"Adverse events [leads to] more discontinuation of treatment, and there is now evidence that discontinuation is closely related to an increase in events," said Dr. Mancia, professor of medicine at the University of Milan and cochair of the ESC hypertension task force. "There is a remarkable relationship between longer time taking antihypertensive drugs and cardiovascular protection."
"We were probably too radical in the previous guidelines" in setting a target systolic pressure at less than 130 mm Hg, said Dr. Renata Cífková, professor and head of preventive cardiology at Thomayer Teaching Hospital in Prague and a member of the ESC hypertension panel. "We saw that this was not evidence based. When we reviewed the same studies and also included the newer studies, like ACCORD, it basically confirmed our new blood pressure targets." Another advantage is that patients and physicians "will feel more comfortable with these goals," both in their achievability and by producing fewer adverse events," she said in an interview.
"This is the first major change in the hypertension guidelines for a number of years," the first full update since 2007, said Dr. Bryan Williams, professor and chairman of medicine at University College, London. "The data presented showed that, while there is indisputable evidence to lower pressures below 150/90 mm Hg, and strong evidence to lower below 140/90 mm Hg, there is limited or no evidence to recommend lowering pressures to below 130/80 mm Hg, and in some situations there is evidence for a signal of harm," said Dr. Williams. "The new guidelines simplify the target, a blood pressure of less than 140 mm Hg for everyone, regardless of their level of risk."
"The change in target means that ‘the lower the better’ is no longer true. This will reduce the number of drugs that patients receive and will avoid some adverse effects," said Dr. Nikolaus Marx, professor and director of medicine at Aachen (Germany) University Hospital.
Other groups came first
As Dr. Smith noted, the ESC is not the first medical group to scale back aggressive blood pressure targets for patients with diabetes or chronic kidney disease, but it may be the first major cardiology society to do so. Last year, the Kidney Disease Improving Global Outcomes foundation issued guidelines for hypertension management in patients with chronic kidney disease (Kidney International Supplement 2012;2:340-414). The expert panel recommended a target pressure of 140/90 mm Hg or below for patients with chronic kidney disease with or without diabetes as long as their daily urine albumin remained below 30 mg. For patients with more severe albuminuria, the panel recommended a target of 130/80 mm Hg or less for all chronic kidney disease patients regardless of their diabetes status.
Earlier this year, the American Diabetes Association published its Standards of Medical Care in Diabetes–2013, which set a target blood pressure for patients with diabetes at less than 140/80 mm Hg (the ESC set a diastolic pressure target of less than 85 mm Hg) (Diabetes Care 2013;36:S11-S66).
Other changes in the ESC guidelines
The ESC guidelines include some other notable changes (Euro. Heart J. 2013;34:2159-219):
• The basic systolic blood pressure goal for elderly patients, defined as 65 years or older, was set as less than 150 mm Hg. The goal can lower to less than 140 mm Hg for "fit elderly patients" younger than 80 years old if treatment is well tolerated.
• The guidelines place new emphasis on using some method for out-of-office blood pressure measurement – either ambulatory or home-based blood pressure measurement – for patients suspected of having either false-positive office-based blood pressure measurements (white coat hypertension) or false-negative office blood pressure levels (masked hypertension).
• The universe of first-line antihypertensive medications was whittled down to four: thiazide diuretics, calcium channel blockers, ACE inhibitors, and angiotensin-receptor blockers. Although the new guidelines call beta-blockers a "cornerstone" of treatment for patients with coronary heart disease and tachyarrhythmias, including atrial fibrillation, they are no longer seen as first-line agents for patients without these coexisting cardiac diseases or for young patients.
• A section on treating hypertension in young adults encourages applying the below 140/90 mm Hg target to these patients as well after a reasonable attempt at lifestyle intervention only.
• An updated approach to managing gestational hypertension and preventing preeclampsia includes use of prophylactic aspirin by women at moderate or high risk of preeclampsia, and treating pregnant women to a blood pressure of less than 150/95 mm Hg if pressure this high is persistent, or to a target of less than 140/90 mm Hg in women with gestational hypertension, symptoms, or subclinical organ damage.