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American and European Guidelines for hypertension management: agreements and disagreements

An article from the e-journal of the ESC Council for Cardiology Practice

The Guidelines for hypertension management published by the large international societies in Europe and in the US re-emphasise the risk linked to hypertension and the benefit of decreasing such a risk. However, there are differences in views on the topic: the guidelines issued by the Joint National Committee (JNC VII) are highly prescriptive while the European guidelines focus on a better detection/control of the presence and progression of organ damage.

Hypertension


Guidelines for hypertension management issued by the Joint National Committee (JNC VII) and by the European Society of Hypertension in conjuction with the European Society of Cardiology (ESH/ESC) (1,2) have recently been published in major scientific journals. This article will briefly examine the major agreements and disagreements between these recommendations and their implications for current clinical practice.

Twofold is the value of the hypertension Guidelines issued by JNC and ESH/ESC (1,2). Firstly, these guidelines may help codify “best practice” behaviour by providing a reference point for practitioners and health authorities. More generally, they serve as one critical component of a well constructed program designed to improve professional practice and health outcomes. However, they are not “built”, to hand out “rigid” rules or for constraining individual medical judgment of single patients. Rather, these guidelines are thought out to help clinicians in their decision-making in view of improving the poor blood pressure control that can be found in daily clinical practice.
Beyond these aims, the two sets of Guidelines also share a number of common important theoretical and practical issues. For example, both the JNC VII and the ESH/ESC Guidelines (1,2) recognise the benefits of antihypertensive treatment when it comes to reduction of fatal and nonfatal cardiovascular events. They also agree on the blood pressure measurement procedure as well as on the use and value of ambulatory blood pressure monitoring and home blood pressure readings. Finally, both Guidelines contain elements regarding 1) the blood pressure targets and thresholds for treatment 2) the use of antiplatelet and lipid-lowering drugs in conjuction with antihypertensive treatment 3) the follow-up strategies 4) the value and indications of combination drug treatment.

A number of major differences exist between the two sets of Guidelines however. Firstly, concerning the main scope of the two sets of recommendations : recommendations are mainly prescriptive in the case of the JNC VII while the ESH/ESC Guidelines are more informative and educational.
Other general differences refer to the type of diagnostic procedures that are to be applied in clinical practice. The American recommendations tend to be simpler and thus less expensive yet also less adequate to detect the presence and/or the progression of organ damage (1). In turn, the ESH/ESC Guidelines guarantee a better and more comprehensive evaluation of target organ damage (2), with the obvious favourable implication this better evaluation has on therapeutic approach.
Moreover, at least two further “diagnostic” differences between the two above mentioned Guidelines deserve to be discussed.
The first one refers to the definition of “pre-hypertension”. The JNC Guidelines have indeed unified the blood pressure categories previously defined as “high-normal” and “normal” (1). They now call the condition in which blood pressure values are between 120 and 139 mmHg systolic and 80-89 mmHg diastolic “pre-hypertension”. For this state, they recommend non-pharmacologic interventions.
The second one refers to the fact that American Guidelines do not recommend any quantification of total cardiovascular risk, whereas European Guidelines regard this issue as a crucial part of the hypertension diagnosis. Indeed, assessment of total risk may be particularly helpful in the above mentioned “prehypertension” category because detection of a high or very high risk state in this category entails antihypertensive drug treatment while a moderate risk in this same category means suggesting life style changes only.

First drug choice

The JNC Guidelines (1) recommended a diuretic in most hypertensive patients, thereby placing drugs such as beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium antagonists and angiotensin II antagonists in a subordinate position. Several reasons do not allow European Guidelines to agree on this crucial point. First, large-scale trials have shown that treatment that is based on diuretics but also on beta-blockers, ACE inhibitors, calcium antagonists and angiotensin II antagonists achieves cardiovascular protection in hypertensive patients (4,5). Second, in most comparison intervention trials, no difference has been found between conventional treatment (i.e., a treatment based on diuretics and beta-blockers) and newer drugs in the primary outcome. The only two exceptions have not been in favour of conventional treatment and diuretics lost, although to a marginal degree, a head-to-head comparison with ACE-inhibitors in one trial (7). Third, meta-analyses of available trial data (6) suggest that some between drug differences may exist with regard to prevention of specific cardiovascular diseases such as stroke, myocardial infarction, heart failure, although not all in favour of diuretics as compared with other drugs. Indeed, lower serum proteins levels accompanying diuretic treatment have been reported to increase the rate of sudden death (7), while diuretic-induced glucose intolerance may favour the development of diabetes and markedly increase the incidence of the metabolic syndrome (8), with long-term adverse consequences for cardiovascular prevention.
            

The Guidelines for hypertension management published by the large international societies in Europe and in the US re-emphasise the risk linked to hypertension and the benefit of decreasing such a risk. However, there are differences in views on the topic: the guidelines issued by the Joint National Committee (JNC VII) are highly prescriptive while the European guidelines focus on a better detection/control of the presence and progression of organ damage.

Guidelines for hypertension management issued by the Joint National Committee (JNC VII) and by the European Society of Hypertension in conjuction with the European Society of Cardiology (ESH/ESC) (1,2) have recently been published in major scientific journals. This article will briefly examine the major agreements and disagreements between these recommendations and their implications for current clinical practice.

Twofold is the value of the hypertension Guidelines issued by JNC and ESH/ESC (1,2). Firstly, these guidelines may help codify “best practice” behaviour by providing a reference point for practitioners and health authorities. More generally, they serve as one critical component of a well constructed program designed to improve professional practice and health outcomes. However, they are not “built”, to hand out “rigid” rules or for constraining individual medical judgment of single patients. Rather, these guidelines are thought out to help clinicians in their decision-making in view of improving the poor blood pressure control that can be found in daily clinical practice.
Beyond these aims, the two sets of Guidelines also share a number of common important theoretical and practical issues. For example, both the JNC VII and the ESH/ESC Guidelines (1,2) recognise the benefits of antihypertensive treatment when it comes to reduction of fatal and nonfatal cardiovascular events. They also agree on the blood pressure measurement procedure as well as on the use and value of ambulatory blood pressure monitoring and home blood pressure readings. Finally, both Guidelines contain elements regarding 1) the blood pressure targets and thresholds for treatment 2) the use of antiplatelet and lipid-lowering drugs in conjuction with antihypertensive treatment 3) the follow-up strategies 4) the value and indications of combination drug treatment.

A number of major differences exist between the two sets of Guidelines however. Firstly, concerning the main scope of the two sets of recommendations : recommendations are mainly prescriptive in the case of the JNC VII while the ESH/ESC Guidelines are more informative and educational.
Other general differences refer to the type of diagnostic procedures that are to be applied in clinical practice. The American recommendations tend to be simpler and thus less expensive yet also less adequate to detect the presence and/or the progression of organ damage (1). In turn, the ESH/ESC Guidelines guarantee a better and more comprehensive evaluation of target organ damage (2), with the obvious favourable implication this better evaluation has on therapeutic approach.
Moreover, at least two further “diagnostic” differences between the two above mentioned Guidelines deserve to be discussed.
The first one refers to the definition of “pre-hypertension”. The JNC Guidelines have indeed unified the blood pressure categories previously defined as “high-normal” and “normal” (1). They now call the condition in which blood pressure values are between 120 and 139 mmHg systolic and 80-89 mmHg diastolic “pre-hypertension”. For this state, they recommend non-pharmacologic interventions.
The second one refers to the fact that American Guidelines do not recommend any quantification of total cardiovascular risk, whereas European Guidelines regard this issue as a crucial part of the hypertension diagnosis. Indeed, assessment of total risk may be particularly helpful in the above mentioned “prehypertension” category because detection of a high or very high risk state in this category entails antihypertensive drug treatment while a moderate risk in this same category means suggesting life style changes only.

First drug choice

The JNC Guidelines (1) recommended a diuretic in most hypertensive patients, thereby placing drugs such as beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium antagonists and angiotensin II antagonists in a subordinate position. Several reasons do not allow European Guidelines to agree on this crucial point. First, large-scale trials have shown that treatment that is based on diuretics but also on beta-blockers, ACE inhibitors, calcium antagonists and angiotensin II antagonists achieves cardiovascular protection in hypertensive patients (4,5). Second, in most comparison intervention trials, no difference has been found between conventional treatment (i.e., a treatment based on diuretics and beta-blockers) and newer drugs in the primary outcome. The only two exceptions have not been in favour of conventional treatment and diuretics lost, although to a marginal degree, a head-to-head comparison with ACE-inhibitors in one trial (7). Third, meta-analyses of available trial data (6) suggest that some between drug differences may exist with regard to prevention of specific cardiovascular diseases such as stroke, myocardial infarction, heart failure, although not all in favour of diuretics as compared with other drugs. Indeed, lower serum proteins levels accompanying diuretic treatment have been reported to increase the rate of sudden death (7), while diuretic-induced glucose intolerance may favour the development of diabetes and markedly increase the incidence of the metabolic syndrome (8), with long-term adverse consequences for cardiovascular prevention.        

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
  

References


1. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003; 289: 2560-2571.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11884263

2. Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology Guidelines for the management of arterial hypertension. J Hypertens 2003; 21: 1011-1053.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12777938

3. Zanchetti A. Costs of implementing recommendations on hypertension management given in recent guidelines. J Hypertens 2003; 21: 2207-2009.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14654733

4. Collins R, Peto R, MacMahon S, et al. Blood pressure, stroke and coronary heart disease. Part 2, Short-term reductions in blood pressure: Overview or randomized drug trials in their epidemiological context. Lancet 1990; 335: 827-838.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1969567

5. Blood Pressure Lowering Treatment Trialists’ Collaboration. ACE inhibitors, calcium antagonists and other blood-pressure-lowering drugs: Results of prospectively designed overviews of randomized trials. Lancet 2000; 356: 1955-1964.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11130523

6. Wing LM, Reid CM, Ryan P, et al. A comparison of outcomes with angiotensin-enzyme inhibitors and diuretic for hypertension in the elderly. N Engl J Med 2003; 348: 583-592.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12584366

7. Siscovick DS, Raghunathan TE, Psaty BM, et al. Diuretic therapy for hypertension and the risk of primary cardiac arrest. N Engl J Med 1994; 330: 1852-1857.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8196728

8. Skafors ET, Lithell HO, Selinus I, Aberg H. Do antihypertensive drugs precipitate diabetes in predisposed men? BMJ 1989; 298: 1147-1152.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2500168

VolumeNumber:

Vol3 N°20

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.