Ten Commandments of Guidelines on High Blood Pressure by ESC/ESH

The 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. The guidelines provide recommendations for doctors to diagnose hypertension, evaluate risk, when and how to treat hypertension and reduce risk, with both lifestyle advice and medications.

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The Ten Commandments of the 2018 ESC/ESH HTN Guidelines on Hypertension in Adults are :

1. Definition of hypertension: Hypertension/High Blood Pressure is defined as a persistent elevation in office systolic BP ≥140 and/or diastolic BP ≥90 mmHg, which is equivalent to a 24 h ambulatory BP monitoring (ABPM) average of ≥130/80 mmHg 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 Blood Pressure. When hypertension/High Blood Pressure 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 24 h ABPM or HBPM.


3. When to consider drug treatment of hypertension: Adults with Grade 1 hypertension (office BP 140-159/90-99) aged up 80 years, 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; ≥160/100 mmHg), drug treatment should be initiated alongside lifestyle interventions.


4. Special considerations in frail and older patients:For people over the age of 80 years, 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 to treat people aged >80 years, on an individual patient basis, but these patients should not be denied treatment, or have treatment withdrawn simply on the basis of age.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 <140 mmHg in all treated patients, including independent older patients who can tolerate treatment. The aim should be to target systolic BP to 130 mmHg for most patients if tolerated. Even lower office systolic BP levels (<130 mmHg) should be considered in patients aged <65 years but not in patients aged 65 years or more. Similar BP targets are recommended for patients with diabetes. Systolic BP should not be targeted to below 120 mmHg 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 are important because they can delay the need for drug treatment or complement the BP lowering effect 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. The only exception would be in a limited number of patients with a lower baseline BP close to their recommended target, who might achieve that target with a single drug, or in some frailer old or very old patients, in whom more gentle reduction of BP may be desirable.


8. A single pill strategy to treat hypertension: Poor adherence to BP-lowering medication is directly related to the number of pills and is a major factor contributing to poor BP control rates. 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. This will control the BP in most patients with a single pill and should improve BP control rates.


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-myocardial infarction, heart failure with reduced ejection fraction, or when heart 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 the established cardiovascular disease or moderate-to-high cardiovascular disease risk according to the SCORE system. Benefit from statin therapy has also been observed in hypertensive patients at the border between low and moderate risk. Antiplatelet therapy, especially low dose aspirin is also indicated for secondary prevention in hypertensive patients but is not recommended for primary prevention, i.e. in patients without cardiovascular disease.

For reference log on to https://doi.org/10.1093/eurheartj/ehy439