New ESH Hypertension Guidelines Aim for Simplified Message

The European Society of Hypertension (ESH) has released updated and expanded guidelines for the management of hypertension.

The guidelines, which are endorsed by the European Renal Association and the International Society of Hypertension, were presented during the 32nd Annual European Meeting on Hypertension and Cardiovascular Protection Meeting in Milan, Italy, on June 24.

The guidelines consensus document was also published online in the Journal of Hypertension. Giuseppe Mancia, MD, professor emeritus of medicine, University Milano-Bicocca, Italy, and Prof Reinhold Kreutz, MD, PhD, Charité – University Medicine Berlin, Germany, were co-chairs of the task force that created the document.

"We have tried to provide a simplified message to key topics with these new guidelines," Kreutz told theheart.org | Medscape Cardiology,

"We have confirmed the definition of hypertension and provide clear guidance for blood pressure monitoring and a simplified general strategy targeting similar blood pressure goals for most patients, although the treatment algorithms of how you get there may be different for different patient groups."

Kreutz added: "Because hypertension is so prevalent and many patients have comorbidities, it is not easy to have one approach for all, but we have tried to simplify the key messages as much as possible, with a target that is more general to the whole population."

While there are no major surprises in the guidelines, there are multiple advances and added-value changes, including clear advice on how to measure blood pressure, an upgrade for beta-blockers in the treatment algorithms, and a new definition and treatment recommendations for "true resistant hypertension."

Definition Remains Unchanged

The definition of hypertension remains unchanged from the previous guidelines ― repeated office systolic blood pressure values of ≥140 mm Hg and/or diastolic blood pressure values of ≥90 mm Hg.

"The definition and classification of hypertension has not changed in these new guidelines," Kreutz said. "While there have been suggestions that the definition/target should be changed again, particularly about blood pressure lowering being beneficial at the very low-pressure range, after reviewing all the evidence we do not agree with this, and we are standing with the definition of hypertension when intervention is beneficial rather than doing nothing or causing harm."

Clear Guidance on Measurement

Kreutz points out that the correct measurement of blood pressure is of key importance, and the new guidelines include a detailed algorithm on how to measure blood pressure. The preferred method is automated cuff-based blood pressure measurement.

"There are still many variations in blood pressure measurement in clinical practice, so we now have clear guidance on how to measure blood pressure in the office but also at home," he commented.

They have upgraded the use of out-of-office blood pressure measurement, particularly home measurement, as useful in long-term management. "In future, there should be more emphasis on follow-up using technology with remote control and virtual care."

Thresholds for Starting Treatment

On thresholds for initiating antihypertensive therapy, the guidelines recommend that treatment be initiated for most patients when systolic blood pressure is ≥140 mm Hg or diastolic blood pressure is ≥90 mm Hg.

The same recommendation is given for patients with grade 1 hypertension (systolic, 140–159 mmHg; and/or diastolic, 90–99 mm Hg) irrespective of cardiovascular risk, although they add that for patients in the lower blood pressure range who have no hypertension-mediated organ damage and who are at low cardiovascular risk, consideration may be given to starting treatment with lifestyle changes only. If, however, blood pressure control is not achieved within a few months of a lifestyle-based approach alone, drug treatment is necessary.

For older patients (aged 80 or older), the task force recommends initiation of drug treatment at 160 mm Hg systolic, although a lower systolic threshold of 140 – 160 mm Hg may be considered. The authors note that thresholds for the initiation of drug treatment for very frail patients should be individualized.

Blood Pressure Targets

In the new guidelines, the blood pressure target is the same as in the previous guidelines for the general population of patients with hypertension. The goal is <140/80 mm Hg for most patients. This accounts for the major portion of the protective effect of blood pressure lowering.

However, the consensus document notes that despite the smaller incremental benefit, an effort should be made to reach a range of 120–129/70–79 mm Hg, but only if treatment is well tolerated to avoid the risk of treatment discontinuation because of adverse events, which might offset, in part or completely, the incremental reduction in cardiovascular outcomes.

Elaborating on this, Kreutz said, "We should aim for the systolic blood pressure to be within the range of below 140 mm Hg down to 120 mm Hg, with a specific target of around 130 mm Hg for most patients and lower in patients in whom drug treatments are well tolerated and who are at high risk.

"The problem is, if we go for a target of lower that 130 mm Hg, the evidence gets weaker, the benefits diminish, and we risk losing patients because of adverse effects from using so many drugs," he added. "But in younger and fitter patients, we would recommend the lower the better, but not below 120 mm Hg."

Kreutz noted that the new guidelines have tried to simplify recommendations on target pressures. "We have tried to simplify guidance to focus on a target of around 130 for almost all patients. Before, it wasn't so clear. There were different targets for different groups of patients with various comorbidities or older patients. But now we are saying the range of 120 to 139 is suitable for the vast majority of patients."

The guidelines do allow slightly higher targets for older and very frail patients.

Drug Treatments

The guidelines advise that blood pressure lowering be prioritized over the selection of specific antihypertensive drug classes. The use of any of the five major drug classes ― angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), beta-blockers, calcium blockers, and thiazide/thiazide-like diuretics ― and their combinations are recommended as the basis of antihypertensive treatment strategies.

They advise starting with a two-drug combination for most patients. The preferred combinations including a renin-angiotensin blocker (either an ACE inhibitor or an ARB) with a calcium blocker or a thiazide/thiazide-like diuretic, preferably in a single-pill combination to reduce pill burden and improve adherence and outcome.

If blood pressure is not controlled with the initial two-drug combination at the maximum recommended and tolerated dose of the respective components, treatment should be increased to a three-drug combination.

"We can control 60% of patients in the general hypertensive population with dual therapy, and up to 90% with triple therapy," Kreutz said. "Only a small percentage need a fourth drug."

A new feature of the guidelines is the upgrading of beta-blockers in the treatment algorithms.

"Beta-blockers may not have previously been considered as a first choice of antihypertensive medication, but we see that in clinical practice, many patients are actually treated with these drugs because there are so many conditions in which beta-blockers have a compelling evidence-based indication or are believed to be favorable," he said. "So, we are now positioning beta-blockers as drugs that can be used at any step of the treatment algorithm if there is a guideline directed indication or other conditions for which they are thought to be beneficial."

The guidelines also recommend that all drugs be given as once-daily preparations and that they be taken preferably in the morning.

"The new TIME study has established that there is no difference in outcome with morning or evening dosing, but we know that adherence is often better when drugs are taken in the morning, and it is not advisable to take diuretics in the evening," Kreutz said.

"True Resistant Hypertension"

The guidelines have introduced a new term, "true resistant hypertension," defined as systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg in the presence of the following conditions: the maximum recommended and tolerated doses of a three-drug combination comprising a renin-angiotensin system blocker (either an ACE inhibitor or an ARB), a calcium blocker, and a thiazide/thiazide-like diuretic were used; inadequate blood pressure control has been confirmed by ambulatory (preferable) or home blood pressure measurement; and various causes of pseudo-resistant hypertension (especially poor medication adherence) and secondary hypertension have been excluded.

"There are many patients who may appear to have resistant hypertension, but we need to screen them carefully to ensure they are adherent to treatment, and then most of these patients are found not to be truly resistant," Kreutz explained. "We estimate that only about 5% of patients have true resistant hypertension."

For these patients with true resistant hypertension, two treatment approaches are recommended.

For those who do not have advanced kidney disease (glomerular filtration rate >40 mL/min), renal denervation can be considered. This is a new II B recommendation.

Kreutz noted that studies of renal denervation excluded patients with advanced kidney disease, so there are no data for this group. For these patients, the guidelines suggest that a combination diuretic approach (chlorthalidone with a loop diuretic) could be considered in light of the results of the recent CLICK study.

Differences From US Guidelines?

Commenting on the new European guidelines for theheart.org | Medscape Cardiology, Paul Whelton, MD, chair of the most recent American College of Cardiology/American Heart Association hypertension guidelines committee, said: "Publication of these guidelines is important. I congratulate the European task force. It is an enormous amount of time and effort."

Whelton, who is Show Chwan Chair in Global Public Health at Tulane University Tulane University School of Medicine, New Orleans, and president of the World Hypertension League, added: "I would say the changes are incremental rather than major, but that is probably appropriate."

He welcomed the greater emphasis on out-of-office blood pressure measurement, saying, "that's where we should be headed."

Asked how the European guidelines differ from the US guidelines, Whelton commented: "There are differences, but they are not huge. The major hypertension guidelines across the world are much more alike than they are different."

He pointed out that both the US and European guidelines aim for a target blood pressure of 130/80 mm Hg for most patients but have different ways of issuing that advice.

"The Europeans recommend a minimum goal of 140/90 mm Hg, and if there are no issues, then press on to get to under 130/80 mm Hg. That's kind of a two-step process," he said. "In the US, we've gone for a more direct approach of just recommending less than 130/80 mm Hg.

"My fear with the European approach is that by saying, get to 140/90 mm Hg first, then move on to 130/80 mmHg, is that you're likely to lose people. And doctors could feel that 140/90 is fine."

More Effort Needed on Implementation

Whelton says that where all hypertension guidelines are lacking is in the implementation of the recommendations.

"We are all falling down on implementation," he said. "We have a huge burden of illness, and it is a very cost-effective area for management, but still, rates of blood pressure control are very bad. Generally speaking, even with a very conservative target of 140/90, the best countries only have control rates of around 30%, and this can be as low as 8% in some low/middle-income countries."

Whelton believes the approach to blood pressure management needs to change.

"We know that the current traditional model of care, where blood pressure is managed by your local doctor, is not working. It is hopeless," he said. "That is not an indictment of these doctors. It's just that they have more pressing issues to deal with, so we need to look at other models."

He suggests that the way forward is through convenient, community-based care delivered by a team in which nonphysicians assist in much of the management and in which reliable, affordable medications are given at the point of care, with patients tracked with electronic health records so as to identify those who are not adhering to their medication regimens.

"We know that using simple protocols will work for the vast majority of people. We don't need to individualize or complicate this too much. That tends to lose people in the process."

Whelton makes the point that it is well known how to diagnose and treat hypertension, yet this is not being done well.

“We are doing these things really badly. In routine care, blood pressure is measured horribly. Nobody would accept a pilot of a plane saying he should be doing all these procedures but he's too busy and it's probably okay, but that's the way blood pressure is often measured in clinical practice," he added. "And we can't really do a good job if were not measuring the key variable properly that the diagnosis is based on."

Whelton also points out that the medical profession is not making enough effort to have patients reach target levels.

"If you're in a country where very few people are being treated and very high pressures are common, then of course you have to focus on that group first. But in most of the Western world, we are long past that, so we can move on down the chain. We then get to a lot more people with moderately high blood pressure getting exposed to increases in risk, and while this is not quite as dramatic as those with very high pressures at the individual risk level, because there are so many of them, that's where a lot of events are occurring," he says.

"If we get everyone to 140/90 mm Hg. we can probably prevent 60% of blood pressure–related events. But if we can get them all down to 130 mm Hg systolic, then we can prevent 75% to 80% of events. It's often quite easy to get to that target, but patients need help and encouragement."

Going forward, he concluded, guidelines should pivot to focus more on implementation.

"We all try to make the guidelines as approachable as possible, but they are encyclopedic, and many doctors just continue doing what they are doing. That is our big challenge."

J Hypertension. Published online June 21, 2023. Full text

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