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2013 European Society of Hypertension and European Society of

Cardiology

Guidelines for the Management of Arterial Hypertension

Mancia et. al, 2013 ESH/ESC Guidelines for the

management of arterial hypertension. Journal of Hypertension. Vol31. No. 7 . July 2013

Jafar Al-Said, M.B. CHb. MD. FASN. FACP.Nephrology and Internal Medicine Consultant

Bahrain Specialist Hospital

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Guideline working groupESH Scientific Council: Josep Redo´n (President) (Spain), Anna Dominiczak (UK), Krzysztof Narkiewicz(Poland), Peter M. Nilsson (Sweden), Michel Burnier (Switzerland), Margus Viigimaa (Estonia), Ettore Ambrosioni(Italy), Mark Caufield (UK), Antonio Coca (Spain), Michael Hecht Olsen (Denmark), Roland E. Schmieder(Germany), Costas Tsioufis (Greece), Philippe van de Borne (Belgium).ESC Committee for Practice Guidelines (CPG): Jose´Luis Zamorano (Chairperson) (Spain), Stephan Achenbach(Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), Hector Bueno (Spain), Veronica Dean(France), Christi Deaton (UK), Cetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai(Israel), Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK), MassimoF. Piepoli (Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera (Poland), Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland). Document Reviewers: Denis L. Clement (ESH Review Co-ordinator) (Belgium), Antonio Coca (ESHReview Co-ordinator) (Spain), Thierry C. Gillebert (ESC Review Co-ordinator) (Belgium), Michal Tendera (ESC Review Co-ordinator) (Poland), Enrico Agabiti Rosei (Italy), Ettore Ambrosioni (Italy), Stefan D. Anker (Germany), Johann Bauersachs (Germany), Jana Brguljan Hitij (Slovenia), Mark Caulfield (UK), Marc De Buyzere (Belgium), Sabina De Geest (Switzerland), Genevie`ve Anne Derumeaux (France), Serap Erdine (Turkey), Csaba Farsang (Hungary), Christian Funck-Brentano (France), Vjekoslav Gerc (Bosnia & Herzegovina), GiuseppeGermano` (Italy), Stephan Gielen (Germany), Herman Haller (Germany), Arno W. Hoes (Netherlands), Jens Jordan (Germany), Thomas Kahan (Sweden), Michel Komajda (France), Dragan Lovic (Serbia), Heiko Mahrholdt (Germany),Michael Hecht Olsen (Denmark), Jan Ostergren (Sweden), Gianfranco Parati (Italy), Joep Perk (Sweden), Jorge Polonia (Portugal), Bogdan A. Popescu (Romania), Zeljko Reiner (Croatia), Lars Ryde´n (Sweden), Yuriy Sirenko (Ukraine), Alice Stanton (Ireland), Harry Struijker-Boudier (Netherlands), Costas Tsioufis (Greece), Philippe van de Borne (Belgium), Charalambos Vlachopoulos (Greece), Massimo Volpe (Italy), David A. Wood (UK). Other entities: ESC Associations: Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Heart hythm Association (EHRA), ESC Working Groups: Hypertension and the Heart, Cardiovascular Pharmacology and Drug Therapy, ESC Councils: Cardiovascular Primary Care, Cardiovascular Nursing and Allied Professions, Cardiology Practice.

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Presentation scheme

Classification.

BP Measurement.

Patient Evaluation.

BP targets.

Management.

Lifestyle.

Medications.

Management for specific groups.

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Class of recommendations

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Levels of Evidence

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Levels of Blood Pressure

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Definition and Classification of BP according to Office measurement.

14090

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Definition of HTN according to the Office, ABMP and Home BP

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BP measurements

Office.

ABPM.

Home.

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Office BP measurement

Rest on a chair for 3-5 min.

Two readings 1-2 min. apart.

Adequate cuff size.

Keep cuff at heart level.

Korotkoff Phase I & V.

Both arms measured on first visit.

Consider standing BP in some patients.

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Clinical indication for out of office BP measurement

White coat HTN.Masked HTN.BP variability. Hypotension or over controlled BP. Resistant HTN.

Specific Indications for ABPM:Nocturnal dip.Confirm difference between home and office.BP variability.

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ABPM Ambulatory BP measurement

24 hours.

Regular daily life.

Diurnal and Nocturnal.

Measurements ever 15-30min.

> 70% of recordings are satisfactory.

In arrhythmia BP reading?

Keep a diary for: Activities. Medications. Sleeping time. Symptoms.

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ABPM

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ABPM Ambulatory BP measurement

Better Correlation with Target Organ Damage.

Stronger Correlation with Morbidity and Mortality.

Bliziotis IA, Destounis A, Stergiou GS. Home vs. ambulatory and office blood pressure in predicting target organ damage in hypertension: a systematic review and meta-analysis. J Hypertens 2012; 30:1289–1299.1299.

Dolan E, Stanton A, Thijs L, Hinedi K, Atkins N, McClory S, et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study. Hypertension 2005; 46:156–161.

Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, Mancia G. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation 2005; 111:1777–1783.

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Home BP measurement

More reflective of the individual daily BP.

Normal Environment.

Cheaper.

More readings.

Day by day variability.

Reflect variation with daily activity.

Kikuya M, Ohkubo T, Metoki H, Asayama K, Hara A, Obara T, et al. Day-by-day variability of blood pressure and heart rate at home as a novel predictor of prognosis: the Ohasama study. Hypertension 2008; 52:1045–1050.

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Home BP measurement

Quite room.

Sitting with back and arm support.

5 min. rest.

Two measurements 1-2 min. apart.

Avoid wrist devises except for obese.

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Home BP monitoringBetter reflect Target organ damage.

Stronger correlation with CV mortality and

morbidity.

Similar Prognostic significant as ABPM.

Gaborieau V, Delarche N, Gosse P. Ambulatory blood pressure monitoring vs. self-measurement of blood pressure at home: correlation with target organ damage. J Hypertens 2008; 26:1919–1927.

Bliziotis IA, Destounis A, Stergiou GS. Home vs. ambulatory and office blood pressure in predicting target organ damage in hypertension: a systematic review and meta-analysis. J Hypertens 2012; 30:1289–1299.

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Cardiovascular risk Assessment

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Estimation of CV Risk

Do we measure CV risk?

Which scoring system we should use?

Is the scoring applicable to our population?

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Stratification of total CV risk in HTN patients

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Cardiovascular Risk Estimation

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Framingham scoring system

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Framingham scoring system

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Is there any regional CV scoring system ????

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Is CVD risk factors the same ??

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CVD Risk Assessment

Recommendations Class

Level

CV risk stratification. I B

Target Organ screening. IIa B

CV risk determines therapy. I B

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Hypertension Patient Evaluation

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Medical History

1- Duration and levels of BP.

2- Secondary causes of HTN.

3- CV risk factors.

4-Target Organ Damage.

5-Drugs and compliance.

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Physical Exam

Looking for signs of:

Secondary HTN.

Target Organ Damage.

Obesity.

Carotid, abdominal or femoral bruit.

Difference in BP:

> 20 mmHg Systolic.

>10 mmHg diastolic.

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History and Physical examination recommendation

Recommendations Class Level

Complete medical history and physical exam I C

Family history I B

Office BP I B

Office BP reading at two different visits I C

Heart rate identification I B

Confirm Dx by ABPM and Home BP II a B

Select ABPM or Home BP II b C

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Laboratory work up for HTN

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Initial Recommended Labs

Hb &/or HCT.

FBS.

Na & K.

S. Creatinine, eGFR.

Uric acid.

Lipid profile.

UA

EKG.

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Additional lab work based on history and physical exam

HbA1c

Quantitative Proteinuria.

ABPM.

ECHO.

24h Holter EKG.

Carotid Doppler.

Peripheral Doppler.

Pulse wave velocity.

Ankle – Brachial index.

Fundoscopy.

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Predictive value, availability and Cost effectiveness of markers of organ damage.

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Asymptomatic Organ damage that influence prognosis

Pulse pressure in elderly > 60mmHg.

LVH on EKG or ECHO.

Carotid wall thickness (IMT > 0.9mm or plaque).

Carotid –femoral PWV > 10 m/s.

Ankle – brachial index > 0.9.

CKD with eGFR 30-60ml/min/1.73m2.

Microalbuminuria ( or alb./Cr. %) 30-300mg/24

hours.

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Recommendation level for investigation to find asymptomatic organ damage

Recommendations Class LevelEKG I BHolter EKG II a CStress EKG I CECHO II a BCarotid Doppler II a BCarotid Femoral PWV II a BAnkle Brachial index II a BS.Cr & eGFR I BUrine protein dipstick I BSpot urine for microalbumine I BFundoscopy in resistant HTN II a CFundoscopy in mild-moderate HTN III CBrain MRI or CT II b C

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Treatment

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Aim for treating Blood pressure

Reduce cardiovascular mortality and

morbidity.Fatal and non fatal Stroke.MI.Heart Failure.Renal failure. It is not treating the numbers

Devereux RB, Wachtell K, Gerdts E, Boman K, Nieminen MS, Papademetriou V, et al. Prognostic significance of left ventricular mass change during treatment of hypertension. JAMA 2004; 292:2350– 2356.

Ibsen H, Olsen MH, Wachtell K, Borch-Johnsen K, Lindholm LH, Mogensen CE, et al. Reduction in albuminuria translates to reduction in cardiovascular events in hypertensive patients: losartan intervention forendpoint reduction in hypertension study. Hypertension 2005; 45:198–202.

Sytkowski PA, D’Agostino RB, Belanger AJ, Kannel WB. Secular trends in long-term sustained hypertension, long-term treatment and cardiovacsular mortality. The Framngham Heart Study 1950 to 1990. Circulation 1996; 93:697–703.

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Who and how do we treat HTN?

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Recommendation for BP Goals in HTN patientsRecommendations Class LevelGoal with Systolic <140mmHg: - with low – moderate CV risk I B - DM I A - previous stroke or TIA II a B - CHD II a B - DM or non DM with CKD II a B

Elderly SBP > 160 reduce SBP: - < 80y to 140-150mmHg I A - >80y to 140-150mmHg I B Fit elderly <80y keep SBP <140mmHg II b CDiastolic BP <90mmHg for all & for DM <85mmHg.

I A

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Lifestyle modification for treating HTN

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Lifestyle changesEquivalent to monotherapy.

Adherence is a major factor.

Smoking cessation.

Regular exercise. 3/2.4mmHg

Salt reduction.

Wt. reduction. 0.7mmHg/kg

BMI < 25 kg/m2.

Waist men < 108 cm in men. women <88cm

Reduce Alcohol. 1/0.7mmHg.

men <140 gm/ wk. women 80 gm/wk in females.

Do your best to convince your patient.

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Recommendation for Lifestyle and level of evidence

Recommendations Class Level

Low salt 5-6gm/day I A

Moderate Alcohol I A

DASH diet I A

Decrease Wt. I A

30min exercise 5-7 days I A

Advice to stop smoking I A

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Medication treatment

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Recommendation for Antihypertensive drug therapy

Recommendations Class Level

HTN Grade 2 & 3. I AHTN Grade I & high CV risk. I BHTN Grade I not improve after life style. II a BElderly with SBP > 160mmHg. I

AElderly (<80y) SBP 140-159mmHg. II b CHigh Normal. III A Young with isolated high systolic. III A

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Pharmaceutical treatment

Reducing BP rather than selection of drug is

most important.

ANY drug group could be used.

Diuretics.

Beta blockers.

RAAS.

Certain therapeutic indications are more

favorable.

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Beta blockersTotal mortality and CV events: less favorable than Ca

blockers.

Stroke: less favorable than Ca blockers and RAS.

Recent MI and Heart failure: Highly effective. Preventing Coronary outcome: Equally effective.

Reducing central pressure and pulse pressure: Lower effect

Regressing target organ as LVH, Aortic stiffness, small art. remodeling, & carotid IMT. Less effective

More side effects.

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Beta blockersWiyonge CS, Bradley HA, Volmink J, Mayosi BM, Mbenin A, Opie LH. Cochrane Database Syst Rev 2012, Nov 14,11:CD002003.doi.

Bradley HA, Wiyonge CS, Volmink VA, Mayosi BM, Opie LH. How strong is the evidence for use of beta-blockers as first line therapy for hypertension? J Hypertens 2006; 24:2131–2141.

Williams B, Lacy PS, Thom SM, Cruickshank K, Stanton A, Collier D,et al. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomes: principal results of the Conduit Artery Function Evaluation (CAFE) study. Circulation 2006; 113:1213–1225.

Boutouyrie P, Achouba A, Trunet P, Laurent S. Amlodipine-valsartan combination decreases central systolic blood pressure more effectively than the amlodipine-atenolol combination: the EXPLOR study. Hypertension 2010; 55:1314–1322

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Beta blockers

Increased wt.

Increase incidence of DM.

Sharma AM, Pischon T, Hardt S, Kruz I, Luft FC. Hypothesis: Betaadrenergicreceptor blockers and weight gain: A systematic analysis. Hypertension 2001; 37:250–254.

Elliott WJ, Meyer PM. Incident diabetes in clinical trials of antihypertensivedrugs: a network meta-analysis. Lancet 2007; 369:201–207.

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Beta blockers

Carvidelol, Nebivolol and Celiprolol have favorable metabolic profile.

Reduce Mortality in COPD patients.Rutten FH, Zuithoff NP, Halk F, Grobbee DE, Hoes AW. Beta-Blockers may reduce mortality and risk of exacerbations in patients with chronic obstructive pulmonary disease. Arch Intern Med 2010;170:880–887.

Kampus P, Serg M, Kals J, Zagura M, Muda P, Karu K, et al. Differential effects of nebivolol and metoprolol on central aortic pressure and left ventricular wall thickness. Hypertension 2011; 57:1122–1128.

Bakris GL, Fonseca V, Katholi RE, McGill JB, Messerli FH, Phillips RA et al. Metabolic effects of carvedilol vs metoprolol in patients with type 2 diabetes mellitus and hypertension: a randomized controlled trial. JAMA 2004; 292:2227–2236.

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DiureticsClassified as the first choice since 1977 JNC

I.

ACCOMPLISH: inferior to Ca blocker in combinaiton with ACE inh.

Clorthalidon and Indapamide rather than HCTZ.

Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. A co-operative study. JAMA 1977;237:255–261.

Jamerson K, Weber MA, Bakris GL, Dahlof B, Pitt B, Shi V, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008; 359:2417–2428

Roush GC, Halford TR, Guddati AK. Chlortalidone compared with hydrochlorothiazide in reducing cardiovascular events: systematic review and network meta-analyses. Hypertension 2012; 59:1110–1117.

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DiureticsSpironolactone favorable effect in heart

failure and in Primary hyperaldosteronism.

Eplerinone is effective in heart failure.

Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999; 341:709–717.

Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, et al., EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med 2011; 364:11–21.

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Ca channel BlockersSuperior to other agents in prevention stroke.

Similar to other agents in prevention of heart failure.

Superior to Betablocker in reducing carotid atherosclerosis and LVH.

Verdecchia P, Reboldi G, Angeli F, Gattobigio R, Bentivoglio M, Thijs L, et al. Angiotensin-Converting Enzyme Inhibitorsand Calcium Channel Blockers for Coronary Heart Disease and Stroke Prevention. Hypertension 2005; 46:386–392

Poole-Wilson PA, Lubsen J, Kirwan BA, van Dalen FJ, Wagener G, Danchin N, et al. Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomised controlled trial. Lancet 2004; 364:849–857.

Fagard RH, Celis H, Thijs L, Wouters S. Regression of left ventricular mass by antihypertensive treatment: a meta-analysis of randomized comparative studies. Hypertension 2009; 54:1084–1091.

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ACE inh and ARBACE inh and ARB are similar in CV outcome

including major cardiac outcome, stroke and all cause death.

No evidence of association of ARB with Cancer.

Combination is contraindicated.

Mann JF, Schmieder RE, McQueen M, Dyal L, Schumacher H, Pogue J, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet 2008; 372:547–553.

ARB Trialists collaboration. Effects of telmisartan, irbesartan, valsartan, candesartan and losartan on cancers in 15 trials enrolling 138 769 individuals. J Hypertens 2011; 29:623–635.

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Renin Inh. Useful as single agent or in combination.

No studies on mortality and morbidity in HTN.

Combination with other RAS contraindicated because of the high CV morbidity shown in ALTITUDE trial.

(Aliskiren Trial in Type 2 Dm using Cardio-renal Endpoint)

No beneficial effect on mortality or hospitalization for heart failure.

Parving HH, Brenner BM, McMurray JJV, de Zeeuw D, Haffer SM, Solomon SD. Cardiorenal endpoints in a trial of aliskiren for type 2 diabetes. N Engl J Med 2012; 367:2204–2213.

Gheorghiade M, Bohm M, Greene SJ, Fonarow GC, Lewis EF, Zannad F, et al., for the ASTRONAUT Investigators and Co-ordinators. Effect of Aliskiren on Postdischarge Mortality and Heart Failure Readmissions Among Patients Hospitalized for Heart Failure. The ASTRONAUT Randomized Trial. JAMA 2013; 309:1125–1135.

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Contraindication of Anti Hypertension medications

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Drugs preferred in specific conditions

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Treatment diagram

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Monotherapy versus combination

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Preferable Combinations

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Treatment Strategies and choice for therapy

Recommendations Class Level

Any drug could be started I A

Target organ specific treatment II a C

Combination drugs for high BP and CV II b C

RAAS combinations III A

Consider combination II a C

Fixed tab combination II b B

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Hypertension in diabetic patients

Recommendations Class Level

Start drug treatment with BP >140 mmHg I

A

Systolic BP Goal <140 mmHg I A

Diastolic BP Goal <85 mmHg I A

RAS preferred for Proteinuria otherwise any drug could be

used. I A

Therapy should consider comorbid condition I C

Double RAS blockade. III B

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Hypertension in Metabolic syndrome patients

Recommendations Class Level

Lifestyle changes I B

RAS and Ca blocker are preferable,

Betablocker are only supplementary. II a

C

Use medication with BP >140/90 mmHg I B

Medication not needed in high normal BP. III B

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White Coat and Masked Hypertension

Recommendations Class

Level

Lifestyle modification if no CV risk II a

C

Drug treatment if with higher CV risk II b C

Medication and lifestyle in masked HTN II a C

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Other SubpopulationElderly.Women.Peripheral vascular disease.Nephropathy.IHD. Stroke.Resistant Hypertension.

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Treating other CV Risk factors

Recommendations Class Level

Statin:

With moderate risk LDL <3 (115) I A

With CHD LDL < 1.8 ( 70) I A

Antiplatelet with Cv events I A

ASA in Cv with CKD or Cv risk II a B

ASA not recommended with low- moderate risk III A

HBA1C < 7 in DM I B

Elderly fragile DM HbA1C 7-8 II a C

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Conclusion for 2013 guidelinesGrade the level of the scientific

evidence.

Enforce out of office BP monitoring.

Cv risk assessment in the approach to patients.

Emphasizing the significance of Target organ damage.

Target BP < 140/90mmHg .

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Conclusion for 2013 guidelines

Liberal approach to initial therapy.

No drug ranking purpose for first line.

Revised two drug combination priority.

Address HTN in certain subpopulation.

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1- When Can we see a Gulf or Middle East CVD risk scoring or HTN guidelines ???

2- Why, all the times, we are following other countries and when can we depend on ourselves ???

Take home questions?

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www.eshonline.org

Mancia et. al, 2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension. Vol31. No. 7 . July 2013

See you in Athens!

www.hypertension2014.org

See you in Athens!

www.hypertension2014.org

Topics:

The Burden of Hypertension in the Gulf and Middle East Countries.Cardiovascular Risk factors in the Gulf region.Do we need regional Hypertension guidelines?Cardiovascular Mortality and Morbidity in the Middle East and the Gulf.

Gulf Hypertension and Cardiovascular

SessionAthens, Greece.