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

Antihypertensive Treatment

The guidelines recommend that all patients should be counseled to adopt lifestyle changes, where appropriate; recognizing, however, that compliance is low and blood pressure response variable, the guidelines also recommend close follow-up and urge that drug treatment should be initiated "in a timely fashion" ( Table 4 ). They emphasize a "flexible threshold" for initiating drug treatment, which should be ≥ 140/90 mm Hg for all hypertension patients and < 140/90 mm Hg in high-risk patients, while stressing that drug treatment should never be delayed unnecessarily, especially in patients at higher level of risk.

 

Drug Therapy Recommendations

In his presentation of the guidelines' recommendations for antihypertensive drug therapy, Prof. Mancia stressed that they reconfirm the conclusion of 2003 that most of the benefit of antihypertensive treatment is due to blood pressure lowering per se and is largely independent of the drugs or class of drugs employed. Thus the guidelines go on to recommend, either as monotherapy or in combination, thiazide-type diuretics (as well as chlorthalidone and indapamide), calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers -- all of which are deemed able to "adequately lower blood pressure and significantly and importantly reduce cardiovascular outcomes."

Regarding beta-blocker as a first-line therapy, the European guidelines differ from the recently released UK national hypertension guidelines update, which removed beta-blockers from consideration as first-line therapy, relegating them to fourth-line treatment only.[15] Prof. Mancia and the other ESH/ESC guidelines authors believe that the UK decision was unjustified, being mistakenly based on the results of the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA)[16] in which the combination of a diuretic plus a beta-blocker was less effective in reducing events -- but only, these authors believe, because of a smaller achieved blood pressure reduction. However, these new European guidelines do advise against the use of beta-blockers in patients with metabolic syndrome or at high risk for diabetes.

The guidelines stipulate that the choice of specific drugs or drug combinations should take into account the following considerations:

  1. Patient's previous experience with particular drug class(es);

  2. The effects of particular drugs on the specific details of a given patient's cardiovascular risk profile;

  3. Presence of subclinical organ damage, cardiovascular disease, renal disease, or diabetes;

  4. Presence of other disorders that may limit use of particular antihypertensive drug classes;

  5. Possible drug interactions;

  6. Cost of drugs (but never a consideration over efficacy, tolerability, or protection of the patient);

  7. Preference for drugs that have a 24-hour effect with once-daily administration; and

  8. Continued attention to side effects.

Prof. Mancia emphasized that because many patients will need to take more than 1 drug over the remaining course of their lifetime, the emphasis on the first-choice drug is often futile. "A vast array of effective and well-tolerated combinations are available," he said. The guidelines recommend a 2-drug combination as initial treatment in patients presenting with grade 2 or 3 hypertension or with high or very high total cardiovascular risk. Fixed combinations are suggested to simplify treatment and improve compliance.

The following 2-drug combinations are recommended because they "have been found to be effective and well tolerated":

  • Thiazide-type diuretic and ACE inhibitor;

  • Thiazide-type diuretic and ARB;

  • CCB and ACE inhibitor;

  • CCB and ARB;

  • CCB and thiazide-type diuretic; and

  • Beta-blocker and CCB.

The "time honored" combination of a thiazide-type diuretic plus a beta-blocker, "although still valid as a therapeutic alternative," should be avoided in patients with the metabolic syndrome or a high risk for diabetes, the guidelines advise.

Special Patient Subsets

Antihypertensive treatment approaches are outlined for special conditions, such as in the elderly or patients with renal dysfunction, diabetes mellitus, metabolic syndrome, cerebrovascular disease, coronary heart disease, and heart failure. Guidelines coauthor Roland E. Schmieder, MD (University of Erlangen-Nürnberg, Germany) outlined new treatment recommendations for patients with the metabolic syndrome (ACE inhibitors, ARBs, CCBs), diabetes mellitus (ACE inhibitors, ARBs) and glaucoma (beta-blockers).[17] ARBs and ACE inhibitors are recommended for prevention or recurrence of atrial fibrillation. All blood pressure-lowering agents are considered appropriate in patients with previous stroke, and ARBs are added to the list of recommended drugs in patients with previous myocardial infarction (along with beta-blockers and CCBs) and heart failure (along with diuretics, beta-blockers, and ACE inhibitors). Treatment of associated risk factors is also covered in the guidelines.

The stated primary goal of treatment is "to achieve maximum reduction in the long-term total risk of cardiovascular disease." Target blood pressures are set as > 140/90 mm Hg in all hypertensive patients and < 130/80 mm Hg in diabetic and high/very high-risk patients

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