hypertension guidelines: european society of cardiology and european society of hypertension

These guidelines were just published this month by the european society of cardiology in concert with the european society of hypertension (see htn esc guidelines 2013 in dropbox, or  doi: 10.3109/08037051.2013.812549).  in general, they are less prescriptive overall or detailed vs. the NICE (Natiional institute for health and clinical excellence of the UK) guidelines (see dropbox as htn nice recs 2011, or http://guidance.nice.org.uk/CG127/Guidance)

general points (my comments in parentheses):

                --need to look at htn in context of overall cardiovascular risk. use the SCORE (or Framingham risk assessment tool). the risk of different levels of hypertension depend on co-incidence of other risk factors (and, from the framingham data, the risk is more than additive with each additional risk factor, such that the attributable risk of hypertension to coronary artery disease is higher in the presence of other risk factors). the presence of organ damage (OD) from htn also increases the risk of CV events.  one issue with the risk models is that age is such a profound risk factor, such that an older person (with fewer remaining years of life) and a high risk, per these 10-year risk models, is treated aggressively, but a younger person (with a low 10-year risk but a much longer life expectancy) may be relatively undertreated.

                --ESC guidelines note advantages of home and ambulatory BP monitoring, including their accuracy in their relationship with clinical outcomes (morbid and fatal events). home and ambulatory measurements are considered complementary since they give somewhat complementary information (eg, ambulatory is 24-hour monitoring, assesses nighttime as well and there is some prognostic value to seeing if the blood pressure "dips" at night; home monitoring gets info on different days over time). the NICE guidelines are much more extensive on this (lots of data, of which most is from 24-hour ambulatory monitoring), and really pushes for non-office based readings, esp if office-based readings are in the grade 1 range (around 30% of these patients are not hypertensive on non-office based monitoring), or if there is a discordance (eg, target organ damage disproportionate to the blood pressure reading). the ESC guidelines strongly support non-office based measurements as well.

                --as with all of the guidelines (including the nearly prehistoric JNC7) history, physical, and lab evaluation should focus on accurate assessment of blood pressure, evaluation for secondary causes, target organ damage, and assessment of other cardiovasc risk factors. unlike the american diabetes assn and some other groups, ESC recommends fasting plasma glucose (instead of A1C, which is an "additional test" for them).

                --they recommend nonpharmacologic therapy (salt restriction, moderation of alcohol intake, DASH diet, wt reduction, exercise, smoking cessation) in grade 1 htn (sbp 140-59 and/or dbp 90-99) , but favor drugs if grade 2 or 3, and also if high-risk grade 1.  i personally favor nonpharmacologic therapy, even with grade 2 (sbp 160-179 and/or dbp 100-109), if in discussion with the patient they feel they are able to make significant lifestyle changes, esp since these changes are important for so many different medical and quality-of-life issues.

                -- blood pressure targets:  they basically agree with the newer guidelines (eg Am Diabetes Assn) that the goal BP overall is systolic <140/90 and <140/85 in diabetics, though dbp in 80-85 range is safe. in elderly with initial sbp>160, reduce to the 140-150 range. for chronic kidney dz,  sbp <130 "may be pursued" if overt proteinuria

                --drugs:  they are less prescriptive here than NICE, feeling that any drug that lowers blood pressure is good (they do not shy away from b-blockers as single agents despite yhe cochrane reviews; they support hydrochlorothiazide as well as chlorthalidone even though there is a pretty strong argument, which i have sent out in the past, that hctz provides less 24-hour bp control and in the lower doses now used, has fewer studies supporting benefit in terms of preventing clinical events.  NICE suggests using calcium blockers in people over 55yo and in those of african-caribbean descent of any age, with ACE/ARBs in those under 55yo and not of african-caribbean descent.  all guidelines suggest using specific drugs if clear co-morbidity dictating it (ie, b-blockers are good to use in recently post-MI hypertensive pts; avoid diuretics if gout.....)

in sum, my assessment is that the NICE guidelines are the most thorough and thoughtful guidelines i've seen. (also 325 pages, instead of the current guidelines with 72 pages.)  but NICE guidelines are well-organized and give lots of information from studies -- eg, on the use of spironolactone in resistant hypertension, or the data on ambulatory monitoring -- with critical analyses.