Similarities and Differences Between the ACC/AHA and ESH/ESC Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
2019; Lippincott Williams & Wilkins; Volume: 124; Issue: 7 Linguagem: Inglês
10.1161/circresaha.118.314664
ISSN1524-4571
Autores Tópico(s)Heart Rate Variability and Autonomic Control
ResumoHomeCirculation ResearchVol. 124, No. 7Similarities and Differences Between the ACC/AHA and ESH/ESC Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBSimilarities and Differences Between the ACC/AHA and ESH/ESC Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in AdultsA Perspective George Bakris George BakrisGeorge Bakris Correspondence to George Bakris, MD, Department of Medicine, ASH Comprehensive Hypertension Center, University of Chicago Medicine, 5841 S Maryland Ave, MC 1027, Chicago, IL 60637. Email E-mail Address: [email protected] From the Department of Medicine, AHA Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, IL. Originally published28 Mar 2019https://doi.org/10.1161/CIRCRESAHA.118.314664Circulation Research. 2019;124:969–971Recent updates of the American (The American College of Cardiology / American Heart Association [ACC/AHA] guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure [BP] in Adults) and European Guidelines (2018 European Society of Hypertension [ESH]/ European Society of Cardiology [ESC] Guidelines) were published.1,2 The ACC/AHA guideline extended the previous Joint National Committee Report 7 (JNC 7)3 to include updated information from clinical trials and meta-analyses on BP level and cardiovascular risk.Before going further, one must remember that Merriam-Webster's dictionary defines a guideline as "a cord or rope to aid a passer over a difficult point or to permit retracing a course", this ensures that people stay on the safest path while mountain climbing.4 Given this definition, written guidelines by experts and those who review them are recommendations by experts in the field. Some but not all guideline writers see patients, nevertheless, guidelines are meant to provide evidence-based guidance to clinicians about best practices.Both ACC/AHA and ESH/ESC guidelines address a variety of topics (Table). Unlike previous BP guidelines, both stress proper measurement of BP with the ACC/AHA guidelines providing very clear guidance on the topic. Both also strongly encourage home BP monitoring by patients. Additionally, both guidelines emphasize starting initial therapy using single combination BP lowering medications because the data are overwhelming for improved adherence and a greater likelihood of BP goal achievement. This was a major emphasis of the ESH/ESC guidelines.Table. Similarities and Differences Between ACC/AHA and ESH/ESC GuidelinesSimilarities ACC/AHA1 ESH/ESC2 More emphasis on home BP and patient empowerment Wider use of home BP monitoring to confirm diagnosis Single-pill combination if >20/10 mm Hg above goal Initial single-pill combination as initial therapy More attention to detail of BP measurement More attention to detail of BP measurement Focus on improving adherence Detection of poor adherenceDifferences Does not have Specific focus on >10%-10-year absolute CV risk- Rather focuses on cardiovascular risk estimator, identified as SCORE system, to consider in timing and intensity of therapy. Specific attention to prevention as BP approaches 130/80 mm Hg Much attention to specific ethnic/racial groupsAdditionally Retained definition of hypertension >140/90 mm Hg and encouraged patient discussion and education to get <130/80 mm Hg in those who require it by the evidence Limits on BP reduction—not below 120/70 mm HgACC/AHA indicates American College of Cardiology/American Heart Association; BP, blood pressure; ESC/ESH, European Society of Cardiology/European Society of Hypertension; and SCORE, Systematic Coronary Risk Evaluation.One of the most distinctive and important differences from previous JNC reports and from the ESH/ESC guideline is the ACC/AHA guideline emphasis on individualized cardiovascular risk assessment before defining treatment options, using the atherosclerotic cardiovascular disease risk calculator available on Android and iPhones. The cornerstone of patient management in the BP range of 130 to 139 / 80 to 89 mm Hg with a <10% 10-year risk is lifestyle modification. The ACC/AHA guideline proposed that patients with greater than a 10%, 10-year cardiovascular risk require more aggressive management to achieve levels below 130/80 mm Hg and in concert with lifestyle modification will require antihypertensive drug therapy. This approach was not as well defined in the ESH/ESC guidelines (Table).The atherosclerotic cardiovascular disease risk calculator uses data from the pooled cohort equation to generate individualized data on cardiovascular risk for patients, so they understand their risk and benefits of achieving BP goals.5 However, most physicians do not spend time informing patients about their 10-year cardiovascular risk and spend almost no time on lifestyle modification education. A table summarizing lifestyle modification approaches which has been expanded from the JNC 7 is in the ACC/AHA guideline.1 This table can be given to all patients with a short explanation by a nurse, nutritionist, or health care professional.An individualized approach for the spectrum of all patients with hypertension, whereas not in the purview of general guidelines, can help determine the best choice for first-line therapy to lower BP in most people. Both ACC/AHA and ESH/ESC guidelines provide algorithms that apply to many patients.1,2 One major change in the pharmacological therapy of both guidelines is the elimination of β-blockers from the first-line therapy of those with primary hypertension and no comorbidities requiring β-blockers.Perhaps the greatest difference between the ACC/AHA and ESH/ESC BP guidelines is the controversy among experts in the field as well as practicing clinicians and patients about BP goal and definition of hypertension. The area of greatest controversy involves the new categories of BP, defining normal BP as <120/80 mm Hg and elevated BP as 120 to 129 / <80 mm Hg. Stage-1 hypertension as 130 to 139 / 80 to 89 mm Hg and stage-2 hypertension replaces the old definition of hypertension, that is, 140/90 mm Hg or greater.1 The ESH/ESC guideline retains 140/90 mm Hg other than to eliminate the term prehypertension and mandate more aggressive therapy.2,8 The ESH/ESC and other guidelines distinguish BP thresholds used to diagnose from those used for treatment targets.2,8Additional ramifications of this new definition of hypertension identify ≈14% more US adults as having primary hypertension. This translates into great insurance costs for patients and increased unreimbursed physician time for visits. The ACC/AHA guideline authors argue that most newly diagnosed hypertensives using the new criteria can be managed with lifestyle modification. Although this author agrees, most physicians fail to properly counsel patients on lifestyle modification because of time constraints related to patient loads and no compensation for extra time. Moreover, insurance companies will increase rates of these newly diagnosed patients irrespective of treatment. This is not the way to improve BP goal achievement.Another major difference between the ACC/AHA and ESH/ESC guidelines is the definition used to extrapolate risk. The ESH/ESC guideline does not use this risk marker and the 10%, 10-year cardiovascular risk designation used by ACC/AHA is troublesome. This 10% risk is not based on randomized controlled clinical outcomes but epidemiological extrapolation of data from trials of much higher risk people generally with a 10-year risk >15% to 20%. The SPRINT (Systolic Blood Pressure Intervention Trial) studied high-risk individuals defined as a 10-year cardiovascular risk of 15% or greater based on Framingham risk score.9 This was also true in the ACCORD trial (Action to Control Cardiovascular Risk in Diabetes) with a similar design in patients with diabetes mellitus and cardiovascular risk >15% over 10 years.10The risk extrapolation to lower levels recommended in the guideline, therefore, could have consequences of over treating people. Data from trials like the HOPE-3 trial (Heart Outcomes Prevention Evaluation) demonstrated no benefit of BP lowering if initial BP is below 140/90 mm Hg in people with low to intermediate cardiovascular risk.11 Additionally, many studies of patients with diabetes mellitus data demonstrate increased cardiovascular risk if BP is lowered to levels of 120/80 mm Hg.12–14To further amplify the point of one size not fitting all, the ACC/AHA guideline lowered the BP goal for older people, and it suggests that a 30-year-old and an 80-year-old should have the same BP goal, that is, <130/80 mm Hg. They point to data from SPRINT to support this assertion. Although this goal may be possible for some older people, it is not for all older people, especially those with poor vascular compliance which the guideline ignored because such patients were not in SPRINT.15 Numerous trials assessed BP lowering in older people with predominant systolic hypertension. Many people in these trials were unable to tolerate BP levels <140 mm Hg let alone <130 mm Hg. Nevertheless, older people did have a clear reduction in cardiovascular events at BP levels between 140 and 150 mm Hg compared with the placebo groups.16–18 The ESH/ESC guideline maintains a BP 18% 10-year cardiovascular risk derived more benefit than harm from aggressive BP lowering treatment.19,20 Moreover, on careful observation this guideline assumes most people are like those used in SPRINT, which is fallacious.In summary, both updates of the ACC/AHA and ESH/ESC guidelines have many positives (Table). Perhaps the only negative in the ACC/AHA guideline was changing the definition of hypertension to ≥130/80 mm Hg. This recommendation is largely derived from SPRINT findings and epidemiological databases of people with higher cardiovascular risk than those to be treated in the guideline. Both guidelines generally agree that subgroups of people who have a >15% 10-year cardiovascular risk will clearly benefit from earlier intervention. Labeling everyone with a broad brush may be fine from a public health prevention perspective but adds excessive burden to an already overworked primary care physician workforce.DisclosuresG. Bakris is the principal investigator of the FIDELIO-DKD trial (Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and Diabetic Kidney Disease; Bayer), Steering Committee CREDENCE (Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants With Diabetic Nephropathy; Janssen), and CALM-2 (Controlling and Lowering Blood Pressure With the MobiusHD™; Vascular Dynamics) and served as a consultant for Merck, Novo Nordisk, KBP, and Relypsa.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to George Bakris, MD, Department of Medicine, ASH Comprehensive Hypertension Center, University of Chicago Medicine, 5841 S Maryland Ave, MC 1027, Chicago, IL 60637. Email [email protected]eduReferences1. 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March 29, 2019Vol 124, Issue 7 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCRESAHA.118.314664PMID: 30920926 Originally publishedMarch 28, 2019 Keywordsrisk assessmentalgorithmshypertensionmortalityblood pressurePDF download Advertisement SubjectsHigh Blood PressureHypertension
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