New guidelines for treatment of arterial hypertension
18 September 2007
The European Society of Cardiology (ESC) and the
European Society of Hypertension (ESH) have revised their 2003 guidelines
for treatment of arterial hypertension based upon the publication of new
In 2000, 26% (972 million) of the adult population worldwide had
hypertension and this figure is estimated to rise by 2025 to 1.56 billion.
Such individuals have an increased risk of stroke or heart disease and the
detection and effective management of such patients presents an enormous
challenge to healthcare systems. Identifying specific patients at risk of
developing organ damage will allow better deployment of preventative
The cornerstone of treatment remains the
introduction of lifestyle measures such as increasing exercise, reducing
body weight and other environmental factors such as reducing the intake of
alcohol and salt before embarking on a treatment programme involving drugs.
Three issues then follow:
First, identifying the high-risk patient
The new guidelines
continue to stratify patients according to level of presenting blood
pressure and the detection of other risk factors — metabolic syndrome,
sub-clinical organ damage or diabetes or finally, established cardiovascular
or renal disease. The two latter categories place patients at moderate to
very high risk and of course, treatment should be very aggressive.
The second issue is the class of drugs to be used
The ESC and ESH agree that the most important factor in reducing an
individual’s cardiovascular risk is lowering blood pressure. Against this
background, there is some evidence emerging that particular classes of drugs
may have the ability to protect against specific organ damage. Although this
is intriguing, further investigation is needed to verify the evidence.
Newer classes of drug, for example, may be able to prevent the
development of Type 2 diabetes or at least delay the onset of this problem,
which inevitably rapidly increases an individual’s cardiovascular risk.
Another interesting area is the detection of sub-clinical organ damage.
Initially this was largely confined to the detection of albuminuria or
elevated creatinine, which is not only important parameters for defining
renal function and progressive renal failure, but also for delineating
increased cardiovascular risk.
However, as methodology has improved the measurement of intimal medial
thickness and pulse wave velocity have become more generally acceptable and
with these the possibility of again defining cardiovascular risk at an
earlier time-point and with more accuracy.
Similarly, microcalcification of medium sized blood vessels using high
resolution CT scanning has been demonstrated to be important although of
course the technology necessary to measure this is much more limited.
However, the concept of earlier detection of vascular damage and the
recognition that it is extremely prognostically important means that we have
new ways of characterising the risk associated with patients and a fresh
impetus to interfere with blood pressure levels at a much earlier point to
prevent irreversible end-organ damage.
The third issue is the target level to be achieved
This has largely remained unchanged from 2003 with the target for the
majority of patients being 140/90mmHg or less. In patients at higher risk
with Type 2 diabetes and hypertension, this level is 130/80, which is now
extended to patients with previous history of stroke or evidence of renal
The importance of detecting and treating hypertension cannot be
overestimated — effective treatment of hypertension reduces the risk of
developing stroke by more than 40% with almost immediate impact and on
coronary artery disease, over a period of several years the risk will be
reduced by more than 20%. This increasing healthcare problem needs to be
tackled promptly and efficiently in an ever enlarging cohort of asymptomatic
1. 2007 Guidelines for the Management of Arterial Hypertension.
European Heart Journal. doi:10.1093/eurheartj/ehm236
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