Europe's Hypertension Strategy: Charting a Different Course?

Shelley Wood

June 14, 2014

ATHENS, GREECE — Europe's premier hypertension meeting kicks off tomorrow with a program that spotlights the subtle ways in which hypertension treatment in Europe—at least for the moment—is charting a different course from that seen on the other side of the Atlantic.

This year's meeting, HYPERTENSION 2014 , is a joint conference of the European Society of Hypertension (ESH) and the International Society of Hypertension (ISH), two organizations that actually released separate guidelines for the treatment of high blood pressure in 2013. Both carried recommendations distinct from a third set of guidelines released by the US National Institutes of Health (NIH)–commissioned writing group that also emerged last year.

As previously reported by heartwire , the ESH was the first out of the gate in June 2013, with new hypertension guidance produced in partnership with the European Society of Cardiology (ESC). Those guidelines took a simplified approach, recommending blood-pressure lowering to less than 140 mm Hg systolic for most patients with systolic BP (SBP) >160 mm Hg, including those with diabetes, previous stroke or transient ischemic attack (TIA), existing CHD, or chronic kidney disease (CKD) and patients at low to moderate cardiovascular risk. A key exception was elderly patients >80 years old, in whom an SBP target of between 140 and 150 mm Hg was recommended.

The ISH guidelines, released in December 2013 in partnership with the American Society of Hypertension (ASH), also advocated lowering BP to below 140/90 mm Hg (including patients with CKD or diabetes) as well as a slightly looser target of <150 mm Hg in patients over age 80.

Where the ESH/ESC and ISH/ASH guidelines differed slightly was on the issue of when to start drug treatment, with the ESH guidelines relying more heavily on the number of CVD risk factors. And conspicuously, the European and international hypertension societies' guidelines differed again from the long-awaited US guidelines from the NIH Joint National Commission 8 (JNC 8), which published its recommendations in the Journal of the American Medical Association late last year. Most notably, the JNC 8/JAMA guidelines used a start-treatment threshold of >150/90 mm Hg in patients 60 years or older as opposed to 80 or older in the other documents. They also recommended different drugs for initial treatment, depending on age and race.

Complicating matters still further, the JNC 8 paper is not the official guidelines from the ACC/AHA to whom the NIH passed off the task of guideline creation in 2013: those guidelines are anticipated early in 2015, Dr Mariell Jessup (University of Pennsylvania School of Medicine, Philadelphia) told heartwire today.

With so much disagreement over BP targets and drug strategies, the ESH/ISH 2014 congress is dedicating a special session to reviewing and debating the different guidelines on Monday. "Each one will be discussed, and each speaker will criticize the guidelines of the other," meeting chair Dr Athanasios J Manolis (Asklepeion Hospital, Athens, Greece) told heartwire . "I think we will see, not who is the winner, but a criticism of the guidelines [with an] open discussion, which will also include the audience."

Other Points of Departure

Guidelines, however, are not the only area in which Europe's blood-pressure doctors are carving out a separate path. Renal denervation, which failed to improve the treatment of resistant hypertension in the only US-based sham-controlled clinical trial, remains an experimental concept in the US, where no devices are approved. In Europe, by contrast, multiple devices hold CE Mark, and the procedure is still performed to varying degrees in different countries.

Special sessions on renal denervation probing "the path forward," among other topics, are found throughout the ESH/ISH program, including several new analyses trying to explain why the SYMPLICITY HTN-3 trial failed, Manolis said.

Those results, he said, were a major surprise to many people who hoped denervation would be the solution in these resistant-hypertension patients. "But it seems we need to focus now on drug treatment rather than moving directly to renal denervation. Instead of using three drugs, maybe we need to use four or five."

This speaks to another major theme of this year's meeting, which is patient noncompliance.

"At this moment in Europe, the compliance is low, as [it is] everywhere, so we are trying to improve patient compliance." This is something physicians and patients have in common on both sides of the Atlantic, he noted: "This is a problem not only in Europe but also in the US."

The big question, he continued, is "how can you improve the compliance? And how can you increase the percentage of patients with resistant hypertension to control their hypertension after SYMPLICITY with renal denervation?"

The Status of Salt

A third area of divergence between Europe and the US is sodium targets. Last year's ESH/ESC guidelines recommended individuals consume no more than 5 to 6 g of salt per day (the equivalent of 2000 to 2300 mg of sodium). That's a far cry from the 1500 mg daily recommended by the AHA (although similar to to the 2300 mg recommended in the 2010 Dietary Guidelines for Americans ).

Sunday at ESH/ISH has a special session dedicated to sodium reduction, including an update on the status of salt-reduction activities globally. Manolis pointed out that, populationwise, sodium intake varies considerably even within Europe.

"Here in the Mediterranean area, we use a lot of salt, and so there will be a lot of discussion in this field. The most important issue for us to discuss is the issue of bread, chips, and snacks and how we physicians can convince the governments to [mandate lower sodium levels] in these types of food or to convince the [individual] bakery to make a bread with less salt."

More than 5000 people are expected to attend HYPERTENSION 2014. More than 2300 abstracts were submitted from more than 87 countries—"a record for a hypertension meeting," Manolis said.

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