review article

Wien Klin Wochenschr (2019) 131:180–185https://doi.org/10.1007/s00508-018-1435-8

What’s new in the ESC 2018 guidelines for arterialhypertension

The tenmost important messages

Jutta Bergler-Klein

Received: 7 November 2018 / Accepted: 11 December 2018 / Published online: 4 February 2019© The Author(s) 2019

Summary The new guidelines on hypertension ofthe European Society of Cardiology (ESC) 2018 haverefined the treatment cut-offs and therapy decisionsin adults. This review highlights important recom-mendations of the guidelines and also on the situ-ation of hypertension in Austria. The general treat-ment targets of blood pressure have been lowered toat least 130/80 mmHg for most patients. The defini-tion of hypertension is specified as a repeated systolicblood pressure in the office of ≥140 and or diastolicBP ≥90 mmHg. For home blood pressure monitoring,an average value of ≥135/85 mmHg is now defined ashypertension. Ambulatory 24h-blood pressure mea-surement is recommended for diagnosis of hyperten-sion and to demask lack of nocturnal blood pressuredipping. Whether drug treatment should be initiatedimmediately or after a delay with lifestyle interventionis focused on the individual high or low cardiovascu-lar risk of the patients and the degree of hypertension.For most patients a combination therapy with singlepill is now recommended as initial therapy for hyper-tension from the start. The salt consumption shouldbe reduced in the majority of patients. The new guide-lines have clarified the treatment of hypertension indifferent comorbidities.

Keywords Systolic blood pressure · Antihypertensivetreatment · diastolic blood pressure · hypertension incoronary disease · hypertension and heart failure

Univ. Prof. J. Bergler-Klein, MD, FESC (�)Department of Cardiology, Medical University of Vienna,Waehringer Guertel 19–20, 1090 Vienna, Austriajutta.bergler-klein@meduniwien.ac.at

Introduction

The new 2018 guidelines on hypertension of the Eu-ropean Society of Cardiology (ESC) have refined thetreatment cut-offs and therapy decision-making inadults [1]. This review focuses on the most importantmessages and also on the situation in Austria.

Ten most important messages

1. What is defined as hypertension?

The definition of hypertension is now specified asa constant, repeated systolic blood pressure (SBP)in the office of ≥140mmHg and or diastolic BP(DBP) ≥90mmHg. Before office determination pa-tients should be seated quietly for 5min.

A 24h ambulatory BP (ABPM) is strongly encour-aged in all patients for screening and diagnosis ofhypertension. It is important to note that in ABPMa lower value with an average of ≥130/80mmHg isalready defined as hypertension. For home BP moni-toring, an average value of ≥135/85mmHg is now de-fined. These values enable patients and physiciansto choose from the available diagnostic tools; how-ever, the different cut-offs for the definitions shouldbe considered. It also empowers patients and theirown responsibility by home measurements to detectand monitor hypertension.

2. Target range for blood pressure treatment

The general treatment targets of BP have been low-ered to at least 130/80mmHg for almost all patients.This is in line with the recommendations of the Amer-ican ACC/AHA guidelines for hypertension [2]. In allpatients that can tolerate treatment, the office SBPshould be lowered to <140mmHg. Office diastolic

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Fig. 1 Staging of hypertension according to bloodpressure and cardiovascular risk by the SCORE sys-tem [1]. CKD chronic kidney disease, CV cardio-vascular, DBP diastolic blood pressure, HMOD hy-pertension-mediated organ damage, SBP systolic blood pres-sure, SCORE Systematic COronary Risk Evaluation. Source

and © [3]. Reproduced by permission of Oxford Univer-sity Press on behalf of the European Society of Cardiology.www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Arterial-Hypertension-Management-of. This figure is not in-cluded under the Creative Commons CC BY license of thispublication

BP should in general be lowered to <80mmHg. Inpatients younger than 65 years old, office systolic BPlower than 130mmHg should be aimed for, but notbelow 120mmHg. In older patients over 65 years, andin old patients up to age 80 years who are capableof an independent life style and are not frail, a tar-get SBP of 130mmHg but not below 130mmHg isrecommended. In old patients over >80 years, treat-ment should generally be initiated in an office SBP≥160mmHg. In frail patients individual decisionswith gentle reductions are advised according to thebenefit expectations of treatment. Importantly, thelower thresholds for BP treatment are now also clearlydefined. Systolic BP should not be lowered to below120mmHg. Diastolic BP should not be lowered tobelow 70mmHg. Therefore, clear target ranges havenow been defined with lower BP cut-offs where anti-hypertensive treatment should not go beyond thesevalues. When starting antihypertensive drugs, the firstobjective should be to lower BP to <140/90mmHg inall patients. If the treatment is then well-tolerated, BPshould be targeted to 130/80mmHg or lower in mostpatients; however, treated SBP should not be targetedto <120mmHg as stated above and DBP not below70mmHg.

3. Grading of degree of hypertension

The degree of hypertension (grades 1–3) determinesthe initiation of treatment and the individual cardio-vascular risk of the patient. Fig. 1 depicts the gradesaccording to BP levels.

4. Treatment initiation: cut-offs revisited in high orlow risk

Whether pharmaceutical treatment should be initi-ated immediately or after a delay with life style in-terventions is focused on high or low cardiovascularrisk of the patients (Fig. 2).

In lower risk patients with grade 1 hypertension(defined as office BP 140–159/90–99mmHg, see Fig. 1)and without end organ damage aged up to 80 years,treatment should be started after a trial of life stylechanges e.g. for 3–6 months. On the other hand,for high risk patients with grade 1 hypertension(140–159/90–99mmHg) medical drug therapy shouldbe initiated immediately without delay. Patients withgrade 2 (160–179/100–109mmHg) or grade 3 hyper-tension (≥180/≥110mmHg) should receive immediateantihypertensive drug treatment along with life styleintervention. Life style changes are enforced in thecurrent guidelines, whether before begin as well asalways during ongoing medical treatment. They in-clude smoking cessation, weight loss, sodium restric-tion, moderation of alcohol, exercising, and healthyfood with high amounts of vegetables and fruits.

5. Sodium restriction, alcohol

A maximum sodium intake of 2.0g per day (about5.0g salt, one small teaspoon) in the general popu-lation and in all hypertensive patients is now recom-mended. Adding salt and processed foods with hid-den salt should be avoided, as they involve 80% ofsalt consumption. The BP lowering effect of sodiumrestriction is endorsed as greater in black patients andin older patients and concomitant diabetes or chronic

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Fig. 2 The 10-year cardiovascular risk categories by the Eu-ropean Systematic COronary Risk Evaluation system (SCORE)[1]. Source and © [3]. Reproduced by permission of Ox-ford University Press on behalf of the European Society of

Cardiology. www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Arterial-Hypertension-Management-of. This figureis not included under the Creative Commons CC BY license ofthis publication

kidney disease. Importantly, sodium restriction mayreduce the necessary number or dose of antihyperten-sive drugs. For cardiovascular event reduction, a con-troversial J-shaped curve for sodium intake has beensuggested in meta-analyses [4]. Overall, lowering thesodium intake is targeted at patients with manifestedhypertension. In hypertensive men, alcoholic drinksshould be limited to 14 units per week, in women to8 units per week (1 unit corresponds to 1/8 l of wineor 1/4 l of beer). Alcohol-free days during the weekand avoidance of binge drinking are advised.

6. Two in one approach: single pill dual drug fromthe start

The new guidelines emphasize that medical treatmentshould in general be started straight away with a com-bination pill of two drugs as usual care. In most pa-tients the currently recommended lower BP targetswill not be reached without modern dual therapy. Fur-thermore, a single pill approach with optimal retarda-tion drug formulation for a long plasma half-life willincrease the medical adherence of the patients. If BP

targets are not reached, augmenting to a single pillwith 3 drugs is preferred.

7. Simplified drug algorithm

For most patients, a combination of a renin-an-giotensin system (RAS) blocker, either an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin re-ceptor blocker (ARB), with a calcium channel blocker(CCB) or thiazide/thiazide-like diuretic (TH) such aschlorthalidone and indapamide is preferred as initialtherapy. If three drugs are required to lower BP to tar-gets, a combination of an ACEI or ARB with a CCB anda TH-diuretic are the right choice, again in a single pillcombination. Beta-blockers are only recommendedin specific indications such as angina, after myocar-dial infarction, heart failure with reduced ejectionfraction or heart rate control in arrhythmias. Beta-blockers should be combined with any of the othermajor antihypertensive drug classes (RAS blockers,CCB, diuretics). A combination of two RAS blockers(ACEI and ARB) is not recommended. In resistant hy-pertension, especially the addition of spironolactone

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(25–50mg o.d.) is recommended. Also, another di-uretic, an alpha-blocker or beta-blocker can be added.Hypertension is defined as resistant when the recom-mended treatment fails to lower office SBP and DBPto <140mmHg and/or <90mmHg, respectively and isconfirmed by 24h ABPM or home BP measurementsdespite confirmed drug adherence. Optimal dosesof tolerated drugs and three or more drugs are rec-ommended along with life style changes. Secondarycauses of hypertension should be excluded. BP re-sistance can be mimicked by severe brachial arterycalcification, white coat hypertension, wrong mea-surements, e.g. with too small cuffs, and of course alack of patient therapy compliance.

8. Special considerations in special groups

Treatment thresholds of office BP are defined as≥140/≥90mmHg and are the same in hypertensivepatients with additional diabetes, coronary artery dis-ease (CAD), chronic kidney disease (CKD), stroke ortransient ischemic attack (TIA); however, in very high-risk patients with CAD, previous stroke or TIA, treat-ment may be considered already in high–normal SBPof 130–<140mmHg. In patients older than 80 years,a threshold of ≥160/≥90mmHg is advised for allgroups, equally in diabetes, CAD, CKD or stroke.

Coronary diseaseIn CAD, diastolic BP should not be lowered <70mmHgas myocardial perfusionmay be impaired in lower val-ues [5]. In CAD, treatment is already recommendedat the threshold of high-normal BP of 130–139/85–89mmHg, as these patients are considered tobe at very high risk.

DiabetesFor patients with diabetes, the same treatment tar-gets are recommended for an office SBP target of130mmHg or lower. SBP should not be loweredto <120mmHg. DBP target should be <80mmHg.In older patients ≥65 years the SBP target range is130–140mmHg if tolerated. A variable visit to visitBP should be noted due to associated increased car-diovascular and renal risk. Caution is emphasizedin autonomic polyneuropathy concerning posturalor orthostatic hypotension. Nocturnal BP should beassessed by 24h ABPM or in order to detect hyper-tension in apparently normotensive diabetic patients.

Chronic kidney diseaseThe RAS blockers (ACEI or ARB) are endorsed asmore effective in reducing albuminuria than otherantihypertensive drugs. The guidelines recommenda RAS blocker and CCB as the initial regimen drugs.In both diabetic or non-diabetic CKD, the SBP tar-get is 130–139mmHg. Individualized treatment isadvocated according to electrolytes. The use ofloop diuretics is recommended when the estimated

glomerular filtration rate (eGFR) is <30ml/min/1.72m2, as thiazide/thiazide-like diuretics are less effec-tive or ineffective at this level. There is risk of hyper-kalemia with spironolactone, especially when eGFR is<45ml/min/1.72 m2 or baseline K+ ≥4.5mmol/l.

Heart failureIn hypertensive patients with preserved or reducedejection fraction (EF), antihypertensive treatmentshould be considered if BP ≥140/≥90mmHg. If anti-hypertensive treatment is not needed, the treatmentof heart failure (HF) should follow the current ESCHF guidelines [6]. In HF with reduced EF the ini-tial antihypertensive regimen advocates an ACEI orARB (or angiotensin receptor/neprilysin inhibitor asindicated by guidelines) plus a TH-diuretic (or loopdiuretic in edema), plus a beta-blocker. The secondstep adds the mineralocorticoid receptor antagonistsspironolactone or eplerenone. It is emphasized notto use non-dihydropyridine CCBs, such as verapamilor diltiazem. Although in general, actively loweringthe BP below 120/70mmHg should be avoided, pa-tients may achieve lower values due to HF guideline-directed medications, which if tolerated should becontinued.

PregnancyFor pregnant women the special considerations areoutlined in the new pregnancy guidelines in cardio-vascular disease [7]. It is important to follow thecompelling contraindications of specific antihyper-tensive drugs, especially ACEI and ARBs in preg-nancy. Beta-blockers may be considered alternativelyin women planning pregnancy or already pregnant,although fetal and neonatal bradycardia have beendescribed. Hypertension is defined as office val-ues of SBP ≥140mmHg and/or DBP ≥90mmHg.The classification of hypertension in pregnancy ismild if BP is 140–159/90–109mmHg, and severe if≥160/110mmHg [1, 7]. The different entities includepre-existing hypertension, gestational hypertension,pre-existing plus superimposed gestational hyperten-sion with proteinuria, pre-eclampsia and antenatallyunclassifiable hypertension. All pregnant womenshould be screened for proteinuria early to detectrenal disease and in the second half of pregnancy fordiagnosis of pre-eclampsia.

9. What else for risk reduction?

Statins should in general be prescribed in hyperten-sive patients with established coronary disease or inmoderate to high cardiovascular risk by SCORE eval-uation (Fig. 2) but are also recommended already inlow to moderate risk. Low dose aspirin is not recom-mended for primary prevention in patients withoutcardiovascular disease. Antiplatelet therapy is indi-cated in hypertensive patients for secondary preven-

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tion e.g. after myocardial infarction or stent interven-tion.

10. Renal denervation not recommended

The use of device-based interventions such as carotidbaroreceptor stimulation with pulse generator orbaroreflex amplification stent device implantation,as well as catheter-based renal denervation for re-duction of sympathetic tone is not recommended forthe routine treatment of hypertension. Currently, notenough evidence for efficacy and safety is consideredto be available.

Discussion

The new ESC guidelines have lowered the treatmenttarget to a BP of 130/80mmHg. The definition of hy-pertension is set at systolic BP ≥140mmHg and/ordiastolic BP ≥90mmHg. This has caused some dis-cussion, although the guidelines clearly aim at espe-cially lowering the high-risk profiles of patients withconcomitant cardiovascular diseases, e.g. coronarydisease or diabetes [8].

Importantly, the new guidelines have also intro-duced lower BP thresholds, below which treatmentshould not be continued, in general SBP 120mmHgas lower systolic threshold. Therefore, the current ESCguidelines have defined clear BP target ranges: SBP of120–130mmHg in patients younger than 65 years oldand 130–139mmHg in those older than 65 years andeven over age 80 years if tolerated. Diastolic BP shouldnot be lowered below 70mmHg. Therefore, the dias-tolic target range is now 70–79mmHg in all patients.It has been realized that excessive BP lowering causesmore adverse events and higher discontinuation ratesby patients [9]. A dilemma in hypertension treatmentremains in discrepancy of systolic or diastolic hyper-tensive BP values, as both components cannot be reg-ulated independently in some patients [8].

A single pill prescription with two or more drug in-gredients is now confirmed as usual care when initi-ating antihypertensive treatment right from the start.This regimen will increase patient compliance and re-duce side effects, as a relatively lower dosage of in-dividual drugs may be applied with better galenics.Beta-blockers are now only recommended in specialsituations, e.g. after myocardial infarction, reducedejection fraction heart failure and arrhythmias.

Austrian perspective

A wider use of out of office measurements is now rec-ommended. Ambulatory 24h BP measurement is use-ful to demask nocturnal hypertension and lack of ade-quate dipping. In Austria, ABPM is not reimbursed byall public healthcare systems so far and will need tobe established further. The salt consumption shouldbe reduced in the majority of patients. The usual con-

sumption of sodium is 3.5–5.5g per day (9–12g of salt),depending on country or region. In Austria, half of theadults consume more than 2 teaspoons of salt per day[10]. There is a causal relationship between the pres-sor effect of excessive sodium intake >5g per day andan increased prevalence of hypertension and SBP risewith age [11]. In Austria as in other European coun-tries the food industry must be involved in the futurein the attempt to decrease hidden sodium consump-tion.

High altitudes above 3000m and possibly 2000mmay contribute to aggravation of hypertension, whichmust be considered especially in the alpine regions ofAustria [1, 12]. Frequent BP measurements and in-tensified antihypertensive medication adaptation arerecommended, e.g. during holidays in mountain ar-eas.

Conclusion

The new ESC guidelines have clearly defined thera-peutic targets with lower thresholds. In most patientsa BP goal of at least 130/80mmHg is recommended,but not below 120/70mmHg. Life style interventionsare enforced in all stages of hypertension.

Funding Open access funding provided by Medical Univer-sity of Vienna.

Conflict of interest J. Bergler-Klein declares that she has nocompeting interests.

Open Access This article is distributed under the terms ofthe Creative Commons Attribution 4.0 International License(http://creativecommons.org/licenses/by/4.0/), which per-mits unrestricted use, distribution, and reproduction in anymedium, provided you give appropriate credit to the origi-nal author(s) and the source, provide a link to the CreativeCommons license, and indicate if changes were made.

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