Start With Multiple-Med Single Pill: New European Hypertension Guidelines

Liam Davenport

October 02, 2018

Patients with hypertension should be started on a two-drug single-pill therapy, rather a single-agent pill followed by watchful waiting, a strategy that should improve both adherence and outcomes, concludes the latest European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines.

The updated guidelines respond to the finding that at least 80% of patients with hypertension in Europe who should have been switched to dual drug therapy remain on just one drug, its authors say.

The 2018 ESC/ESH Guidelines for the Management of Arterial Hypertension, now published in the European Heart Journal and on the ESC website, were presented in full at European Society of Cardiology (ESC) Congress 2018. Highlights of the new document were presented at the ESH annual sessions in June and reported by | Medscape Cardiology at the time.

The guidelines' blood pressure (BP) thresholds for treatment have been made less conservative, with therapy to be considered in patients at low to moderate cardiovascular risk and grade 1 hypertension, including those 65 to 80 years of age, and in those with high normal blood pressure.

Blood pressure treatment targets were lowered to a systolic BP of less than 130 mm Hg for patients younger than 65 years and less than 140 mm Hg for older patients. The target diastolic blood pressure is now 80 mm Hg.

The new document, which replaces the 2013 European guidelines, arrives in the wake of updated guidelines for the management of hypertension developed jointly by the American College of Cardiology (ACC), the American Heart Association (AHA), and other societies. As reported last year, the controversial document lowered the diagnostic BP threshold and treatment goal to 130/80 mm Hg for most patients.

Initiate With Single-Pill Combination Therapy

The recommendation to use single-pill combination drug therapy is aimed at changing the way clinicians look at treatment, ESC chairperson of the Guidelines Task Force, Bryan Williams, MD, University College London, told | Medscape Cardiology.

"What we're trying to do here is normalize the concept that starting treatment of hypertension with one drug in the majority of patients is pretty futile, because you won't get control," he said.

"So, if you're aiming to control blood pressure, start with two. You've got a much higher chance of getting them controlled — probably 70% plus will get controlled with two medications," he added.

And, "ideally use it as a single pill, so the patient still sees it as starting treatment with one pill, but actually they're getting much more effective treatment."

Using two drugs at the same time, rather than one, is "well accepted" in other medical arenas, such as antibiotic therapy, HIV management, and the treatment of asthma, he said.

In Europe, he noted, less than 50% of hypertensive patients have their blood pressure well controlled, yet clinical trials of single-pill combinations have indicated they can achieve control rates in the order of 80%. "This implies that if we could get this more widely adopted, then we would see better control."

130 to <140 mm Hg Is "High Normal "

Drug treatment can be considered in patients with high-normal blood pressure, defined as 130 to 139 mm Hg/85 to 89 mm Hg, if they have high cardiovascular risk due to established cardiovascular disease, especially coronary artery disease, the new document states.

Previously, BP-lowering therapy was not recommended for this group. Although evidence to support it isn't strong, Williams said, "we do think, if there's any advantage of treating people below 140/90 mm Hg, it's in the very-high-risk patients, and particularly in those with coronary disease."

In addition, patients with grade 1 hypertension who are at low to moderate risk and who do not have evidence of hypertension-mediated organ damage should be on drug therapy if they remain hypertensive after lifestyle interventions.

For most patients younger than 65 years, the recommended BP target is 120 to 129 mm Hg, whereas it is 130 to 39 mm Hg for most who are 65 and older.

It is now recommended that fit older patients between 65 and 80 years receive BP-lowering medication and lifestyle interventions if their systolic blood pressure is 140 to 159 mm Hg and the treatment is well tolerated. This group, in the previous guidelines, was only to be considered for antihypertensive therapy.

Patients older than 80 years should also be treated to the 130 to 139 mm Hg target, the new document states, provided the treatment is tolerated. Older age alone is not a sufficient reason to withdraw therapy, it notes.

The target for diastolic blood pressure has also been lowered from the 2013 guidelines, down to <80 mm Hg in all patients, regardless of risk level or the presence of comorbidities.

Start With Which Meds?

The new guidelines attempt to simplify the treatment algorithm for hypertension, recommending as first-line an ACE inhibitor or angiotensin-receptor blocker (ARB) combined with a calcium-channel blocker and/or a thiazide or thiazide-like diuretic. The use of beta blockers is reserved for patients with specific indications for the drug class.

New in the 2018 document, the addition of low-dose spironolactone to existing treatment or further diuretic therapy if spironolactone is not tolerated is recommended for patients whose hypertension remains resistant.

The updated guidelines recommend the wider use of out-of-office ambulatory blood pressure monitoring or, in particular, home blood pressure monitoring "if logistically and economically feasible." That approach is recommended especially for patients who are suspected of having white-coat or masked hypertension at in-office measurements.

The document emphasizes the need for a healthy lifestyle for all patients, regardless of blood pressure, with advice including salt restriction, alcohol moderation, healthy eating, regular exercise, weight control, and smoking cessation. New in the guidelines is a recommendation against binge drinking.

Williams declares receiving speaker fees, honoraria, consultancy, advisory board fees from, or being an investigator or committee member for Boehringer-Ingelheim, Daichi Sankyo, Novartis, Servier, Vascular Dynamics, and Pfizer; and being a trustee of BP UK. Disclosures for the other task force members are provided in the document.

European Society of Cardiology (ESC) Congress 2018: 2018 ESC/ESH Guidelines on Arterial Hypertension. Presented August 26, 2018.

Eur Heart J. 2018;39:3021-3104. Full text

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