2018 ESC/ESH Guidelines for the management of arterial hypertension

1. 2018 ESC/ESH Guideline for the
management of arterial
hypertension
Dr. Julfikar Saif
Resident, Phase A
Department of oncology, BSMMU
Violet Unit, Internal Medicine

2. Spoiler…its gonna take a while!!!!

3. Level of evidence

4. Classification of recommendation

5. Definition
• Hypertension is defined as the level of BP at
which the benefits of treatment (either with
lifestyle interventions or drugs) unequivocally
outweigh the risks of treatment, as
documented by clinical trials

6. Detection of hypertension

7. Screening
• Hypertension is predominantly asymptomatic
condition
• >50% patients unaware at the time of detection
• Best detected by structured population
screening programmes or opportunistic
measurement of BP
• BP must be recorded in medical record and be
aware of

8. Screening

9. Blood pressure measurement
• Options
– Office BP measurement
– Out of office BP measurement
• Ambulatory Blood Pressure Monitoring (ABPM)
• Home Blood Pressure Monitoring (HBPM)

10. Office Blood Pressure monitoring
• Most widely performed
• Easy, cost effective
• Most of the studies use office BP

11. Office Blood pressure Monitoring
• Method
– Quiet environment, comfortably seated for
5minutes
– Arms rested
– Proper sized cuff
– Measure in both arm
– 3 measurements 1-2 minutes apart
– Exclude orthostatic hypotension in first visit and
elderly
– Record pulse

13. Office Blood Pressure
Monitoring…Issues
• White coat hypertension
– Inappropriately high office BP
– Over diagnosis
• Masked hypertension
– Inappropriately normal office BP
– Under diagnosis

14. Cont…
• In order to overcome
– Unattended office BP measurement
• 5-15mm less SBP than conventional office BP
• Unclear prognostic value currently
• Out of office BP measurement

15. Ambulatory BP monitoring….advantage
• Can identify white-coat and masked
hypertension
• Stronger prognostic evidence
• Night-time readings
• Measurement in real-life settings
• Additional prognostic BP phenotypes
• Abundant information from a single
measurement session, including short-term BP
variability

16. Cont…
• Detect postural and postprandial hypotension
in treated and untreated patient
• Evaluation of resistant hypertension
• Assessment of symptoms of hypotension
during course of treatment
• Evaluate considerable variability of office BP

17. Ambulatory BP monitoring….diadvantage
• Expensive and sometimes limited availability
• Can be uncomfortable

18. Home BP monitoring…advantage
• Can identify white-coat and masked
hypertension
• Cheap and widely available
• Measurement in a home setting, which may
be more relaxed than the doctor’s office
• Patient engagement in BP measurement
• Easily repeated and used over longer periods
to assess day-to-day BP variability

19. Home BP monitoring…disadvantage
• Only static BP is available
• Potential for measurement error
• No nocturnal readings

21. Definition of HTN according to
different BP measurement…
Category SBP (mmHg) DBP (mmHg)
Office BPa ≥140 and/or ≥90
Ambulatory BP
Daytime (or
awake) mean
≥135 and/or ≥85
Night-time (or
asleep) mean
≥120 and/or ≥70
24 h mean ≥130 and/or ≥80
Home BP mean ≥135 and/or ≥85

22. Classification of hypertension
Category Systolic (mmHg) Diastolic (mmHg)
Optimal <120 And <80
Normal 120-129 And/or 80-84
High Normal 130-139 And/or 85-89
Grade 1 Hypertension 140-159 And/or 90-99
Grade 2 Hypertension 160-179 And/or 100-109
Grade 3 Hypertension >180 And/or >110
Isolated Systolic
Hypertension
>140 And <90

23. Classification of hypertension

24. Confirmation of HTN
• Should not be based on single high reading
unless
– Very high BP eg Grade 3 HTN
– Clear evidence of hypertension mediated organ
damage (HMOD)
• Number of visit and time interval is dependent
on severity of initial recording
– Substantial elevation means fewer visit and even
shorter interval between visit

26. First presentation as hypertension

27. For others…Cont…

28. Work up of hypertension

29. History…Risk factors…
• Family and personal history of hypertension,
CVD, stroke, or renal disease
• History of associated risk factors (e.g. familial
hypercholesterolaemia)
• Smoking history
• Dietary history and salt intake

30. Cont…
• Alcohol consumption
• Lack of physical exercise/sedentary lifestyle
• Previous hypertension in pregnancy/pre-
eclampsia

31. Cont…
• Sleep history, snoring, sleep apnoea
(information also from partner)
– Most common cause of secondary HTN
– May cause resistant HTN
• History of erectile dysfunction
– May influence treatment
– Possible indicator of CV risk

32. History and symptoms of HMOD, CVD,
stroke, and renal disease
• Brain and eyes: eg. headache, vertigo,
impaired vision, TIA, stroke, carotid
revascularization, cognitive impairment,
dementia (in the elderly)
• Cardiac: chest pain, shortness of breath,
oedema, myocardial infarction, coronary
revascularization, history of palpitations,
arrhythmias (especially AF), heart failure

33. Cont…
• Renal: thirst, polyuria, nocturia, haematuria,
• Peripheral arteries: cold extremities,
intermittent claudication, peripheral pulse
• Patient or family history of CKD (e.g. polycystic
kidney disease)

34. History…possible secondary
hypertension
• Young onset of grade 2 or 3 hypertension (<40
years), or sudden development of
hypertension or rapidly worsening BP in older
patients
• Recreational drug/substance
abuse/concurrent therapies: corticosteroids,
nasal vasoconstrictor, chemotherapy,
yohimbine, liquorice

35. Cont…
• History of renal/urinary tract disease
• Symptoms suggestive of thyroid disease
• History of spontaneous or diuretic-provoked
hypokalaemia, episodes of muscle weakness,
and tetany (hyperaldosteronism)

36. Cont…
• History of or current pregnancy and oral
contraceptive use
• Repetitive episodes of sweating, headache,
anxiety, or palpitations, suggestive of
Phaeochromocytoma
• History of sleep apnoea

37. Antihypertensive Drug Treatment
• Current/past antihypertensive medication
including effectiveness and intolerance to
previous medications
• Adherence to therapy

38. Physical examination
• Body Habitus
– Adherence to therapy
– Waist circumference
• Signs of HTN mediated organ damage
– Neurological examination and cognitive status
– Fundoscopic examination for hypertensive
retinopathy
– Palpation and auscultation of heart and carotid
arteries
– Palpation of peripheral arteries
– Comparison of BP in both arms (at least once)

39. Cont…
• Secondary hypertension
– Skin inspection: cafe-au-lait patches of
neurofibromatosis (phaeochromocytoma)
– Kidney palpation for signs of renal enlargement in
polycystic kidney disease
– Auscultation of heart and renal arteries for
murmurs or bruits indicative of aortic coarctation,
or renovascular hypertension

40. Cont…
• Secondary Hyepertension
– Comparison of radial with femoral pulse: to detect
radio-femoral delay in aortic coarctation
– Signs of Cushing’s disease or acromegaly
– Signs of thyroid disease

41. Investigations
• Routine laboratory tests
– Haemoglobin and/or haematocrit
– Fasting blood glucose and glycated HbA1c
– Blood lipids: total cholesterol, LDL cholesterol,
HDL cholesterol
– Blood triglycerides
– Blood potassium and sodium

42. Cont…
• Routine laboratory tests
– Blood creatinine and eGFR
– Blood liver function tests
– Urine analysis: microscopic examination; urinary
protein by dipstick test or, ideally,
albumin:creatinine ratio
– 12-lead ECG
– Blood uric acid

43. Cont…
• There is emerging evidence that an increase in
serum uric acid to levels lower than those
typically associated with gout is independently
associated with increased CV risk in both the
general population and in hypertensive
patients. Measurement of serum uric acid is
recommended as part of the screening of
hypertensive patients

44. Recommesndation..
• ECG, Echocardiography (when ecg abnormal), usg
examination of carotid, eGFR, Albumin creatinine
ratio, fundoscopy => class I
• Renal doppler imaging, Brain imaging in setting of
cognitive decline => IIa
• ABI, Pulse wave velocity => IIb

45. Cont…

46. Genetic testing
• Usually polygenic and highly heterogeneous
• Some rare monogenic form
– Glucocorticoid remidiable aldosteronism
– Liddle’s syndrome
– Inherited form of phaeochromocytoma and
paraganglioma

47. Genetic testing

48. Hypertension mediated organ
damage/HMOD
• stratifying the risk of patients with
hypertension
– Along with risk factors and associated HTN by
SCORE (Systematic COronary Risk Evaluation
System)
• BP treatment-induces regression of some (but
not all) manifestations of HMOD,

49. SCORE (Systematic COronary Risk
Evaluation System)
• Detect 10 year cardiovascular risk
• Stratification of patients
• influences treatment decisions

50. Cont

51. Cont…

52. Cont…

53. Limitation
• It applies for European population
• Multiplication factor available to calculate risk
factor for First Generation Immigrant from
southern asia (1.4)

54. Cont…SCORE…

55. Treatment of hypertension

56. Changes from last guideline
2013 2018
BP treatment goal An SBP goal of <140 mmHg
is recommended.
first objective to lower BP
to <140/90 mmHg in all
patients and provided
treatment is well tolerated,
treated BP values should
be targeted to <130/80
mmHg or lower in most
patients
In patients <65 years SBP
should be lowered to a BP
range of 120–129 mmHg in
most patients
BP target 65-80 SBP target of between
140–150 mmHg is
recommended for older
patients (65–80 years).
recommended that SBP
should be targeted to a BP
range of 130–139 mmHg.

57. Changes from last guideline
2013 2018
BP target >80 An SBP target between
140–150 mmHg should be
considered in people older
than 80 years, with an
initial SBP >160 mmHg,
provided that they are in
good physical and mental
condition.
An SBP target range of
130–139 mmHg is
recommended for people
older than 80 years, if
tolerate
DBP target <90 mmHg is always
recommended, except in
patients with diabetes, in
whom values <85 mmHg
are recommended
<80 for all patients
irrespective of level of risk
or comorbidities

58. Treatment goal
• Must Lower BP of all patient <140/90
– If tolerated ideal goal <130/80
• If diabetes
– Ideal goal <130/80
• Older patients ( >65yr)
– Goal is SBP 130-140
• Diastolic BP <80 should be targeted in all
• Systolic bp <120 not associated with favorable
risk benefit ratio

60. Treatment options
• Lifestyle modification
• Pharmacological treatment
• Device based treatment

61. Changes from last guideline
2013 2018
Diagnosis and
screening
Office BP is recommended • Repeated office BP
measurements; or
• ABPM and/or HBPM if
logistically and economically
feasible
high normal (130–
139/85–89 mmHg)
Unless compelling evidence
no initiating drug therapy
Drug treatment maybe
considered if CV risk very high
(SCORE)
Older patients Antihypertensive drug
treatment may be considered
in the elderly (<80 years)
when SBP is in the 140–159
mmHg range, provided that
antihypertensive treatment is
well tolerated
BP-lowering drug treatment and
lifestyle intervention is
recommended in fit older
patients (>65 years but not >80
years) when SBP is in the grade
1 range (140–159 mmHg),
provided that treatment is well
tolerated

62. Cont…treatment…

63. Lifestyle Modification
• Dietary sodium restriction
– 1tsf salt= 6gm (cdc), 1gm salt= .39mg sodium
– 80% salt consumption is hidden consumption from
processed food
– Increased potassium intake associated with BP
reduction and a protective effect

64. Cont…Moderation of alcohol
consumption
– New meta analysis suggest reduction of alcohol
consumption even in light drinkers is beneficial
– Alcohol free days advised, and avoid binge
drinking
– unit = ((drink volume x strength)/1000)

65. Other dietary change
• Studies and meta analysis shows Mediterranean diet
reduces CV and all cause mortality
• RCT in high risk individuals showed Mediterranean
diet over 5years resulted in 29% CV risk reduction
compared with a low fat diet, and 39% reduction in
stroke

66. Weight reduction
• Anti obesity drug maybe used
• Bariatric surgery decreases CV risk in severely
obese patients

67. Regular exercise
• Though exercise acutely increases BP
• Aerobic exercise reduces strongly reduces DBP and
also to a bit lesser extent resting, SBP
• At least 15% decreased mortality in cohort study
• Additional benefit in 300 min light exercise and 150
minute vigorous exercise weekly

68. Smoking cessation…
• Studies using ABPM indicate both normotensive and
untreated hypertensive smoker present higher daily BP
value compared to non smoker
• Smoking cessation single most effective lifestyle
measure in prevention of CVD
• CBT, Vareniciline, Nicotine replacement therapy alone
or even better in combination recommended

69. Pharmacological treatment
• Single most effective proven modality
• Initial guidelines monotherapy then increased their
dose (though little proven benefit and more adverse
effect) or switched to different monotherapy
• Newer guidelines use stepped up approach of adding
drug
• Irrespective of region
– Only about 40% HTN patients treated
– Of these only 35% achive target <140/80

70. Cont…
• Why treatment strategy failing?
– Treatment inertia (many patient on monotherapy
and suboptimal dose)
– Patient adherence issue
– Insufficient combination treatment
– Complexity of current treatment strategy (more the
number of pill more non-adherence)
– Efficacy of pharmacological therapy (only 5-10%
patuent exhibit resistance to treatment regimen)

71. Cont…
• So
– Encourage the use of combination in most
patients in context to lower BP target
– Enable use of SPC (single pill combination) in most
patients to increase adherence
– Follow a treatment algorithm that is simple and
applies to all patients and is pragmatic with the
use of SPC in all patients except maybe high-
normal and frail elderly patients

72. Cont…
• Major classes of anti-hypertensive drugs
– RAS (renin angiontensin system) inhibitor
• ACE inhibitor
• Angiotensin receptor blocker
• Direct renin inhibitor –aliskiren
– Calcium channel blocker
• Dihydropyridne (amlodipine)
• Non-dihidropyridine (verapamil,diltiazem)

73. Cont…
• Diuretics
• Thiazide (hydrochlrothiazi and bendriflumethiazide)
• thiazide like (chlorthalidone, indapamide)
• Beta blockers
– Recent increase in use of vasodilating
betablockers such as labetalol, carvedilol,
nebivolol
– Nebivolol has favorable effect on central BP, aortic
stiffness, endothelial dysfunction, less sexual
dysfunction and no risk of new onset diabetes

74. Cont…
• Other classes of antihypertensive drugs
– Alphablockers
– Frusemide
– Potassium sparing diuretics
• Important options in case of resistant HTN

75. Changes from last guideline
2013 2018
Initiation of
treatment
Initiation of with a two-
drug combination may be
considered in patients
with markedly high
baseline BP or at high CV
risk
recommended to initiate an
antihypertensive treatment with a
two-drug combination, preferably in
a SPC.
exceptions are frail older patients
and
those at low risk and with grade 1
hypertension (particularly if SBP is
<150 mmHg
Treatment of
resistant HTN
Mineralocorticoid
receptor antagonists,
amiloride, and the alpha-1
blocker doxazosin should
be considered if no
contraindication
low-dose spironolactone to existing
treatment, or the addition of further
diuretic therapy if intolerant to
spironolactone, with either
eplerenone, amiloride, higher-dose
thiazide/thiazide-like diuretic or a
loop diuretic, or the addition of
bisoprolol or doxazosin.

76. Core of drug treatment strategy for
uncomplicated HTN

77. Drug treatment strategy for HTN and
coronary artery disease

79. Drug treatment strategy for HTN with CKD

80. Drug treatment strategy for HTN with CKD
• CKD is defined as <60ml/min/1.72m2
• Thiazide/thiazide like
– Less effective when eGFR <45ml/min
– Ineffective when eGFR <30ml/min (loop diuretic used)
• ACE/ARB can not be used if serum potassium
>5.5mmol/L
• Risk of hyperkalemia with spironolactone
– when eGFR <45ml/min
– When baseline serum potassium >4.5mmol/L

82. Drug treatment strategy for HTN & HFrEF
(heart failure with reduced ejection fraction)
• CCB contraindicated in class III, IV HFrEF

85. Drug treatment strategy for
hypertension and atrial fibrillation

87. Atherosclerosis
• Carotid plaque
– CCB>BB/Diuretic, ACEi>diuretic
– Plus life style change, antiplatelet and statin
• LEAD (lower extremity arterial disease)
– If critical limb ischaemia present BP reduction
done slowly to avoid worsening ischaemia
– RAS inhibitor, CCB and diuretic used
– Beta blocker can be considered

88. Stroke and hypertension

89. Hypertension in diabetic patient

90. Hypertension in COPD
• Beta blocker issue
– Maintains CV protective role
– May affect basal lung function
– May diminish emergency beta agonist effect
– Cardioselective beta blocker is safe
• Diuretics not recommended
• CCB, RAS blocker or combination preferable
• If response poor use thiazide/beta blocker

91. Device based HTN treatment
• This is a fast moving field
• Principally targeting treatment of resistant
HTN
– Carotid baroreceptor stimulation (pacemaker and
stent
– Renal denervation
– Creation of arterio venous fistula
– Carotid body surgery

92. Device based HTN treatment

93. Resistant HTN

94. Demographies
• True prevelance probably <10%
• Older age (especially >75 years)
• Obese
• More common in black people
• Excess dietary sodium intake
• High baseline BP and chronicity of
uncontrolled hypertension

95. Etiology
• Obstructive sleep apnoea and other Undetected
secondary forms of hypertension
• Lifestyle factors, such as obesity or large gains in
weight, excessive alcohol consumption, and high
sodium intake.
• Intake of vasopressor or sodium-retaining
substances,
• Some prescription and non prescription drug
• Advanced HMOD, particularly atherosclerosis, CKD or
large-artery stiffening.

96. Cont…
• Pseudo resistant HTN
– Poor adherence to prescribed medicines
– White-coat phenomenon
– Poor office BP measurement technique
– Marked brachial artery calcification
– Physician inertia

97. Treatment of Resistant HTN

98. Cont…
• Spironolactone very effective in treating resistant
HTN
• But may only be used if
– when eGFR <45ml/min
– When baseline serum potassium >4.5mmol/L
• Alternatives are bisoprolol and doxazosin
– Not as effective but significantly better than
placebo

99. White coat hypertension

100. Masked hypertension

101. Hypertensive urgency and emergency
• severe hypertension (grade 3) plus acute
hypertension mediated organ damage
• which is often life threatening
• requires immediate but careful intervention to
lower BP
• usually with intravenous therapy

102. Cont…presentations of hypertensive emergency
• Malignant hyoertension
– Characterised by severe hypertension (grade 3)
associated with fundoscopic changes (flame shaped
hemorrhage and/or papilloedema) , microangiopathy
and DIC and can be associated with encephalopathy
(15% cases) acute heart failure, and acute
deterioration of renal function
– hallmark is small artery fibrinoid necrosis in the
kidney, retina, and brain
– Malignant indicates poor prognosis without treatment

103. • Severe hypertension associated with other
clinical conditions eg. Aortic dissection, AMI,
acute heart failure
• Patient with sudden severe hypertension due
to phaeochromocytoma
• Pregnant woman with severe hypertension or
pre-eclampsia
Cont…presentations of hypertensive emergency

104. Cont…
• Hypertensive urgency
– Severe hypertension in patients presenting to the
emergency department but no clinical evidence of
acute HMOD.
– require BP reduction but they do’nt usually
require admission to hospital
– BP reduction is best achieved with oral medication
according to the drug treatment algorithm
– However they require urgent outpatient review
that BP is coming under control

105. Diagnostic workup
• Usual routine investigations for hypertension
• Plus
– Fibrinogen
– LDH, haptoglobin
– Pregnancy test in women of child bearing age

106. Cont…
• Specific tests by indication
– Troponin, CK-MB, NT-Pro BNP
– CXR (fluid overload)
– Echocardiography
– CT angiography
– Brain imaging
– Renal USG
– Urine drug screen for amphetamine and cocaine

107. Clinical
presentation
Timeline and target
for BP reduction
First-line treatment Alternative
Malignant
hypertension with or
without acute renal
failure
•Several hours
•Reduce MAP by 20–
25%
•Labetalol
•Nicardipine
•Nitroprusside
•Urapidil
Hypertensive
encephalopathy
Immediately reduce
MAP by 20–25%
Labetalol,
nicardipine
Nitroprusside
Acute coronary
event
Immediately reduce
SBP to <140 mmHg
Nitroglycerine,
labetalol
Urapidil
Acute cardiogenic
pulmonary oedema
Immediately reduce
SBP to <140 mmHg
Nitroprusside or
nitroglycerine (with
loop diuretic)
Urapidil (with loop
diuretic)
Acute aortic
dissection
Immediately reduce
SBP to <120 mmHg
AND heart rate to
<60 bpm
Esmolol and
nitroprusside or
nitroglycerine or
nicardipine
Labetalol OR
metoprolol
Eclampsia and
severe pre-
eclampsia/HELLP
Immediately reduce
SBP to <160 mmHg
AND DBP to <105
mmHg
Labetalol or
nicardipine and
magnesium sulfate
Consider delivery

108. Cont…
• Rapid uncontrolled BP lowering not
recommended
• Sometimes oral ACE/ARB or beta blocker very
effective
• Should be screened for secondary
hypertension
• Monthly follow up until target BP achieved

109. Perioperative HTN management

110. Hypertension in pregnancy
• Occurs in 5-10% of pregnancies
• Associated with
– Maternal risk
– Foetal risk

111. Cont…spectrum
• Pre-existing hypertension
• Gestational hypertension
– Develops after 20 weeks and resolves within
6week post partum
• Pre-existing hypertension with superimposed
gestational hypertension with proteinuria
• Pre-eclampsia
• Antenatal unclassifiable hypertension

112. Investigation
• Usual investigations
• Plus
– Urine for protein (initial to detect CKD, from 2nd
trimester to establish diagnosis of preeclampsia)
– USG

113. treatment
• Mild (<160/110)
– Treat if BP persistently >150/95 or gestation
hypertension
– Alpha methyl dopa
– Labetalol
– Calcium channel blocker
– Beta blocker

114. • Severe (>160/90)
– Depending on the time of delivery
– Labetalol
– Methyldopa
– Magnesium sulphate

117. cont
• All drug tramsmitted to some extent in breast
milk
• More propranolol and nifedipine

118. Oral contraceptive pill and hormone
replacement therapy
• OCP
– Small but significant rise in BP
– Reversible
– Estrogen>progesteron
– Not recommended if BP elevated
• HRT
– Though contains estrogen no proof that significant
elevation of BP in normotensive
– Not contraindicated in HTN

119. Hypertension and sexual dysfunction
• Male are more affected
• Due to endothelial dysfunction
• May be a herald of HTN
• Independent risk factor of CV event and early
marker of vascular damage
• Information about sexual dysfunction should
be collected at diagnosis and follow up

120. Cont…
• May be the reason for denial of commencing
treatment
• Antihypertensive may be responsible
– Thiazide/thiazide like diuretic
– Conventional beta blocker
– Centrally acting drug (eg clonidine)
• ACEi, ARB, CCB, vasodilating beta blocker may
have neutral or beneficial effect
• Phosphodiesterase inhibitor should be prescribed
only in absence of nitrate, alpha blocker

121. Hypertension and malignancy
• Elevated BP present in 1/3rd patients
• Drugs responsible
– Sorefinib
– Sunitinib
– Bevacizumab
– Pazopanib
• Rx
– RAS blocker, dihydropyridine