ASL di Milano, Direttore Servizio Educazione, all’Appropriatezza ed EBM, Via Ricordi, 1-20131 Milano, Italy
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The European Society of Hypertension-European Society of Cardiology Guidelines are the most comprehensive recommendations available. This review aims to discuss some new information and recurring problems in these guidelines.
The trend of the continuous lowering of treatment goals is finally reversed. New targets include the following: (1) hypertensive (adult) patients at low to moderate risk: blood pressure <140/90 mmHg; (2) elderly hypertensive patients: if fit and aged <80 years, systolic blood pressure <140 mmHg can be considered; in frail elderly patients, target should be adapted to individual tolerability. If aged >80 years, systolic blood pressure of 150 to 140 mmHg only should be considered if they are in good physical and mental condition (i.e. in frail elderly patients can be higher); (3) high-risk patients, with diabetes, cardiovascular disease or nephropathy: systolic blood pressure <140 mmHg because lower targets are not supported by valid evidence; and (4) high-normal blood pressure, even with organ damage and multiple risk factors: no drug treatment, only lifestyle changes.
Guidelines reaffirm that the main benefit of antihypertensive treatment is lowering of blood pressure and that the main drug classes are all suitable for the initiation and maintenance of treatment, either as monotherapy or in some combinations.
The approach to initial monotherapy is ‘liberal’, as usual. This happens without establishing priorities and so justifies, the common strategies employing the most expensive drugs and combinations. A cornerstone of this strategy is not to recognise the important differences between the most used but less efficacious hydrochlorothiazide, and the or thiazide-like such as diuretics and chlorthalidone and indapamide, which more often do not require adding a second (or third or fourth) drug to reach the target. This is more evident in current practice.
The new European Society of Hypertension-European Society of Cardiology Guidelines, after decades of increasingly aggressive target reductions, restore a unified target of <140/90 mmHg (and a much higher one for the elderly, but the guidelines continue to avoid a cost-effective approach in drug therapies, actually justifying the use of much more expensive strategies). One of the main mechanisms underlying this policy is to deny the superiority of thiazide-like diuretics.