New ESC/ESH hypertension guidelines recommend 2-in-1 combo pill as initial therapy

The new 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines for the management of arterial hypertension recommend starting treatment for most patients with a two-in-one pill containing an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in combination with a calcium channel blocker (CCB) or diuretic.

The new guidelines, released at the ESC Congress 2018 held in Munich, Germany, also recommend a less conservative approach in the treatment of hypertension, with lower blood pressure (BP) thresholds and treatment targets even for older patients. [Eur Heart J 2018, doi:10.1093/eurheartj/ehy339]

BP thresholds and treatment targets

While the definition of hypertension remains unchanged at an office BP of ≥140/90 mm Hg, patients with grade 1 hypertension (office BP, 140–159/90–99 mm Hg) at high or very high cardiovascular (CV) risk are now recommended to start drug treatment immediately, whereas those with low or moderate CV risk should start drug treatment if their BP is uncontrolled after 3–6 months of lifestyle modification.  

For patients with grade 2 or grade 3 hypertension (office BP, 160–179/100–109 mm Hg and ≥180/110 mm Hg, respectively), immediate drug treatment should be given with an aim to achieve BP control within 3 months.

“The office BP threshold for treatment is ≥140/90 mm Hg for individuals aged 18–79 years, and ≥160/90 for those aged ≥80 years,” said Professor Bryan Williams, ESC chairperson of the guidelines task force from the University College London, UK.

“The treatment target is an office BP of <140/90 mm Hg for all patients. If treatment is well tolerated, the target BP should be ≤130/80 mm Hg, but not below 120/70 mm Hg, in most patients younger than 65 years of age,” said Williams. “In patients aged 65 years or above, the target BP is 130–<140/70–<80 mm Hg if tolerated, with close monitoring of adverse effects of treatment.”

Achieving BP control with combo pill

“A major element of novelty in the 2018 guidelines is the recommendation to initiate treatment in most patients with a two-drug combination pill,” said Professor Giuseppe Mancia, ESH chairperson of the guidelines task force from the University of Milano-Bicocca in Milan, Italy. “This approach provides greater BP reduction vs monotherapy, reduces heterogeneity of the BP response, enhances BP control by improving treatment adherence and reducing therapeutic inertia, and is shown to reduce CV events.”

“An ACEI or ARB in combination with a CCB or a diuretic is the preferred core initial treatment strategy for patients with uncomplicated hypertension and most patients with hypertension-mediated organ damage, cerebrovascular disease, diabetes or peripheral artery disease,” Mancia continued. “Initial monotherapy is now reserved for patients with BP in the high-normal range, very old patients, and frail older patients.”

For patients with uncontrolled BP despite initial therapy with an ACEI or ARB plus a CCB or diuretic, the new guidelines recommend second-line treatment with a triple combination pill containing an ACEI or ARB plus a CCB and a diuretic. For those who need further escalation of therapy, recommended third-line treatment is with a triple combination pill together with spironolactone or another diuretic, an alpha-blocker or a beta-blocker.

“Beta-blockers can be considered at any treatment step when there is a specific indication for their use, such as heart failure, angina, post-MI atrial fibrillation, or younger women with or planning pregnancy,” Mancia added.

“Device-based therapies are not recommended for the routine treatment of hypertension due to the absence of evidence of their ability to substantially lower BP and protect against CV events,” Mancia noted. “Use of these therapies should be limited to the setting of clinical studies and randomized controlled trials until further evidence on their safety and efficacy becomes available.”