Tuesday, June 19, 2007

New European guidelines on hypertension

New European guidelines on hypertension

Milan, Italy - New guidelines for the management of arterial hypertension have been issued at the European Society of Hypertension (ESH) meeting in Milan, Italy [1]. The recommendations, which were drawn up jointly by task forces from ESH and the European Society of Cardiology (ESC), also appear in the June 2007 issue of the Journal of Hypertension.

Cochair of the task forces, Dr Guy de Backer (University Hospital, Ghent, Belgium), told heartwire that 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 four 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 read the text only 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 lower 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 an MI, 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


ISH (elderly) - Diuretics, calcium antagonists

Metabolic syndrome - CE 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=end-stage renal disease; 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 arterial stiffness.

Mancia G, de Backer G, Dominiczak A, et al. 2007 guidelines for the management of arterial hypertension. J Hypertens 2007; 25: 1105-1187


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