ESH 2023 Guidelines Release on Arterial Hypertension: Important Takeaways till Now

Milan: The European Society of Hypertension (ESH), the leading hypertension society in Europe, updated and expanded 2023 ESH Guidelines for the Management of Arterial Hypertension yesterday, presenting some of the recommendations during the 32nd Annual European Meeting on Hypertension and Cardiovascular Protection Meeting in Milan, Italy, on June 24, 2023.

Arterial hypertension is a common and leading preventable cause of heart attack, stroke, kidney failure and death that impacts 1.28 billion adults worldwide. Some risk factors for hypertension include obesity, poor diet, lack of exercise and stress. Arterial hypertension constitutes the most prevalent and important risk factor for cardiovascular morbidity and mortality globally despite the availability of effective pharmacological treatments. In addition, approximately half of individuals with hypertension do not meet guideline-directed blood pressure (BP) goals. While medication and lifestyle changes can help decrease hypertension, they alone are sometimes not enough.

While the guidelines are available in the European Journal of Hypertension, in yesterday's sessions, certain key aspects relating to the Definition of hypertension, Blood Pressure Measurement, Total Cardiovascular risk and organ damage, Drug treatment initiation, Target Blood Pressure values, Antihypertensive drugs and treatment algorithms, Old patients and patient Patient follow-up, were shared by leading experts.

Here are some top takeaways from the sessions:

The definition of Hypertension remains unchanged. 

In the session dealing with the definition of hypertension, R. Cifkova (Prague, CZECH REPUBLIC), referred to the definition of hypertension as 

"Hypertension is the level of arterial BP at which the benefits of an intervention exceed the dose of inaction." (G.Rose)

The speaker noted that most hypertension guidelines worldwide use the definition of hypertension BP >=140/90 MM/HG and that changing the definition of hypertension makes sense only if we change the threshold for the initiation of drug treatment

The speaker also noted that there is no agreement in the classification of BP categories by various guidelines and hence put forward that the definition of hypertension classification of office BP categories hypertension grades and stages remain the same as in ESC/ESH guidelines 2018.

(Content Source: ESH 2023/ESC/ESH 2018 guidelines on Arterial HY)

Blood Pressure Measurement

G.S. Stergiou (Athens, GREECE) in his session laid emphasis on the accurate BP measurement for diagnosis of Hypertension. The ESH 2023 guidelines call for the use of Validated electronic upper arm-cuff BP monitors for all methods of BP measurement whether its office BP measurement or Home BP measurement Ambulatory BP measurement

Office BP measurement remains the gold standard for the Basis for hypertension evaluation while Home BP is recommended for most treated individuals. Ambulatory BP has been suggested Unique diagnostic method for additional insights.

New clinical conditions or co-morbidities adding to CV risk identified 

There is a known link between hypertension and CV risk. In the new ESH guidelines, in the section of Factors Influencing CV Risk in Patients with Hypertension, the guidelines have now included additional clinical conditions or co-morbidities. These new conditions include Resistant hypertension, Sleep disorders (including OSA), COPD, Gout, Chronic inflammatory diseases, Nonalcoholic fatty liver disease (NASH), Chronic infections (including long COVID-19), Migraine, Depressive syndromes, Erectile dysfunction

Drug treatment initiation

The guidelines lay down the following important pointers for drug treatment initiation

• • In patients 18 to 79 years, the recommended office threshold for initiation of drug treatment is 140 mmHg for SBP and/or 90 mmHg for DBP (I A)
  • In patients ≥80 years, the recommended office SBP threshold for initiation of drug treatment is 160 mmHg (I B)
  • However, in patients ≥80 years a lower SBP threshold in the range 140 – 160 mmHg may be considered (II C)
  • The office SBP and DBP thresholds for initiation of drug treatment in frail patients should be individualized (I C)
  • In adult patients with a history of CVD, predominantly CAD, drug treatment should be initiated in the high-normal BP range (SBP ≥130 or DBP ≥80 mmHg) (I A)

Target Blood Pressure values

The guidelines reiterate the Office BP targets for most people in the general adult hypertensive population as 

Systolic BP Target Range: 140-120 mm/Hg

Diastolic BP Target Range: 80-70 mm/Hg

Antihypertensive drugs and treatment algorithms- Beta Blockers find space in the initial management 

While talking about the use and choice of Antihypertensive drugs, Antihypertensive drugs and treatment algorithms M. Burnier (Lausanne, SWITZERLAND) pointed to an important recommendation in the ESH guidelines stating that " BP lowering should be prioritised over the selection of specific antihypertensive drug classes because the treatment benefit largely originates from BP reduction."  He added that the criteria to select anti-hypertensive drugs as basis of therapy in hypertensive patients should include a proven ability to reduce BP as monotherapy, Evidence from the RCTs that they reduce morbidity and mortality versus placebo and a favourable tolerability and safety profile .

Some of the pointers from the guidelines are as follows

Old patients

Speaking about Hypertension in older patients, A. Benetos (Nancy, FRANCE) noted that In these guidelines, ESH has identified 2 age groups of older adults, 65 to 79 years and >=80 years. Most individuals in the "65 to 79 group" have preserved functional status, low frailty level, whereas the >= 80 group presents a large functional heterogeneity with a substantial percentage of very frail/dependent individuals

Therefore, there is a stress on an initial assessment of the functional status/Frailty level should be performed with simple and rapid methods (I/C). This assessment should be repeated often since health status can rapidly deteriorate in older people

Patient follow-up

Talking about the take of the guidelines on patient follow-up, R. Kreutz (Berlin, GERMANY) stressed that every clinician should aim for optimal BP control within the 1st three months of initiation of therapy and adjust drug treatment if necessary. During the first three months ( Initiation Phase), repeated visits with BP measurements, including virtual visits may be required.

In the short-term follow-up that is 1-year horizon, clinicians should aim at maintaining optimal BP control. For patients not difficult to control and with low-rise, a repeat visit after 1 year is advised, while in patients difficult to control or high risk a repeat visit <1 year is advised. 

In the case of Long term Followup that is a horizon of >= 3 years, again with patients not difficult to control and with low risk, an annual follow-up with a basic check-up program or extended check-up ( eg HMOD re-evaluation) every >=3 years may be planned. 

In the case of patients with difficult-to-control BP or at high risk or with already treated secondary hypertension, Individualized and more frequent followup may be planned.