ESHThe European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) have jointly released recommendations for management of high blood pressure or arterial hypertension in adults aged ≥18 years during recently held ESC Congress 2018. The updated guideline has been published in the European Heart Journal and replaces the one released in 2013.
The latest European guidelines recommend 140/90mmHg as high blood pressure contrary to ACC/AHA guidelines which lowered the threshold of High B.P to130/80.
Comparison of Updated Guideline with the previous Guideline :
|Office BP is recommended for screening and diagnosis of hypertension.||It is recommended to base the diagnosis of hypertension on:
· Repeated office BP measurements: or
· Out -of-office BP measurements with ABPM and/or HBPM if logistically and economically feasible.
High normal BP (130-139/85-89 mmHg): unless the
Necessary evidence is obtained, it is not recommended to initiate antihypertensive drug therapy at high-normal BP.
High normal BP (130-139/85-89 mmHg): drug treatment may bay considered when CV risk is very high due to established CVD, especially CAD.
Treatment of low-risk grade 1 hypertension:
Initiation of antihypertensive drug treatment should also be considered in grade 1 hypertensive patients at low-moderate-risk, when BP is within this range at several repeated visits or elevated by ambulatory BP criteria, and remains within this range despite a reasonable period of time with lifestyle measures.
Treatment of low-risk grade 1 hypertension:
In patients with grade 1 hypertension at low-moderate-risk and without evidence of HMOD, BP-lowering drug treatment is recommended if the patient remains hypertensive after a period of lifestyle intervention.
Antihypertensive drug treatment may be considered in the elderly (at least when younger than 80 years) when SBP is in the 140-159 mmHg range, provided that antihypertensive treatment is well tolerated.
BP-lowering drug treatment and lifestyle intervention is recommended in fit older patients (>65 years but not>80 years) when SBP is in the grade 1 range (140-159 mmHg), provided that treatment is well tolerated.
|BP treatment targets||BP treatment targets|
|An SBP goal of <140 mmHg is recommended||· It is recommended that first objective of treatment should be to lower BP to <140/190 mmHg in all patients and, provide that the treatment is well tolerated, treated BP values should be targeted to 130/80 mmHg or lower in most patients.
· In patients<65 years it is recommended that SBP should be lowered to a BP range of 120-129 mmHg in most patients.
|BP treatment targets in older patients (65-80 years)||BP Treatment targets in older patients (65-80 years)|
|An SBP target of between 140-150 mmHg is recommended for older patients (65-80 years).||In older patients (>65 years), it is recommended that SBP should be targeted to a BP range of 130-139 mmHG.|
|BP treatment targets in patients aged over 80 years||BP Treatment targets in patients aged over 80 years|
|An SBP target between 140-150 mmHg should be considered in people older than 80 years with an initial SBP > 160 mmHg provided that they are in good physical and mental condition||An SBP target range of 130-139 mmHg is recommended for people older than 80 years if tolerated.|
|DBP targets||DBP targets|
|A DBP target of <90 mmHg is always recommended, except in patients with diabetes, in whom values <85 mmHg are recommended||A DBP target of <80 mmHg should be considered for all hypertensive patients, independent of the level of risk and comorbidities|
|Initiation of drug treatment||Initiation of drug treatment|
|Initiation of antihypertensive therapy with a two-drug combination may be considered in patients with markedly high baseline BP or at high CV risk.||It is recommended to initiate an antihypertensive treatment with a two-drug combination, preferably in an SPC. The exceptions are trail older patients and those at low risk and with grade 1 hypertension (particularly if SBP is <150 mmHg)|
|Resistant hypertension||Resistant hypertension|
|Mineral corticoid receptor antagonists, amiloride, and the alpha-1 blocker doxazosin should be considered if no contraindication exists.||Recommended treatment of resistant hypertension is the addition of low-dose spironolactone to existing treatment, or the addition of further diuretic therapy if intolerant to spironolactone, with either eplerenone, amiloride, higher-dose thiazide/thiazide-like diuretic or a loop diuretic, or the addition of bisoprolol or doxazosin.|
|Device-based therapy for hypertension||Device-based therapy for hypertension|
|In case of the ineffectiveness of drug treatment, invasive procedures such as renal denervation and baroreceptor stimulation may be considered||Use of device-based therapies is not recommended for the routine treatment of hypertension, unless in the context of clinical studies and RCTs, until further evidence regarding their safety and efficacy becomes available.|
Key Recommendations are :
- It is now recommended that patients with low-moderate-risk grade 1 hypertension (office BP 140–159/90–99), even if they do not have HMOD, should now receive drug treatment if their BP is not controlled after a period of lifestyle intervention alone.
- The new evidence suggests that lowering office SBP to <140 mmHg is beneficial for all patient groups, including independent older patients.
- For diabetes, targeting the SBP to <140 mmHg and towards 130mmHg, is beneficial on major outcomes.
- For patients with CKD, the evidence suggests that the target BP range should be 130–139mmHg.
- The optimal DBP target of <80 mmHg is recommended in the new guidelines.
- Always start treatment in most patients with two drugs, not one.
- In women with hypertension with pregnancy, ACE inhibitors or ARBs and diuretics should be avoided, and the preferred medications to lower BP may include alpha-methyldopa, labetalol, or Calcium Channel Blockers.
- Antiplatelet therapy like low-dose aspirin is recommended only for secondary prevention in hypertensive patients, not for primary prevention.
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Dr. Kamal Kant Kohli
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