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Opinion

VIEWPOINT
The 2018 European Society of Cardiology/
European Society of Hypertension and 2017
American College of Cardiology/American Heart
Association Blood Pressure Guidelines
More Similar Than Different

Paul K. Whelton, MB, Clinical practice guidelines are an important estab- diuretics, calcium channel blockers, angiotensin-
MD, MSc lished resource in medicine and public health. Clinical converting enzyme inhibitors, and angiotensin recep-
Department of practice guidelines are particularly well suited to condi- tor blockers), reserving combinations with β-blockers
Epidemiology, Tulane
tions such as high blood pressure (BP) that are com- for specific clinical conditions; (8) use lower BP treat-
University School of
Public Health and mon, result in a substantial disease burden and utiliza- ment targets than those previously recommended,
Tropical Medicine, tion of health care resources, incur individual and societal including lower BP targets in older adults, adults with
New Orleans, cost, demonstrate large variation in practice patterns, diabetes, and adults with a variety of comorbid condi-
Louisiana; and
Department of
and have enough high-quality evidence to guide deci- tions; (9) emphasize functionality rather than chrono-
Medicine, Tulane sion-making. Although many BP-related clinical prac- logical age in managing high BP in older adults; and
University School of tice guidelines have been developed by individual coun- (10) use strategies known to improve the control of
Medicine, New Orleans,
tries and professional societies, few would dispute that hypertension. In addition, both guidelines identify evi-
Louisiana.
2 such reports released during the past 12 months—the dence gaps for which additional research is needed to
Bryan Williams, MD 2017 American College of Cardiology (ACC)/American resolve areas of current uncertainty.
UCL Institute of Heart Association (AHA)1 and 2018 European Society of The guidelines vary in the details of their common-
Cardiovascular Cardiology (ESC)/European Society of Hypertension ality but generally encourage greater use of out-of-
Sciences, University
(ESH)2 guidelines—have substantial influence beyond office BP measurements, lower BP thresholds for initi-
College London,
London, United their immediate regions of origin. ating antihypertensive drug therapy, and lower BP
Kingdom; and National Presentation and publication of these 2 compre- treatment targets, which collectively should lead to a
Institute for Health hensive guidelines have resulted in comparisons and lower BP and fewer BP-related complications.5 Other re-
Research, UCL
Hospitals Biomedical
vigorous debate, with an emphasis on differences3 cent comprehensive BP clinical practice guidelines from
Research Centre, rather than how their core recommendations can be Canada6 and Australia7 have also recommended lower
London, United implemented to improve the health of the public. This BP treatment targets than in previous guidelines.
Kingdom.
may lead to an impression that experts cannot agree or A key change in both guidelines is the approach to
that the evidence is flawed or insufficient, providing treatment of BP in older adults, which is closer than ever
support for those who are content with the status quo to that proposed for younger adults. Emerging evi-
of lamentable hypertension control globally.4 Against dence that lowering BP seems to protect against cogni-
Editorial page 1757
this backdrop, it is important to recognize that the con- tive decline8 may help reinforce the importance of im-
vergence of the 2017 ACC/AHA (US) and 2018 ESC/ESH proving BP treatment and hypertension control rates,
Author Audio (European) guidelines is greater now than ever before. with no age-related end date and cessation of therapy
Interview
The 2 guidelines have much in common (eTable only when it is poorly tolerated or the patient experi-
in the Supplement), including recommendations to ences functional decline to the point at which treat-
Supplemental (1) base diagnosis and management of hypertension ment is futile.
content on accurate BP measurements; (2) perform out-of- Despite their similarities, the guidelines take a differ-
office BP readings to confirm high office readings and ent position in several areas. The most apparent is in clas-
to recognize “white coat” and “masked” hypertension; sification of BP. The definition of hypertension in the
(3) use cardiovascular disease (CVD) risk estimation, European guideline is unchanged, reflecting the level of
in addition to BP levels, for therapeutic decision- BP (ⱖ140/90 mm Hg) at which drug treatment is recom-
making; (4) utilize a similar array of drug treatment mended for all patients. In the US guideline, hyperten-
and nonpharmacological lifestyle interventions as the sion is defined by an average systolic BP of at least
core strategy for BP lowering; (5) add antihyperten- 130 mm Hg or diastolic BP of 80 mm Hg or higher, based
sive drug treatment to nonpharmacological therapy at on an interpretation of risk and treatment effect. This
Corresponding
lower BP thresholds than previously recommended; results in a different approach to treatment of adults with
Author: Paul K. (6) use combination drug therapy, preferably in the a systolic BP of 130 through 139 mm Hg or diastolic BP of
Whelton, MB, MD, MSc, form of a single combination pill, to improve treat- 80 through 89 mm Hg, who are classified as having
1440 Canal St, Room
ment adherence; (7) utilize combinations of the same stage 1 hypertension in the US guideline and high-
2015, New Orleans, LA
70112 (pkwhelton classes of antihypertensive drugs for treatment of normalBPintheEuropeanguideline.TheUSguidelinerec-
@gmail.com). most adults with hypertension (thiazide/thiazide-like ommends nonpharmacological therapy for all adults with

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Opinion Viewpoint

stage 1 hypertension and additional antihypertensive drug therapy for ACC/AHA guidelines, whereas the European guideline provides rec-
the approximately 30% in this highly prevalent BP category who are ommendations for concomitant treatment with statins in many
deemed to be at high risk for atherosclerotic CVD (10-year risk of ath- patients who have hypertension with a low-moderate or high risk of
erosclerotic CVDⱖ10%). In contrast, the European guideline pre- CVD. It also recommends antiplatelet therapy and aspirin for second-
dominantly recommends lifestyle interventions, with consideration ary but not primary prevention of CVD.
of antihypertensive drug therapy only in adults at very high risk, Two final differences relate to the process used for guideline
ie, with established CVD, especially coronary artery disease. development. The US writing committee had no BP-related com-
The decision in the US guideline to reclassify hypertension and mercial relationships and used an independent evidence review
base treatment of stage 1 hypertension on CVD risk estimation has committee, in addition to literature review, to analyze the data for
important implications for older adults, many of whom would meet key questions. The European guideline task force considered the
the risk threshold for drug treatment. Even though BP thresholds latter option unnecessary because many relevant systematic
for treatment in older adults have been reduced in the European reviews had been published recently in high-quality journals. Both
guideline, they remain higher than the US recommendations at BP processes resulted in similar outputs, raising an important question
levels of 140/90 mm Hg or higher for patients older than 65 years regarding the value and need for rigorous independent assess-
and 160/90 mm Hg or higher for patients older than 80 years who ments when high-quality systematic reviews are already in the
have not previously been treated. public domain. Interpretation of the results and considerations of
Both guidelines recommend lower BP targets during com- local factors, policies, and feasibility of implementation was what
bined lifestyle and antihypertensive drug therapy. In the US guide- led to the guideline differences.
line, the target is lower than 130/80 mm Hg in almost all patient Adoption of the ACC/AHA and ESC/ESH guideline recommen-
groups, except older adults, among whom the target is systolic BP dations will be challenging for patients, clinicians, and health care
lower than 130 mm Hg. In the European guideline, the first objec- systems. The fundamental issue is that too many adults have un-
tive is to reduce BP to less than 140/90 mm Hg, with a target of healthy lifestyles that put them at risk for adverse consequences in-
130/80 mm Hg or lower, if tolerated, in adults younger than 65 years cluding stroke, myocardial infarction, heart failure, and CKD.10 The
but not in adults 65 years and older, for whom the target is below best solution is a change to healthier lifestyles but dissemination,
140 to 130/80 mm Hg, if tolerated. acceptance, and implementation of the ACC/AHA and ESC/ESH core
Another difference in BP targets relates to patients with chronic recommendations for diagnosis and treatment of hypertension will
kidney disease (CKD). The European guideline recommends a target likely result in substantially better public health.5 It seems unlikely
of less than 140/90 mm Hg, with flexibility for individualized man- that current models of care can respond adequately to meet the
agement depending on treatment tolerance and impact on renal func- guideline recommendations. Potential solutions include minimiz-
tion and electrolyte levels. The US guideline recommends a target ing barriers to accurate diagnosis and management of hyperten-
below 130/80 mm Hg, largely based on the favorable CVD and sion, a progressive shift to team-based care, better application of
all-cause mortality experience in SPRINT participants with CKD at strategies for enhanced therapeutic adherence, and greater involve-
baseline.9 Both guidelines recommend management of additional ment of patients in their own care. The latter could also reduce the
CVD risk factors, but the US guideline generally defers to other burden for primary care clinicians.

ARTICLE INFORMATION Cardiology/American Heart Association Task Force 6. Nerenberg KA, Zarnke KB, Leung AA, et al;
Conflict of Interest Disclosures: Dr Whelton on Clinical Practice Guidelines. Hypertension. Hypertension Canada. Hypertension Canada’s 2018
reports having served as chair of the 2017 ACC/AHA 2018;71(6):1269-1324. doi:10.1161/HYP Guidelines for Diagnosis, Risk Assessment,
blood pressure guideline committee. Dr Williams .0000000000000066 Prevention, and Treatment of Hypertension in
reports receiving grants and personal fees from 2. Williams B, Mancia G, Spiering W, et al; ESC Adults and Children. Can J Cardiol. 2018;34(5):506-
Vascular Dynamics Inc, fees from Novartis for Scientific Document Group. 2018 ESC/ESH 525. doi:10.1016/j.cjca.2018.02.022
serving on a study advisory board, fees from Daiichi Guidelines for the management of arterial 7. Gabb GM, Mangoni AA, Anderson CS, et al.
Sankyo for educational lectures, fees from Servier hypertension. Eur Heart J. 2018;39(33):3021-3104. Guideline for the diagnosis and management of
for educational lectures, fees from Boehringer doi:10.1093/eurheartj/ehy339 hypertension in adults–2016. Med J Aust. 2016;205
Ingelheim for educational lectures, and fees from 3. Messerli FH, Bangalore S. The blood pressure (2):85-89. doi:10.5694/mja16.00526
Pfizer for educational lectures outside the landscape: schism among guidelines, confusion 8. Williamson JD; SPRINT Research Group.
submitted work; and served as chair of the 2018 among physicians, and anxiety among patients. A randomized trial of intensive vs standard systolic
ESC-ESH Guidelines on Arterial Hypertension J Am Coll Cardiol. 2018;72(11):1313-1316. doi:10.1016 blood pressure control and the risk of mild cognitive
Guideline Task Force, and chair of the ESC Council /j.jacc.2018.07.026 impairment and dementia: results from SPRINT
on Hypertension, 2016-2018. Mind. Abstract ID: 27525. https://ep70
4. Mills KT, Bundy JD, Kelly TN, et al. Global
Additional Contributions: We thank Robert M. disparities of hypertension prevalence and control: .eventpilotadmin.com/web/planner.php?id=AAIC18.
Carey, MD, and Giuseppe Mancia, MD, PhD, for a systematic analysis of population-based studies 9. Wright JT Jr, Williamson JD, Whelton PK, et al;
valuable suggestions that improved the text. from 90 countries. Circulation. 2016;134(6):441-450. SPRINT Research Group. A randomized trial of
doi:10.1161/CIRCULATIONAHA.115.018912 intensive versus standard blood-pressure control.
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NMA/PCNA Guideline for the Prevention, and deaths in US adults: an analysis of national skepticism vs lifestyle realism? JAMA. 2018;319(2):
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Blood Pressure in Adults: Executive Summary: /jamacardio.2018.1240
A Report of the American College of

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