ESH '07: New Consensus

Hypertension Guidelines From the

European Society of
Hypertension/European Society of
Cardiology (ESH/ESC)
ESC Congress, Vienna, 09 2007

Aim of guidelines
Educational, rather than prescriptive or coercive
Scientific/professional organizations

Administration (e.g. Min of Health)

Financing (e.g. CNAS)

Protocols

Reimbursement

Studies
Evidence

Guidelines

Definition and Classification of Blood Pressure Levels (ESH)

(2003 version)
Category

Systolic
(mmHg)

Diastolic
(mmHg)

Optimal

< 120

< 80

Normal

120-129

80-84

High normal

130-139

85-89

- Grade 1 (mild)

140-159

90-99

- Grade 2 (moderate)

150-179

100-109

- Grade 3 (severe)

180

10

- Isolated systolic hypertension*

140

< 90

Hypertension

*Isolated systolic hypertension graded (1, 2, or 3).

When SBP and DBP fall into

different categories, the highest
category is used in assessing total
cardiovascular risk.
The authors have again omitted the
"prehypertension" category, as
defined in JNC 7, because they
believe that it implies that:
a large part of the population is sick;
this raises anxiety and leads to
unnecessary physician visits.

Seventh Report of the Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

Category

SBP mmHg

DBP mmHg

< 120

< 80

Prehypertension

120-139

80-89

Hypertension stage 1

140-159

90-99

Hypertension stage 2

160

100

Normal

Blood Pressure Measurement

Methods
office blood pressure should be used as a reference
ambulatory blood pressure monitoring (ABPM) may
improve prediction of cardiovascular risk in both treated
and untreated patients. ABPM is particularly recommended
if office blood pressure measurements vary widely or are
unexpectedly high in patients at otherwise low
cardiovascular risk
self-measurement of blood pressure at home is
encouraged

Blood Pressure Thresholds for Definition of

Hypertension According to Type of Measurement
The guidelines point out that blood pressure thresholds for
the definition of hypertension differ according the type of
measurement used
Type of Measurement

SBP
(mm Hg)

DBP
(mm Hg)

140

90

24-hour

125-130

90

Day

130-135

85

Night

120

70

Home

130-135

85

Office or clinic

DBP = diastolic blood pressure; SBP = systolic blood pressure

Can we correctly measure blood pressure ?

!! Physicians are often not capable of adequately
measuring blood pressure themselves;
The office blood pressure recordings are not
sufficiently reliable and the timing of the start of the
treatment is often not satisfactory.
In a survey of 114 doctors, not a single physician
completely followed the recommended blood
pressure measuring techniques of the American
Heart Association.

The most common mistakes

Due to sphygmomanometers
In one study, 58% of aneroid sphygmomanometers have
been shown to have errors >4mmHg, with ~33% of these
having errors >7mmHg
of 543 manual sphygmomanometers, only 14% were in
perfect working order
The average time since last service was 18 months
Devices for home blood pressure measurement are
produced worldwide at a rate of more than 10 million a
year. Only a small percentage of those devices are
sufficiently validated on a frequent basis

Due to doctor/nurse
the white coat hypertensive response during an office visit can be
significant.
too short of a resting period before measurement
BP should be measured just before antihypertensive medication is taken
to estimate the trough or nadir effect.
use of an inappropriately sized cuff
deflating the cuff too quickly
failure to palpate maximal systolic pressure before auscultation
Auscultation of Kortokoff sounds still underestimates intra-arterial
systolic levels by 58 mmHg and overestimates diastolic levels by 37
mmHg.
not measuring the BP in both arms.
BP taken with a sphygmomanometer by an unfamiliar doctor may raise
the SAP >20 mmHg within the first few minutes, an effect that attenuates
within 510 min and that is less pronounced when a nurse measures the
pressure
a similar pattern can be seen with the DBP

 Based on these inaccuracies, up to 21% of patients are

misdiagnosed with uncontrolled hypertension.
We usually wait to treat patients until their blood pressure
is high, but this may not be the optimal timing.
Vascular wall damage mediated by BP possibly begins
early.

Cardiovascular risk
Total Cardiovascular Risk particular emphasis on:
a) Target organ damage
b) Subclinical organ damage
c) The metabolic syndrome is not regarded as a "pathogenetic
entity" but rather as "a cluster of risk factors often
associated with high blood pressure which markedly
increases cardiovascular risk:
BP 130/85 mm Hg
Low high-density lipoprotein cholesterol:
< 1.0 mmol/L (40 mg/dL)
< 1.2 mmol/L (46 mg/dL)

High triglycerides: > 1,7 mmol/L (150 mg/dL)

Altered fasting glucose: 5.6-6.9 mmol/L (102-125 mg/dL)
Abdominal obesity: waist circumference:
> 102 cm
> 88 cm

Factors influencing prognosis

Risk factors

Subclinical organ damage

Systolic and diastolic BP level

LVH EKG: Sokolow>38, Cornell>2440mm/ms

Levels of pulse pressure (in the elderly)

LVH Echo: LVMI125 ; 110

Age: 55 ; >65

Carotid wall thickening (IMT>0.9mm) or plaque

Smoking

Carotid femoral pulse wave-velocity>12m/s

Dyslipidemia: TC>190 or LDLc>115 or

HDLc<40 or TG>150

Ankle-brachial index<0.9

Fasting plasma glucose 102-125

Slight increase in plasma creatinine:

1.3-1.5 mg/dL ; 1.2-1.4 mg/dL

Abnormal glucose tolerance

Low eGFR <60mL/min/1.73m2 or

Low creatinine clearance <60mL/min

Abdominal obesity
>102cm ; >88cm

Microabuminuria: 30-300mg/24h; or
albumine/creatinine ratio (mg/g): 22 , 31

Family history of premature CV disease

<55 ; <65

Factors influencing prognosis

Established CV or renal disease

Cerebrovascular disease: ischemic stroke, cerebral haemorrhage, transient ischemic

attack
Heart disease: myocardial infarction, angina, coronary revascularisation, heart failure
Renal disease: diabetic nephropathy, renal impairment (sCr>1.5M, 1.4W), proteinuria
Peripheral artery disease
Advanced retinopathy: haemorrhages or exudates, papilloedema
Diabetus mellitus
Fasting plasma glucose 126mg/dL on repeated measurements
or
Postload plasma glucose >198mg/dL

Stratification of Cardiovascular Risk

Other Risk Factors
Subclinical Organ
Damage or Disease
No other risk factors
1-2 risk factors
? 3 risk factors,
metabolic syndrome,
subclinical organ
damage or diabetes
Established CV or
renal disease

Normal
Average
risk
Low
added risk
Moderate
added risk

High
normal
Average
risk
Low
added risk
High
added risk

Very high
added risk

Very high
added risk

Blood Pressure
Grade 1
Grade 2
hypertension hypertension
Low
Moderate
added risk
added risk
Moderate
Moderate
added risk
added risk
High
High
added risk
added risk

Very high
added risk

Very high
added risk

Grade 3
hypertension
High added
risk
Very high
added risk
Very high
added risk

Very high
added risk

High Vs Very high risk subjects

BP 180 mmHg systolic and/or 110 mmHg diastolic
Systolic BP >160 mmHg with low diastolic BP (< 70
mmHg)
Diabetes mellitus
Metabolic syndrome
3 cardiovascular risk factors
One or more of the following subclinical organ damage

EKG or echo LVH

Ultrasound evidence of carotid artery wall thickening or plaque
Increased arterial stiffness
Slight increase in serum creatinine
Reduced estimated glomerular filtration rate or creatinine clearance
Microalbuminuria or proteinuria

Established cardiovascular or renal disease.

New European Guidelines on

Treatment of Hypertension

WHY TO TREAT ?

Significant reduction in CV mortality/morbidity

Benefit at older ages, including ISH
Proportional CV risk reduction in men/women
Benefit across various ethnic groups
Major reduction in cause specific events
Stroke (-30 to -40%)
CHD (-20%)
CHF (> -40%)

Benefits largely depends on BP lowering per se

Conclusions based on multiple types of evidence
Several drugs beneficial
BP is related to CV events
For similar BP reduction little/no events between different
treatments

WHEN TO TREAT ?

General HT population

High risk patients

(CAD/cerebrovascular
disease/diabets/renal dysfunction)

Threshold

140/90 mmHg

130/85 mmHg

Target

< 140/90 mmHg

< 130/80 mmHg

Concept of flexible threshold / target for therapy in relation to total CV risk

HOW TO TREAT ?
Lifestyle measures
Instituted with adequate behavioural/expert support and
periodical reinforcement!!

smoking cessation
weight reduction and maintenance
reduction of excessive alcohol intake
physical exercise
reduction of salt intake
increases in fruit and vegetable intake
decreases in saturated and total fat intake
unproven in preventing CV complications
low compliance
BP response highly variable

Drug Therapy Recommendations

Primary benefits of antihypertensive therapy are related to BP
reduction.
Five important drug classes

Diuretics
calcium-channel blockers
ACE-inhibitors
beta-blockers (UK and USA: Anglo-Scandinavian Cardiac Outcomes TrialBlood Pressure Lowering Arm (ASCOT-BPLA / ESH advise against the use of
beta-blockers in patients with metabolic syndrome or at high risk for diabetes)
angiotensin-receptor blockers

Monotherapy or in combination
No one is a choice of First-Line Therapy
All suitable for initiation/maintenance of treatment
If we have to make a choice, it should depend on comorbidities.
Monotherapy allows to achieve BP target in only a limited number of
hypertensive patients.

The guidelines recommend a 2-drug combination as initial

treatment in:
patients presenting with grade 2 or 3 hypertension or
with high or very high total cardiovascular risk

The following 2-drug combinations are recommended because

they "have been found to be effective and well tolerated":

Thiazide-type diuretic and ACE inhibitor;

Thiazide-type diuretic and ARB;
CCB and ACE inhibitor;
CCB and ARB;
CCB and thiazide-type diuretic
Beta-blocker and CCB.

Initiation of Antihypertensive Treatment

Other Risk Factors,
Subclinical Organ
Damage or Disease

Blood Pressure
Normal

High normal

Grade 1 HPT

Grade 2 HPT

Grade 3 HPT

No other risk factors

No blood pressure
intervention

No blood pressure
intervention

Lifestyle changes
for several months,
then drug treatment
if blood pressure
uncontrolled

Lifestyle changes
for several weeks,
then drug
treatment
if blood pressure
uncontrolled

Lifestyle changes
+ immediate drug
treatment

1-2 risk factors

Lifestyle changes

Lifestyle changes

Lifestyle changes
for several weeks,
then drug treatment
if blood pressure
uncontrolled

Lifestyle changes
for several weeks,
then drug
treatment if blood
pressure
uncontrolled

Lifestyle changes +i
immediate drug
treatment

3 risk factors,
metabolic syndrome,
subclinical organ
damage

Lifestyle changes

Lifestyle changes and

consider drug treatment

Lifestyle changes
+drug treatment

Lifestyle
changes+drug
treatment

Lifestyle changes+im
immediate drug
treatment

Diabetes

Lifestyle changes

Lifestyle changes + drug

treatment

Established
cardiovascular or
renal disease

Lifestyle changes
+immediate drug treatment

Lifestyle changes
+immediate drug
treatment

Lifestyle changes
+immediate drug
treatment

Lifestyle changes
+immediate drug
treatment

Lifestyle changes
+immediate drug
treatment

Special Patient Subsets

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

LVH = left ventricular hypertrophy; ESRD = renal failure; PAD = peripheral arterial disease;
ISH = isolated systolic hypertension

Special Patient Subsets

Antihypertensive Treatment: Preferred Drugs as Per New European Guidelines
Clinical event

Treatment

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

Beta blockers, nonhydropyridine calcium antagonists

Permanent

ESRD/proteinuria

ACE inhibitors, angiotensin receptor blockers, loop diuretics

PAD

Calcium antagonists

LVH = left ventricular hypertrophy; ESRD = renal failure; PAD = peripheral arterial disease;
ISH = isolated systolic hypertension

Special Patient Subsets

Antihypertensive Treatment: Preferred Drugs as Per New European Guidelines

Condition

Treatment

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

Conditions favouring use of some

antihypertensive drug classes
ACE Inhibitors

Heart failure;
LV dysfunction;
Post MI;
Diabetic nephropathy;
LV hypertrophy;
Carotid atherosclerosis;
Proteinuria/microalbuminuria;
Atrial fibrillation;

Metabolic syndrome.

Conditions favouring use of some

antihypertensive drug classes
ARB

Heart failure
Post MI
Diabetic nephropahy
Proteinuria/microalbuminuria
LV hypertrophy
Atrial fibrillation
Metabolic syndrome
ACEI induce cough

Conditions favouring use of some

antihypertensive drug classes
Thiazide Diuretics
ISH (elderly)
Heart failure
HT in blacks

Anti-aldosterone Diuretics
Heart failure
Post MI

Loop Diuretics
End stage renal disease
Heart failure

Conditions favouring use of some

antihypertensive drug classes
Beta blockers

Angina pectoris
Post MI
Heart failure
Tachyarrythmias
Glaucoma
Pregnancy

Conditions favouring use of some

antihypertensive drug classes
CA (dihydropyridines)

ISH (elderly)
Angina pectoris
LV hypertrophy
Carotid/coronary atherosclerosis
Pregnancy
HT in blacks

CA (verapamil/diltiazem)
Angina pectoris
Carotid atherosclerosis
Supraventriular tachycardia

The gap between recommandation and real BP

control
Proportion of patients treated/non treated for HTA in Europe (WolfMaler et al. Hypertension 2004; 43:10-17)

100
80
60

75

74

74

73

68

25

26

26

27

32

England

Sweden

Germany

Spain

Italy

40
20
0

treated

untreated

Approximately 70% of patients in Europe do not reach BP goal < 140/90

mmHg (Wolf-Maler et al. Hypertension 2004; 43:10-17)
100
80
60
60

79

70

21

30

Sweden

Germany

81

72

40
20

40

19

28

0
England

BP goal achieved

Spain

BP goal not achieved

Italy

Reasons for inadequate control of BP

Ineffective drugs
Resistant HTA (ASCOT + Spironolactone 25-50 mg/day,
irrespective of plasma aldosterone );
Guideline confusion;
Drug costs;
Drug side - effects;
Poor compliance;
Physician inertia;

How to overcome obstacles for inadequate BP

control
1.
2.
3.
4.
5.

Use non drug methods;

Use higher drug doses (if tolerated)
Use the right drugs/combination;
Use more drugs + fewer tablets;
Future prospects?
Education
Cheaper, more effective drugs
More trial data

NEW METHODS

Aliskiren renin inhibitor

Vaccination against hypertension (CYT006-AngQb
Switzerland, ATR12181, China)
Vaccine against angiotensin II, obtained by coupling the
octapeptide with a virus like particle;
It produces anti-angiotensin II antibodies
NF-kB inhibition (?) prevent vascular damages in
hypertension
Erythropoietin prevent vascular (cerebral) damage via NO
formation.
ACE inhibitors + NO donor group (NCX899 Merck)

Critical Comments of ESH Guidelines

1.

Suzanne Oparil,
President of the American Society of Hypertension

2.

the scholarship of the guidelines

for primary care physicians it might be better to
focus on blood pressure, the most easily modifiable
cardiovascular risk factor, rather than including all
risk factors and the metabolic syndrome
in the United States, guidelines cannot omit grading
of recommendations according to level of scientific
evidence, as in the European guidelines.

Lars H. Lindholm, (Sweden), President of the

International Society of Hypertension

inclusion of beta blockers as first-line treatment

Newer Beta-blockers

Negative evidence for beta-blockers from the AngloScandinavian Cardiac Outcomes Trial-Blood Pressure
Lowering Arm (ASCOT-BPLA), Controlled Onset Verapamil
Investigation of Cardiovascular End Points (CONVINCE) and
Medical Research Council (MRC) trials, and from a 2005
meta-analysis.
Carvedilol and nebivolol are the 2 leading newer
antihypertensive agents in the United States.
Carvedilol, a nonselective beta-blocker and an alpha1-blocker
with no intrinsic sympathomimetic activity, was approved in
the United States for the treatment of heart failure in 1995, but
has only recently been actively marketed for hypertension.
Nebivolol has high specificity for the beta1 receptor and may
have a nitric oxide-mediated vasodilatory effect.