New ESH/ESC Guidelines Signal Progress in Hypertension Management

The updated and recently released 2007 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) Guidelines for the Management of Arterial Hypertension [1], emphasize the assessment of total cardiovascular (CV) risk, along with proper measurement of blood pressure (BP) and novel recommendations to appropriately guide treatment strategies. The information from both is needed to improve patient management. Importantly, the BP threshold for initiating treatment and the treatment targets are lowered. In high‐risk patients, the treatment target is <130/80 mmHg, and treatment strategies should include consideration of prescribing aspirin and a statin.

Risk assessment

Importantly, age must be considered when determining CV risk. Total CV risk should be based on absolute risk, that is, the risk of an individual to have an event within 10 years. The Guidelines however state that relative risk, i.e. the increase in risk compared to the average risk of the general population, is a better guide for treatment in younger patients. Thus the 2007 ESH/ESC Guidelines recommend use absolute risk to guide treatment in the elderly and relative risk in younger patients.

As regards the thresholds for initiating treatment of high blood pressure additional evidence accumulated over the last few years supports the importance of blood pressure reduction per se for protecting hypertensive patients. In the 2007 Guidelines, the threshold for initiating drug treatment is set at >140/90 mmHg in all hypertensive patients, and at <140/90 mmHg in patients with a high‐risk profile. Thus, drug treatment should be initiated in persons who were considered as normotensive in the previous guidelines. This “flexible threshold” for treatment highlights the importance of the total CV risk to guide treatment. For low risk, the threshold for initiating treatment is about 140/90 mmHg, whereas for high risk the threshold is <140/90 mmHg.

The new 2007 ESH/ESC Guidelines presents a simplified assessment of risk, considering subclinical organ damage as a criterion for identifying patients at high risk. Notably, serum creatinine, estimated glomerular filtration rate (GFR) or estimated creatinine clearance, and microalbuminuria should be done for the routine assessment of organ damage, since a marked increase in CV risk is present even with a slight increase in serum creatinine (>1.4 mg/dL). An enormous amount of evidence now shows that in diabetic patients and in the general population, microalbuminuria predicts both renal outcomes and CV events. In addition to the traditional risk markers, two new recommended measures are recommended measures for assessment of organ damage; ankle‐brachial ratio and pulse wave velocity. The difference between ankle BP and brachial BP is a marker of advanced atherosclerotic disease. The greater the pulse wave velocity, the greater the arterial stiffness, which is of prognostic importance.

Treatment

Regarding the treatment of high blood pressure, lifestyle changes are recommended for everyone. This should be done seriously, possibly with the help of professionals, and reinforced by the clinician periodically. Importantly, however, drug treatment should not be delayed when there is evidence of a lack of effect of such measures.

With regard to drug treatment the new 2007 Guidelines emphasise that a large proportion of the benefit is coupled to the reduction of BP per se. Thiazide diuretics, ACE inhibitors, calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs), and beta blockers (BBs) are all suitable for antihypertensive treatment. If single drug treatment of initial combination treatment is insufficient, a more aggressive combination strategy should be implemented early. The evidence is now overwhelming that most persons with hypertension can only have good BP control with combination treatment. Thus, the guidelines state it is not meaningful to discuss what drug should be taken alone for the first 3 or 4 weeks, when it is necessary to take 2 or 3 drugs for a lifetime.

So, the question is not which drug, but which drugs should be used in the combination. There is a strong case in favour of combination treatment being the most important strategy for BP control. Thus, this is a practical approach, because nearly all patients will require combination treatment to control BP to target levels. Therefore, in the new 2007 ESH/ESC Guidelines, combination treatment is considered an appropriate first treatment option.

There is however evidence that some drugs are better than others for certain conditions. For patients with proteinuria and microalbuminuria, or patients in special need of renal protection, RAS inhibition is more effective. Also, for the prevention of atrial fibrillation, drugs that inhibit the renin‐angiotensin system (RAS) seems to be of special benefit. For the large patient group with the metabolic syndrome, ARBs, ACE inhibitors, or CCBs are preferred over diuretics or BB. Importantly, in the new Guidelines, there are a number of important elective indications, based on additional risks or significant co‐morbidities, in the hypertensive patient to guide appropriate choice of drug treatment.

In patients with isolated office hypertension, where office BP is high but ambulatory blood pressure (ABP) or home blood pressure (HBP) are within the normal range, there is a greater cardiovascular risk, based on novel evidence. Masked hypertension, where the office blood pressure (OBP) is within the normal range, but the HBP or ABP are elevated also is a high‐risk condition. Current epidemiological research indicate that about 1 in 7 persons have masked hypertension. Assessment of ABP or HBP should be used more often based on the evidence of its prognostic importance, as well as the evidence that involving patients in the treatment strategies improves compliance and adherence to therapy.

As regards the diabetic patient population, the presence of diabetes and hypertension includes a implementation of intense lifestyle measures, as well as a lower threshold (high normal blood pressure) for initiating drug treatment. There is also strong emphasis of a lower treatment target (<130/80 mmHg), as well as proper and aggressive management of other risk factors, particularlyfor patients in need a statin as well as of antiplatelet treatment.

For the treatment of patients with diabetes and hypertension, all classes of antihypertensive agents are useful, including BB and diuretics. In fact, diuretics may be used in diabetich in order to find an appropriate and effective combination treatment, which is extremely common in diabetics if target pressures are to reached. However, since RAS inhibition is of major importance in diabetics for primary and secondary endpoint prevention, it is appropriate to include it early in the combination treatment. ACE inhibitors and ARBs may readily prevent the appearance of microalbuminuria and diabetic nephropathy and may also slow the progression of diabetic nephropathy.

Importantly, the 2007 ESH/ESC Guidelines are intended to be educational, not prescriptive. This is because guidelines treat diseases in general, and this could be very different from situations in individual patients. Clinical judgment is required to apply the Guidelines to specific patients in daily clinical practice.

APPENDIX: Some Important Features of the 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension

Definition and Classification of Hypertension

• Assure proper blood pressure measurement as well as assessment of total cardiovascular (CV) risk to diagnose high blood pressure and guide treatment.

• Use absolute risk to guide treatment in the elderly and relative risk in younger patients.

• Classification of blood pressure;

• If a systolic and diastolic blood pressure fall into different categories, the higher category is used to quantify total CV risk, decisions about drug treatment, and estimation of treatment efficacy.

• Isolated systolic hypertension should be graded (grades 1, 2, 3) according to the same systolic blood pressure values indicated for systolic‐diastolic blood pressure. The association with a low diastolic blood pressure should be considered an additional risk.

• The threshold for defining and treating hypertension should be considered flexible, based on the blood pressure level and total CV risk.

• Place a person in the high‐risk category if there are multiple risk factors, diabetes, or organ damage.

Identification of Organ Damage

• Use all the appropriate tests to identify organ damage.

• Assess organ damage in more organ systems (heart, blood vessels, kidney, brain) since multiorgan damage is associated with worse prognosis.

• Assess organ damage routinely with tests e.g. to reveal microalbuminuria, along with serum creatinine, estimated glomerular filtration rate (GFR) or estimated creatinine clearance, etc.

• Start implementing assessments of organ damage by e.g. ankle‐brachial ratio and pulse wave velocity.

• Continously assess organ damage throughout treatment.

Goals of Treatment

• Reduce blood pressure to reduce risk and prevent CV events.

• Prevent worsening of organ damage.

• Prevent appearance of high‐risk conditions, such as e.g. diabetes and proteinuria

Treatment

• Implement a strategy of a “flexible threshold” for initiating drug treatment: >140/90 mmHg in all hypertensive patients, and <140/90 mmHg in high‐risk patients.

• Recommend lifestyle changes for all patients.

• Use appropriate drug classes to initiate and maintain antihypertensive treatment.

• Current evidence supports the importance of BP reduction per se rather than the drug selected to initiate treatment to obtain the greatest benefit.

• Some drug regimens versus others may be used in special conditions, as outlined in the Guidelines.

• Consider combination treatment as an appropriate first treatment option.

• Imlement aggressive blood pressure reduction in high‐risk patients, where the degree of BP reduction during the first 6 months is crucial to prevent events.

• Aim for a BP target <130/80 mmHg in patients with diabetes, renal disease, cerebrovascular disease, or coronary heart disease.