The Specialist Forum Volume 13 No 11 November 2013 | Page 68

HYPERTENSION

Arterial hypertension:
new international guidelines
Dr Sharon Truter, Counselling Psychologist (Neuropsychology)

H

ypertension has been described as the ‘leading global risk for
mortality in the world’. Globally, the prevalence of hypertension
or high blood pressure (BP) is estimated to be between 30%45% in the general population, with a steep increase in older people.
According to the South African Hypertension Guideline 2011, approximately 10% of the population have hypertension.
The European Society of Hypertension (ESH) and the European
Society of Cardiology (ESC) released their new guidelines earlier this
year. Several significant changes to hypertension treatment have been
indicated. According to the new guidelines, ‘lifestyle changes are the
cornerstone for the prevention of hypertension’, including reduction of
salt (to roughly half the present levels) and alcohol, as well as maintaining a healthy body weight, regular exercise, and the elimination of
smoking. In addition, the guidelines highlight the lack of awareness of
the potential problems of hypertension amongst patients, with poor
long-term adherence to treatment, and the ‘inertia’ of doctors, who
don’t take appropriate action when confronted with patients with uncontrolled blood pressure.
The 2013 task force reviewed all relevant data since the last revision
(in 2007), with 18 specific diagnostic and therapeutic areas identified
as containing significant changes. A major development is the decision
to recommend a single systolic blood pressure target of 140 mmHg for
almost all patients. This contrasts with the 2007 version which recommended a 140/90 mmHg target for moderate to low risk patients, and
130/80 mmHg target for high risk patients. 
Other changes include:
• An increasing role for home blood pressure monitoring, alongside
ambulatory blood pressure monitoring.
• A greater emphasis on assessing the totality of risk factors for
cardiovascular and other diseases. For example, most people with
hypertension also have additional risk factors such as organ damage, diabetes and other cardiovascular risk factors. These need to
be considered together before initiating treatment, and during the
follow-up.
• Special emphasis on specific groups, for example diabetics, the
young, the elderly, and drug treatment of patients over 80 years.
Women are also considered separately, for example during pregnancy.  Special consideration is given to new treatments such as
renal denervation for resistant hypertension – which is described as
‘promising’, although more trials are called for.
• New guidance on how and when to take antihypertensive drugs. The
report indicated no treatment for high normal blood pressure, no
specific preference for single drug therapy, and an updated protocol
for drugs taken in combination.  The guidance takes a liberal attitude
to choice of first step drugs, noting the evidence that the beneficial
effect of hypertension depends largely on blood pressure lowering.
Rather than presenting a hierarchy of drugs (a generic first, second,
third choice and so on), the approach taken promotes individualised

treatment, for example to help physicians decide which drugs to give
in which clinical/demographic condition.

Relationship between BP, cardiovascular and
renal damage
The relationship between BP values, cardiovascular (CV) and renal
morbid- and fatal events has been addressed in a large number of observational studies. The results can be summarised as follows:
• Office BP bears an independent continuous relationship with the
incidence of several CV events [stroke, myocardial infarction, sudden
death, heart failure and peripheral artery disease (PAD)] as well as
of end-stage renal disease (ESRD).This is true at all ages and in all
ethnic groups.
• The relationship with BP extends from high BP levels to relatively low
values of 110–115 mmHg for systolic BP (SBP) and 70–75 mmHg for
diastolic BP (DBP). SBP appears to be a better predictor of events
than DBP after the age of 50 years, and in elderly individuals pulse
pressure (the difference between SBP and DBP values) has been reported to have a possible additional prognostic role. This is indicated
also by the particularly high CV risk exhibited by patients with an
elevated SBP and a normal or low DBP [isolated systolic hypertension (ISH)].
• A continuous relationship with events is also exhibited by out-ofoffice BP values, such as those obtained by ambulatory blood
pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). The relationship between BP and CV morbidity and
mortality is modified by the concomitance of other CV risk factors.
Metabolic risk factors are more common when BP is high than when
it is low.

Hypertension and total CV risk
The ESH/ECS guidelines emphasise that prevention of coronary heart
disease (CHD) should be related to quantification of total (or global) CV
risk. The concept is based on the fact that only a small fraction of the
hypertensive population has an elevation of BP alone, with the majority
exhibiting additional CV risk factors. In addition, when concomitantly
present, BP and other CV risk factors may potentiate each other, leading to a total CV risk factor that is greater than the sum of its individual
components.
The guideline also stresses that antihypertensive treatment strategies as well as others, should be individualised. High-risk patients often
require a combination of antihypertensive drugs with other therapies
such as aggressive lipid-lowering treatment.
Several computerised methods have been developed to estimate
total CV risk. These include for example the Systematic Coronary Risk
Evaluation model also known as HeartScore, which is available at
www.heartscore.org. The authors noted that these assessments have
limitations.

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November 2013 | Cardiology & Stroke Forum