ESH '07: New Consensus Hypertension Guidelines From the European Society of Hypertension/European Society of Cardiology (ESH/ESC)

Linda Brookes, MSc

Disclosures

September 17, 2007

In This Article

Definition and Classification of Blood Pressure

The new guidelines use the same blood pressure classification as used in the 2003 version, which itself was based on the 1999 World Health Organization (WHO)/International Society of Hypertension (ISH) classification,[7] and is similar to that in the sixth report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure (JNC VI)[8] rather than JNC 7.[9]

This latest classification comprises categories of optimal, normal, and high-normal blood pressure, followed by 3 grades of hypertension, and a separate category for isolated systolic hypertension ( Table 1 ). The 3 grades of hypertension correspond to mild, moderate, and severe hypertension, but these terms are not used, in order to avoid confusion with categories of total cardiovascular risk. Isolated systolic hypertension is graded as 1, 2, or 3 according to the systolic blood pressure (SBP) level, provided that the diastolic blood pressure (DBP) is < 90 mm Hg. When SBP and DBP fall into different categories, the highest category is used in assessing total cardiovascular risk.

As with the previous ESH/ESC guidelines, the authors have again omitted the "prehypertension" category, as defined in JNC 7,[9] because they believe that it implies that a large part of the population is sick and that this raises anxiety and leads to unnecessary physician visits. The authors also felt that the population of people who would fall into a prehypertension category would be too diverse to allow treatment recommendations for the whole group.

 

Blood Pressure Measurement

Recommended blood pressure measurement procedures follow the latest ESH practice guidelines.[10,11] Guidelines coauthor Stéphane Laurent, MD, PhD (Pompidou Hospital, Inserm U652, and University Paris Descartes, France) explained that although office blood pressure should be used as a reference, the guidelines acknowledge that ambulatory blood pressure monitoring (ABPM) may improve prediction of cardiovascular risk in both treated and untreated patients.[12] They recommend ABPM particularly if office blood pressure measurements vary widely or are unexpectedly high in patients at otherwise low cardiovascular risk; in addition, self-measurement of blood pressure at home is encouraged.

The guidelines point out that blood pressure thresholds for the definition of hypertension differ according the type of measurement used ( Table 2 ). The assumption is that most office blood pressure is the traditional brachial measurement; measurement of central blood pressure needs further evaluation in large-scale studies to confirm its prognostic role before it can be recommended for routine use, the guidelines say.

 

Total Cardiovascular Risk

As before, one of the central themes that the guidelines stress is that the threshold for hypertension, and the need for drug treatment, should be considered as flexible, based on the level and profile of total (global) cardiovascular risk. In line with this, the 2003 classification of cardiovascular risk, as low, moderate, high, and very high to indicate the 10-year risk of cardiovascular morbidity and mortality, is also retained in the 2007 guidelines ( Table 3 ).

In the assessment of cardiovascular risk, the new guidelines place particular emphasis on identification of target organ damage, and a separate section is devoted to searching for subclinical organ damage. The guidelines note that hypertension-related subclinical alterations in several organs indicate progression in the cardiovascular disease continuum, increasing the risk beyond that due to the simple presence of risk factors, and they recommend measuring for the possible presence of organ damage at various intervals throughout treatment.

The list of renal markers of organ damage has been expanded. Estimates of the creatinine clearance by the Cockroft-Gault formula[13] or glomerular filtration rate by the Modification of Diet in Renal Disease (MDRD)[14] are recommended as more precise assessments of cardiovascular risk in renal dysfunction. Assessment of microalbuminuria is now considered essential in routine testing because it predicts both renal outcomes and cardiovascular events, and urinalysis by dipstick testing is easy and relatively straightforward to carry out, Prof. Mancia said.

Further measurements added to the list of markers of subclinical organ damage include carotid-femoral pulse wave velocity (> 12 m/sec) -- although this technology is not widely available -- and ankle-brachial blood pressure index (< 0.9). Echocardiography is recommended, and a finding of concentric left ventricular hypertrophy is identified as the cardiac structural parameter that most increases cardiovascular risk.

The metabolic syndrome is not regarded in the guidelines as a "pathogenetic entity" but rather as representing "a cluster of risk factors often associated with high blood pressure which markedly increases cardiovascular risk," ie:

  • Blood pressure ≥ 130/85 mm Hg;

  • Low high-density lipoprotein cholesterol: < 1.0 mmol/L (40 mg/dL) in men; < 1.2 mmol/L (46 mg/dL) in women;

  • High triglycerides: > 1/7 mmol/L (150 mg/dL);

  • Altered fasting glucose: 5.6-6.9 mmol/L (102-125 mg/dL); and

  • Abdominal obesity: waist circumference > 102 cm in men; > 88 cm in women.

 

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