NICE, ESH, ESC

.
..
ESH General Secretary

Journal of Hypertension 2013

Blood Pressure 2013

JNC 8: Initial Question Areas Being Addressed

Among adults with hypertension, does initiating

antihypertensive pharmacological therapy at specific
BP thresholds improve health outcomes? (when to
initiate drug treatment)
Among adults, does treatment with antihypertensive
pharmacological therapy to a specific BP goal lead to
improvements in health outcomes? (how low should
you go)
In adults with hypertension, do various
antihypertensive drugs or drug classes differ in
comparative benefits and harms on specific health
outcomes? (How do we get there?)

2013 ESH/ESC Hypertension Guidelines

Classes of recommendations

2013 ESH/ESC Hypertension Guidelines

New aspects
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)

Epidemiological data on hypertension and BP control in Europe.

Strengthening of the prognostic value of home blood pressure monitoring (HBPM) and of its role for diagnosis and
management of hypertension, next to ambulatory blood pressuremonitoring (ABPM).
Update of the prognostic significance of night-time BP, whitecoat hypertension and masked hypertension.
Re-emphasis on integration of BP, cardiovascular (CV) risk factors, asymptomatic organ damage and clinical
complications for total CV risk assessment.
Update of the prognostic significance of asymptomatic organ damage, including heart, blood vessels, kidney, eye
and brain.
Reconsideration of the risk of overweight and target body mass index (BMI) in hypertension.
Hypertension in young people.
Initiation of antihypertensive treatment. More evidence-based criteria and no drug treatment of high normal BP.
Target BP for treatment. More evidence-based criteria and unified target systolic blood pressure (SBP) (<140 mmHg)
in both higher and lower CV risk patients.
Liberal approach to initial monotherapy, without any all-ranking purpose.
Revised schema for priorital two-drug combinations.
New therapeutic algorithms for achieving target BP.
Extended section on therapeutic strategies in special conditions.
Revised recommendations on treatment of hypertension in the elderly.
Drug treatment of octogenarians.
Special attention to resistant hypertension and new treatment approaches.
Increased attention to organ damage-guided therapy.
New approaches to chronic management of hypertensive disease.

DIAGNOSTIC EVALUATION

2013 ESH/ESC Hypertension Guidelines

Blood pressure management, history, and

physical examination

2013 ESH/ESC Hypertension Guidelines

Definitions of hypertension by office and out-of-office

blood pressure levels (mmHg)

2013 ESH/ESC Hypertension Guidelines

ABP - Prognostic Significance

Better correlation with organ damage
Stronger relationship with morbid / fatal events (not in all studies)
Better predictive value reported in
- General population
- Young / old subjects
- Males / females
- Untreated / treated hypertensives
- High risk patients
- Patients with CV / renal disease
Nighttime BP stronger predictor than daytime BP with little
additional information from
- Night / day BP ratio
- Dipping phenomenon (poor reproducibility)
- Extreme dipping

2013 ESH/ESC Hypertension Guidelines

Clinical indications for out-of-office

blood pressure measurement for diagnostic purposes

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2013 ESH/ESC Hypertension Guidelines

ABP - Additional Analysis

BP variability / morning BP surge / BP load /

arterial stiffness index
Added predictive value not yet clear
Should be regarded as experimental / not for
routine use

2013 ESH/ESC Hypertension Guidelines

Exercise BP

The overall results question the clinical utility

of BP measurements during exercise testing
for diagnostic and prognostic purposes in
patients with HT

However, exercise testing is useful as a

general prognostic indicator using exercise
capacity and ECG data
An abnormal BP response may warrant ABPM

2013 ESH/ESC Hypertension Guidelines

BP during Laboratory Stress

A number of mental stress tests have been applied to
evoke an increased BP via a problem of mathematical /
technical / decisional nature
Do not reflect real life stress / are not well standardized /
have limited reproducibility and correlations to each
other
Results on independent relationship of BP response
with future hypertension not unanimous (and additional
explained role small)

BP measurements during mental stress tests are

currently not clinically useful

2013 ESH/ESC Hypertension Guidelines

Central blood pressure

Although central BP and AI measurements are of great

interest for mechanistic analyses in pathophysiology,
pharmacology and therapeutics, more investigation is
needed before recommending their routine clinical use

2013 ESH/ESC Hypertension Guidelines

Laboratory investigations

2013 ESH/ESC Hypertension Guidelines

Search for asymptomatic organ damage,

cardiovascular disease, and chronic kidney disease

2013 ESH/ESC Hypertension Guidelines

Stratification of total CV risk in categories of

low, moderate, high and very high risk

TREATMENT APPROACH

2013 ESH/ESC Hypertension Guidelines

Initiation of antihypertensive drug treatment

2013 ESH/ESC Hypertension Guidelines

Blood pressure goals in hypertensive patients

JNC 8: Initial Question Areas Being Addressed

Among adults with hypertension, does initiating

antihypertensive pharmacological therapy at specific
BP thresholds improve health outcomes? (when to
initiate drug treatment)
Among adults, does treatment with antihypertensive
pharmacological therapy to a specific BP goal lead to
improvements in health outcomes? (how low should
you go)
In adults with hypertension, do various
antihypertensive drugs or drug classes differ in
comparative benefits and harms on specific health
outcomes? (How do we get there?)

BP Level-When to initiate/How Low to go

General population
Elderly
Diabetes
Kidney Disease

JNC 8: Initial Question Areas Being Addressed

1. When to initiate drug treatment ?

2. How low should you go?

JNC 8- Recommendation 1

In the general population aged 60 years, initiate pharmacologic

treatment to lower BP at SBP 150 mmHg or DBP 90 mmHg and
treat to a goal of <150/90 mmHg
(Strong Recommendation-Grade A)

Corollary Recommendation

In the general population aged 60 years, if pharmacological

treatment for high BP results in lower achieved SBP (eg, <140mmHg)
and treatment is well tolerated and without adverse effects on health
or quality of life, treatment does not need to be adjusted
(Expert Opinion, -Grade E)

JNC 8: Initial Question Areas Being Addressed

1. When to initiate drug treatment?

2. How low should you go?

JNC 8-Recommendation 2

In the general population <60 years, initiate pharmacologic

treatment to lower BP at DBP 90 mmHg and treat to a goal DBP
<90 mmHg.
(For ages 30-59 years, Strong Recommendation-Grade A
For ages 18-29 years, Expert Opinion Grade E)

JNC 8-Recommendation 3

In the general population <60 years, initiate

pharmacologic treatment to lower BP at SBP
140 mmHg and treat to a goal SBP <140 mmHg.
(Expert Opinion Grade E)

JNC 8: Initial Question Areas Being Addressed

1. When to initiate drug treatment?

2. How low should you go?

JNC 8-Recommendation 4

In the population aged 18 with CKD, initiate pharmacologic

treatment to lower BP at SBP 140 mmHg or DBP 90 mmHg
and treat to a goal SBP<140mmHg and goal DBP<90mmHg
(Expert Opinion, -Grade E)

JNC 8: Initial Question Areas Being Addressed

1. When to initiate drug treatment?

2. How low should you go?

JNC 8-Recommendation 5

In the population aged 18 with diabetes, initiate

pharmacologic treatment to lower BP at SBP 140 mmHg or
DBP 90 mmHg and treat to a goal SBP<140mmHg and goal
DBP<90mmHg
(Expert Opinion, -Grade E)

2013 BP Guideline Goals-for DM

<140/90 mmHg

KDIGO/KDOQI

NICE

JNC 8

<140/85 mmHg

ESH/ESC

<140/80 mmHg

Am Diabetes Assoc.-

2013 ESH/ESC Hypertension Guidelines

Treatment strategies and choice of drugs

2013 ESH/ESC Hypertension Guidelines

Monotherapy vs. drug combination strategies

to achieve target BP
(IIbC)

Moving from a less intensive to a more intensive therapeutic strategy

should be done whenever BP target is not achieved.

2013 ESH/ESC Hypertension Guidelines

Treatment strategies in white-coat and

masked hypertension

2013 ESH/ESC Hypertension Guidelines

Antihypertensive treatment strategies in the elderly

2013 ESH/ESC Hypertension Guidelines

Young Hypertensive Adults

Isolated DBP elevation possible
Long-term CV risk possibly more closely related to DBP than
SBP
No RCT-based recommendations
Drug treatment may be considered prudent with BP target <
140/90 mmHg
Selective SBP elevation sometimes associated with normal
central SBP Because there is no evidence on drug effects,
close FU / lifestyle changes advisable

18516 M

JNC 8: Initial Question Areas Being Addressed

3.How do we get there?

JNC 8-Recommendation 6
In the general, non-black population including those with DM, initial
antihypertensive treatment should include a thiazide-type diuretic, CCB,
ACEI or ARB
(Moderate recommendation-Grade B)

JNC 8: Initial Question Areas Being Addressed

3.How do we get there?

JNC 8-Recommendation 7
In the general, black population including those with DM, initial
antihypertensive treatment should include a thiazide-type diuretic or CCB
(For general black population: Moderate recommendation-Grade B
For black population with DM: Weak recommendation-Grade C)

JNC 8: Initial Question Areas Being Addressed

3.How do we get there?

JNC 8-Recommendation 8
In the population 18-80 years of age with CKD and hypertension, initial
(or add-on) antihypertensive treatment should include an ACE inhibitor or
ARB to improve kidney outcomes. This applies to all CKD patients

regardless of race or diabetes status.

(Moderate Recommendation-Grade B)

Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With Hypertension
Guideline

Population

Goal BP,
mm Hg

Initial Drug Treatment Options

2014 Hypertension
guideline

General 60y
General <60 y
Diabetes
CKD

<150/90
<140/90
<140/90
<140/90

Nonblack: thiazide-type diuretice, ACEI, ARB, or CCB

Black: thiazide-type diuretic or CCB
Thiazide-type diuretice, ACEI, ARB, or CCB
ACEI or ARB

ESH/ESC 2013

General nonelderly
General elderly <80y
General 80y
Diabetes
CKD no proteinuria
CKD + proteinuria

<140/90
<150/90
<150/90
<140/85
<140/90
<130/90

-Blocker, diuretic, CCB, ACEI, or ARB

General <80y
General 80y
Diabetes

<140/90
<150/90
<130/80

Thiazide, -blocker (age <60y), ACEI (nonblack), or ARB

CKD

<140/90

ACEI or ARB with additional CVD risk

ACEI, ARB, thiazide, or DHPCCB without additional CVD risk
ACEI or ARB

ADA 2013

Diabetes

<140/80

ACEI or ARB

KDIGO 2012

CKD no proteinuria
CKD + proteinuria

140/90
130/80

ACEI or ARB

NICE 2011

General <80y
General 80y

<140/90
<150/90

<55y: ACEI or ARB

55y or black : CCB

ISHIB 2010

Black, lower risk

Target organ damage or
CVD risk

<135/85
<130/80

Diuretic or CCB

CHEP 2013

ACEI or ARB
ACEI or ARB

100%

0%

Bangalore et al, JACC 2007;50:563-72

JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

2013 ESH/ESC Hypertension Guidelines

Treatment of risk factors associated with hypertension

JNC 8: Initial Question Areas Being Addressed

3.How do we get there?

JNC 8-Recommendation 9
Referral to a hypertension specialist may be indicated
for patients in whom goal BP can not be attained using the above strategy
or
>for the management of complicated patients for whom additional clinical
consultation is needed.
(Expert opinion-Grade E)

2013 ESH/ESC Hypertension Guidelines

Treatment strategies in hypertensive patients with

resistant hypertension

JNC 8
Short
Simple
Practical
Despite all our guidelines the epidemiological data indicate that there has
been little improvement in blood pressure control.
We have to do a better job and we hope these new guidelines will help.

Despite all available

guidelines the epidemiological data indicate that there

has been little improvement in blood pressure control.

We have to do a better job and I hope that USA and ESH new guidelines
will help.