2013 ESH ESC Hypertension Guidelines

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1 : 2013 ESH/ESC Guidelines for the management of arterial hypertensionEuropean Heart JournalAdvance Access published June 14, 2013
2 : ESH ESC HT guidelines
3 : What’s new for 2013 (1) Epidemiological data on hypertension and BP control in Europe. (2) 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 pressure monitoring (ABPM). (3) Update of the prognostic significance of night-time BP, white-coat hypertension and masked hypertension.
4 : (4) Re-emphasis on integration of BP, cardiovascular (CV) risk factors, asymptomatic organ damage (OD) and clinical complications for total CV risk assessment. (5) Update of the prognostic significance of asymptomatic OD, including heart, blood vessels, kidney, eye and brain. (6) Reconsideration of the risk of overweight and target body mass index (BMI) in hypertension.
5 : (7) Hypertension in young people. (8) Initiation of antihypertensive treatment. More evidence-based criteria and no drug treatment of high normal BP. (9) 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.
6 : (10) Liberal approach to initial monotherapy, without any all-ranking purpose. (11) Revised schema for priorital two-drug combinations. (12) New therapeutic algorithms for achieving target BP. (13) Extended section on therapeutic strategies in special conditions.
7 : (14) Revised recommendations on treatment of hypertension in the elderly. (15) Drug treatment of octogenarians. (16) Special attention to resistant hypertension and new treatment approaches. (17) Increased attention to OD-guided therapy. (18) New approaches to chronic management of hypertensive disease.
8 : New for 2013
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10 : Same with 2003, 2007 HT : BP = 140/90
11 : Office BP measurement Sit 3-5 min before. At least 2 times, 1–2 min apart. Consider average BP if appropriate. First visit: both arms – use higher value. Elderly, DM: check orthostatic hypotension.
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13 : Indications for out-of-office BP HBPM or ABPM Suspicious of white-coat or masked HT BP vary in same / different visits Hypotension: autonomic, orthostatic, post-prandial, drug-induced High BP in pregnant women Resistant HT Specific I/C for ABPM Marked difference between office BP and home BP Suspicious nocturnal HT Assess BP variability Assess dipping* status *Dipping: BP normally decrease at night No dipping ->inc. CV events: OSA, DM, CKD
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17 : Search for asymptomatic organ damage EKG in all HT patients (I, B) Stress EKG if chest pain (I, C) Serum Cr eGFR, urine protein (dipstick), microalbuminuria (spot) in all HT patients (I,B) Difficult-to-control HT: fundoscopy (IIa, C) ABI (IIa, C)
18 : When to start Anti-HT Rx BP = 140/90 after lifestyle change (I, B) BP = 160/100: start drug promptly (I, A) Elderly: SPB = 160 mmHg (I,A) Not recommend anti-HT drug for High normal BP (130-139 / 85-89 mmHg) (III, A) ISH in young patient, but should close F/U with lifestyle change (III, A) 2007 Elderly: start drug if BP = 140/90 DM, CKD, CVD: start drug if BP > 130 / 85
19 : Initiation of lifestyle changes and antihypertensive drug treatment. Risk Fx: male, age = 55 (M) = 65 (F), smoking, dyslipidemia, IFG, abnormal OGTT, obesity, abdominal obesity, FHx premature CVD < 55 yr (M), < 65 yr (F) Unified target SBP < 140 mmHg in both lower, higher CV risk DM: high to very high risk Risk: Low Moderate High Very high
20 : BP target SBP < 140 mmHg DM (I,B) Low-moderate CV risk (I,A) Previous stroke/TIA, CHD, CKD (IIa) Elderly < 80 yr: SPB keep 140-150 mmHg (I, A) Elderly > 80 yr: 140-150 mmHg if good physical and mental condition (I, B) DBP < 90 mmHg for all Except DM: DBP < 85 mmHg
21 : Lifestyle change (I,A for all) Salt restriction 5-6 gm/day Moderate alcohol intake: not more than 20-30 gm/d (M), 10-20 gm/d (F) Increased fruits, vegetables Reduce weight to BMI of 25 kg/m2, waist circumference < 102 cm (M), < 88 cm (F) Regular exercise = 30 min/day, = 5 days/wk Stop smoking
22 : 1 drink Moderate drinking: no more than two drinks a day for men and no more than one drink a day for women. * One drink = 0.6 fluid oz. = 13.7 gm of alcohol
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26 : New
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28 : Drug choice / treatment strategy Start / maintain, monotherapy / combination Diuretics, BB, CCB, ACEI, ARB all suitable recommended (I, A). Some drugs should be preferred in specific conditions (IIa, C). Markedly high baseline BP or high CV risk: start two-drug combination may be considered (IIb, C). Main benefit of drug: to reduce BP. Most patients need = 2 drugs to achieve target BP.
29 : Monotherapy vs. drug combination strategies to achieve target BP. Moving from a less intensive to a more intensive therapeutic strategy should be done whenever BP target is not achieved.
30 : Combination of 2 antagonists of RAS: not recommended and should be discouraged (III, A). Combinations of 2 drugs at fixed doses in single tablet may be recommended and favored (IIb, B).
31 : Possible combinations of classes of antihypertensive drugs. Only DHP-CCB should normally be combined with beta-blockers Thiazide + BB: increased new-onset DM Green continuous lines: preferred combinations; Green dashed line: useful combination (with some limitations); Black dashed lines: possible but less well-tested combinations; Red continuous line: not recommended combination.
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33 : White-coat masked HT White-coat HT, no risk Fx: lifestyle change close F/U (IIa, C) White-coat HT + high CV risk or TOD: consider drug Rx (IIb, C) Masked HT: lifestyle change + drug Rx (IIa, C)
34 : Elderly Age < 80 yr: may consider start drug when SBP =140 mmHg target < 140 if tolerated (IIb, C) Age > 80 yr: 140-150 mmHg if good physical and mental condition (I, B). When reach > 80 yr: consider to continue drug if well-tolerated (IIa, C) Frail elderly: depend on clinician’s judgement (I, C) All drugs are recommended and can be used (I, A) Diuretics CCB: preferred in isolated systolic HT (I, A). Start drug when SBP =160 mmHg: -> aim SBP 140-150 mmHg (I, A)
35 : Pregnant women If BP > 160/110 mmHg, treatment is recommended (I, C). Consider drug Rx (IIb, C) BP =150/95mmHg, or BP =140/90 mmHg + TOD Methyldopa, labetolol, nifedipine preferred (IIa, B) Pre-eclampsia: IV labetolol or nitroprusside (IIa, B)
36 : DM Start drug Rx when SPB =140 mmHg (I, A). Target SBP < 140/85 mmHg (I, A). All classes of drugs are recommended and can be used (I, A). RAS blockers preferred, especially if having proteinuria / microalbuminuria (I, A).
37 : Metabolic syndrome Start drug Rx if =140/90 mmHg (I, B). Target BP < 140/90 mmHg (I, B). Lifestyle changes, particularly weight loss and exercise (I, B). RAS blockers and CCB should be preferred (IIa, C). BB* and thiazides: only as add-on Rx (IIa, C). * Newer vasodilating BB (carvedilol, nebivolol): affect insulin sensitivity LESS than metoprolol. Nebivolol – not worsen glucose tolerance when added to HCTZ.
38 : HT with nephropathy Target SBP < 140 mmHg (IIa, B). Overt proteinuria: target SBP < 130 mmHg may be considered (IIb, B). RAS blockers indicated for HT with over proteinuria or microalbuminuria (I, A). Recommend combining RAS blockers with other anti-HT drugs to achieve target BP (I, A). Combining two RAS blockers is not recommended (III, A). Aldosterone antagonists not recommened in CKD (III, C).
39 : Atherosclerosis, arteriosclerosis, peripheral artery disease Target BP < 140/90 mmHg. Carotid atherosclerosis: CCB, ACEI (IIa, B). PAD: BB may be considered. Their use does not appear to be associated with worsening of PAD symptoms (IIIb, A).
40 : Resistant HT MR antagonist, amiloride, doxazosin should be considered. If drugs are ineffective: renal denervation and baroreceptor stimulation may be considered (IIb, C) (only by experienced operators at restricted HT centers).
41 : Summary: ESH ESC 2013 SBP < 140 recommended in DM should be considered in CHD, previous stroke/TIA, CKD/DKD SPB < 130 may be considered in overt proteinuria
42 : Summary: ESH ESC 2013


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New Hypertension Guidelines 2013
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