Guidelines on Hypertension Management Revisited in 2009: ESH Position Statement

Milan, Italy – In 2007 the ESH-ESC (European Society of Cardiology) Guidelines for the Management of Arterial Hypertension were published. During a Plenary Session at the European Meeting on Hypertension 2009 Prof. Giuseppe Mancia, MD (University of Milan Bicocca, Italy) announced the Guidelines on hypertension management revisited in 2009: ESH position statement will be published in the October 2009 issue of the Journal of Hypertension.

Reasons for the update
“The update of the 2007 European guidelines is necessary because between 2007 when the most recent European guidelines were published and 2009 a number of important trials have been published, meta-analyses and other studies with new important information. The data of these studies confirms and reinforces our recommendations, but also different and controversial interpretations created confusion at the level of clinical practice,” said Prof. Mancia. A situation that led the European Society of Hypertension to reconsider their document.

In this new context there are new questions, explained Prof. Mancia: the assessment of total CV risk, the role of microalbuminuria and proteinuria (evidence shows that microalbuminuria predicts renal and CV outcome in diabetes, hypertension); first choice drugs and combination treatment (what first choice and which combinations), the new information on the BP target/threshold for drug treatment, the new evidence in specific conditions and the additional treatment goals, the long-term protection by antihypertensive treatment, the treatment for the very elderly, the importance of the J curve phenomenon…

Thresholds and goals
Hypertension treatment, thresholds and goals will remain the same as in 2007, Prof. Mancia said. And he added: “The more aggressive goal in high-risk individuals is not supported by outcome studies, and further very strong evidence is needed.” “In the absence of prospective evidence, retrospective analysis of outcome trials suggest that in patients with high cardiovascular risk there is some reason for concern when on-going treatment BP approaches 120 mmHg systolic, and 70 mmHg diastolic,” said Prof. Mancia. “The blood pressure level below which event rate increases is likely to be different between patients, according to their age, clinical conditions, effectiveness of blood flow autoregulation. And recommendation to aggressively reduce BP in high risk patients should probably be tempered.”

*Threshold/goal identical in the elderly (> 80 years).
Another important question is the search for subclinical organ damage – routine are Scr (> 1.4-1.5 mg/dl) GFR, macroalbuminuria and proteinuria, and EKG, recommended are LVH (Echo), concentric LVH, LA enlargement, CA thickening/plaques), ankle/brachial ratio, arterial stiffening, Prof. Mancia noted.

Hypertension treatment
As to first choice drug treatment, Prof. Mancia stressed that the 2007 ESH/ESC Guidelines indicated five drug classes for initiation of therapy: diuretics, ACE-inhibitors, calcium antagonists, angiotensin receptor antagonists, beta-blockers. But now “protective effects of ACE inhibitors, or angiotensin receptor antagonists or calcium antagonists, alone or in combination treatment, have been shown by new trials or further analysis of old trials,” he said. “And data in hypertension as well as in a variety of other cardiovascular and renal conditions.”

The situation of beta blockers is more complicated: “They are usually employed together with diuretics, and two large trials – LIFE and ASCOT – gave negative results. But several trials have given positive results: HAPPHY, IPPPSH, STOP 2, INVEST, UKPDS. Meta-analyses are discrepant, and recent evidence and meta-analyses are not unfavourable to beta blockers” explained Prof. Mancia. “Beta blockers are superior to other drugs in patients with CHD and are similar to other drugs in patients without CHD, but are inferior to calcium antagonist in stroke prevention, but superior in congestive heart failure prevention”.

In other words, said Prof. Mancia: “All drugs have relative advantages and inconveniences: no drug can be generally prescribed, but no drug should be generally prescribed. Classification of drugs as first, second, third or fourth choice betrays reference to an average patient who hardly exists in clinical practice. So, it is much better to try to indicate which drug might be preferred in which patients under which circumstance.”

Regardless of the drug employed, explained Prof. Mancia, “monotherapy allows us to achieve blood pressure target in only a limited number of hypertensive patients. So, the use of more than one agent is necessary to achieve target BP in the majority of patients. And a vast array of effective and well tolerated combinations is available today.”

For the high and very high risk patients, some arguments suggest treatment with a two drug combination, said Prof. Mancia: “The need of a lower blood pressure target makes combination treatment even more necessary. Chance of an event within short time makes early BP control advisable. Benefit of early blood pressure control is suggested by retrospective analysis of trial data. And early blood pressure control and good tolerability of combination treatment limits the patient’s inconvenience or frustration and improves compliance.”

If in the 2007 ESH/ESC Guidelines the combination between some classes of antihypertensive drugs was summarized by the now famous hexagon, today new evidence (data from ACCOMPLISH, ADVANCE, HYVET, ASCOT, ONTARGET) confirm these recommendations but “other combinations are to be considered or employed according to demographic or clinical conditions” said Prof. Mancia: diuretic + beta-blocker; ACE-inhibitors or angiotensin receptor antagonists + diuretic; calcium antagonist + diuretic; calcium antagonist (dihydropyridine) + beta-blocker; combination with an alpha-blocker, combination with a central agent; combination with an antialdosterone drug; aliskiren + diuretic, calcium antagonist; ACE-inhibitors or angiotensin receptor antagonists; three-drug combinations…

Special conditions: octagenarians, diabetics…
Prof. Mancia illustrated also the new evidence on special conditions and additional treatment goals: in the very elderly population, in diabetic patients, or patients with atrial fibrillation, in antiplatelet treatment, in patients with cognitive dysfunction or dementia, in children and adolescents…

“For the very elderly, for the octogenarians, evidence of benefits has previously been inconclusive” stressed Prof. Mancia: “But there aren’t reasons to interrupt successful or well tolerated treatment when a patient turns 80.” And he concluded: “Although tolerability to treatment is superior to any expectations, alterations of blood pressure control mechanisms in elderly patients cannot be forgotten. And optimal blood pressure goal is still uncertain.”

In conclusion: much evidence, much data, many interpretations, many controversies, and many suggestions. The ESH Task Force is working on the new position statement for publication in October.