New European Guidelines for Management of Arterial Hypertension

Classification of Hypertension

Table 1. WHO/ISH Definition and Classification of Blood Pressure Levels

Category	Systolic (mm Hg)	Diastolic (mm Hg)
Optimal	< 120	< 80
Normal	120-129	80-84
High-normal	130-139	85-89
Hypertension:
Grade 1 (mild)	140-159	90-99
Grade 2 (moderate)	150-179	100-109
Grade 3 (severe)	≥ 180	≥ 10
Isolated systolic hypertension	≥ 140	< 9

The most common risk factors for cardiovascular disease used for stratification are: 

1. Levels of SBP/DBP

2. Men aged > 55 years

3. Women aged > 65 years

4. Smoking

5. Dyslipidemia

6. Family history of premature cardiovascular disease (men < 55 years, women < 65 years)

7. Abdominal obesity (abdominal circumference ≥ 102 cm [40 in] in men, 88 cm [35 in] in women)

8. C-reactive protein ≥ 1 mg/dL

Goals of Treatment

The primary goal of treatment is to achieve the maximum reduction in the long-term total risk of cardiovascular morbidity and mortality. On the basis of current evidence from trials, blood pressures should be lowered to < 140/90 mm Hg at least, and, if tolerated, to levels < 130/80 mm Hg in diabetic patients.

Therapeutic Approach

The guidelines for initiating antihypertensive treatment are based on 2 criteria:

1. The total level of cardiovascular risk  and

2. SBP and DBP levels (Table 1).

The total level of cardiovascular risk is the main indication for intervention, but lower or higher blood pressure values are also less or more stringent indicators for blood pressure-lowering intervention.

Recommendations for individuals with high normal blood pressure (SBP 130-139 or DBP 85-89 mm Hg on several occasions) include:

1. Assess other risk factors, TOD (particularly renal), diabetes, associated clinical conditions

2. Initiate lifestyle measures and correction of other risk factors or disease

3. Stratify absolute risk:

-Very high/high: begin drug treatment

-Moderate: monitor blood pressure frequently

-Low: no blood pressure intervention

Recommendations for individuals with grades 1 and 2 hypertension (SBP 140-179 mm Hg or DBP 90-109 mm Hg on several occasions) include:

1. Assess other risk factors (TOD, diabetes, associated clinical conditions 

2. Initiate lifestyle measures and correction of other risk factors or disease 

3. Stratify absolute risk

-Very high/high: begin drug treatment promptly

-Moderate: monitor BP and other risk factors for ≥3 months:

-- SBP ≥ 140 or DBP ≥ 90 mm Hg: begin drug treatment

-- SBP < 140 or DBP < 90 mm Hg: continue to monitor

-Low: monitor BP and other risk factors for 3-12 months:

-- SBP ≥ 140 or DBP ≥ 90 mm Hg: consider drug treatment and elicit patient's preference

-- SBP < 140 or DBP < 90 mm Hg: continue to monitor

Recommendations for individuals with grade 3 hypertension (SBP ≥ 180 or DBP ≥ 110 mm Hg on repeated measurements within a few days):

-Begin drug treatment immediately.

-Assess other risk factors, TOD, diabetes, associated clinical conditions.

-Add lifestyle measures and correction of other risk factors or diseases.

Lifestyle Changes

Lifestyle measures recommended include smoking cessation, weight reduction, reduction of excessive alcohol intake, physical exercise, reduction of salt intake, and increase in fruit and vegetable intake and decrease in saturated and total fat intake.

Choice of Antihypertensive Agents

The guidelines stress that the main benefits of antihypertensive therapy are due to the lowering of blood pressure per se. They list the standard major classes of antihypertensive agents suitable for the initiation and maintenance of therapy:

a. Diuretics

b. Beta-blockers

c. Calcium channel blockers (CCBs)

d. ACE inhibitors

e. Angiotensin-receptor blockers (ARBs).

Table 2. Indications for the Major Classes of Antihypertensive Drugs

Drug	Conditions Favoring Use
Diuretics (thiazide)	CHF; elderly; ISH; hypertensives of African origin
Diuretics (loop)	Renal insufficiency; CHF
Diuretics (antialdosterone)	CHF; post MI
Beta-blockers	Angina pectoris; post MI; CHF (up-titration); pregnancy; tachyarrhythmias
CCBs (dihydropyridine)	Elderly; ISH; angina pectoris; peripheral vascular disease; carotid atherosclerosis; pregnancy
CCBs (verapamil, diltiazem)	Angina pectoris, carotid atherosclerosis; supraventricular tachycardia
ACE inhibitors	CHF; LV dysfunction; post MI; nondiabetic nephropathy; type 1 diabetic nephropathy; proteinuria
ARBs	type 2 nephropathy; diabetic microalbuminuria; proteinuria; LV hypertrophy; ACE inhibitor cough
Alpha-blockers	BPH; hyperlipidemia

ARBs, angiotensin receptor blockers; BPH, benign prostatic hyperplasia; CCBs, calcium channel blockers; CHF, congestive heart failure; ISH, isolated systolic hypertension; MI, myocardial infarction; LV, left ventricular

Combination Therapy

Drug combinations found to be effective and well tolerated include:

1. Diuretic and beta-blocker

2. Diuretic and ACE inhibitor or ARB

3. CCB (dihydropyridine) and beta-blocker

4. CCB and ACE inhibitor or ARB

5. CCB and diuretic

6. Alpha-blocker and beta-blocker

7. Other combinations (eg, with centrally acting agents, including alpha₂-adrenoceptor agonists and imidazoline-I₂ receptor modulators, or ACE inhibitors or ARBs) can be used, if necessary.

8. In many cases, 3 or 4 drugs may be necessary.

Other Aspects of the Guidelines

As well as detailed sections on treatment of special populations, other hypertension treatment areas covered in the guidelines include the present status of genetic analysis, relative benefits of ambulatory/home blood pressure, follow-up strategies, the importance of long-acting agents, evaluation of adverse effects, and implementation/compliance/adherence. Treatments for associated risk factors include lipid-lowering agents, antiplatelet therapy, and glycemic control.

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