Clinical Implications of the 2013 ESH/ESC Hypertension Guidelines: Targets, Choice of Therapy, and Blood Pressure Monitoring

Sverre E. Kjeldsen 0 1 2 Tonje A. Aksnes 0 1 2 Luis M. Ruilope 0 1 2 0 L. M. Ruilope Hypertension Unit, Hospital 12 de Octubre , Madrid, Spain 1 T. A. Aksnes Department of Cardiology, Akershus University Hospital , Lrenskog, Norway 2 S. E. Kjeldsen (&) Department of Cardiology, Oslo University Hospital , Ulleval, Oslo, Norway The European Society of Hypertension (ESH)/ European Society of Cardiology (ESC) 2013 guidelines for the management of arterial hypertension included simplified blood pressure (BP) targets across patient groups, more balanced discussion on monotherapy vs. combination therapy, as well as reconfirmation of the importance of outof-office BP measurements. In light of these updates, we wished to review some issues raised and take a fresh look at the role of calcium channel blocker (CCB) therapy; an established antihypertensive class that appears to be a favorable choice in many patients. Relaxed BP targets for high-risk hypertensive patients in the 2013 ESH/ESC guidelines were driven by a lack of commanding evidence for an aggressive approach. However, substantial evidence demonstrates cardiovascular benefits from more intensive BP lowering across patient groups. Individualized treatment of high-risk patients may be prudent until more solid evidence is available. Individual patient profiles and preferences and evidence for preferential therapy benefits should be considered when deciding upon the optimal antihypertensive regimen. CCBs appear to be a positive choice for monotherapy, and in combination with other agent classes, and may provide specific benefits beyond BP lowering. Ambulatory and home BP monitoring have an increasing role in defining the diagnosis and prognosis of hypertension (especially non-sustained); however, their value for comprehensive diagnosis and appropriate treatment selection should be more widely acknowledged. In conclusion, further evidence may be required on BP targets in high-risk patients, and optimal treatment selection based upon individual patient profiles and comprehensive diagnosis using out-of-office BP measurements may improve patient management. - While a lack of compelling evidence for aggressive blood pressure (BP) targets in high-risk patients with hypertension has driven more relaxed target recommendations in the European Society of Hypertension/European Society of Cardiology 2013 guidelines for the management of arterial hypertension, substantial evidence exists that further cardiovascular (CV) benefits are available from more intensive BP lowering. Until more solid evidence is available, individualized treatment of high-risk patients may be prudent Selection of the optimal therapy regimen should be based on a patients individual demographics, BP, CV risk, co-morbidities, and preference, as well as evidence for preferential beyond-BP-lowering benefits of different antihypertensive agents. Calcium channel blockers are a favorable choice for monotherapy and in combination with other agent classes in many patients, and may provide benefits over other classes for certain CV outcomes Out-of-office BP measurements provide more comprehensive information to inform accurate diagnoses of hypertensive conditions, and are more prognostic of patient outcome than office measurements. Ambulatory and home BP monitoring are likely to play an increasing role in hypertension management in the future, although their value for patient evaluation and appropriate treatment selection should be more widely acknowledged 1 Introduction The European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) guidelines for the management of arterial hypertension were updated in 2013, implementing a number of changes since the previous 2007 version [1, 2]. A key amendment for 2013 was the recommendation for more simplified blood pressure (BP) targets across groups of patients with hypertension, with all subjects to be treated to systolic BP (SBP) of \140 mmHg (apart from elderly patients) and to diastolic BP (DBP) of \90 mmHg (apart from those with diabetes mellitus) [2]. Further updates in the ESH/ESC guidelines include: more specific lifestyle recommendations, such as limiting salt intake to 56 g/day and lowering body mass index to 25 kg/m2; more balanced discussion on the advantages and disadvantages of initiating monotherapy versus combination therapy; recommendation against dual renin-angiotensin system (RAS) blockade (owing to concerns about renal damage and increased incidence of stroke); reconfirmation of the importance of ambulatory BP monitoring (ABPM) and strengthened endorsement of the prognostic value of home BP monitoring (HBPM) for the diagnosis of isolated office (white coat) and isolated ambulatory (masked) hypertension [2]. With regard to the choice of antihypertensive agent, the 2013 ESH/ESC guidelines reconfirm that a diuretic, bblocker, calcium channel blocker (CCB), angiotensin II receptor blocker (ARB), and angiotensin-converting enzyme (ACE) inhibitor are all suitable for use as monotherapy, and in some combinations with each other [2]. Of these agents, b-blockers appear to be losing favor as recommended initial monotherapy in other recent guidelines [3, 4], and the combination of an ARB and an ACE inhibitor is no longer endorsed [24]. Dihydropyridine CCBs have no compelling contraindications for use and are a preferred drug in many combination strategies [2], making them a favorable choice for many hypertensive patients. Indeed, CCBs have been cleared of the suspicion of increasing the incidence of coronary events [2, 5]; and these agents may even be slightly more effective than other agents in preventing stroke [68]. In the light of the ESH/ ESC guidelines update, we wished to take a fresh look at this established class of antihypertensive agent. The aim of this article is to review some key issues raised in the updated 2013 ESH/ESC guidelines, with a particular focus on the role of CCB therapy. 2 Simplified BP Targets vs. the Lower the Better The achieved level of SBP and DBP control is directly associated with the risk of cardiovascular (CV) disease (CVD) and stroke, across patient ages and ethnicities [9, 10]. Reducing the incidence of mortality and morbidity associated with CVD is linked to substantial socioeconomic and healthcare cost savings [11]. Therefore, should BP targets be more aggressive than suggested in the latest 2013 ESH/ESC guidelines? The 2013 ESH/ESC recommendation for a BP target of \140/90 mmHg for most patients is based on a review of randomized controlled trial (RCT) data [12] that suggested a lack of evidence for a more aggressive, and previously recommended, BP target of \130/80 mmHg in patients with high CV risk [2]. However, the authors of the review state that despite scant evidence for lowering SBP below 130 mmHg in patients with diabetes or high/very high CV risk, a more aggressive approach may be prudent because antihypertensive therapy to lower SBP to \1 (...truncated)