European blood pressure guidelines will stick with the 140/90 mm Hg diagnostic threshold and instead focus on improving control rates through initial two-drug antihypertensive combinations for most patients.
Topline release of new joint European Society of Cardiology (ESC)/European Society of Hypertension (ESH) blood pressure guidelines at the latter's annual conference in Barcelona on Saturday is to be followed by full publication at the ESC meeting in August.
"There are many consistencies with the U.S. guideline, but there also is a slightly more conservative approach to the threshold and the target," Bryan Williams, MD, of University College London and the guideline writing committee chair for the ESC, told 51˶.
The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline revised the diagnostic thresholds to 130/80 mm Hg for stage 1 hypertension -- what the ESC calls high-normal -- and 140/90 mm Hg for stage 2, with pharmacologic treatment for stage 2 and high-risk stage 1.
"Their suggestions are reasonable and pragmatic," commented William White, MD, a past president of the American Society of Hypertension. "There's been some criticism of the ACC/AHA 2017 guidelines for a couple of reasons -- that it was based so much on one study, SPRINT, and that SPRINT's population was not below [age] 60 in general and all had risk."
The European guideline writers shied away from "medicalizing" the 130-140 mm Hg systolic group, Williams said.
Rather, "we still strongly believe that the most important objective is to get all our patients who are treated below 140 systolic. That should be the first target. When you have lower targets, people try to get below that number in the worried well. Let's try to get everyone below 140."
The ESC/ESH recommendations included a range for pharmacologic treatment aims from under 140 to 130 mm Hg, with consideration of going below 130 mm Hg for those who tolerate it well, but not below 120 mm Hg.
For people over age 65, the target was below 140 to 130 mm Hg, but not any lower.
"That's a big change, because in the past the target was 150 to 140 in those over 65," Williams noted. "The blood pressure targets are more aggressive, but we're talking about mobile, fit, non-frail elderly." For the frail elderly and those in residential facilities, there's not much evidence, so clinicians have to use their judgment, he added.
The American College of Physicians and American College of Family Physicians guidelines from 2017 controversially recommended a 150 mm Hg systolic threshold for diagnosis and treatment of average and lower-risk adults age 60 and older.
"The Europeans have a nice kind of medium here," White noted.
For treatment, the ESC/ESH guideline aimed to cut clinical inertia that contributes to poor control rates.
"One of the objectives was to simplify treatment recommendations, and we've done that," Williams said. "We know what optimal treatment should be for most people. Why don't we normalize the concept that the patient should be treated with two drugs as initial therapy? Most guidelines get around to saying that, but don't say it directly enough. Start with two drugs -- we've made that completely clear."
While those just above the treatment threshold or the frail elderly would be exceptions, the emphasis for two-antihypertensive combination therapy for most patients was on single pill combinations, if at a cost acceptable to the healthcare system.
White cautioned, though: "But for somebody who is 140/90 I don't even know that even I would consider starting two drugs, because I think there are a lot of people who demonstrate really substantial reductions with one drug and they would probably get symptomatically low if you started them on two drugs. That is not a one size fits all."
Other aspects of the European guidelines to be discussed in more detail with the full release in August are an emphasis on statin therapy for many more hypertensive patients than currently receive them, based on their total cardiovascular risk, blood pressure in pregnancy, hypertension emergencies, resistant hypertension, atrial fibrillation, and anticoagulation, and a stronger recommendation for home and ambulatory blood pressure monitoring.