New European hypertension guidelines: ≤140 mm Hg for all

News - June 19, 2013

Presented at the European Society of Hypertension 2013 Scientific Sessions in Milan, Italy, the new ESC/ESH guidelines are an update to those last published in 2007.

Perhaps the biggest change in the new document is the adoption of a single systolic blood pressure target for almost all patients: 140 mmHg. This replaces the previous, more complicated target, which included both systolic and diastolic recommendations for different levels of risk (140/90 mmHg for moderate- to low-risk patients and 130/80 mmHg for high-risk patients).  There was not enough evidence to justify two targets.

The new guidelines do make exceptions for special populations, such as those with diabetes and the elderly. For those with diabetes, the ESH/ESC writing committee recommend that physicians treat patients to <85 mm Hg diastolic blood pressure.
In patients younger than 80 years old, the systolic blood-pressure target should be 140 to 150 mm Hg, but physicians can go lower than 140 mm Hg if the patient is fit and healthy. The same advice applies to octogenarians, although physicians should also factor in the patient's mental capacity in addition to physical health if targeting to less than 140 mm Hg.

Like the 2007 guidelines, patients can be stratified into four categories: high-normal blood pressure (130-139 systolic or 85-89 mm Hg diastolic), grade 1 hypertension (140-159 systolic or 90-99 diastolic mm Hg), grade 2 hypertension (160-179 systolic or 100-109 mm Hg diastolic), or grade 3 hypertension (>180 systolic or >110 mm Hg diastolic). The presence or absence of other cardiovascular risk factors or organ damage/disease should be then factored into treatment decisions for the management of blood pressure (a full risk-assessment algorithm is included in the guidelines).

A salt intake of approximately 5 to 6 g per day is recommended, in contrast with a typical intake of 9 to 12 g per day. A reduction to 5 g per day can decrease systolic blood pressure about 1 to 2 mm Hg in normotensive individuals and 4 to 5 mm Hg in hypertensive patients.
A reduction of BMI to 25 kg/m2 and reducing waist circumferences to <102 cm in men and <88 cm in women is advised. Losing about 5 kg can reduce systolic blood pressure by as much as 4 mm Hg, while aerobic endurance training in hypertensive patients can reduce systolic blood pressure 7 mm Hg.

The approach to drug therapy for hypertension has also been thoroughly revised. Drugs are no longer suggested for the treatment of high normal blood pressure. No single drug or class is given special preference, since the benefits of treatment are largely based on the blood-pressure-lowering effect of the drugs. The guidelines recommend an individualized approach to treatment, based on clinical and demographic considerations.

The guidelines provide perspective on renal denervation for resistant hypertension, which is believed to be promising but more trials are needed before it can be fully assessed.

The new guidelines put a greater emphasis on considering hypertension within the context of additional cardiovascular and other risk factors. Home blood-pressure monitoring and ambulatory blood-pressure monitoring also gain an increased role.

Source:  Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension. Eur Heart J 2013; DOI: 10.1093/eurheartj/eht.151. Link

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