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escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-17/definition-of-hypertension-and-
pressure-goals-during-treatment-esc-esh-guidelin
Abbreviations
CV: cardiovascular
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SPC: single-pill combination
Introduction
Hypertension continues to be the most common preventable cardiovascular risk factor
for major cardiovascular events in Europe. Blood pressure (BP) control remains largely
unsatisfactory. In Europe, >150 million people are affected by hypertension and its
prevalence is predicted to rise by 15% to 20% by 2025. Significant efforts have been
made in recent decades to improve BP control worldwide [1]. However, the lack of BP
control in ≥40% of the population remains a major missed opportunity for European
healthcare systems. For this reason, development of new guidelines appeared timely and
appropriate.
Therefore, the 2018 ESC/ESH Guidelines on hypertension were developed. The purpose
of the review and update of the guidelines was to evaluate and incorporate new
evidence into the guideline recommendations. The principal aim was to improve
pragmatically the diagnostic accuracy of hypertension and the therapeutic efficacy of
antihypertensive management, with the challenging aim of improving BP control and
reducing the related cardiovascular burden.
The key novel aspects of the ESC/ESH Guidelines are the improvement of individual
cardiovascular risk stratification and BP targets to be achieved, the timing for starting
pharmacological treatment and the time to get to target, the prevalent role of initial
combination therapy, and the promotion of adherence to treatments [2].
2 - Treatment thresholds
a. High normal BP (130–139/85–89 mmHg):
Drug treatment may be considered when cardiovascular (CV) risk is very high due to
established cardiovascular disease (CVD), especially coronary artery disease (CAD).
(Recommendation; Class IIb)
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b. Treatment of low-risk grade 1 hypertension:
c. Older patients:
In older patients (65–80 years): in older patients (≥65 years), it is recommended that SBP
should be targeted to a BP range of 130–139 mmHg.
In patients aged over 80 years: an SBP target range of 130–139 mmHg is recommended,
if tolerated.
1 - White-coat hypertension
White-coat hypertension is defined as an elevated office untreated BP, but is normal
when measured by ABPM, HBPM, or both [4]. The difference between the higher office
and the lower out-of-office BP is referred to as the “white coat effect”, and is believed to
reflect mainly the pressor response to an alerting reaction elicited by office BP
measurements by a doctor or a nurse, although other factors are probably also involved
[5]. It can account for up to 30 to 40% of people (and >50% in the very old) with an
elevated office BP. It is more common with increasing age, in women, and in non-
smokers. Its prevalence is lower in patients with HMOD, when office BP is based on
repeated measurements, or when a doctor is not involved in the BP measurement. A
significant white-coat effect can be seen at all grades of hypertension (including resistant
hypertension), but the prevalence of white-coat hypertension is greatest in grade 1
hypertension.
The white-coat effect is used to describe the difference between an elevated office BP
(treated or untreated) and a lower home or ambulatory BP in both untreated and
treated patients.
2 - Masked hypertension
Masked hypertension refers to untreated patients in whom BP is normal in the office but
is elevated when measured by HBPM or ABPM [6]. It can be found in approximately 15%
of patients with a normal office BP. The prevalence is greater in younger people, males,
smokers, and those with higher levels of physical activity, alcohol consumption, anxiety,
and job stress. Obesity, diabetes, chronic kidney disease (CKD), family history of
hypertension, and high–normal office BP are also associated with an increased
prevalence of masked hypertension. It is associated with dyslipidaemia and
dysglycaemia, HMOD [7], adrenergic activation, and increased risk of developing
diabetes, and sustained hypertension [6].
4 - Secondary hypertension
Secondary hypertension is hypertension due to an identifiable cause, which may be
treatable with an intervention specific to the cause. A high index of suspicion and early
detection of secondary causes of hypertension are important because interventions may
be curative, especially in younger patients; however, interventions later in life are less
likely to be curative (i.e., removing the need for antihypertensive medication) because
longstanding hypertension results in vascular and other organ damage that sustains the
elevated BP. Nevertheless, intervention is still important because it will often result in
much better BP control with less medication.
Terms of hypertension
I - True normotension: is used when both office and out-of-office BP measurements are
normal
III - Masked uncontrolled hypertension (MUCH): in which the office BP is controlled but
home or ambulatory BP is elevated.
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treatment decisions. Reprinted by permission of Oxford University Press on behalf of the
European Society of Cardiology from Williams B et al [3].
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Arterial-Hypertension-
Management-of
BP: blood pressure; CKD: chronic kidney disease; CV: cardiovascular; DBP: diastolic blood
pressure; HMOD: hypertension-mediated organ damage; SBP: systolic blood pressure;
SCORE: Systematic COronary Risk Evaluation
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Arterial-Hypertension-
Management-of
a Refers
to patients with previous stroke and does not refer to blood pressure targets
immediately after acute stroke.
bTreatment decisions and blood pressure targets may need to be modified in older
patients who are frail and independent.
CAD: coronary artery disease; CKD: chronic kidney disease (includes diabetic and non-
diabetic CKD); DBP: diastolic blood pressure; SBP: systolic blood pressure; TIA: transient
ischaemic attack
Diabetes
For patients with diabetes, the same treatment targets are recommended for an office
SBP target of 130 mmHg or lower [13]. SBP should not be lowered to <120 mmHg. The
DBP target should be <80 mmHg. In older patients (≥65 years) the SBP target range is
130–140 mmHg if tolerated. A variable visit-to-visit BP should be noted due to associated
increased cardiovascular and renal risk. Caution is emphasised in autonomic
polyneuropathy concerning postural or orthostatic hypotension. Nocturnal BP should be
assessed by 24-hr ABPM in order to detect hypertension in apparently normotensive
diabetic patients.
Coronary disease
In CAD, diastolic BP should not be lowered to <70 mmHg as myocardial perfusion may be
impaired in lower values [14]. In CAD, treatment is already recommended at the
threshold of high–normal BP of 130–139/85–89 mmHg, as these patients are considered
to be at very high risk.
Heart failure
In hypertensive patients with preserved or reduced ejection fraction (EF),
antihypertensive treatment should be considered if BP is ≥140/≥90 mmHg. If
antihypertensive treatment is not needed, the treatment of heart failure (HF) should
follow the current ESC HF Guidelines [15]. In HF with reduced EF, the initial
antihypertensive regimen advocates an ACEI or ARB (or angiotensin receptor/neprilysin
inhibitor as indicated by guidelines) plus a thiazide diuretic (or loop diuretic in oedema),
plus a beta-blocker. The second step adds the mineralocorticoid receptor antagonist
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spironolactone or eplerenone. Although in general actively lowering the BP below 120/70
mmHg should be avoided, patients may achieve lower values due to HF guideline-
directed medications which, if tolerated, should be continued.
Conclusion
The new ESC Guidelines have clearly defined therapeutic targets with lower thresholds,
below which treatment should not be continued. In most patients, a BP goal of at least
130/80 mmHg is recommended, but not below 120/70 mmHg. Lifestyle interventions are
re-enforced in all stages of hypertension. In particular, the guidelines clearly aim at
lowering the high-risk profiles of patients with concomitant cardiovascular diseases, e.g.,
coronary disease or diabetes.
Notes to editor
Author:
Dr Ihab S. Ramzy
E-mail: ihab.ramzy@nhs.net
Author disclosures:
The content of this article reflects the personal opinion of the author/s and is not
necessarily the official position of the European Society of Cardiology.
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