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Guidelines for managing arterial hypertension

Robert Fagard
29 May, 2014  
This article summarises the 2013 guidelines for the management of arterial hypertension, with an emphasis on diagnostic evaluation and treatment strategies
 
Robert Fagard MD PhD
Hypertension and Cardiovascular Rehabilitation Unit,
Faculty of Medicine, Department of Cardiovascular Diseases, KU Leuven University, Leuven, Belgium
 
The 2013 update of the European Society of Hypertension (ESH)/European Society for Cardiology (ESC) hypertension guidelines focuses on diagnostic and therapeutic aspects. Decisions on the management of the hypertensive patient depend on total cardiovascular risk, based on blood pressure level, risk factors, organ damage, diabetes and clinical disease. Treatment requires lifestyle measures and antihypertensive drugs, tailored to the individual patient. The goal of treatment is <140/90mmHg in most patients with few exceptions. 
 
A major risk
Hypertension is a major, if not the major, risk factor for cardiovascular and renal disease and has been listed as the first cause of death worldwide. The overall prevalence of hypertension appears to be approximately 30–45% in the European general population. Its complications include sudden death, myocardial infarction, angina pectoris, heart failure, transient ischaemic attack, peripheral vascular disease and renal insufficiency. Randomised, placebo-controlled trials have convincingly shown that antihypertensive treatment reduces cardiovascular morbidity and mortality. For example, the incidence of stroke is reduced by about 30–40% and the incidence of coronary heart disease by approximately 15–25%.
 
The risk of hypertension becomes greater in the presence of other cardiovascular risk factors such as smoking, dyslipidemia, abdominal obesity, physical inactivity, glucose intolerance, and diabetes, and when high blood pressure caused subclinical organ damage or overt cardiovascular or renal disease. Therefore it is not only important to consider the blood pressure level but also other risk factors, target organ damage and associated clinical conditions. The aim of the current manuscript is to summarise the 2013 ESH/ESC guidelines for the management of arterial hypertension,(1) with emphasis on diagnostic evaluation and treatment strategies. The updated guidelines follow the guidelines jointly issued by the two societies in 2007.(2)
 
Total cardiovascular risk stratification
Decisions on the management of the hypertensive patient depend on the initial level of total cardiovascular risk. The stratification of total risk in different categories is based on blood pressure level, cardiovascular risk factors, asymptomatic organ damage and presence of diabetes, symptomatic cardiovascular disease or chronic kidney disease, as outlined in Figure 1. The classification in low-, moderate-, high- and very-high risk refers to the ten-year risk of cardiovascular mortality, based on the SCORE chart for risk estimation and as defined in the 
2012 ESC guidelines on cardiovascular disease prevention.(3)
 
Diagnostic evaluation
The initial evaluation of a patient with hypertension should: (i) confirm the diagnosis of hypertension; (ii) assess cardiovascular risk, organ damage, and concomitant clinical conditions; and (iii), detect causes of secondary hypertension. This calls for blood pressure measurement, medical history including family history, physical examination, laboratory investigations, and further diagnostic tests. Some of the investigations are needed in all patients, others only in specific patient groups.
 
Blood pressure measurement
Office blood pressure
Conventional office blood pressure measurement by use of a validated device is the gold standard for screening, diagnosis and management of hypertension. Hypertension is defined as systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg. The diagnosis of hypertension should be based on at least two blood pressure measurements in the sitting position per visit on at least two visits.
 
Out-of-office blood pressure
Out-of-office blood pressure, assessed by ambulatory or home blood pressure monitoring, is an important adjunct to office blood pressure measurement. The prediction of cardiovascular events is significantly better with out-of-office blood pressure than with office blood pressure. Prognosis is better in white-coat hypertension than in sustained hypertension and appears to be similar to that in true normotension. The incidence of cardiovascular events is about two times higher in masked hypertension than in true normotension and similar to the incidence in sustained hypertension. Cut-offs for the definition of hypertension are: 130/80mmHg for 24-hour blood pressure, 135/85mmHg for daytime ambulatory and home blood pressure, and 120/70mmHg for night-time blood pressure. Major indications for out-of-office BP are suspicion of white-coat, masked or nocturnal hypertension, suspected hypotension, considerable variability of office blood pressure, and treatment-resistant hypertension.  
 
Cardiovascular risk factors
Total, LDL and HDL cholesterol, and fasting triglycerides and glucose are considered routine tests in all hypertensive patients.
 
Search for asymptomatic organ damage and symptomatic disease
Heart
An ECG is recommended in all hypertensive patients; additional tests (echocardiography, exercise testing, Holter monitoring) should be considered based on history, physical examination and ECG findings.
 
Arteries
Carotid and peripheral ultrasound, pulse wave velocity and ankle-brachial index should be considered as additional tests 
if indicated.
 
Kidney
Measurement of serum creatinine and estimation of glomerular filtration rate, assessment of urinary protein and micro-albuminuria are recommended in all hypertensive patients.
 
Search for secondary hypertension
All patients should undergo simple screening tests for secondary hypertension, including clinical history, physical examination and laboratory investigations, and a focused search should be undertaken when indicated.
 
Treatment approach
Lifestyle changes
Appropriate lifestyle changes are the cornerstone for the prevention of hypertension and are also important for its treatment. The following lifestyle measures are recommended, based on their effects on blood pressure and/or cardiovascular risk:
  • Salt restriction to 5–6g/day
  • Moderation of alcohol consumption (<20–30g of ethanol per day in men and <10–20g in women).
  • Increased consumption of vegetables, fruits and low-fat dairy products
  • Reduction of weight to body mass index of 25 kg/m2
  • Regular exercise (≥30 min of moderate dynamic exercise on five to seven days per week)
  • Smoking cessation.
 
Initiation of antihypertensive drug treatment
Prompt initiation of antihypertensive drugs is recommended in patients at high or very high cardiovascular risk. Antihypertensive drugs should be considered in patients at moderate or low risk when blood pressure remains >140/90mmHg after, respectively, several weeks or months of appropriate lifestyle measures, or in case of persistently elevated out-of-office blood pressure. In elderly patients drug treatment is recommended when systolic blood pressure is ≥160mmHg, or ≥140mmHg if younger than 80 years and treatment is well tolerated. It is not recommended to initiate antihypertensive treatment at high normal blood pressure and in younger patients with isolated systolic hypertension.
 
Blood pressure goals
Systolic blood pressure
A systolic blood pressure goal of <140mmHg is recommended in all hypertensive patients, with few exceptions. In elderly hypertensive patients less than 80 years of age, there is solid evidence to reduce systolic blood pressure to between 150 and 140mmHg, but a goal of <140mmHg may be considered in fit elderly. In individuals older than 80 years, it is recommended to reduce blood pressure to between 150 and 140mmHg if they are in good physical and mental condition.
 
Diastolic blood pressure
A diastolic blood pressure of <90 mmHg is always recommended, except in patients with diabetes, in whom values <85mmHg are recommended.
 
Choice of antihypertensive drugs
Diuretics, beta-blockers, calcium antagonists, ACE inhibitors and angiotensin receptor blockers are all suitable for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in combination therapy. Some agents should be considered as the preferential choice in specific conditions, such as coronary heart disease, heart failure, diabetes or renal dysfunction.  
 
Initiation of antihypertensive therapy with two-drug combination may be considered in patients with markedly high baseline blood pressure or at high cardiovascular risk. Among the many possible combinations, some are considered more suitable than others (Figure 2). 
 
Treatment strategies in special conditions
White-coat and masked hypertension
In white-coat hypertensive patients without additional risk factors, therapeutic intervention is limited to lifestyle changes and close follow-up is warranted. In case of higher cardiovascular risk, antihypertensive drug treatment may be considered. 
 
In masked hypertension, both lifestyle measures and drug treatment should be considered because of the high cardiovascular risk. 
 
Elderly
When antihypertensive therapy is indicated as described above, all antihypertensive agents can be used, although diuretics and calcium antagonists may be preferred in isolated systolic hypertension.
 
Pregnancy 
Drug treatment is recommended in severe hypertension in pregnancy (blood pressure >160/110mmHg), and may be considered in case of persistent blood pressure ≥150/95mmHg, and in those with blood pressure ≥140/90mmHg in the presence of gestational hypertension, asymptomatic organ damage or symptoms. 
 
Methyldopa, labetalol and nifedipine should be considered preferential antihypertensive drugs in pregnancy. Blockers of the renin–angiotensin system should be avoided in women with child-bearing potential.
 
Diabetes
It is recommended to start drug treatment when systolic blood pressure is ≥140 mmHg. The blood pressure target is <140/85mmHg. All classes of antihypertensive drugs can be used, though blockers of the renin-angiotensin system may be preferred, especially in the presence of proteinuria or micro-albuminuria, but simultaneous administration of two blockers of the renin-angiotensin system should be avoided.
 
Nephropathy
It is recommended to start drug treatment when systolic blood pressure is ≥140mmHg, targeting <140mmHg. A target of <130mmHg may be considered in case of overt proteinuria, and blockers of the renin- angiotensin system (although not in combination) are indicated in the presence of proteinuria or micro-albuminuria. 
 
Cerebrovascular disease
It is not recommended to intervene with blood pressure-lowering therapy during the first week after acute stroke, although clinical judgment should be used in the face of very high systolic blood pressure values. Antihypertensive treatment is recommended in hypertensive patients with a history of stroke or transient ischemic attack when systolic blood pressure is ≥140mmHg, targeting <140mmHg. All drug regimens are recommended in these patients, provided that blood pressure is effectively reduced. 
 
Heart disease
Coronary heart disease
It is recommended to start drug treatment when systolic blood pressure is ≥140mmHg, and all antihypertensive agents can be used, targeting <140 mmHg. Beta-blockers are recommended in case of recent myocardial infarction, and beta-blockers and calcium antagonists in patients with angina pectoris.
 
Heart failure
Diuretics, beta-blockers, ACE-inhibitors, angiotensin receptor blockers and/or mineralocorticoid receptor antagonists are recommended in patients with heart failure or severe left ventricular dysfunction. There is no evidence that antihypertensive therapy per se or any particular drug is beneficial in case of preserved ejection fraction. Lowering of systolic BP to around 140mmHg should be considered in all of these patients.
 
Left ventricular hypertrophy
Antihypertensive therapy is recommended, and initiation with one of the agents that have shown greater ability to regress left ventricular hypertrophy should be considered, that is, ACE inhibitors, angiotensin receptor blockers and calcium antagonists.
 
Resistant hypertension
In case of true treatment-resistant hypertension, addition of a mineralocorticoid receptor antagonist, amiloride, and/or the alpha-blocker doxazocin should be considered. In case of ineffectiveness of drug treatment invasive procedures such as renal denervation and baroreceptor stimulation may be considered.  
 
Treatment of associated risk factors 
It is recommended to use statin therapy in hypertensive patients at moderate to high cardiovascular risk, targeting an LDL cholesterol value <3.0mmol/l (115mg/dl). When overt coronary heart disease is present, it is recommended to administer statin therapy to achieve LDL cholesterol levels <1.8mmol/l (70mg/dl).
 
Antiplatelet therapy, in particular low-dose aspirin, is recommended in hypertensive patients with previous cardiovascular events. Aspirin should also be considered in hypertensive patients with reduced renal function or at high risk, provided that blood pressure is well controlled. Aspirin is not recommended for cardiovascular prevention in low-moderate risk hypertensive patients, in whom absolute benefit and harm are equivalent.
 
In hypertensive patients with diabetes, a HbA1c target of <7.0% is recommended with anti-diabetic treatment. In more fragile elderly patients with a longer diabetes duration, more comorbidities and at high risk, treatment to a HbA1c target of <7.5–8.0% should be considered.
 
Follow-up and improvement of blood pressure control
Individuals with high normal blood pressure or white-coat hypertension, even in untreated, should be scheduled for regular follow-up, at least annually, to measure office and out-of-office blood pressure, to check the cardiovascular risk profile and to reinforce recommendations on lifestyle changes. After initiation of antihypertensive drug therapy in patients with hypertension, the patient should be seen at two to four-week intervals to evaluate the effects on blood pressure and to assess possible side-effects.
 
Once the target blood pressure is reached, a visit interval of a few months is reasonable. Depending on the local organisation of health resources, many of the later visits may be performed by non-physician healthcare workers, such as nurses.  For stable patients, home blood pressure monitoring and electronic communication with the physician may also provide an acceptable alternative. It is advisable to assess risk factors and asymptomatic organ damage at least every two years. The finding of an uncontrolled blood pressure should always lead to a search for the cause(s), such as poor adherence, persistent white-coat effect or use of blood pressure-raising substances. Appropriate actions should be taken for better blood pressure control, avoiding physician inertia.
 
References
  1. Mancia G et al. 2013 European Society of Hypertension/European Society of Cardiology Guidelines for the management of arterial hypertension. Eur Heart J 2013;34:2159–219.
  2. Mancia G et al. 2007 Guidelines for the management of arterial hypertension: the European Society of Hypertension/European Society of Cardiology Task Force for the management of arterial hypertension. J Hypertens 2007;25:1105–187.
  3. Perk J et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J 2012;33:1635–1701.