Implications of Guidelines for Hypertension Management in Europe
2019; Lippincott Williams & Wilkins; Volume: 124; Issue: 7 Linguagem: Inglês
10.1161/circresaha.119.314724
ISSN1524-4571
AutoresMassimo Volpe, Giovanna Gallo, Allegra Battistoni, Giuliano Tocci,
Tópico(s)Nutritional Studies and Diet
ResumoHomeCirculation ResearchVol. 124, No. 7Implications of Guidelines for Hypertension Management in Europe Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBImplications of Guidelines for Hypertension Management in Europe Massimo Volpe, Giovanna Gallo, Allegra Battistoni and Giuliano Tocci Massimo VolpeMassimo Volpe Correspondence to Massimo Volpe, MD, FESC, FAHA, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy. Email E-mail Address: [email protected] From the Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Italy (M.V., G.G., A.B., G.T.) IRCCS Neuromed, Pozzilli, Italy (M.V., G.T.). , Giovanna GalloGiovanna Gallo From the Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Italy (M.V., G.G., A.B., G.T.) IRCCS Neuromed, Pozzilli, Italy (M.V., G.T.). , Allegra BattistoniAllegra Battistoni From the Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Italy (M.V., G.G., A.B., G.T.) and Giuliano TocciGiuliano Tocci From the Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Italy (M.V., G.G., A.B., G.T.) Originally published28 Mar 2019https://doi.org/10.1161/CIRCRESAHA.119.314724Circulation Research. 2019;124:972–974Hypertension continues to be the most common preventable cardiovascular risk factor in Europe. Blood pressure (BP) control in the continent remains largely unsatisfactory. For this reason, development of new guidelines has appeared timely and appropriate. In this article, we highlight the novel or controversial aspects of 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines and discuss how they will influence physicians' management of hypertension in Europe.Hypertension accounts in Europe for >150 million people affected, and its prevalence is predicted to rise by 15% to 20% within 2025.1Because hypertension is the most common preventable risk factor for major cardiovascular events, significant efforts have been made in the last decades to improve BP control worldwide and in Europe.2,3 However, the lack of BP control in ≥40% of the population still stands as a major missed opportunity for European healthcare systems.1The 2018 ESC/ESH guidelines on hypertension were promoted with the principal aim to pragmatically improve the diagnostic accuracy of hypertension and the therapeutic efficacy of antihypertensive management, with the challenging scope of improving BP control and reducing the related cardiovascular burden. Needless to say that, because US guidelines4 were issued only a few months earlier, the task force efforts were also an opportunity to compare with the North-American guidelines beside providing European physicians with an updated expert point of view.The key novel aspects of ESC/ESH guidelines that we will discuss are the improvement of individual cardiovascular risk stratification and BP targets to achieve, the timing to start pharmacological treatment and time to get to target, the prevalent role of initial combination therapy, and the promotion of adherence to treatments.Diagnostic Aspects and BP TargetsThe latest ESC/ESH guidelines further highlight the importance of the systematic estimation of total cardiovascular risk in the individual hypertensive patients, endorsing the paradigm shift from the view of cardiovascular risk factors as separate silos to a more comprehensive assessment of individual total cardiovascular risk profile. Every doctor should systematically estimate individual cardiovascular risk in each hypertensive patient at the time of initial diagnosis or whether any changes occur. In Europe, the SCORE system (Systematic Coronary Risk Evaluation)5 is the most frequently adopted tool for this purpose, and it is now recommended also for individuals aged >65 years.6 Current European Guidelines also reemphasize the importance of detecting hypertension-mediated organ damage, which may indeed contribute to refine total cardiovascular risk and the consequent therapeutic strategy7 and should be undertaken for a proper identification of the subjects at higher cardiovascular risk, beyond the SCORE system. In the attempt to provide a more realistic assessment of cardiovascular risk and to predict nonfatal cardiovascular events, European guidelines support the approach based on multiplying by 3-fold the estimated risk of fatal events,8 consistent with the US guidelines based on the Framingham algorithm.With regard to BP measurements, European guidelines suggest a recommended frequency over time, according to initial BP level and cardiovascular profile.1 Office BP remains the gold standard, although there is a reinforced endorsement for out-of-office measures (ambulatory and home BP monitoring). Automated, unobserved measurement is now viewed as an emerging tool to detect white-coat and masked hypertension, and it is encouraged to support diagnosis of hypertension.Although these aspects are consistent with the US guidelines, definition, classification, and grading of hypertension have been left unchanged in the European guidelines, in contrast with US guidelines.4 In fact, the 2017 American College of Cardiology/American Heart Association guidelines have introduced remarkable changes in definition and grading of hypertension, which have not been shared by the European Task Force.1 According to the US classification, more than a half of the European population would result hypertensive with considerable implications for all European healthcare systems. On the contrary, it was felt that there is not sufficient evidence, beside SPRINT (Systolic Blood Pressure Intervention Trial),9 about the benefits of starting an antihypertensive therapy for systolic BP (SBP) values <140 mm Hg, except for high-risk individuals.After all, the practical consequence of this evident difference in the classification does not translate in major differences in the recommended therapeutic management as illustrated in the Table.Table. Recommended Therapeutic Management of BP in European and American Guidelines2018 ESC/ESH Guidelines2017 ACC/AHA GuidelinesHigh-normal BP 130–139/85–89 mm HgGrade 1 hypertension 140–159/90–99 mm HgGrade 2 hypertension 160–179/100–109 mm HgGrade 3 hypertension ≥180/110 mm HgNormal BP <120/80 mm HgElevated BP 120–129/ 10%Promote optimal lifestyle habits and reassess in 1 yNonpharmacological therapy and reassess in 3–6 moNonpharmacological therapy and BP-lowering medicationNonpharmacological therapy and BP-lowering medicationLow-to-moderate CV riskLifestyle advicePharmacological treatment should be started after 3–6 mo of lifestyle intervention10-y ASCVD risk <10%Nonpharmacological therapy and reassess in 3–6 moACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CAD, coronary artery disease; CV, cardiovascular; ESC, European Society of Cardiology; and ESH, European Society of Hypertension.One criticism raised to the former unique BP threshold (<140/90 mm Hg)10 was that a large proportion of apparently well-controlled patients fell within the high-normal BP range and could be exposed to a relevant risk. Recent randomized clinical trials and meta-analyses have indeed suggested to reconsider these thresholds and most importantly, the consequent clinical behaviors. SPRINT is paradigmatically quoted to support the beneficial effect of a more intensive BP control in high-risk patients in the high-normal range. Those who were randomized to an SBP target <120 mm Hg (intensive treatment) had a better cardiovascular outcome than those who were randomized to an SBP target <140 mm Hg (standard treatment).9 However, several specific methodological criticisms, mostly linked to the unique BP measurement technique, have been raised to SPRINT,11 and although the study unequivocally shows that a tighter BP control is beneficial,9 the implications of its results in a larger population remain controversial. The concept that the lower is the better has been also advocated for hypertension control also based on large meta-analyses,12–14 showing significant reductions in the rate of combined major cardiovascular events, myocardial infarction, stroke, heart failure, and all-cause mortality in patients treated with more intensive BP-lowering strategies. Therefore, 2018 ESC/ESH guidelines recommend a first BP target <140/90 mm Hg in all patients. However, BP should be further lowered to BP values <130/80 mm Hg in most patients, especially in those at high or very high cardiovascular risk, if therapy is tolerated.1 This suggested therapeutic target is consistent with the BP goal <130/80 mm Hg recommended by 2017 American College of Cardiology/American Heart Association Guidelines.4 In patients aged 65 years, at any level of cardiovascular risk, should reach SBP levels between 130 and 140 mm Hg, with a close monitoring of adverse events. The suggested target of diastolic BP is <80 mm Hg for all hypertensive patients, independently of age, comorbidities, and established cardiovascular disease.1Therapeutic AspectsAlthough the benefits of pharmacological treatment have been well established in patients affected by grade 2 and 3 hypertension and at high or very high cardiovascular risk, the role of drugs on top of lifestyle interventions in grade 1 hypertension or in individuals with low-to-moderate risk has been debated for many years. Physicians should consider not only immediate but lifetime cardiovascular risk reduction, long-term exposure to risk factors, hypertension-mediated organ damage, comorbidities, and hypertension severity and duration15 and should initiate adequate and immediate therapeutic interventions to prevent treatment failures.Regarding initiation of treatment, European and American guidelines share the same straightforward approach, which appears to be helpful for doctors. This is an improvement compared with former guidelines that offered a crowd of options. In patients with grade 1 hypertension and at high risk or showing hypertension-mediated organ damage, prompt initiation of drugs is recommended simultaneously with lifestyle interventions. Drug treatment may be also considered in patients with high-normal BP when cardiovascular risk is very high because of history of established cardiovascular disease.1 In young adults, there is clear evidence that therapy should be started in grade 2 or 3 hypertensives, or in patients with grade 1 hypertension and high cardiovascular risk profile. Moreover, ESC/ESH guidelines suggest starting BP-lowering drugs also in younger adults with grade 1 hypertension and low-to-moderate risk. In fact, an earlier treatment can prevent the development of more severe hypertension and of subclinical or overt hypertension-mediated organ damage, often not reversible when therapeutic interventions are delayed.16 This recommendation may have an important preventive meaning over the years in terms of limiting hypertension-related events.In our opinion, the current recommendation of a time frame within which therapeutic BP targets must be obtained is also of key importance. Now it is recommended that BP control must be achieved within 3 months, consistently with data derived from retrospective analyses and meta-analyses.16–18Previous ESC/ESH guidelines recommended to start treatment with monotherapies, based on 5 principal drug classes, uptitrating the dose or switching to another drug class when BP control was not achieved.10 This former approach substantially failed because more than three-quarters of hypertensive patients require a combination therapy to achieve the goal. The new guidelines' firm commitment to promote initiation with combination therapy in most patients finds its roots also in the recommendation to achieve a BP target 80% of patients require a a three-drug combination approach to reach recommended BP goals.In patients with resistant hypertension, European guidelines recommend to add a mineralocorticoid receptor antagonist. In patients who do not tolerate mineralocorticoid receptor antagonist because of side-effects, β-blockers, doxazosin, or amiloride could be added.1 The role of renal sympathetic denervation, despite its perspective usefulness, awaits solid confirmation.A final remark is required to highlight the gaps to fill which are listed in the guidelines, such as the definition of the optimal BP targets for patients according to cardiovascular risk and comorbidities, the best treatment in different ethnic groups, and the ideal home and ambulatory BP monitoring goals.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Massimo Volpe, MD, FESC, FAHA, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy. Email massimo.[email protected]itReferences1. 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March 29, 2019Vol 124, Issue 7 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCRESAHA.119.314724PMID: 30920931 Originally publishedMarch 28, 2019 Keywordshypertensionguidelineshigh blood pressurecardiovascular preventionantihypertensive therapyPDF download Advertisement SubjectsHypertension
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