|By ESC Review Coordinators Thierry Gillebert, Ghent University, Belgium and Michal Tendera, Medical University of Silesia, Katowice, Poland |
The 2013 ESH/ESC Guidelines for the management of arterial hypertension were released and presented at the ESH meeting in Milan in June this year and published simultaneously in the European Heart Journal and Journal of Hypertension.
Because of new evidence on several diagnostic and therapeutic aspects, the present guidelines differ in many respects from the 2007 edition. In an introductory ‘New Aspects’ section, the chairpersons Robert Fagard (ESC) and Giuseppe Mancia (ESH) have summarised the principal changes.
Office blood pressure (BP) or out-of-office BP?
For office BP, auscultatory or oscillometric semi-automatic sphygmomanometers are increasingly used instead of manual mercury sphygmomanometers. Out-of-office (ambulatory or home) BP monitoring provides a large number of BP measurements away from the medical environment, which represents a more reliable assessment and hence has a better prognostic yield. Home BP monitoring and ambulatory BP monitoring are complementary and not competitive methods. Out-of-office BP is usually lower than office BP. The guidelines provide validated definitions of hypertension for various BP monitoring modalities.
White-coat and masked hypertension?
White-coat hypertension is the subject of an ongoing debate. In some studies, its long-term cardiovascular risk was found to be intermediate between sustained hypertension and true normotension, but this was not confirmed in meta-analyses. This uncertainty could be the result of treatment leading to reduction of cardiovascular risk.
Masked hypertension is defined as a clinical condition in which a patient’s office BP level is <140/90 mmHg but ambulatory or home BP readings are in the hypertensive range. Several factors may raise out-of-office BP relative to office BP. The prevalence is higher when office BP is in the high normal range.
Both white-coat and masked hypertension are associated with cardiovascular risk factors, organ damage, long-term risk of diabetes and progression to sustained hypertension. Lifestyle changes should be considered in both white-coat and masked hypertension. Drug therapy may be considered in white-coat hypertension with a high cardiovascular risk, and should be considered in masked hypertension.
Drugs for low-to-moderate risk grade 1 hypertension?
The evidence favouring drug treatment in these individuals is scant because no trial has specifically addressed this condition. Arguments in favour of treating even low-to-moderate risk grade 1 hypertensives are that waiting increases total risk, a large number of safe antihypertensive drugs are now available, and many antihypertensive agents are out of patent with a good cost–benefit ratio.
The ‘lower the better’ or the J-shaped curve hypothesis?
Previous guidelines suggested lower targets for BP in high-risk populations. The new guidelines present an almost unified target SBP (<140 mmHg) in both higher and lower risk patients. This implies that high-normal SBP shouldn’t be lowered, not even in diabetes or chronic kidney disease. In individuals older than 80 years the target is a SBP of 140-150 mmHg. The DBP target is <90 mmHg except in diabetes, where evidence supports lower values.
Are all antihypertensive drugs or combinations equal?
The current guidelines reconfirm that diuretics (thiazides, chlorthalidone and indapamide), beta-blockers, calcium antagonists (CACB), angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) are all suitable for the initiation and maintenance of antihypertensive treatment, but some drugs are preferred in specific conditions. The many side effects of beta-blockers, including new-onset diabetes in predisposed patients, are acknowledged.
Resistant hypertension: are we up to quick renal denervation?
Resistant hypertension is present if a patient has persistent hypertension after employment of lifestyle measures and pharmacotherapy with diuretics plus two other antihypertensive drugs. Renal denervation or baroreceptor stimulation may be considered in truly resistant patients, confirmed with ambulatory BP monitoring and with SBP ≥160 mmHg or DBP ≥110 mmHg). Unless more evidence is available on the long-term efficacy and safety, it is recommended that these procedures remain in the hands of experienced operators.
Viewpoints may differ, but in our opinion, the guidelines carefully reflect different points of view and formulate balanced advice.