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HBP RECOMMANDATION 2007

HBP RECOMMANDATION 2007

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MISE AU POINT SUR LE TRAITEMENT DE L'HYPERTENSION ARTÉRIELLE; DU DIAGNOSTIC A LA PRISE EN CHARGE
MISE AU POINT SUR LE TRAITEMENT DE L'HYPERTENSION ARTÉRIELLE; DU DIAGNOSTIC A LA PRISE EN CHARGE

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ESC and ESH Guidelines
2007 Guidelines for the management of arterialhypertension
The Task Force for the Management of Arterial Hypertension of theEuropean Society of Hypertension (ESH) and of the EuropeanSociety of Cardiology (ESC)
Authors/Task Force Members: Giuseppe Mancia, Co-Chairperson (Italy), Guy De Backer,Co-Chairperson (Belgium), Anna Dominiczak (UK), Renata Cifkova (Czech Republic)Robert Fagard (Belgium), Giuseppe Germano (Italy), Guido Grassi (Italy), Anthony M. Heagerty(UK), Sverre E. Kjeldsen (Norway), Stephane Laurent (France), Krzysztof Narkiewicz (Poland),Luis Ruilope (Spain), Andrzej Rynkiewicz (Poland), Roland E. Schmieder (Germany),Harry A.J. Struijker Boudier (Netherlands), Alberto Zanchetti (Italy)
ESC Committee for Practice Guidelines (CPG): Alec Vahanian, Chairperson (France), John Camm (United Kingdom),Raffaele De Caterina (Italy), Veronica Dean (France), Kenneth Dickstein (Norway), Gerasimos Filippatos (Greece),Christian Funck-Brentano (France), Irene Hellemans (Netherlands), Steen Dalby Kristensen (Denmark), Keith McGregor(France), Udo Sechtem (Germany), Sigmund Silber (Germany), Michal Tendera (Poland), Petr Widimsky (Czech Republic),Jose Luis Zamorano (Spain)ESH Scientific Council: Sverre E. Kjeldsen, President (Norway), Serap Erdine, Vice-President (Turkey),Krzysztof Narkiewicz, Secretary (Poland), Wolfgang Kiowski, Treasurer (Switzerland), Enrico Agabiti-Rosei (Italy),Ettore Ambrosioni (Italy), Renata Cifkova (Czech Republic), Anna Dominiczak (United Kingdom), Robert Fagard(Belgium), Anthony M. Heagerty, Stephane Laurent (France), Lars H. Lindholm (Sweden), Giuseppe Mancia (Italy),Athanasios Manolis (Greece), Peter M. Nilsson (Sweden), Josep Redon (Spain), Roland E. Schmieder (Germany),Harry A.J. Struijker-Boudier (The Netherlands), Margus Viigimaa (Estonia)Document Reviewers: Gerasimos Filippatos (CPG Review Coordinator) (Greece), Stamatis Adamopoulos (Greece),Enrico Agabiti-Rosei (Italy), Ettore Ambrosioni (Italy), Vicente Bertomeu (Spain), Denis Clement (Belgium), Serap Erdine(Turkey), Csaba Farsang (Hungary), Dan Gaita (Romania), Wolfgang Kiowski (Switzerland), Gregory Lip (UK),Jean-Michel Mallion (France), Athanasios J. Manolis (Greece), Peter M. Nilsson (Sweden), Eoin O’Brien (Ireland),Piotr Ponikowski (Poland), Josep Redon (Spain), Frank Ruschitzka (Switzerland), Juan Tamargo (Spain),Pieter van Zwieten (Netherlands), Margus Viigimaa (Estonia), Bernard Waeber (Switzerland), Bryan Williams (UK),Jose Luis Zamorano (Spain)
The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized.No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submissionof a written request to Oxford University Press, the publisher of the
European Heart Journal
and the party authorized to handle such permissions on behalf of the ESC.
Disclaimer.
The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they werewritten. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, overridethe individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with thatpatient, and where appropriate and necessary the patient’s guardian or carer. It is also the health professional’s responsibility to verify the rules and regulationsapplicable to drugs and devices at the time of prescription.The affiliations of Task Force members are listed in the Appendix. Their Disclosure forms are available on the respective society Web Sites. These guidelines alsoappear in the
Journal of Hypertension
, doi:10.1097/HJH.0b013e3281fc975a
*
Correspondence to Giuseppe Mancia, Clinica Medica, Ospedale San Gerardo, Universita Milano-Bicocca, Via Pergolesi, 33
20052 MONZA (Milano), Italy Tel:
þ
39039 233 3357; fax:
þ
39 039 32 22 74, e-mail: giuseppe.mancia@unimib.it
*
Correspondence to Guy de Backer, Dept. of Public Health, University Hospital, De Pintelaan 185, 9000 Ghent, Belgium Tel:
þ
32 9 240 3627; fax:
þ
32 9 240 4994;e-mail: Guy.DeBacker@ugent.beEuropean Heart Journal (2007)
28
, 1462
1536doi:10.1093/eurheartj/ehm236
&
2007 The European Society of Cardiology (ESC) and European Society of Hypertension (ESH). All rights reserved. For Permissions, pleasee-mail: journals.permissions@oxfordjournals.org
 
Table of Contents
1. Introduction and purposes . . . . . . . . . . . . . . . 14632. Definition and classification of hypertension . . . . . 14642.1 Systolic versus diastolic and pulse pressure . . 14642.2 Classification of hypertension . . . . . . . . . . 14652.3 Total cardiovascular risk . . . . . . . . . . . . . 14652.3.1 Concept . . . . . . . . . . . . . . . . . . 14652.3.2 Assessment. . . . . . . . . . . . . . . . . 14662.3.3 Limitations . . . . . . . . . . . . . . . . . 14683. Diagnostic evaluation . . . . . . . . . . . . . . . . . . 14693.1 Blood pressure measurement . . . . . . . . . . 14693.1.1 Office or clinic blood pressure . . . . . . 14693.1.2 Ambulatory blood pressure. . . . . . . . 14693.1.3 Home blood pressure . . . . . . . . . . . 14713.1.4 Isolated office or white coat hypertension 14713.1.5 Isolated ambulatory or maskedhypertension . . . . . . . . . . . . . . . . 14723.1.6 Blood pressure during exercise andlaboratory stress . . . . . . . . . . . . . 14723.1.7 Central blood pressure . . . . . . . . . . 14733.2 Family and clinical history . . . . . . . . . . . . 14733.3 Physical examination . . . . . . . . . . . . . . . 14733.4 Laboratory investigations . . . . . . . . . . . . 14733.5 Genetic analysis . . . . . . . . . . . . . . . . . 14743.6 Searching for subclinical organ damage . . . . 14753.6.1 Heart . . . . . . . . . . . . . . . . . . . . 14763.6.2 Blood vessels . . . . . . . . . . . . . . . 14763.6.3 Kidney . . . . . . . . . . . . . . . . . . . 14773.6.4 Fundoscopy . . . . . . . . . . . . . . . . 14783.6.5 Brain . . . . . . . . . . . . . . . . . . . . 14784. Evidence for therapeutic management of hypertension 14784.1 Introduction . . . . . . . . . . . . . . . . . . . . 14784.2 Event based trials comparing active treatmentto placebo . . . . . . . . . . . . . . . . . . . . . 14794.3 Event based trials comparing more and lessintense blood pressure lowering . . . . . . . . 14804.4 Event based trials comparing different activetreatments . . . . . . . . . . . . . . . . . . . . 14804.4.1 Calcium antagonists versus thiazidediuretics and
b
-blockers . . . . . . . . . 14804.4.2 ACE inhibitors versus thiazide diureticsand
b
-blockers . . . . . . . . . . . . . . 14804.4.3 ACE inhibitors versus calciumantagonists . . . . . . . . . . . . . . . . 14804.4.4 Angiotensin receptor antagonists versusother drugs . . . . . . . . . . . . . . . . 14814.4.5 Trials with
b
-blockers. . . . . . . . . . . 14814.4.6 Conclusions . . . . . . . . . . . . . . . . 14824.5 Randomized trials based on intermediateendpoints . . . . . . . . . . . . . . . . . . . . . 14824.5.1 Heart . . . . . . . . . . . . . . . . . . . . 14824.5.2 Arterial wall and atherosclerosis . . . . 14834.5.3 Brain and cognitive function . . . . . . . 14844.5.4 Renal function and disease. . . . . . . . 14844.5.5 New onset diabetes . . . . . . . . . . . . 14855. Therapeutic approach . . . . . . . . . . . . . . . . . 14865.1 When to initiate antihypertensive treatment . 14865.2 Goals of treatment . . . . . . . . . . . . . . . . 14875.2.1 Blood pressure target in the generalhypertensive population . . . . . . . . . 14875.2.2 Blood pressure targets in diabetic andvery high or high risk patients . . . . . . 14885.2.3 Home and ambulatory blood pressuretargets . . . . . . . . . . . . . . . . . . . 14895.2.4 Conclusions . . . . . . . . . . . . . . . . 14895.3 Cost-effectiveness of antihypertensivetreatment . . . . . . . . . . . . . . . . . . . . . 14896. Treatment strategies . . . . . . . . . . . . . . . . . . 14906.1 Lifestyle changes . . . . . . . . . . . . . . . . . 14906.1.1 Smoking cessation. . . . . . . . . . . . . 14906.1.2 Moderation of alcohol consumption . . . 14906.1.3 Sodium restriction . . . . . . . . . . . . 14916.1.4 Other dietary changes . . . . . . . . . . 14916.1.5 Weight reduction . . . . . . . . . . . . . 14916.1.6 Physical exercise . . . . . . . . . . . . . 14916.2 Pharmacological therapy . . . . . . . . . . . . . 14926.2.1 Choice of antihypertensive drugs . . . . 14926.2.2 Monotherapy . . . . . . . . . . . . . . . . 14956.2.3 Combination treatment . . . . . . . . . 14957. Therapeutic approach in special conditions . . . . . 14977.1 Elderly . . . . . . . . . . . . . . . . . . . . . . . 14977.2 Diabetes mellitus . . . . . . . . . . . . . . . . . 14987.3 Cerebrovascular disease . . . . . . . . . . . . . 14997.3.1 Stroke and transient ischaemic attacks . 14997.3.2 Cognitive dysfunction and dementia . . 15007.4 Coronary heart disease and heart failure . . . 15007.5 Atrial fibrillation . . . . . . . . . . . . . . . . . 15017.6 Non-diabetic renal disease . . . . . . . . . . . 15017.7 Hypertension in women . . . . . . . . . . . . . 15027.7.1 Oral contraceptives . . . . . . . . . . . . 15027.7.2 Hormone replacement therapy . . . . . 15037.7.3 Hypertension in pregnancy . . . . . . . . 15037.8 Metabolic syndrome . . . . . . . . . . . . . . . 15047.9 Resistant hypertension . . . . . . . . . . . . . . 15067.10 Hypertensive emergencies . . . . . . . . . . . . 15077.11 Malignant hypertension . . . . . . . . . . . . . 15078. Treatment of associated risk factors . . . . . . . . . 15088.1 Lipid lowering agents . . . . . . . . . . . . . . 15088.2 Antiplatelet therapy . . . . . . . . . . . . . . . 15098.3 Glycaemic control . . . . . . . . . . . . . . . . 15099. Screening and treatment of secondary forms of hypertension . . . . . . . . . . . . . . . . . . . . . . . 15109.1 Renal parenchymal disease . . . . . . . . . . . 15109.2 Renovascular hypertension . . . . . . . . . . . 15109.3 Phaeochromocytoma . . . . . . . . . . . . . . . 15119.4 Primary aldosteronism . . . . . . . . . . . . . . 15119.5 Cushing’s syndrome . . . . . . . . . . . . . . . . 15129.6 Obstructive sleep apnoea . . . . . . . . . . . . 15129.7 Coarctation of the aorta . . . . . . . . . . . . . 15129.8 Drug-induced hypertension . . . . . . . . . . . 151210. Follow-up . . . . . . . . . . . . . . . . . . . . . . . . 151211. Implementation of guidelines . . . . . . . . . . . . . 1513APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . 1514References . . . . . . . . . . . . . . . . . . . . . . . . 1515
1. Introduction and purposes
For several years the European Society of Hypertension(ESH) and the European Society of Cardiology (ESC)decided not to produce their own guidelines on the diagnosisand treatment of hypertension but to endorse the guidelineson hypertension issued by the World Health Organization(WHO) and International Society of Hypertension (ISH)
1,2
ESC and ESH Guidelines 1463
 
with some adaptation to reflect the situation in Europe.However, in 2003 the decision was taken to publish ESH/ESC specific guidelines
3
based on the fact that, becausethe WHO/ISH Guidelines address countries widely varyingin the extent of their health care and availability of economic resource, they contain diagnostic and therapeuticrecommendations that may be not totally appropriate forEuropean countries. In Europe care provisions may oftenallow a more in-depth diagnostic assessment of cardiovascu-lar risk and organ damage of hypertensive individuals as wellas a wider choice of antihypertensive treatment.The 2003 ESH/ESC Guidelines
3
were well received by theclinical world and have been the most widely quoted paperin the medical literature in the last two years.
4
However,since 2003 considerable additional evidence on importantissues related to diagnostic and treatment approaches tohypertension has become available and therefore updatingof the previous guidelines has been found advisable.In preparing the new guidelines the Committee estab-lished by the ESH and ESC has agreed to adhere to the prin-ciples informing the 2003 Guidelines, namely 1) to try tooffer the best available and most balanced recommendationto all health care providers involved in the management of hypertension, 2) to address this aim again by an extensiveand critical review of the data accompanied by a series of boxes where specific recommendations are given, as wellas by a concise set of practice recommendations to be pub-lished soon thereafter as already done in 2003;
5
3) to pri-marily consider data from large randomized trials but alsoto make use, where necessary, of observational studiesand other sources of data, provided they were obtained instudies meeting a high scientific standard; 4) to emphasizethat guidelines deal with medical conditions in general andtherefore their role must be educational and not prescrip-tive or coercive for the management of individual patientswho may differ widely in their personal, medical and cul-tural characteristics, thus requiring decisions differentfrom the average ones recommended by guidelines; 5) toavoid a rigid classification of recommendations by thelevel or strength of scientific evidence.
6
The Committeefelt that this is often difficult to apply, that it can onlyapply to therapeutic aspects and that the strength of a rec-ommendation can be judged from the way it is formulatedand from reference to relevant studies. Nevertheless, thecontribution of randomized trials, observational studies,meta-analyses and critical reviews or expert opinions hasbeen identified in the text and in the reference list.The members of the Guidelines Committee established bythe ESH and ESC have participated independently in thepreparation of this document, drawing on their academicand clinical experience and applying an objective and criti-cal examination of all available literature. Most have under-taken and are undertaking work in collaboration withindustry and governmental or private health providers(research studies, teaching conferences, consultation), butall believe such activities have not influenced their judge-ment. The best guarantee of their independence is in thequality of their past and current scientific work. However,to ensure openness, their relations with industry, govern-ment and private health providers are reported in the ESHand ESC websites (www.eshonline.org and www.escardio.org) Expenses for the Writing Committee and preparationof these guidelines were provided entirely by ESH and ESC.
2. Definition and classification of hypertension
Historically more emphasis was placed on diastolic than onsystolic blood pressure as a predictor of cardiovascularmorbid and fatal events.
7
This was reflected in the earlyguidelines of the Joint National Committee which did notconsider systolic blood pressure and isolated systolic hyper-tension in the classification of hypertension.
8,9
It wasreflected further in the design of early randomized clinicaltrials which almost invariably based patient recruitment cri-teria on diastolic blood pressure values.
10
However, a largenumber of observational studies has demonstrated that car-diovascular morbidity and mortality bear a continuousrelationship with both systolic and diastolic blood press-ures.
7,11
The relationship has been reported to be lesssteep for coronary events than for stroke which has thusbeen labelled as the most important ‘hypertensionrelated’ complication.
7
However, in several regions of Europe, though not in all of them, the attributable risk,that is the excess of death due to an elevated bloodpressure, is greater for coronary events than for strokebecause heart disease remains the most common cardiovas-cular disorder in these regions.
12
Furthermore, both systolicand diastolic blood pressures show a graded independentrelationship with heart failure, peripheral artery diseaseand end stage renal disease.
13
16
Therefore, hypertensionshould be considered a major risk factor for an array of car-diovascular and related diseases as well as for diseasesleading to a marked increase in cardiovascular risk. This,and the wide prevalence of high blood pressure in the popu-lation,
17
19
explain why in a WHO report high blood pressurehas been listed as the first cause of death worldwide.
20
2.1 Systolic versus diastolic and pulse pressure
In recent years the simple direct relationship of cardiovascu-lar risk with systolic and diastolic blood pressure has beenmade more complicated by the findings of observationalstudies that in elderly individuals the risk is directly pro-portional to systolic blood pressure and, for any given systoliclevel, outcome is inversely proportional to diastolic bloodpressure,
21
23
with a strong predictive value of pulse pressure(systolic minus diastolic).
24
27
The predictive value of pulsepressure may vary with the clinical characteristics of the sub-jects. In the largest meta-analysis of observational data avail-able today (61 studies in almost 1 million subjects withoutovert cardiovascular disease, of which 70% are fromEurope)
11
both systolic and diastolic blood pressures wereindependently and similarly predictive of stroke and coronarymortality, and the contribution of pulse pressure was small,particularly in individuals aged less than 55 years. By con-trast, in middle aged
24,25
and elderly
26,27
hypertensivepatients with cardiovascular risk factors or associated clinicalconditions, pulse pressure showed a strong predictive valuefor cardiovascular events.
24
27
It should be recognized that pulse pressure is a derivedmeasure which combines the imperfection of the originalmeasures. Furthermore, although figures such as 50 or55 mmHg have been suggested,
28
no practical cutoff valuesseparating pulse pressure normality from abnormality atdifferent ages have been produced. As discussed in section3.1.7 central pulse pressure, which takes into account the‘amplification phenomena’ between the peripheral arteries
ESC and ESH Guidelines1464

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