Late last year the new American Hypertension Guidelines 2017 managed to supplant the NICE lipid guideline of 2014 with the dubious honour of being the most controversial guideline ever published. They re-defined hypertension, set ambitious treatment targets and created a huge debate around their potential for overdiagnosis and overtreatment.
This month has seen the publication of new European Hypertension Guidelines 2018 produced by the European Societies of Hypertension and Cardiology. These guidelines have some key differences but are broadly similar to the American ones and propose significant changes in practice. We have read the guideline (all 98 pages of it!) and bearing in mind the ‘guidelines not tramlines’ mantra these are our Top 5 learning points:
- Wider use of out of office BP measurement with ambulatory (ABPM) and especially home (HMBP) monitoring when ‘logistically and economically feasible’. Hypertension is defined as a persistent elevation in office systolic BP ≥ 140 mmHg and/or diastolic ≥ 90 mmHg, but with adjustments for HBPM (mean ≥ 135/85) and ABPM (mean ≥ 130/80).
- Thresholds for starting drug treatment are ≥ 140/90 office for most patients up to age 80, but with a more relaxed threshold of ≥ 160/100 over 80. Very high-risk patients, e.g. with established cardiovascular disease, may be treated in the ‘high normal’ range of 130-139/85-89.
- Elderly people should have their hypertension actively managed but according to biological rather than chronological age with consideration of frailty, independence and tolerability. They should not have treatment withheld purely on the basis of age.
- Start treatment with drug combinations using a renin angiotensin drug with either calcium channel blocker or diuretic for most patients. The guideline sets out to ‘normalise’ the concept of starting with two drugs, the rationale being that ‘monotherapy is usually inadequate, most patients need combinations, and this will improve speed, efficiency and predictability of BP control’. They recommend that ideally these should be in single pill combinations to improve adherence and recommend this strategy for all patients except those of lowest risk or frailer very old patients.
- Target: treat all patients to achieve a target of <140/90 and provided that treatment is well tolerated treated BP levels should then be targeted to <130/80 in most patients aged under 65. For patients aged over 65 a more relaxed systolic target of 130-139 is recommended.
Doubtless these guidelines will prove as controversial as the American ones. But we GPs know that guidelines should be individually applied according to clinical judgement and patient choice, and that for hypertension lifestyle change comes first and people at higher absolute risk should be our treatment priority. As a recent BMJ editorial pointed out all the debate and controversy over thresholds and targets should not distract from the main issue of under treatment of people already at high risk. A greater use of out of office measurement, a first target of getting all patients under 140/90 and offering patients the option of quicker better control with combinations of drugs seem a start along this road.
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This blog was originally published via the Hot Topics Blog, NB Medical on 4th October 2018.