glucose, BP ≥ 130/85 mmHg, low HDL-cholesterol and high TG (as defined above) indicates the presence of metabolic syndrome.

Box 2 Guidance for correct office blood pressure measurements

Blood pressure (BP) measurement

When measuring BP, care should be taken to:

Allow the patients to sit for several minutes in a quiet room before beginning BP measurements Take at least two measurements spaced by 1–2 minutes, and additional measurements if the first two are quite different Use a standard bladder (12-13 cm long and 35 cm wide) but have a larger and a smaller bladder available for fat and thin arms, respectively. Use the smaller bladder in children Have the cuff at the heart level, whatever the position of the patient Use phase I and V (disappearance) Korotkoff sounds to identify systolic and diastolic BP, respectively Measure BP in both arms at first visit to detect possible differences due to peripheral vascular disease. In this instance, take the higher value as the reference one Measure BP 1 and 5 min after assumption of the standing position in elderly subjects, diabetic patients, and in other conditions in which postural hypotension may be frequent or suspected Measure heart rate by pulse palpation (at least 30 sec) after the second measurement in the sitting position

Table 2 Methods of subclinical organ damage detection

Area of assessment	Detection methods
Heart	Electrocardiography (should be routine in patients with high BP): left ventricular (LV) hypertrophy patterns of strain ischemia arrhythmias geometric patterns – concentric hypertrophy carries the worse prognosis Echocardiography is recommended when a more sensitive detection of LV hypertrophy is considered useful
	Transmitral Doppler: diastolic dysfunction
Brain	Magnetic resonance imaging (MRI) or CAT (CT): silent brain infarcts lacunar infarctions microbleeds white matter lesions Availability and costs do not allow indiscriminate use of these techniques Cognitive tests initial brain deterioration in elderly patients with hypertension
Kidney	Serum creatinine of glomerular filtration rate or creatinine clearance (should be routine for patients with hypertension): hypertension-related renal damage - based on reduced renal function or Dipstick: urinary protein – dipstick negative patients low-grade albuminuria (microalbuminuria) should be determined in spot urine and related to urinary creatinine excretion
Blood vessels	Ultrasound scanning of carotid arteries: vascular hypertrophy asymptomatic atherosclerosis is deemed useful
	Pulse wave velocity: large artery stiffening (leading to isolated systolic hypertension in the elderly)
	Ankle-brachial index: peripheral arterial disease (PAD) – advanced PAD signaled by low index
Eye	Fundoscopy (recommended in severe hypertension only): hemorrhages exudates papilloedema
	Mild retinal changes are largely non-specific except in young patients

Table 3 Guideline’s recommendations on preferred drug classes for various conditions and those conditions for which there is compelling evidence, or evidence suggestive, of contraindication to use of a class of agents

Drug Class	Conditions favoring use	Compelling contraindications	Possible contraindications
Thiazide diuretics	isolated systolic hypertension (elderly) heart failure hypertension in blacks	gout	metabolic syndrome glucose intolerance pregnancy
Diuretics (antialdosterone)	heart failure post-MI	renal failure hyperkalemia
Loop diuretics	end stage renal disease heart failure
Beta blockers	angina pectoris post-MI heart failure tachyarrhythmias glaucoma pregnancy	asthma A-V block (grade 2 or 3)	peripheral arterial disease metabolic syndrome glucose intolerance athletes and physically active patients chronic obstructive pulmonary disease
Calcium antagonists (dihydropyridines)	isolated systolic hypertension (elderly) angina pectoris LV hypertrophy carotid/coronary atherosclerosis pregnancy hypertension in blacks		tachyarrhythmias heart failure
Calcium antagonists (verapamil, diltiazem)	angina pectoris carotid atherosclerosis supravenricular tachycardia	A-V block (grade 2 or 3) heart failure
ACE inhibitors	heart failure LV dysfunction post-MI diabetic nephropathy LV hypertrophy carotid atherosclerosis proteinuria/mircroalbuminuria atrial fibrillation metabolic syndrome	pregnancy angioneurotic edema hyperkalemia bilateral renal artery stenosis
Angiotensin receptor antagonists	heart failure post-MI diabetic nephropathy proteinuria/mircroalbuminuria LV hypertrophy atrial fibrillation metabolic syndrome ACEI-induced cough	pregnancy hyperkalemia bilateral renal artery stenosis

Abbreviations: ACEI, ACE inhibitors; LV, Left ventricle; MI, myocardial infarction.

Table 4 Common causes of resistant hypertension

○ Poor adherence to therapeutic plan ○ Failure to modify lifestyle including: ○ weight gain ○ heavy alcohol intake (NB: binge drinking) ○ Continued intake of drugs that raise blood pressure (eg, liquorice, cocaine, glucocorticoids, non-steroid anti-inflammatory drugs) ○ Obstructive sleep apnea ○ Unsuspected secondary cause ○ Irreversible or scarcely reversible organ damage ○ Volume overload due to: ○ inadequate diuretic therapy ○ progressive renal insufficiency ○ high sodium intake ○ hyperaldosteronism Causes of spurious resistant hypertension: ○ Isolated office (white-coat) hypertension ○ Failure to use large cuff on large arm ○ Pseudohypertension

Table 5 Hypertensive emergencies

○ Hypertensive encephalopathy (most dangerous condition associated with malignant phase hypertension) ○ Hypertensive left ventricular failure ○ Hypertension with myocardial infarction ○ Hypertension with unstable angina ○ Hypertension and dissection of the aorta ○ Severe hypertension associated with subarachnoid hemorrhage or cerebrovascular accident ○ Crisis associated with pheochromocytoma ○ Use of recreational drugs such as amphetamines, LSD, cocaine or ecstasy ○ Hypertension perioperatively ○ Severe pre-eclampsia or eclampsia