ESH Upgrades Denervation, Details Comorbidities in New Hypertension Guideline

The European Society of Hypertension (ESH) has released an updated, comprehensive hypertension guideline, which has many parts that are similar to a previous 2018 document but which also expands on other areas, like the management of high blood pressure in specific patient populations and in the presence of various comorbidities.

In addition, reflective of changes over the past several years, the document provides recommendations for the use of renal denervation as an option in certain patients and includes a section on the interplay between COVID-19, hypertension, and antihypertensive medications.

Of note, the guideline was crafted by the ESH alone, in contrast to the 2018 iteration, which was created in collaboration with the European Society of Cardiology (ESC). According to Giuseppe Mancia, MD (University of Milano-Bicocca, Milan, Italy), chair of the latest guideline, the ESC informed the ESH that it wanted to release guidelines only under the ESC name and offered just three spots on the writing committee to ESH representatives. Mancia told TCTMD that ESH leadership found this unacceptable.

“We were not pleased with this because obviously I think there should be only one guideline in Europe, but there was nothing we could do,” he said. “We have a lot of important experts in hypertension and thought that we could have shared guidelines and not just have a marginal position in the guidelines of the European Society of Cardiology. Also, in hypertension, cardiology is a very important component, but there are other components outside cardiology that are important for hypertension.”

The ESC has its own updated hypertension guideline due in 2024.

The Expansive ESH Guideline

The 2023 ESH update, published in the Journal of Hypertension and presented at the recent European Meeting on Hypertension and Cardiovascular Protection in Milan, Italy, represents a major update, nearly doubling the number of pages found in the 2018 document. The effort was co-chaired by Reinhold Kreutz, MD, PhD (Charité – Universitätsmedizin Berlin, Germany).

In addition to updating sections on diagnosis, treatment, and follow-up, the authors provide more in-depth discussions on the management of hypertension in specific patient populations—including women and younger and older adults—and in patients with various other medical conditions, such as obesity, multiple forms of heart disease, chronic kidney disease, diabetes, glaucoma, and immune-related inflammatory diseases. For the first time, the guideline provides advice on handling high BP across childhood, adolescence, and the transition to adulthood.

A key feature of the document, Mancia said, is that it provides a mix of educational material, with detailed reviews of existing evidence for those who want to learn more, and simplified, actionable recommendations for busy clinicians at the end of each section.

Overall, Mancia said, sections on BP measurement and classification and treatment of hypertension are similar to what was found in the 2018 document, although there has been a tweak in how out-of-office BP measurement techniques—ie, home and ambulatory readings—are discussed.

Because of the extensive literature based on office BP measurements, recommendations on classification of hypertension, thresholds for treatment initiation, and treatment goals remain based on those clinic-based values, Mancia said. But in recognition of the useful information that can be gleaned from out-of-office monitoring, the authors also provide recommendations “to perform ambulatory or home blood pressure—or even better, both—whenever this is available,” he added.

Differences Between European, US Guidelines

When the 2018 European guidance was released, there was discussion about how it differed from the comprehensive guidance released by US groups in 2017. The documents diverged in terms of how hypertension was defined, how low BP should be reduced, and what type of treatment should be used to get to various goals.

Specifically, the US guideline provided a lower BP threshold to define stage 1 hypertension (130/80 mm Hg vs 140/90 mm Hg) and provided recommendations for more-aggressive treatment goals. The European document, on the other hand, put more emphasis on using at least two antihypertensive medications to initiate treatment, with a preference for single-pill combinations to boost compliance.

Some of those differences remain with the 2023 ESH update. But last year, key representatives of the European and US documents, including Mancia, Kreutz, Paul Whelton, MD (Tulane University School of Public Health and Tropical Medicine, New Orleans, LA), chair of the US guidelines, and Bryan Williams, MD (University College London, England), ESC chair for the 2018 European guidelines, published a paper highlighting that the advice given on the two sides of the Atlantic Ocean are more alike than different.

“Don’t be sidetracked by some differences because on the major principles these guidelines are similar,” Mancia said.

Seeking an Impact on Clinical Practice

Regarding the release of these recommendations, Mancia said, “I hope they will have an impact.”

But he underscored the difficulty that has been seen in translating guideline recommendations into meaningful changes in clinical practice. For instance, despite the strong recommendations for starting with at least two antihypertensive medications to get BP under control, studies have shown that most patients continue to start with just one. “This is just an example of guidelines’ failure to exert a substantial impact, but we hope it will be different in the future,” Mancia said.

In an editors’ commentary in Hypertension discussing the 2023 ESH guideline, Whelton and colleagues pick up a similar thread.

“Despite the large number of national and international BP guidelines around the world, general population surveys demonstrate that BP guidelines are not being well implemented in any part of the world,” they write. “The level of BP, which is the basis for diagnosis and management, continues to be poorly measured in routine clinical practice and control of hypertension remains suboptimal, even to a conservative blood pressure target such as a systolic/diastolic BP < 140/90 mm Hg.”

Thus, there should be a greater focus on implementation of guideline recommendations, they say. “Given the enormous health, social, and financial burden of high BP, better diagnosis and management should be an imperative for clinicians, government, and others responsible for the provision of healthcare services. Hopefully, the 2023 ESH [guideline] will help enable this.”