June 20, 2007 — New guidelines for the management of arterial hypertension have been issued at the European Society of Hypertension (ESH) meeting in Milan, Italy. The recommendations, which were drawn up jointly by task forces from ESH and the European Society of Cardiology, also appear in the Journal of Hypertension.
Co-chair of the task forces, Dr Guy de Backer (University Hospital, Ghent, Belgium) told heartwire the guidelines are essentially an update to 2003 recommendations. The new document is 82 pages long, and lists 825 references, reflecting the vast amount of data published on the subject of hypertension in the past 4 years, he noted.
Asked to pick out highlights for heartwire, de Backer said this was a difficult task, "as there has been no one dramatic change, rather small changes in each area. The most important thing is that this is an update and the numerous references have been critically evaluated. We have kept the general framework and added what we think is most important from the literature."
For the clinician, the main messages can be found in a number of boxes in the paper, which contain position statements, he noted. "All you need to do is look at the position statements in the boxes, and only read the text if you want more detail." The task forces are working hard to produce a pocket version of the new guidelines for release at the ESC meeting in Vienna in September, he added.
No One Choice of First-Line Therapy
The overall goal for blood-pressure reduction has remained the same — to get BP to 140/90 mm Hg in the large majority of people. However, there has been a change in the recommendation for those with comorbidities, de Backer said. For example, there is a new goal of 130/80 mm Hg for people with established cardiovascular disease or diabetes.
In terms of treatment recommendations, he said the new guidelines shy away from recommending one particular class of antihypertensive over another as first-line therapy, rather they emphasize the importance of selecting therapy for each individual, according to any comorbidities they may have.
"We have noted the five important drug classes — diuretics, calcium-channel blockers, ACE-inhibitors, beta-blockers and angiotensin-receptor blockers," he said. But from then on, "if we have to make a choice it should depend on comorbidities."
For example, the best choice of first-line agent for someone with hypertension who also has diabetes is either an ACE inhibitor or an angiotensin-receptor blocker. For those who have suffered a myocardial infarction, the most appropriate drug to use first is a beta-blocker and in the elderly, the first-line drug of choice is generally a calcium-channel blocker to reduce the risk of stroke, he noted.
He added, however, that the emphasis on identification of first-line therapy is often pretty futile, because the majority of patients require multiple blood pressure medications.
Antihypertensive Treatment: Preferred Drugs as Per New European Guidelines
Subclinical organ damage
Treatment
LVH
ACE inhibitors, calcium antagonists, angiotensin receptor blockers
Asymptomatic atherosclerosis
Calcium antagonists, ACE inhibitors
Microalbuminuria
ACE inhibitors, angiotensin receptor blockers
Renal dysfunction
ACE inhibitors, angiotensin receptor blockers
Clinical event
Previous stroke
Any BP-lowering agent
Previous MI
Beta blockers, ACE inhibitors, angiotensin receptor blockers
Angina pectoris
Beta blockers, calcium antagonists
Heart failure
Diuretics, beta blocker, ACE inhibitors, angiotensin receptor blockers, antialdosterone agents
Atrial fibrillation
— Recurrent
Angiotensin receptor blockers, ACE inhibitors
— Permanent
Beta blockers, nonhydropyridine calcium antagonists
ESRD/proteinuria
ACE inhibitors, angiotensin receptor blockers, loop diuretics
PAD
Calcium antagonists
Condition
ISH (elderly)
Diuretics, calcium antagonists
Metabolic syndrome
ACE inhibitors, angiotensin receptor blockers, calcium antagonists
Diabetes mellitus
ACE inhibitors, angiotensin receptor blockers
Pregnancy
Calcium antagonists, methyldopa, beta blockers
Blacks
Diuretics, calcium antagonists
LVH = left ventricular hypertrophy; ESRD = renal failure; PAD = peripheral arterial disease; ISH = isolated systolic hypertension.
Other subjects on which there is more information in the new guidelines include the taking of ambulatory BP measurements, and those performed at home by patients themselves, de Backer noted, adding that the advice for interpreting ambulatory and home BP measurements "is more detailed now."
Extra information can be found on subclinical organ damage, including details about novel markers for renal damage and for arterial stiffness.
J Hypertens. 2007;25:1105-1187.
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