1. Introduction
Hypertension is considered one of the most significant causes of global morbidity and mortality regardless of the treatment progressions through the past decades [Citation1,Citation2]. In 2017 and 2018, recent guidelines were published jointly by the American Heart Association (AHA)/American College of Cardiology (ACC) and the European Society of Cardiology (ESC)/European Society of Hypertension (ESH), respectively [Citation3,Citation4]. Both guidelines aim for improving the detection, evaluation, prevention, and management of arterial hypertension in the adult population.
2. The definition of hypertension
In line with the 2018 ESC/ESH guidelines, the definition of hypertension is not changed compared to the previous ones, in which hypertension is defined as office systolic blood pressure (BP) ≥140 mmHg and office diastolic BP ≥ 90 mmHg, which is equal to either 24 h mean ambulatory blood pressure monitoring (ABPM) ≥130/80 or home blood pressure monitoring (HBPM) ≥135/85 mmHg.
On the other hand, the definition of hypertension is perhaps one of the main significant and controversial updates of the 2017 ACC/AHA guidelines, which is redefined as systolic BP ≥ 130 and diastolic BP ≥ 80 mmHg, and differs from the previous definition of Seventh Report of the Joint National Committee (JNC7) guidelines [Citation5]. This new definition was based on data derived from observational studies and clinical trials, and partly influenced by the results of Systolic Blood Pressure Intervention Trial (SPRINT) [Citation6]. However, evidence obtained from multiple randomized clinical trials does not univocally support this new threshold criteria; hence, the European guidelines maintain their previous definition. Similarly, and in line with the European guidelines, the National Institute of Clinical Excellence (NICE) guidelines for the diagnosis and management of hypertension in the UK have maintained the previous definition of hypertension in their latest published update [Citation7].
The redefined lowered threshold of American guidelines would noticeably increase the global prevalence of hypertension at the time that BP control rate (to <140/90 mmHg) for the majority of the world is approximately less than 15% [Citation8]. Accordingly, various studies have estimated the impact of the new threshold of American guidelines on the overall prevalence of hypertension among the adult population. In 2018, Munter et al. reported that the prevalence of hypertension among the US adults would significantly increase according to the ACC/AHA guidelines criteria compared to the JNC7 guidelines (45.6% vs 31.9%), while the antihypertensive treatment would be recommended for a limited percentage of US adults (36.2%) and (34.3%), respectively [Citation9]. Correspondingly, another study estimated that the hypertensive population in Canada would be nearly doubled if the 2017 ACC/AHA guidelines was adopted [Citation10].
Furthermore, analysis of the Pre-Eclampsia New Emerging Team (PE-NET) and the Maternal Health Clinic (MHC) postpartum databases demonstrated that with implementing the American guidelines, the prevalence of hypertension postpartum would be doubled [Citation11]. A similar increase in prevalence would be expected in hemophilia patients while a cohort study of 701 Dutch and UK hemophilia patients illustrated that the prevalence of hypertension in those patients was significantly higher compared to the general population (49% vs 40%) [Citation12].
In the UK, cross-sectional study results of national survey data from England, the USA and Canada demonstrated that the prevalence of hypertension among these countries was the highest in England (30%) and around only 34% of individuals had a BP <140/90 mmHg [Citation13]. Therefore, by adopting the 2017 ACC/AHA guidelines in the UK, those individuals of high normal BP will be labeled as hypertensive patients; thus, the overall prevalence of hypertension in the UK will be dramatically increased. Consequently, this would lead to a further cost burden on the health care system, as more individuals would need antihypertensive treatment. An intensive blood pressure treatment approach has been shown to be cost-effective among the high-risk patients [Citation14] However, increase in clinical encounters necessitates the expansion of public health infrastructure, which may be challenging to implement and could affect health care delivery. These health-economic burdens, as well as the adverse events related to intensive BP control might exceed the expected clinical benefits in ‘non high-risk’ patients if fully applying the American guidelines.
In the recent European guidelines, additional emphasis has been given to resistant hypertension. Resistant hypertension is confirmed when the recommended triple combination treatment strategy including a diuretic fail to reduce the office BP readings <140/90 mmHg. In addition to this, as per the new recommendations, the patient adherence to the treatment should be confirmed using different methods, preferably urine or blood test for drug screening (class Ic recommendation). This confirmation of treatment adherence can aid in the diagnosis of resistant hypertension and thus avoiding unnecessary more drugs prescribed to those patients of poor medication adherence. However, its implementation in routine clinical practice in the UK could be challenging in some places [Citation15].
3. Measurement methods
According to the recent ESC/ESH guidelines, the diagnosis of hypertension can be confirmed by either repeated office BP measurements or out-of-office BP measurement with 24 h ABPM and/or HBPM, if feasible. Among similarities, both guidelines encourage the use of out of office BP measurements either with ABPM or/and HBPM for diagnosis and assessment of the treatment efficacy. These measurements could have a favorable impact on the clinical practice in the UK by aiding in the confirmation of hypertension diagnosis as well as the detection of white coat and masked hypertension. Furthermore, there is evidence that HBPM could enhance the therapy adherence and BP monitoring [Citation16] whereas the ABPM is found to be a more sensitive predictor of cardiovascular morbidity and mortality compared to the office BP [Citation17]. A further recommendation of wider use of out of office BP measurements has also been supported by the latest NICE guidelines.
4. Treatment target
The 2018 ESC/ESH guidelines recommended new BP treatment target ranges for both the systolic BP and diastolic BP. In all hypertensive patients, it is recommended that the first treatment target is to reduce the BP levels to <140/90 mmHg. In case if antihypertensive treatment is well tolerated, then the targeted BP values should be aimed at 130/80 mmHg or lower in most patients. The ACC/AHA guidelines consider a similar target for BP treatment to be ≤130/80 mmHg in most patients. The 2019 NICE guidelines recommended a BP target <140/90 mmHg.
5. Initiation of antihypertensive treatment
In a comparison of the 2018 ESC/ESH guidelines with the previous version, the prior recommendation of no commencement of the antihypertensive therapy in patients with high normal BP 130–139/85–89 mmHg has changed from ‘not recommended’ (class III) to ‘may be considered’ (class IIb). Thus, antihypertensive therapy may be considered now in patients with elevated BP 130–139/85–89 mmHg when cardiovascular disease (CVD) risk is very high such as coronary artery disease.
Despite the difference in the BP classification of 130–139/85–89 mmHg category between both sets of guidelines, the decision to initiating antihypertensive treatment in this category is almost similar. The treatment decision is relied on the assessment of CVD risk and accompanying disorders. According to the ACC/AHA guidelines, this category is defined as stage 1 hypertension, in which the initial recommended treatment is lifestyle intervention while antihypertensive medication is recommended in high-risk patients who have existing atherosclerotic CVD, or their calculated 10-year risk of atherosclerotic CVD ≥ 10%. However, the recent NICE guidelines did not recommend to initiate the treatment in this particular category of patients with BP 130–139/85–89 mmHg and a high-risk of CVD.
6. Combination therapy
One of the significant updates in both guidelines, which could improve the treatment adherence and thus the management of hypertension in the UK, is a single-pill combination therapy. According to both the American and European guidelines, it is recommended to initiate the treatment with the single-pill combination of at least two drugs.
In case of uncomplicated hypertension, treatment can be a combination of either an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) combined with either a calcium channel blocker (CCB) or a diuretic. Furthermore, a triple combination pill of ACEi or ARB, CCB and a diuretic is recommended, if necessary. Triple combination therapy, with the addition of low-dose spironolactone or the addition of other drugs such as a further diuretic, an alpha-blocker or a beta-blocker are indicated for the treatment of resistant hypertension. This recommended pharmacological treatment strategy is highly based on the result of the PATHWAY-2 study [Citation18].
7. Expert opinion
On the bases of the abovementioned developments in both guidelines, we welcome several recommendations which could have a significant impact on the management of hypertension in the UK such as the broader use of the out-of-office BP measurements and proactive initiation of a single-pill combination in order to improve adherence and BP control. However, in our opinion, the improvement of hypertension management in the UK may not be able to take advantage of the 2017 ACC/AHA approach. This is due to the incremental harm of adopting the new definition may overcome any incremental benefits. The demerits include adverse effects of intensive treatment on newly diagnosed patients, raising health-care costs as well as the risk of anxiety and depression, as more people will be labeled as hypertensive patients. Therefore, we support the 2018 ESC/ESH guidelines and believe the new evidence is reflected in the 2019 update of the NICE guidelines.
Declaration of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Reviewer Disclosures
One referee was involved in the preparation of the 2017 ACC/AHA hypertension guidelines. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.
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References
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