New European Hypertension Guidelines Not in Harmony With US Guidance

The Europeans have updated their hypertension guidelines, with changes regarding how to diagnose and treat the condition and how aggressive doctors should be in lowering blood pressure, according to a preview of the new document. Of note, at least some of the proposed recommendations are out of step with those released, amid controversy, by American hypertension experts last year.

Two of the major changes in the joint guidance from the European Society of Cardiology (ESC) and European Society of Hypertension (ESH), according to ESC chairperson Bryan Williams, MD (University College London, England), are an emphasis on using at least two drugs to initiate treatment in the vast majority of patients and on using single-pill combinations to enhance compliance, which will ultimately boost blood pressure control rates.

Williams predicted a “phenomenal” impact if such a strategy is employed, with greater use of single-pill therapy bringing about 80% of patients under control. Facilitating this approach, he added, is the fact that the field has been able to focus in on three major categories of drugs to treat most patients: renin-angiotensin system blockers, calcium channel blockers, and diuretics. There are simple algorithms in the new guidelines to help guide clinicians.

“I think this will dramatically simplify treatment, and really, there’s no excuse for patients not to be treated with optimal therapy in the right number of drugs and the right type of drugs,” Williams said. The treatment approach is very simple, he added, and “we hope that that will get imprinted on the mind of doctors and that they’ll start doing that on a regular basis.”

I think this will dramatically simplify treatment, and really, there’s no excuse for patients not to be treated with optimal therapy in the right number of drugs and the right type of drugs. Bryan Williams

Williams said he hopes the new ESC/ESH guidance will help make a dent in the global burden of hypertension.

“We’ve got to do something about this,” Williams said, adding that the guideline has “broken through the obsession with producing complexity, and it’s actually produced a very, very simple, pragmatic guideline for the people who are seeing these patients, which are predominantly primary care doctors.”

Continental Divide

Of note, the new guidance—which was previewed at the ESH Meeting on Hypertension and Cardiovascular Protection in Barcelona, Spain, over this past weekend ahead of its full publication and presentation at the upcoming ESC Congress in Munich, Germany, in August—differs in key ways from the comprehensive US guidelines released last year.

The Europeans maintained traditional blood pressure categories, with grade 1 hypertension starting at an office pressure of 140/90 mm Hg, whereas the Americans lowered the threshold for stage 1 hypertension to 130/80 mm Hg. Williams said he doesn’t think the move to lower that threshold is justified. “I think it has medicalized lots of people in the United States,” he said. “I know why they did it, because they wanted to emphasize that these people with what we call high-normal blood pressure should be getting lifestyle advice to try and reduce their risk of progressing to more overt hypertension. But I don’t think they should have called them hypertensive.”

Williams took issue with the US recommendation to initiate drug treatment to lower blood pressure in patients in this 130 to 139 mm Hg range who have established cardiovascular disease or an estimated 10-year risk of at least 10%. Most of the recommendations in the ESC/ESH guideline call for treatment starting at 140/90 mm Hg, he pointed out, though there may be people in the “high, high-normal” range who might get treatment if they’re very high risk. “But that’s got to be an individual decision and we don’t think the evidence is very strong in support of it,” he said.

There is also a continental divide in terms of treatment goals, in that the Europeans have not been as aggressive in lowering targets to reflect the SPRINT data. The US guideline recommends lowering blood pressure to less than 130/80 mm Hg for all adults, even those with various comorbidities, who have confirmed hypertension and known cardiovascular disease or a high estimated risk.

The European document establishes target ranges, advising a systolic target of 130 mm Hg, but not lower than 120 mm Hg, for most adults younger than 65. For adults 65 and older, regardless of comorbidities, the treatment target range is the same as the one in younger patients with chronic kidney disease: less than 140 mm Hg, but no lower than 130 mm Hg.

The first priority for all patients, however, is to get below 140 mm Hg, Williams said. Then the recommendations make it clear to doctors that it is reasonable to aim lower in younger patients because they’ll be more likely to tolerate those levels. Remarking on the difference between the US and European targets, Williams said, “The idea of taking all older people below 130, I think it’s just too much.”

On Diagnosis, Lifestyle, and Device-Based Therapies

The new ESC/ESH guideline elevates out-of-office blood pressure-monitoring strategies to be on par with repeated office-based measures for confirming a diagnosis of hypertension. It is clear from years of accumulated evidence, Williams said, that either home or ambulatory monitoring can be useful and in some cases—for ruling out white coat hypertension, for example—may even be preferred to repeated office measurements.

Thus, if a screening blood pressure is over 140/90 mm Hg, either repeated office measurements or home/ambulatory monitoring can be used to confirm a hypertension diagnosis, according to the new recommendations. Home monitoring could have the added benefit of getting patients more involved in managing their condition, Williams said: “It’s all about trying to get the patient engaged in the fact that this is an important treatment and that they can help themselves by doing that.”

The guidelines also continue to maintain the importance of incorporating lifestyle changes—stopping smoking, eating less salt, moderating alcohol consumption, getting more exercise, and maintaining an ideal body weight. Those measures are a key component of managing hypertension, but most patients will still need medications to get their blood pressure down, Williams said.

Another noteworthy addition to the guidelines is a class III recommendation against using device-based therapies. The prior iteration of the European guidance came out before the SYMPLICITY HTN-3 trial failed to show a significant benefit of renal denervation. Some promising data have come out of pilot studies since then, but there is still not enough support to use these types of devices outside of the context of research studies, Williams said.

“There’s still a debate to be had about the positioning of device-based therapies, and I don’t think what the guidelines said should be interpreted as overly negative,” he explained. “I think it’s basically saying that we need more data and we should be participating in these trials, and there are of course many more trials to come, and it’s quite possible that recommendation will soften if they continue to provide positive data.”