A peek at the European hypertension guidelines: What’s new in 2018?

The 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) (ESC/ESH) hypertension guideline, which is slated for full release at the ESC Congress in August, maintains the 2013 classification system based on blood pressure (BP) levels yet extends drug therapy to more patient groups, with combination therapy as the first-step treatment strategy recommended for most patients with hypertension, says a renowned cardiologist.

Professor Giuseppe Mancia from the University of Milano-Bicocca in Milan, Italy and co-chair of the European hypertension guideline development task force was cautious not to offer snippets of the update at APSC 2018 in Taipei.

The ESH 2018 held in Barcelona, Spain however gave away many important aspects in a widely attended session that represented the first official presentation of the guidelines. Hypertension is still defined as an office BP greater than 140/90 mm Hg. A BP target of less than 140/90 mm Hg is recommended for most patients with hypertension, including the elderly.  For those younger than 65 years, an even lower systolic BP (SBP) of less than 130 mm Hg is targeted but should not be any lower than 120 mm Hg. For patients 65 years and older, clinicians should aim for an SBP of no less than 130 mm Hg or as tolerated. A diastolic BP of less than 80 mm Hg is recommended for all patients on drug therapy.

The European BP thresholds, particularly in the elderly, are less aggressive than that of the 2017 US guidelines which classify the 130–139/80–89 mm Hg range as already a stage 1 hypertension. “For older patients with a very high BP, I think we should not aim any lower than 130 mm Hg,” said Mancia.

For the 2018 pharmacological update, either an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) plus either a calcium-channel blocker (CCB) or a diuretic, preferably in single-pill form, are recommended as a first-step therapy for uncomplicated hypertension. Stepped-up treatment would require an ACEi or an ARB plus a CCB and diuretic, again, in a single pill when possible. For those who are not at goal despite treatment, spironolactone, a more standard diuretic, an alpha-blocker or a beta-blocker may be added.

Beta-blockers have a compelling indication for use in all patients with high-risk conditions such as heart failure, myocardial infarction, coronary heart disease or atrial fibrillation, and diabetes.

Beta-blockers differ in their pharmacological properties, and this is mentioned in the guidelines which, as in 2013, consider both classical and vasodilator beta-blockers for first-step combination treatment in a number of conditions.

“Combination therapy in a single pill is now a first-step treatment for primary hypertension,” Mancia said. “Two drugs in one pill, when possible, supports better treatment adherence among patients.”