2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension

Abbreviations:
ABPM	=	ambulatory blood pressure monitoring
ACE	=	angiotensin converting enzyme
ARB	=	angiotensin receptor blocker
A-V	=	atrio-ventricular
BB	=	beta-blocker
BP	=	blood pressure
CHD	=	coronary heart disease
CKD	=	chronic kidney disease
CV	=	cardiovascular
CVD	=	cardiovascular disease
DBP	=	diastolic blood pressure
ECG	=	electrocardiogram
EF	=	ejection fraction
eGFR	=	estimated glomerular filtration rate
ESC	=	European Society of Cardiology
ESH	=	European Society of Hypertension
ESRD	=	end-stage renal disease
HBPM	=	home blood pressure measurement
HT	=	hypertension
ISH	=	isolated systolic hypertension
LV	=	left ventricle
LVH	=	left ventricle hypertrophy
OD	=	organ damage
PAD	=	peripheral artery disease
PWV	=	pulse wave velocity
RAS	=	renin-angiotensin system
RF	=	risk factor
SBP	=	systolic blood pressure
TIA	=	transient ischaemic attack.

Introduction

Principles

The 2013 ESH/ESC guidelines continue to adhere to some fundamental principles that inspired the 2003 and 2007 guidelines, namely (i) to base recommendations on properly conducted studies identified from an extensive review of the literature, (ii) to consider, as the highest priority, data from randomized, controlled trials and their meta-analyses, but not to disregard the results of observational and other studies of appropriate scientific caliber, and (iii) to grade the level of scientific evidence and the strength of recommendations in order to more effectively alert physicians on recommendations that are based on the opinions of the experts rather than on evidence (Tables 1 and 2). When appropriately recognized, this can avoid guidelines being perceived as prescriptive and favour the performance of studies where opinion prevails and evidence is lacking.

Table I. Classes of recommendations.

Classes of recommendations	Definition	Suggested wording to use
Class I	Evidence anchor general agreement that a given treatment or procedure is beneficial, useful, effective	Is recommended/is indicated
Class II	Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure
Class IIa	Weight of evidence/opinion is in favour of usefulness/efficacy	Should be considered
Class IIb	Usefulness/efficacy is less well established by evidence/opinion	May be considered
Class III	Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful	Is not recommended

Table II. Levels of evidence.

Level of evidence A	Data derived from multiple randomized clinical trials or meta-analyses
Level of evidence B	Data derived from a single randomized clinical trial or large non-randomized studies
Level of evidence C	Consensus of opinion of the experts and/or small studies, retrospective studies, registries

This shortened version of the ESH/ESC guidelines is for the practicing physician who often requires simplified information. However, whenever the physicians would like to know the source of the data upon which the recommendations are based, they are encouraged to consult the extensive version of the ESH/ESC guidelines where adequate references are given. These guidelines, however, do not override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient.

New aspects

Because of new evidence on several diagnostic and therapeutic aspects of hypertension, the present guidelines differ from the 2007 ones in several points:

1. Re-emphasis on integration of blood pressure (BP), cardiovascular (CV) risk factors (RF), asymptomatic organ damage (OD) and clinical complications for total CV risk assessment.

2. Update of the prognostic significance of out-of-office BP (both ambulatory and home BP), white coat hypertension and masked hypertension.

3. Initiation of antihypertensive drug treatment only in patients with SBP or DBP values > 140 or 90 mmHg, independent of level of total CV risk.

4. Unified target SBP (< 140 mmHg) in both higher and lower CV risk patients.

5. Revised recommendations on treatment of hypertension in young people and in the elderly.

6. Liberal approach to initial monotherapy, without any all-ranking purpose scheme.

7. Revised therapeutic algorithm for achieveing target BP.

8. Revised attention to resistant hypertension.

Definitions and classifications

The continuous relationship between BP and CV and renal events make the distinction between normotension and hypertension difficult. In practice, however, cut-off BP values are universally used to facilitate the decision about treatment (Table 3).

Table III. Definitions and classification of office blood pressure levels (mmHg).

Category	Systolic		Diastolic
Optimal	< 120	and	< 80
Normal	120–129	and/or	80–84
High normal	130–139	and/or	85–89
Grade 1 hypertension	140–159	and/or	90–99
Grade 2 hypertension	160–179	and/or	100–109
Grade 3 hypertension	≥ 180	and/or	≥ 110
Isolated systolic hypertension	≥ 140	and	< 90

In order to help prognosis, total CV risk should be stratified in different categories (low, moderate, high and very high risk referred to the 10-year risk of CV mortality), based on BP category, CV risk factors, asymptomatic OD and presence of diabetes, and symptomatic CV disease or chronic kidney disease (CKD), as summarized in Fig. 1.

Figure 1. Stratification of total CV risk in categories of low, moderate, high and very high risk according to SBP and DBP and prevalence of RFs, asymptomatic OD, diabetes, CKD stage or symptomatic CVD. Subjects with a high normal office but a raised out-of-office BP (masked hypertension) have a CV risk in the hypertension range. Subjects with a high office BP but normal out-of-office BP (white-coat hypertension), particularly if there is no diabetes, OD, CVD or CKD, have lower risk than sustained hypertension for the same office BP.

Diagnostic evaluation

The initial evaluation of a patient with hypertension should (i) confirm the diagnosis of hypertension, (ii) detect causes of secondary hypertension, and (iii) asses CV risk, OD and concomitant clinical conditions. This calls for BP measurement, medical history including family history, physical examination, laboratory investigation and further diagnostic tests. Some of the investigations are needed in all patients; others only in specific patient groups.

Blood pressure measurement

Office and out-of-office BP

While conventional office BP measurement currently remains the “gold standard” for screening, diagnosis and management of hypertension, it is generally accepted that out-of-office BP provides important adjunct information.

At present, BP can no longer be estimated using a mercury manometer in many – although not all – European countries. Auscultatory or oscillometric semiautomatic sphygmomanometers are used instead, but these devices should be validated according to standardized protocols and their accuracy checked periodically. Table 4 gives instructions for correct office BP measurements, and Table 5 provides clinical indications for out-of-office BP measurement, both measurements at home (HBPM) or 24-hour ambulatory BP monitoring (ABPM).

Tables IV. Office blood pressure measurement.

When measuring BP in the office, care should betaken: To allow the patients to sit for 3–5 minutes before beginning BP measurements To take at least two BP measurements, in the sitting position, spaced 1–2 min apart, and additional measurements. If the first two are quite different. Consider the average BP if deemed appropriate To take repeated measurements of BP to improve accuracy in patients with arrhythmias, such as atrial fibrillation To use a standard bladder (12–13 cm wide and 35 cm long), but have a larger and a smaller bladder available for large (arm circumference > 32 cm) and thin arms, respectively To have the cuff at the heart level, whatever the position of the patient When adopting the auscultatory method, use phase I and V (disappearance) Korotkoff sounds to identify systolic and diastolic BP, respectively To measure BP in both arms at first visit to detect possible differences. In this instance, take the arm with the higher value as the reference To measure at first visit, BP I and 3 min after assumption of the standing position in elderly subjects, diabetic patients, and in other conditions in which orthostatic hypotension may be frequent or suspected To measure, in case of conventional BP measurement, heart rate by pulse palpation (at least 30 s) after the second measurement in the sitting position

Table V. Clinical indications for out-of-office blood pressure measurement for diagnostic purposes.

Clinical indications for HBPM or ABPM Suspicion of white-coat hypertension – Grade 1 hypertension in the office – High office BP in individuals without asymptomatic organ damage and at low total CV risk Suspicion of masked hypertension – High normal BP in the office – Normal office BP in individuals with asymptomatic organ damage or at high total CV risk Identification of white-coat effect in hypertensive patients Considerable variability of office BP over the same or different visits Autonomic, postural, post-prandlal, siesta-and drug-induced hypotension Elevated office BP or suspected pre-eclampsla in pregnant women Identification of true and false resistant hypertension

Specific indications for ABPM Marked discordance between office BP and home BP Assessment of dipping status Suspicion of nocturnal hypertension or absence of dipping, such as in patients with sleep apnoea, CKD. or diabetes Assessment of BP variability

ABPM, ambulatory blood pressure monitoring; BP, blood pressure; CKD, chronic kidney disease; CV, cardiovascular; HBPM, home blood pressure monitoring.

Office BP is usually higher than ambulatory and home BP and the difference increases as office BP increases. Cut-off values for the definition of hypertension by home and ambulatory BP are reported in Table 6.

Table VI. Definitions of hypertension by office and out-of-office blood pressure levels.

Category	Systolic BP (mmHg)		Diastolic BP (mmHg)
Office BP	≥ 140	and/or	≥ 90
Ambulatory BP
Daytime (or awake)	≥ 135	and/or	≥ 85
Nighttime (or asleep)	≥ 120	and/or	≥ 70
24-h	≥ 130	and/or	≥ 80
Home BP	≥ 135	and/or	≥ 85

White-coat and masked hypertension

The term “white coat” or “isolated office” hypertension refers to a condition in which BP is elevated in the office at repeated visits and normal out of the office either on ABPM or HBPM. Conversely, BP may be normal in the office and abnormally high out of medical environment, which is termed “masked” or “isolated ambulatory” hypertension.

Cut-off values to be used are those in Table 6.

Central blood pressure

Owing to the variable superposition of incoming and reflected pressure waves along the arterial tree, aortic BP (central BP) may be different from brachial BP. Central BP can be estimated indirectly by various methods. The current guidelines consider that, despite the growing interest in these methods, more investigation is needed before recommending the routine measurement of central BP for clinical use.

Medical history

The information to be obtained at the time of the first diagnosis of hypertension is indicated in Table 7.

Table VII. Personal and family medical history.

1. Duration and previous level of high BP, including measurements at home

2. Secondary hypertension

a) Family history of CKD (polycystic kidney)

b) History of renal disease, urinary tract infection, haematuria, analgesic abuse (parenchymal renal disease)

c) Drug/substance intake, e.g. oral contraceptives, liquorice, carbenoiolone, vasoconstrictive nasal drops, cocaine, amphetamines, gluco- and mineralocorticosteroids, non-steroidal anti-inflammatory drugs, erythropaietin, cyclosporine

d) Repetitive episodes of sweating, headache, anxiety, palpitations (pheochromocytoma)

e) Episodes of muscle weakness and tetany (hyperaldosteronism)

f) Symptoms suggestive of thyroid disease

3. Risk factors

a) Family and personal history of hypertension and CVD

b) Family and personal history of dyslipidaemia

c) Family and personal history of diabetes mellitus (medications, blood-glucose levels, polyuria)

d) Smoking habits

e) Dietary habits

f) Recent weight changes; obesity

g) Amount of physical exercise

h) Snoring; sleepapnoea (information also from partner)

i) Low birth-weight

4. History and symptoms of organ damage and cardiovascular disease

a) Brain and eyes: headache, vertigo, impaired vision, TIA, sensory or motor deficit, stroke, carotid revascularization

b) Heart: chest pain, shortness of breath, swollen ankles, myocardial inlanction, revascularization, syncope, history of palpitations, arrhythmias, especially atrial fibrillation

c) Kidney: thirst, polyuria, nocturia, haematuria

d) Peripheral arteries: cold extremities, intermittent claudication, pain-free walking distance, peripheral revascularization

e) History of snoring/chronic lung disease/sleep apnoea

f) Cognitive dysfunction

5. Hypertension management

a) Current antihypertensive medication

b) Past antihypertensive medication

c) Evidence of adherence or lack of adherence to therapy

d) Efficacy and adverse effects of drugs

BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; TIA, transent schamic attack.

Physical examination

Physical examination aims to establish or verify the diagnosis of hypertension, establish current BP, screen for secondary causes of hypertension and refine global CV risk. Procedures for BP measurement are indicated in tables 4 and 5 above. Other information to be obtained by physical examination are in Table 8.

Table VIII. Physical examination for secondary hypertension, organ damage and obesity.

Signs suggesting secondary hypertension Features of Cushing syndrome Skin stigmata of neurofibromatosis (pheochromocytoma) Palpation of enlarged kidneys (polycystic kidney) Auscultation of abdominal murmurs (renovascular hypertension) Auscultation of precordial or chest murmurs (aortic coarctation; aortic disease; upper extremity artery disease) Diminished and delayed femoral pulses and reduced femoral blood pressure compared to simultaneous arm BP (aortic coarctation; aortic disease; lower extremity artery disease) Left-right arm BP difference (aortic coarctation; subclavian artery stenosis)

Signs of organ damage Brain: motor or sensory defects Retina: fundoscopic abnormalities Heart: heart rate, 3^rd or 4^th heart sound, heart murmurs, arrhythmias, location of apical impulse, pulmonary rales, peripheral oedema Peripheral arteries: absence, reduction, or asymmetry of pulses, cold extremities, ischaemic skin lesions Carotid arteries: systolic murmurs

Evidence of obesity Weight and height Calculate BMI: body weight/height^2 (kg/m^2) Waist circumference measured in the standing position, at a level midway between the lower border of the costal margin (the lowest rib) and uppermost border of the iliac crest

BP, blood pressure; BMI, body mass index.

Laboratory investigations

Laboratory investigations are directed at providing evidence for additional risk factors, searching for secondary hypertension and looking for OD. Investigations should proceed from the most simple to the more complicated ones, as summarized in Table 9.

Table IX. Laboratory investigations.

Routine tests Haemoglobin and/or haematocrit Fasting plasma glucose Serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol Fasting serum triglycerides Serum potassium and sodium Serum uric acid Serum creatinine (with estimation of GFR) Urine analysis: microscopic examination; urinary protein by dipstick test; test for microalbuminuria 12-lead EGG

Additional tests, based on history, physical examination, and findings from routine laboratory tests Haemoglobin A1c (if fasting plasma glucose is > 5.6 mmol/L (102 mg/dL) or previous diagnosis of diabetes) Quantitative proteinuria (if dipstick test is positive); urinary potassium and sodium concentration and their ratio Home and 24-h ambulatory BP monitoring Echocardiogram Holter monitoring in case of arrhythmias Carotid ultrasound Peripheral artery/abdominal ultrasound Pulse wave velocity Ankle-brachial index Fundoscopy

Extended evaluation (mostly domain of the specialist) Further search for cerebral, cardiac, renal, and vascular damage, mandatory in resistant and complicated hypertension Search for secondary hypertension when suggested by history, physical examination, or routine and additional tests

BP, blood pressure; ECG, electrocardiogram; GFR, glomerular filtration rate.

Searching for asymptomatic organ damage

Owing to the importance of asymptomatic OD as an intermediate stage in the continuum of CV disease, and as a determinant of overall CV disease, signs of organ involvement should be sought carefully by appropriate techniques as indicated below.

Search for asymptomatic organ damage, cardiovascular disease, and chronic kidney disease

Searching for secondary forms of hypertension

A specific, potentially reversible cause of BP elevation can be identified in a relatively small number of adult patients with hypertension. However if basal work-up leads to the suspicion of a secondary form of hypertension, the patient should be referred to a specialized centre where specific diagnostic procedures may be preferred.

Treatment approach

Recommendations of previous Guidelines revised

The 2007 ESH/ESC Guidelines, like many other scientific guidelines, recommended the use of antihypertensive drugs in patients with grade 1 hypertension even in the absence of other risk factors or OD after nonpharmacological treatment had proved unsuccessful. This recommendation also specifically included the elderly hypertensive patient. The 2007 Guidelines also suggested drug treatment of patients with diabetes, previous CVD or CKD even when their BP was in the high normal range (130–139/85-89 mmHg). Furthermore, a lower BP target was recommended for these high or very-high risk patients (< 130/80 mmHg) than in patients at low-moderate risk (< 140/90 mmHg). These recommendations were reappraised in a 2009 ESH Task Force document on the basis of an extensive critical review of the evidence. The following now summarizes the conclusions for the current Guidelines: attention should be directed to the Class of recommendation and the Level of evidence, in order to distinguish what is considered compelling and what simply prudent.

When to initiate antihypertensive drug treatment

Initiation of antihypertensive drug treatment

Blood pressure treatment targets

Fig. 2 also summarizes recommendations and suggestions for treatment initiation and BP targets in the context of total risk stratification of hypertensive individuals.

Figure 2. Initiation of lifestyle changes and antihypertensive drug treatment. Targets of treatment are also indicated. Colours are as in Figure 1. Consult Section 6.6 for evidence that, in patients with diabetes, the optimal DBP target is between 80 and 85 mmHg. In the high normal BP range, drug treatment should be considered in the presence of a raised out-of-office BP (masked hypertension). Consult section 4.2.4 for lack of evidence in favour of drug treatment in young individuals with isolated systolic hypertension.

Blood pressure goals in hypertensive patients

Treatment strategies

Lifestyle changes

Appropriate lifestyle changes are the cornerstone for the prevention of hypertension. They are also important for its treatment, although they should never delay the initiation of drug therapy in patients at high level of risk. Beside the BP-lowering effect, lifestyle changes contribute to the control of other CV risk factors and clinical conditions.

The lifestyle measures that have been shown to be capable of reducing BP and are therefore recommended are:

• (i) salt restriction to 5–6 g/day;

• (ii) moderation of alcohol consumption to no more than 20–30 g of ethanol per day in men and 10–20 g per day in women;

• (iii) high consumption of vegetables and fruits and low-fat dairy products

• (iv) reduction of weight to body mass index of 25 kg/m² and waist circumference to < 102 cm in men and < 88 cm in women;

• (v) at least 30 min of moderate dynamic exercise on 5 to 7 days per week

Pharmacological therapy

Choice of antihypertensive drugs

The current guidelines reconfirm that all major classes of antihypertensive agents are suitable for the initiation and maintenance of antihypertensive treatment either in monotherapy or in some combinations, and that no all-purpose ranking of drugs for general antihypertensive usage is evidence based. All classes have their advantages but also contraindications, and may be preferentially used or avoided in specific conditions. Contra-indications and preferred indications are listed in Tables 10 and 11.

Table X. Compelling and possible contra-indications to the use of antihypertensive drugs.

Drug	Compelling	Possible
Diuretics (thiazides)	Gout	Metabolic syndrome Glucose intolerance Pregnancy Hypercalcaemia Hypokalaemia
Beta-blockers	Asthma A-V block (grade 2 or 3)	Metabolic syndrome Glucose intolerance Athletes and physically active patients Chronic obstructive pulmonary disease (except for vasodilator beta-blockers)
Calcium antagonists (dihydropyridines)		Tachyarrhythmia heart failure
Calcium antagonists	A-V block (grade 2 or 3, trifascicular block)
(verapamil, diltiazem)	Severe LV dysfunction Heart failure
ACE inhibitors	Pregnancy	Women with child bearing potential
	Angioneurotic oedema
	Hyperikalaemia
	Bilateral renal artery stenosis
Angiotensin receptor blockers	Pregnancy	Women with child bearing potential
	Hyperkalaemia
	Bilateral renal artery stenosis
Mineralocorticoid receptor antagonists	Acute or severe renal failure (eGFR < 30 mL/min) Hyperkalaemia

A-V, atrio-ventricular; eGFt, estimated glomerular filtration rate; LV, left ventricular.

Table XI. Drugs to be preferred in specific conditions.

Condition	Drug
Asymptomatic organ damage
LVH	ACE inhibitor, calcium antagonist, ARB
Asymptomatic atherosclerosis	Calcium antagonist, ACE inhibitor
Microalbuminuria	ACE inhibitor, ARB
Renal dysfunction	ACE inhibitor, ARB
Clinical CV event
Previous stroke	Any agent effectively lowering EP
Previous myocardial infarction	EB, ACE inhibitor, ARB
Angina pectoris	BB, calcium antagonist
Heart failure	Diuretic, BB, ACE inhibitor, ARB, mineralocorticoid receptor antagonists
Aortic aneurysm	BB
Atrial fibrillation	Consider ARB, ACE inhibitor, BB or mineralocorticoid receptor antagonist
Atrial fibrillation, prevention, ventricular rate control	BB, non-dihydropyridine calcium antagonist
ESRD/proteinuria	ACE inhibitor, ARB
Peripheral artery disease	ACE inhibitor, calcium antagonist
Other
ISH (elderly)	Diuretic, calcium antagonist
Metabolic syndrome	ACE inhibitor, ARB, calcium antagonist
Diabetes mellitus	ACE inhibitor, ARB
Pregnancy	Methyldopa, BB, calcium antagonist
Blacks	Diuretic, calcium antagonist

ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, beta-blocker; BP, blood pressure; CV, cardiovascular; ESRD, end-stage renal disease; ISH, isolated systolic hypertension; LVH, left ventricular hypertrophy.

Monotherapy and combination therapy

The current Guidelines share the 2007 Guidelines opinion that monotherapy can reduce BP to target only in a limited number of patients and that most patients require the combination of at least two drugs, and they reconfirm that initiation with a drug combination can be considered in patients at high CV risk or with markedly high BP. The algorithm of Fig. 3, however, is a modification of the 2007 one, to emphasize that adding drugs to drugs should be done with attention to results and any compound overtly ineffective or minimally effective should be replaced, rather than retained in an automatic step-up multiple-drug approach.

Figure 3. Monotherapy vs. drug combination strategies to achieve target BP. Moving from a less intensive to a more intensive therapeutic strategy should be done whenever BP target is not achieved.

Combinations to be preferred or avoided are illustrated in Fig. 4.

Figure 4. Possible combinations of classes of antihypertensive drugs. Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well tested combinations; red continuous line: not recommended combination. Although verapamil and diltiazem are sometimes used with a beta-blocker to improve ventricular rate control in permanent atrial fibrillation, only dihydropyridine calcium antagonists should normally be combined with beta-blockers.

Strengths of recommendations about choice of drugs and combinations of antihypertensive agents are given in the summary table below.

Treatment strategies and choice of drugs

Treatment strategies in special conditions

Summary recommendations for antihypertensive treatment strategies in various conditions are listed below.

White-coat and masked hypertension

Treatment strategies in white-coat and masked hypertension

Elderly

Antihypertensive treatment strategies in the elderly

Young adults

Table

Recommendations	Class^a	Level^b
Antihypertensive drug treatment, in addition to lifestyle measures, may be considered prudent in young adults with DBP > 90 mmHg and, especially when other risk factors are present, BP should be reduced to < 140/90 mmHg	IIa	B
Antihypertensive drug therapy is not recommended in young individuals with isolated elevation of brachial SBP, but these individuals should be followed closely with lifestyle recommendations	III	A

Women

Treatment strategies in hypertensive women

Diabetes mellitus

Treatment strategies in patients with diabetes

Metabolic syndrome

Treatment strategies in hypertensive patients with metabolic syndrome

Diabetic and non-diabetic nephropathy

Therapeutic strategies in hypertensive patients with nephropathy

Cerebrovascular disease

Therapeutic strategies in hypertensive patients with cerebrovascular disease

Heart disease

Therapeutic strategies in hypertensive patients with heart disease

Atherosclerosis, arteriosclerosis and peripheral artery disease

Therapeutic strategies in hypertensive patients with atherosclerosis, arteriosclerosis, and peripheral artery disease

Resistant hypertension

Therapeutic strategies in patients with resistant hypertension

Treatment of associated risk factors

Treatment of ristors associated with hypertension

Follow-up

Follow-up visits

After invitation of antihypertensive drug therapy, it is important to see the patient at 2- to 4-week intervals to evaluate the effects on BP and to assess possible side-effects. Some medications will have an effect within days or weeks but a continued delayed response may occur during the first 2 months. Once the target is reached, a visit interval of a few months is reasonable.

Elevated blood pressure at control visits

Patients and physicians have a tendency to interpret an uncontrolled BP at a given visit as due to occasional factors and thus to downplay its clinical significance. Due attention should be given to poor adherence or irregular consumption of drugs (sometimes because of adverse effects), to the white coat effect and to substances or drugs opposing the antihypertensive effect of treatment.

Can antihypertensive medication be stopped?

In some patients, in whom treatment is accompanied by an effective BP control for an extended period, it may be possible to reduce the number and dosage of drugs. This may be particularly the case if BP control is accompanied by healthy lifestyle changes. Reduction of medications should be made gradually and the patient should frequently be checked because of the risk of reappearance of hypertension.

Improvement of blood pressure control in hypertension

Despite overwhelming evidence that hypertension is a major CV risk factor and that BP lowering substantially reduce the risk, there is evidence that all over the world (i) a noticeable proportion of hypertensive individuals are unaware of this condition or, if aware, do not undergo treatment; (ii) target BP values are seldom achieved; (iii) failure to achieve BP control is associated with persistence of an elevated CV risk; and (iv) the rate of awareness of hypertension and BP control is improving slowly or not at all. As a consequence, high BP remains a leading cause of death and CV morbidity in Europe, as elsewhere in the world. Overall, three main causes of the low rate of BP control in real life have been identified: (i) physician inertia; (ii) patient low adherence to treatment, and (iii) deficiencies of healthcare systems in their approach to chronic diseases. Methods to improve adherence to physicians’ recommendations are listed in Table 12.

Table XII. Methods to improve adherence to physicians’ recommendations.

Patient level

Information combined with motivational strategies (see Section 5.1.6 on smoking cessation)

Group sessions

Self-monitoring of blood pressure

Self-management with simple patient-guided systems.

Complex interventions^a

Drug treatment level

Simplification of the drug regimen

Reminder packaging

Health system level

Intensified care (monitoring, telephone follow-up, reminders

home visits, telemonitoring of home blood pressure, social support, computer-aided counselling and packaging)

Interventions directly involving pharmacists

Reimbursement strategies to improve general practitioners’ involvement in evaluation and treatment of hypertension

^aAlmost ill of the interventions that were effective for long-term carewere complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counselling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, supportive care, worksite- and pharmacy-based programmes.

Acknowledgement

The contribution of Mrs Clara Sincich and Mrs Donatella Mihalich is gratefully acknowledged.

Appendix

ESH and ESC entities that participated in the development of the ESH/ESC Guidelines are listed in the extended version of the Guidelines (J Hypertens 2013; 31: 1281–1357).