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2018 ESC/ESH Clinical Practice Guidelines in the spotlight - Arterial Hypertension

ESC Congress News 2018 - Munich, Germany

2018 ESC/ESH Joint Guidelines for the Management of Arterial Hypertension provide updated recommendations for the diagnosis, risk reduction and treatment of patients with this condition.(1) Professor Anthony Heagerty (Division of Cardiovascular Sciences, University of Manchester, Manchester, UK) and Professor Guy De Backer (Department of Public Health, Ghent University, Ghent, Belgium), Review Coordinators for these guidelines, summarise why the new changes are so important and what they will mean for clinical practice.

Hypertension
Risk Factors and Prevention
Cardiovascular Nursing


AMH-2018-congress-news.jpg  De-Backer-2018-congress-news.jpg“There are two key issues,” explains Prof. De Backer. “The first is that hypertension is a silent, chronic condition so there are problems with detection and screening; the second is that even when it is diagnosed, control of blood pressure is very, very poor.”

The first main change since the previous ESC/ESH Guidelines in 2013 relates to diagnosis of high blood pressure, as Prof. Heagerty highlights. “There is now more evidence to suggest that doctors can diagnose hypertension more confidently based on a patient’s home measurement, which reduces the number of people with ‘white-coat syndrome’ who are treated unnecessarily.” Prof. De Backer continues, “It’s important to note that the new guidelines do not change the definition of hypertension categories, as the recent American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines have; the ESC/ESH Guidelines still include blood pressure categories as ‘optimal’, ‘normal’, ‘high-normal’, ‘grade 1, 2 and 3 hypertension’ and ‘isolated systolic hypertension’; definitions are still based on doctors’ office measurements. However, it is accepted that there are more devices around for the measurement of blood pressure that are cheaper and more easily available than they used to be, and that these are being used by patients at home. Diagnosis can therefore now be based on home/ambulatory measurements by the patient, not just at the doctor’s office.”

“New evidence has also come to light,” says Prof. Heagerty, “that suggests the target for acceptable blood pressure control should be lowered, and it is now 130/80 for the majority of patients.” Indeed, the findings from the SPRINT study, which also informed the recent ACC/AHA Guidelines, showed that treating systolic blood pressure to a lower target significantly reduced the rates of cardiovascular events and death.(2)

“We can now provide increased protection to more patients because the target for blood pressure control has been lowered”-Prof. Heagerty.

Although more patients can now be treated, Prof. Heagerty acknowledges that this change may cause a degree of nervousness in the prescribing community. “Firstly, a larger number of patients will require drug treatment as well as lifestyle advice to achieve the new target for blood pressure control, and secondly, additional patients will need more than one drug. There will be concerns among doctors relating to two areas: the first is the possibility of side effects-although if drug regimens are selected to suit individual patients these will be kept to a minimum-and secondly, some patients will get very low pressures and suffer consequences such as falls, but again, careful monitoring should avoid such issues.”

And what about any changes to drug therapy? “Previously, it was recommended to start with one agent and add others in a step-wise manner,” says Prof. De Backer. “Experience showed, however, that this was insufficient, so the new recommendation is to start with two antihypertensive agents in the large majority of patients (those without intolerance or contraindications).” In terms of how this might impact clinical practice, both experts are clear. “There will be an increase in the use of low-dose combination therapy, i.e. fixed-dose combinations, which will reduce the pill number,” says Prof. De Backer. Prof Heagerty agrees. “Patient compliance is increasingly recognised as a big issue and there is a need to minimise the number of pills taken in an effort to improve compliance rates,” he says.

“Patient follow-up and more attention to treatment compliance will become even more important.”-Prof. De Backer.

Any other significant changes? Prof. De Backer explains, “There is an emphasis on the importance of looking at a patient’s total cardiovascular risk, not just blood pressure. Experts advise that we should be measuring hypertension-mediated organ damage; if this is present, then stronger intervention is urged.” Indeed, the updates cover drug therapy extending to additional groups of patients. “There is a section at the end covering important subgroups, such as pregnant women, certain ethnic groups and those with ‘white-coat’ hypertension, in which treatment strategies are different,” says Prof. De Backer. “The main changes are summarised in a table at the end of the full document and, similarly, there is a table of gaps in the scientific evidence detailing which new studies are required. These new guidelines are therefore more accessible and easier to read for busy clinicians and researchers alike.”

1. 2018 ESC/ESH Guidelines for the Management of Arterial Hypertension. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339.
2. The SPRINT Research Group. New Engl J Med 2015;373:2102–2116.

 

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Notes to editor

About the European Society of Cardiology

The European Society of Cardiology brings together healthcare professionals from more than 150 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

About ESC Congress 2018

ESC Congress is the world’s largest and most influential cardiovascular event contributing to global awareness of the latest clinical trials and breakthrough discoveries. ESC Congress 2018 takes place 25 to 29 August at the Messe München in Munich, Germany. Explore the scientific programme