Highlights from the new European Guidelines on arterial hypertension: What is new? - Josep Redòn
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Highlights from the new
European Guidelines on arterial
hypertension: What is new?
Josep Redòn
Hospital Clinico, University of Valencia,
Valencia, SpainThe 2013 ESH/ESC guidelines – main changes
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219Increased emphasis on the use of out-of-office
BP monitoring
• Major advantage of out-of-office BP monitoring:
A large number of BP measurements away from the
medical environment
– Represents a more reliable assessment of actual BP than
office BP
– Correlates more strongly with organ damage and CV events than
office BP
• There is an increasing role for HBPM for the diagnosis
and management of hypertension, alongside ABPM
– The two methods should be regarded as complementary, rather
than competitive or alternative
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219Definitions of hypertension by office and
out-of-office BP levels
Category Systolic BP Diastolic BP
(mmHg) (mmHg)
Office BP ≥140 and/or ≥90
Ambulatory BP
Daytime (or awake) ≥135 and/or ≥85
Night-time (or asleep) ≥120 and/or ≥70
24-h ≥130 and/or ≥80
Home BP ≥135 and/or ≥85
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219Clinical indications for out-of-office
BP measurement for diagnostic purposes
Clinical indications for HBPM or ABPM Specific indications for ABPM
Suspicion of white-coat hypertension Marked discordance between office BP
and home BP
Suspicion of masked hypertension Assessment of dipping status
Identification of white-coat effect in Suspicion of nocturnal hypertension or
hypertensive patients absence of dipping, such as in patients
with sleep apnoea, CKD, or diabetes
Considerable variability of office BP over the Assessment of BP variability
same or different visits
Autonomic, postural, post-prandial, siesta- and
drug-induced hypotension
Elevated office BP or suspected pre-eclampsia
in pregnant women
Identification of true and false resistant
hypertension
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219Greater emphasis on assessing totality of
CV risk
Blood pressure (mmHg)
Other risk factors, Grade 2 HT
asymptomatic organ High normal Grade 1 HT Grade 3 HT
SBP 160–179
damage or disease SBP 130–139 SBP 140–159 SBP ≥180
or DBP
or DBP 85–89 or DBP 90–99 or DBP ≥110
100–109
No other risk factors Low risk Moderate risk High risk
Moderate to
1–2 risk factors Low risk Moderate risk High risk
high risk
Low to Moderate to
≥3 risk factors High risk High risk
moderate risk high risk
Organ damage, CKD stage Moderate to High to
High risk High risk
3 or diabetes high risk very high risk
Symptomatic CVD, CKD
stage ≥4 or diabetes with Very high risk Very high risk Very high risk Very high risk
organ damage/risk factors
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219Single SBP target for almost all patients • SBP
Exceptions to the rule: BP goals in special populations • In patients with diabetes, DBP values
The 2013 ESH/ESC guidelines stress the need for
combination therapy to improve BP goal achievement
• Advantages of initiating treatment with combination therapy include:
– A prompter response in a larger number of patients (potentially beneficial
in high-risk patients)
– A greater probability of achieving target BP in patients with higher BP
values
– A lower probability of discouraging patient adherence with many
treatment changes
– Physiological and pharmacological synergies between different classes
provide greater BP reduction and cause fewer side-effects
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219Combination therapy: two drugs are much
more effective than one
1.4
observed to expected additive effects
Incremental SBP reduction ratio of
1.2 1.01
For the major drug classes, the incremental
1.0 effect on SBP lowering of doubling the dose
of monotherapy is ~20% of that achieved by
adding a drug from another class
0.8
0.6
Adding a drug from
another class
0.4
0.22 Doubling the dose of
one drug
0.2 (from standard to twice
standard dose)
0
All major
classes
Wald et al. Am J Med 2009;122:290–300Monotherapy and combination therapy in the
2013 ESH/ESC treatment guidelines
Choose between
Mild BP elevation Marked BP elevation
Low/moderate CV risk High/very high CV risk
Single agent Two-drug combination
Switch to Previous agent Previous combination Add a
different agent at full dose at full dose third drug
Full-dose Two-drug Switch to different Three-drug
monotherapy combination two-drug combination
at full doses combination at full doses
Moving to a more intensive therapy should be
done whenever BP target is not achieved
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219Possible combinations of classes of antihypertensive
drugs in the 2013 ESH/ESC guidelines
Thiazide diuretics
β-blockers ARBs
Other
antihypertensives CCBs
Combinations
Preferred
Useful ACEIs
Possible Mancia et al. 2013 ESH/ESC Guidelines
Not recommended J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219Stepwise OLM/AML/HCTZ treatment progressively improved BP
lowering in patients with hypertension and diabetes (APEX study)
AML OLM/AML OLM/AML OLM/AML OLM/AML/HCTZ OLM/AML/HCTZ
5 mg 20/5 mg 40/5 mg 40/10 mg 40/10/12.5 mg 40/10/25 mg
(n=200) (n=188) (n=176) (n=163) (n=144) (n=100)
0
-5 –4.1
baseline using LOCF (mmHg)
Change in SeBP from
-10
–8.2 –9.2
–10.4 –10.4
-15 –13.7
–14.0
-20
–18.0
–19.3
-25 –22.6
SBP
DBP
-30 –27.6 –28.0
Dual combination Triple combination
All changes pStepwise OLM/AML/HCTZ treatment improved proportions of
patients with hypertension and diabetes achieving SeBP
thresholds (APEX study)
Dual combination Triple combinationAdherence is a key factor in the 2013 ESH/ESC
guidelines advice on improvement of BP control
• Low adherence is an important factor in poor BP control
– Concerns a large number of patients
– Its relationship with high CV risk has been fully documented
• Low adherence is extremely common
– After 6 months, at least one-third of patients may stop their initial
treatment
– On a daily basis, 10% of patients forget to take their medication
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219The 2013 ESH/ESC guidelines provide a starting point
for the future by listing methods to improve adherence
Patient level
Information combined with motivational strategies
Group sessions
Self-monitoring of blood pressure
Self-management with simple patient-guided systems
Complex interventions
Drug treatment level
Simplification of the drug regimen
Reminder packaging
Health system level
Intensified care (monitoring, telephone follow-up, reminders, home visits, telemonitoring
of home blood pressure, social support, computer-aided counselling and packaging)
Interventions directly involving pharmacists
Reimbursement strategies to improve general practitioners’ involvement in evaluation and
treatment of hypertension
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219The 2013 ESH/ESC guidelines also stress the role
of team-based strategies in disease management
• There seems to be little doubt that, for effective disease
management, a multidisciplinary approach is required
• Physicians, nurses and pharmacists should be represented
• Beneficial effects of pharmacists and nurses have been seen for:
– Patient education
– Behavioural and medical counselling
– Assessment of adherence to treatment
– Pharmacist–physician interaction over guideline-based therapy
• Nurses may be particularly important for implementing lifestyle
changes
• Team-based care has been shown to:
– Reduce SBP by ~10 mmHg
– Increase BP control by ~22%
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219
Walsh et al. Med Care 2006;44:646–57Interdisciplinary teams: meta-analysis shows that
involving pharmacists reduces CVD risk vs. usual care
• Pharmacist care was associated with significant BP reductions
• Significant benefits also seen for cholesterol levels and smoking status
Favours usual care
0
Mean difference in
0
DBP (mmHg)
Mean difference in
–3.8*
SBP (mmHg)
–5 –5
–8.1*
–10
*pNurse practitioner-based care can significantly
improve BP reduction vs. usual care
Change in Change in
Change in BP over 12 months SBP DBP
(mmHg)
*P=0.003; **P=0.013 for comparison with usual care group
Allen et al. Circ Cardiovasc Qual Outcomes 2011;4:595–602Adherence and BP control improve when
physicians and patients work together
Spanish cluster-randomised study (79 physicians and 877 patients)
OR for adherence
= 1.91 (95% CI 1.19–3.05)
OR for uncontrolled SBP
0.62 (95% CI 0.50–0.78)
Controlled blood pressure
Intervention included counting patients’ pills, designating a family member to
support adherence behaviour, and providing educational information Pladevall et al. Circulation 2010;122:1183–91Mode of care delivery
• Normally delivered on a face-to-face basis
• Other methods are also available
– Telephone interviews and videoconferences
• Telephone contact is effective in changing patient behaviour –
additional advantages include:
– More patients can be reached
– Little or no time/working hours lost
– Patients’ concerns can be addressed in a timely manner, tailoring
treatment and ultimately improving adherence
– Potentially useful addition to office visits to establish good
physician–patient relationship
Mancia et al. 2013 ESH/ESC Guidelines
J Hypertens 2013;31:1281–357
Eur Heart J 2013;34:2159–219The role of information and
communication technologies
• Home blood pressure telemonitoring can improve BP control
• Self-monitoring may increase patient motivation and thus aid
adherence
PThe future: technology may soon make self-monitoring part of daily life
Summary
• The management of hypertension is changing:
– Increased use of out-of-office BP measurement – ABPM and
HBPM (including telemonitoring)
– Self-monitoring of BP
– Team-based approaches
• Adherence is a key factor in improving BP control and
treatment simplification does have a role to play
• 2013 ESH/ESC guidelines provide guidance and promote
individualised treatment approach
– The physician has to decide what is the best treatment for the
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