European recommendations on arterial hypertension

After a detailed review of the new recommendations for the diagnosis and treatment of hypertension, I would like to note several fundamentally new positions, as well as those provisions that have gone down in history.
Blood pressure level and diagnosis of hypertension
The key position is the definition and classification of blood pressure levels (Table 1), which has remained practically the same. At the same time, such definitions of hypertension by blood pressure level as mild, moderate and severe, which can be incorrectly interpreted in comparison with the general cardiovascular risk, are completely excluded from it. Experts considered it inappropriate to introduce such a category of blood pressure as prehypertension, according to the recommendations of the Joint National Committee of the USA in 2003 [3].
In the diagnostic plan, blood pressure numbers are specified for diagnosing hypertension depending on the place and method of measurement at a doctor's appointment, independently at home and according to daily monitoring data (Table 1). For the first time, together with the already known phenomenon of "white coat hypertension" or "isolated office hypertension" ; for "isolated ambulatory hypertension" ; the concept of "masked hypertension" is introduced, in which elevated BP numbers are registered only at home. New sections have been introduced on the assessment of blood pressure dynamics during stress tests and its significance, as well as the need to determine central blood pressure.
Risk stratification
Elevated blood pressure is one of the main independent risk factors for the development of stroke and coronary heart disease (CHD), as well as cardiovascular complications: myocardial infarction (MI) and heart failure [1,2].
One of the main provisions of the recommendations is the risk stratification of complications, or the determination of the prognosis, taking into account which the patient's treatment strategy is designed. The list of risk factors (RF), which were already taken into account earlier, was supplemented by fasting hyperglycemia and impaired glucose tolerance test; the requirements for the definition of dyslipidemia have increased and, very symptomatically, an elevated level of C-reactive protein (CRP) has been disavowed as a prognostic factor. The section "Target organ damage" has been changed to the section "Subclinical organ damage". Among these markers, determinations of the humeral index (<0.9) and pulse wave speed (>12 m/s) appear for the first time.
Metabolic syndrome is mentioned because it is a tangle of FR, often associated with elevated blood pressure and significantly increasing cardiovascular risk. However, it is not concluded that it is a pathogenetic entity. The list of renal markers of damage to this organ has been expanded to include determination of creatinine clearance according to the Cockroft-Gault formula or glomerular filtration rate according to the MDRD formula. Microalbuminuria is now considered an essential component of the assessment of organ damage because its determination is a simple and relatively inexpensive method. Concentric myocardial hypertrophy has been identified as a structural cardiac parameter that significantly increases cardiovascular risk. It is recommended whenever possible to detect multiple organ involvement (eg, heart, blood vessels, kidney, and brain), as multiorgan involvement is associated with the worst prognosis.
Determination of organ lesions is recommended not only before the start of treatment (to stratify the initial risk), but also in its process to monitor the effectiveness of interventions (regression of left ventricular myocardial hypertrophy or reduction of microalbuminuria as indicators of protection) (Table 2).
For the first time, it is noted that there is reason to consider elevated heart rate (HR) as a HR because there is considerable evidence of its association with both the risk of cardiovascular morbidity and mortality and all-cause mortality. There is evidence that elevated heart rate increases the risk of developing new cases of hypertension and is often associated with metabolic disorders and metabolic syndrome. However, due to the rather wide range of accepted limits of normal rhythm (60-90 beats/min), it is currently difficult to determine its cut-off value for increasing the accuracy of general cardiovascular risk stratification.
For the first time, for practical purposes, a list of basic diagnostic elements is proposed for the classification of persons in the category of high and very high risk (Table 3). It should be noted that multiple RAs, diabetes, or organ damage inevitably place an individual with hypertension and even high-normal BP in the high-risk category.
Risk factors, subclinical organ damage and established cardiovascular and renal diseases in combination with blood pressure levels form the core of assessing the severity of hypertension, determining the prognosis and the intensity of treatment measures in the form of a risk stratification table (Table 2). In this table, some characteristics in the first part (FR, organ lesions and diseases) have been changed and for the first time a dotted line indicates how the definition of hypertension can vary depending on the severity of the overall cardiovascular risk.
Along with the previously used indices (Framinghamsky, SCORE), a simpler table is introduced, in which the availability, prognostic value and cost of various methods and indicators are evaluated on a 4-point scale (Table 3).
Antihypertensive therapy:
goal and target BP level
In the section on the therapeutic management of patients with hypertension, the main attention is focused on such aspects as the goals of treatment, levels of blood pressure reduction, the choice of drug classes, and the peculiarities of the management of certain groups of patients. Of great practical importance is the provision of how quickly antihypertensive therapy should be initiated (Table 4). The immediate prescription of drugs or observation of the patient in the conditions of compliance with recommendations for lifestyle modification (non-drug treatment) depends not only (even not so much) on the BP level, but mainly on the degree of cardiovascular risk.
The goal of treating patients with hypertension and ways to achieve it are formulated as follows:
- the primary goal in the treatment of hypertension is the maximum reduction of the overall risk of cardiovascular diseases in the distant period;
- achieving the goal requires control over elevated blood pressure per se, and even correction of all reversible risk factors;
- Blood pressure should be reduced to at least <140/90 mm Hg. and to lower values, if tolerated, in all patients with hypertension;
– the target blood pressure should be maintained <130/80 mm Hg. in patients with diabetes and in patients with high or very high risk, as well as with associated conditions (stroke, MI, renal dysfunction, proteinuria);
- reduction of systolic blood pressure <140, and especially <130 mm Hg, even with combined therapy, can be a difficult task, especially in the elderly, in patients with diabetes and in general in patients with cardiovascular diseases;
- to achieve the target blood pressure, antihypertensive therapy should be prescribed before the appearance of significant damage to the cardiovascular system.
The new target blood pressure level for patients with coronary heart disease is attracting attention - less than 130/80 mm Hg. [1]. More recently, lowering and maintaining blood pressure at <140/90 mm Hg was recommended for people suffering from hypertension on the background of coronary heart disease, and blood pressure <130/80 mm Hg for concomitant diabetes and renal failure. [2]. Recently, there are more and more data that the further reduction of blood pressure in the majority of patients with stable coronary artery disease can affect the prognosis of this disease [4]. The importance of blood pressure control in patients with coronary heart disease was found in the post-hoc analysis of data from the INVEST study [5]. It was shown that, regardless of the type of treatment, in patients with arterial hypertension in combination with coronary heart disease, the frequency of cardiovascular events decreased dramatically as BP reduction was achieved and was significantly lower in individuals with controlled BP compared to those without such control. More than 7,064 hypertensive patients with coronary heart disease were included in the EUROPA study, which accounted for 58% of the entire population of people in this study - patients with a blood pressure level >140/90 mm Hg. [6]. This group of patients with CAD on the background of hypertension, randomized to receive perindopril 8 mg, continued to take previously prescribed antihypertensive drugs (62% b-blockers and 31% calcium antagonists). In this study, perindopril 8 mg reduced blood pressure to 128/78 mmHg. and significantly reduced the risk of cardiac complications.
The new recommendations state that when the initial blood pressure level is in the range of 130/139–85/89 mm Hg, the decision to prescribe antihypertensive therapy is tied to the level of general risk in this patient [1]. In the case of diabetes, the presence of a history of cerebrovascular disease, atherosclerotic disease of the coronary (CHD) or peripheral arteries, the use of antihypertensive therapy was associated with a decrease in fatal and non-fatal cardiovascular complications in several studies (PROGRESS, HOPE). Since patients with coronary artery disease are considered to be at high risk of developing complications, more careful control of the blood pressure level or prescribing drugs already at a normal blood pressure level can provide additional benefits in prevention. I would like to note that in the studies listed above, mainly ACE inhibitors (ramipril and perindopril) were used. It can be assumed with a high degree of confidence that the use of these drugs for a greater reduction in blood pressure (<130/80 mm Hg) allows to obtain the maximum vasoprotective effect in patients with coronary artery disease in combination with arterial hypertension. Recently, on a large group of patients with hypertension and coronary artery disease, in two large Russian studies (PREMIERA and PRIVILEGE), it was shown that the addition of perindopril to the basic treatment contributes not only to a significant decrease in blood pressure (from 159/95 to 126/79 mm Hg ), but also improvement of the clinical condition [7,8]. This provision of the recommendations on hypertension is in accordance with the principles of management of patients with stable angina pectoris in terms of optimal prevention of complications [9]. As recently shown by new large epidemiological programs, including the international REACH, with a high prevalence of coronary artery disease in patients with hypertension, blood pressure control is clearly insufficient - according to various estimates, only 40–60% of patients with hypertension [10,11].
Antihypertensive therapy:
drug selection
The main benefits of antihypertensive treatment are due to the reduction of blood pressure as such (per se). Five major classes of antihypertensive drugs: thiazide diuretics, calcium channel blockers, ACE inhibitors, angiotensin receptor antagonists, and β-blockers are suitable for initiating and maintaining antihypertensive treatment, either alone or in combination. b-blockers, especially in combination with thiazide diuretics, should not be used in patients with metabolic syndrome or at high risk of developing diabetes. Since many patients require the appointment of more than one drug, too much attention to the choice of the first drug is often not justified. However, there are many conditions in which certain drugs have been shown to be preferred over others, either as initial therapy or as part of a combination.
When choosing a specific drug or a combination of drugs, you should be guided by the following circumstances:
1. previous favorable or unfavorable experience of using this class of drugs in a specific patient;
2. the effect of drugs on cardiovascular risk factors according to the cardiovascular risk profile of a specific patient;
3. the presence of subclinical damage to target organs, clinically expressed cardiovascular diseases, kidney damage and diabetes, in which the use of some drugs can have a beneficial therapeutic effect, while others do not;
4. the presence of other disorders that may limit the use of certain classes of antihypertensive drugs;
5. the possibility of interaction with other drugs as part of combined therapy;
6. the price of drugs for both a specific patient and the health care system, but price considerations should not dominate the effectiveness, tolerability and protective characteristics of a specific patient.
As before, increased attention should be paid to the side effects of drugs, since they are the most important reason for refusal of treatment (lack of adherence to treatment). With regard to specific patients, the drugs may be different in terms of the development of undesirable phenomena. The BP-lowering effect should last for 24 hours. This can be monitored during a visit to the doctor or at home before the next dose of the drug or with the help of ambulatory (daily) determination of blood pressure. Preference should be given to drugs with an BP-lowering effect within 24 hours after a single dose. Such a simple scheme of drug use increases adherence to treatment.
Thus, the new recommendations for the diagnosis and treatment of hypertension of the EOAG/EOC of 2007 contribute to the implementation of the experience accumulated and gained in recent years on the optimal management of this most common disease of modern civilization in broad clinical practice, which means increasing the effectiveness of treatment and improving the prognosis.