Managing Hypertension – the 2018 ESC Guidelines and beyond

Dr Asif QasimDr Asif Qasim. Consultant Cardiologist.

The ESC Hypertension Guidelines released at ESC in Munich in September 2018, were jointly developed by the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). The guidelines provide recommendations in diagnosis, evaluating risk, when and how to treat hypertension and risk reduction with both lifestyle advice and medications. One of the most widely debated changes has been the recommendation for first line drug therapy to be a combination of ACEI or CCB with a thiazide diuretic, with beta blockers as first line only where there is an additional indication such as angina, dysrhythmia, heart failure or after myocardial infarction. The role of renal denervation therapy requires further consideration as well with recent positive studies presented at ESC 2018 and TCT 2018 suggesting a role for RDN especially in difficult to control hypertension or in patients with poor drug tolerance.

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These Ten Commandments of Hypertension were compiled by Bryan Willians and Giuseppe Mancia who led development of the guidelines.

Published in the European Heart Journal in September 2018 . Link Here

  1. Definition of hypertension: Hypertension is defined as a persistent elevation in office systolic BP 140 and/or diastolic BP 90mmHg, which is equivalent to a 24h ambulatory BP monitoring (ABPM) average of 130/80mmHg or a home BP monitoring (HBPM) average 135/85.
  2. Screening and diagnosis of hypertension: Screening programmes should be established to ensure that office BP is measured in all adults, at least every 5 years and more frequently in people with a high normal BP. When hypertension is suspected the diagnosis of hypertension should be confirmed either by repeated office BP measurements, over a number of visits, or by ‘out of office’ BP measurement using 24h ABPM or HBPM.
  3. When to consider drug treatment of hypertension: Adults with Grade 1 hypertension (office BP 140-159/90-99) aged up 80years, should receive drug treatment if their BP is not controlled after a period of lifestyle intervention alone. For high-risk patients with Grade 1 hypertension, or patients with higher grades of hypertension (g. Grade 2 hypertension; 160/100mmHg), drug treatment should be initiated alongside lifestyle interventions.
  4. Special considerations in frail and older patients: For people over the age of 80years, who have not yet received treatment for their BP, BP treatment should be considered when office systolic BP is 160 Frailty, dependency and expectations of treatment benefit will influence the decision treat people aged >80years, on an individual patient basis, but these patients should not be denied treatment, or have treatment withdrawn simply on the basis of age.
  5. How low should BP be lowered? ‘A target range’ for treated BP has been introduced. Office systolic BP should be lowered to <140mmHg in all treated patients, including independent older patients who can tolerate treatment. The aim should be to target systolic BP to 130mmHg for most patients, if tolerated. Even lower office systolic BP levels (<130mmHg) should be considered in patients aged <65years but not in patients aged 65years or more. Similar BP targets are recommended for patients with diabetes. Systolic BP should not be targeted to below 120mmHg because the balance of benefit vs. harm becomes concerning at these levels of treated systolic BP. Office diastolic BP should be lowered to <80.
  6. Treatment of hypertension—lifestyle interventions are important: The treatment of hypertension involves lifestyle interventions and drug therapy. Lifestyle interventions can delay the need for drug treatment or complement the effects of drug treatment. Moreover, lifestyle interventions such as sodium restriction, alcohol moderation, healthy eating, regular exercise, weight control, and smoking cessation, all have health benefits beyond their impact on BP.
  7. Start treatment in most patients with two drugs, not one: Monotherapy is usually inadequate therapy for most people with hypertension, especially now that the BP treatment targets for many patients, are lower than in previous guidelines. Initial therapy with a combination of two drugs should now be considered usual care for hypertension.
  8. A single pill strategy to treat hypertension: Poor adherence is directly related to the number of pills and is a major factor contributing to poor BP control. Single pill combination therapy is now the preferred strategy for initial two-drug combination treatment of hypertension and for three drug combination therapy when required.
  9. A simplified drug treatment algorithm: A combination of an ACE inhibitor or ARB with a CCB or thiazide/thiazide-like diuretic is the preferred initial therapy for most patients. For those requiring three drugs, a combination of an ACE-inhibitor or ARB with a CCB and a thiazide/thiazide-like diuretic should be used. Beta blockers should be used when there is a specific indication for their use, e.g. angina, post MI, heart failure, or when rate control is required.
  10. Managing cardiovascular disease risk in hypertensive patients — going beyond BP: Hypertensive patients frequently have concomitant cardiovascular risk factors. Statin therapy should be more commonly used in hypertensive patients with established cardiovascular disease or moderate-to-high cardiovascular disease risk according to the SCORE system.

Discuss the diagnosis and management of complex hypertension in the Hypertension Case Discussion Group supported by Medtronic. Join the group here, and take a look at trending cases from the group below.

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