Summary of the European Society of Hypertension 2013 Hypertension Guidelines presented during the Eighth Hypertension and Cardiovascular highlight session in Bahrain on Sept. 11th 2013.

1. 1
Jafar Al-Said, M.B. CHb. MD. FASN. FACP.
Nephrology and Internal Medicine Consultant
Bahrain Specialist Hospital

2. Guideline working group
ESH Scientific Council: Josep Redo´n (President) (Spain), Anna Dominiczak (UK), Krzysztof Narkiewicz
(Poland), Peter M. Nilsson (Sweden), Michel Burnier (Switzerland), Margus Viigimaa (Estonia), Ettore Ambrosioni
(Italy), Mark Caufield (UK), Antonio Coca (Spain), Michael Hecht Olsen (Denmark), Roland E. Schmieder
(Germany), Costas Tsioufis (Greece), Philippe van de Borne (Belgium).
ESC Committee for Practice Guidelines (CPG): Jose´Luis Zamorano (Chairperson) (Spain), Stephan Achenbach
(Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), Hector Bueno (Spain), Veronica Dean
(France), Christi Deaton (UK), Cetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai
(Israel), Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh
(Belgium), Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK), Massimo
F. Piepoli (Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera
(Poland), Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland).
Document Reviewers: Denis L. Clement (ESH Review Co-ordinator) (Belgium), Antonio Coca (ESHReview Co-
ordinator) (Spain), Thierry C. Gillebert (ESC Review Co-ordinator) (Belgium), Michal Tendera (ESC Review Co-
ordinator) (Poland), Enrico Agabiti Rosei (Italy), Ettore Ambrosioni (Italy), Stefan D. Anker (Germany), Johann
Bauersachs (Germany), Jana Brguljan Hitij (Slovenia), Mark Caulfield (UK), Marc De Buyzere (Belgium), Sabina De
Geest (Switzerland), Genevie`ve Anne Derumeaux (France), Serap Erdine (Turkey), Csaba Farsang (Hungary),
Christian Funck-Brentano (France), Vjekoslav Gerc (Bosnia & Herzegovina), GiuseppeGermano` (Italy), Stephan
Gielen (Germany), Herman Haller (Germany), Arno W. Hoes (Netherlands), Jens Jordan (Germany), Thomas Kahan
(Sweden), Michel Komajda (France), Dragan Lovic (Serbia), Heiko Mahrholdt (Germany),Michael Hecht Olsen
(Denmark), Jan Ostergren (Sweden), Gianfranco Parati (Italy), Joep Perk (Sweden), Jorge Polonia (Portugal), Bogdan
A. Popescu (Romania), Zeljko Reiner (Croatia), Lars Ryde´n (Sweden), Yuriy Sirenko (Ukraine), Alice Stanton
(Ireland), Harry Struijker-Boudier (Netherlands), Costas Tsioufis (Greece), Philippe van de Borne (Belgium),
Charalambos Vlachopoulos (Greece), Massimo Volpe (Italy), David A. Wood (UK). Other entities: ESC Associations:
Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Association
for Cardiovascular Prevention & Rehabilitation (EACPR), European Heart hythm Association (EHRA), ESC Working
Groups: Hypertension and the Heart, Cardiovascular Pharmacology and Drug Therapy, ESC Councils:
Cardiovascular Primary Care, Cardiovascular Nursing and Allied Professions, Cardiology Practice. 2

3. Presentation scheme
 Classification.
 BP Measurement.
 Patient Evaluation.
 BP targets.
 Management.
 Lifestyle.
 Medications.
 Management for specific groups.
3

4. Class of recommendations
4

5. Levels of Evidence
5

6. 6
Levels of Blood Pressure

7. Definition and Classification of BP
according to Office measurement.
7
140
90

8. Definition of HTN according to the
Office, ABMP and Home BP
8

9. BP measurements
 Office.
 ABPM.
 Home.
9

10. Office BP measurement
 Rest on a chair for 3-5 min.
 Two readings 1-2 min. apart.
 Adequate cuff size.
 Keep cuff at heart level.
 Korotkoff Phase I & V.
 Both arms measured on first visit.
 Consider standing BP in some patients.
10

11. Clinical indication for out of office BP measurement
 White coat HTN.
 Masked HTN.
 BP variability.
 Hypotension or over controlled BP.
 Resistant HTN.
Specific Indications for ABPM:
 Nocturnal dip.
 Confirm difference between home and office.
 BP variability.
11

12. ABPM
Ambulatory BP measurement
 24 hours.
 Regular daily life.
 Diurnal and Nocturnal.
 Measurements ever 15-30min.
 > 70% of recordings are satisfactory.
 In arrhythmia BP reading?
 Keep a diary for:
 Activities.
 Medications.
 Sleeping time.
 Symptoms.
12

13. ABPM
13

14. ABPM
Ambulatory BP measurement
 Better Correlation with Target Organ Damage.
 Stronger Correlation with Morbidity and Mortality.
Bliziotis IA, Destounis A, Stergiou GS. Home vs. ambulatory and office blood pressure
in predicting target organ damage in hypertension: a systematic review and meta-
analysis. J Hypertens 2012; 30:1289–1299.
1299.
Dolan E, Stanton A, Thijs L, Hinedi K, Atkins N, McClory S, et al. Superiority of
ambulatory over clinic blood pressure measurement in predicting mortality: the
Dublin outcome study. Hypertension 2005; 46:156–161.
Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, Mancia G. Prognostic
value of ambulatory and home blood pressures compared with office blood pressure
in the general population: follow-up results from the Pressioni Arteriose Monitorate e
Loro Associazioni (PAMELA) study. Circulation 2005; 111:1777–1783.
14

15. Home BP measurement
 More reflective of the individual daily BP.
 Normal Environment.
 Cheaper.
 More readings.
 Day by day variability.
 Reflect variation with daily activity.
Kikuya M, Ohkubo T, Metoki H, Asayama K, Hara A, Obara T, et al. Day-by-day
variability of blood pressure and heart rate at home as a novel predictor of
prognosis: the Ohasama study. Hypertension 2008; 52:1045–1050.
15

16. Home BP measurement
 Quite room.
 Sitting with back and arm support.
 5 min. rest.
 Two measurements 1-2 min. apart.
 Avoid wrist devises except for obese.
16

17. Home BP monitoring
 Better reflect Target organ damage.
 Stronger correlation with CV mortality and morbidity.
 Similar Prognostic significant as ABPM.
Gaborieau V, Delarche N, Gosse P. Ambulatory blood pressure monitoring vs. self-
measurement of blood pressure at home: correlation with target organ damage.
J Hypertens 2008; 26:1919–1927.
Bliziotis IA, Destounis A, Stergiou GS. Home vs. ambulatory and office blood
pressure in predicting target organ damage in hypertension: a systematic review and
meta-analysis. J Hypertens 2012; 30:1289–1299.
17

18. Cardiovascular risk Assessment
18

19. Estimation of CV Risk
 Do we measure CV risk?
 Which scoring system we should use?
 Is the scoring applicable to our population?
19

20. Stratification of total CV risk in HTN patients
20

21. Cardiovascular Risk Estimation
21

22. Framingham scoring system
22

23. Framingham scoring system
23

24. Is there any regional CV scoring system ????
24

25. 25

26. CVD Risk Assessment
Recommendations Class Level
 CV risk stratification. I B
 Target Organ screening. IIa B
 CV risk determines therapy. I B
26

27. Hypertension Patient Evaluation
27

28. Medical History
1- Duration and levels of BP.
2- Secondary causes of HTN.
3- CV risk factors.
4-Target Organ Damage.
5-Drugs and compliance.
28

29. Physical Exam
Looking for signs of:
 Secondary HTN.
 Target Organ Damage.
 Obesity.
 Carotid, abdominal or femoral bruit.
 Difference in BP:
 > 20 mmHg Systolic.
>10 mmHg diastolic.
29

30. History and Physical examination recommendation
Recommendations Class Level
Complete medical history and physical exam I C
Family history I B
Office BP I B
Office BP reading at two different visits I C
Heart rate identification I B
Confirm Dx by ABPM and Home BP II a B
Select ABPM or Home BP II b C
30

31. Laboratory work up for HTN
31

32. Initial Recommended Labs
 Hb &/or HCT.
 FBS.
 Na & K.
 S. Creatinine, eGFR.
 Uric acid.
 Lipid profile.
 UA
 EKG.
32

33. Additional lab work based on history and physical exam
 HbA1c
 Quantitative Proteinuria.
 ABPM.
 ECHO.
 24h Holter EKG.
 Carotid Doppler.
 Peripheral Doppler.
 Pulse wave velocity.
 Ankle – Brachial index.
 Fundoscopy.
33

34. Predictive value, availability and Cost effectiveness of
markers of organ damage.
34

35. Asymptomatic Organ damage that influence
prognosis
 Pulse pressure in elderly > 60mmHg.
 LVH on EKG or ECHO.
 Carotid wall thickness (IMT > 0.9mm or plaque).
 Carotid –femoral PWV > 10 m/s.
 Ankle – brachial index > 0.9.
 CKD with eGFR 30-60ml/min/1.73m2.
 Microalbuminuria ( or alb./Cr. %) 30-300mg/24 hours.
35

36. Recommendation level for investigation to find
asymptomatic organ damage
Recommendations Class Level
EKG I B
Holter EKG II a C
Stress EKG I C
ECHO II a B
Carotid Doppler II a B
Carotid Femoral PWV II a B
Ankle Brachial index II a B
S.Cr & eGFR I B
Urine protein dipstick I B
Spot urine for microalbumine I B
Fundoscopy in resistant HTN II a C
Fundoscopy in mild-moderate HTN III C
Brain MRI or CT II b C
36

37. 37

38. Aim for treating Blood pressure
Reduce cardiovascular mortality and morbidity.
 Fatal and non fatal Stroke.
 MI.
 Heart Failure.
 Renal failure.
38
It is not treating the numbers
Devereux RB, Wachtell K, Gerdts E, Boman K, Nieminen MS, Papademetriou V, et al. Prognostic significance of
left ventricular mass change during treatment of hypertension. JAMA 2004; 292:2350– 2356.
Ibsen H, Olsen MH, Wachtell K, Borch-Johnsen K, Lindholm LH, Mogensen CE, et al. Reduction in albuminuria
translates to reduction in cardiovascular events in hypertensive patients: losartan intervention forendpoint
reduction in hypertension study. Hypertension 2005; 45:198–202.
Sytkowski PA, D’Agostino RB, Belanger AJ, Kannel WB. Secular trends in long-term sustained hypertension,
long-term treatment and cardiovacsular mortality. The Framngham Heart Study 1950 to 1990. Circulation 1996;
93:697–703.

39. Who and how do we treat HTN?
39

40. Recommendation for BP Goals in HTN patients
Recommendations Class Level
Goal with Systolic <140mmHg:
- with low – moderate CV risk I B
- DM I A
- previous stroke or TIA II a B
- CHD II a B
- DM or non DM with CKD II a B
Elderly SBP > 160 reduce SBP:
- < 80y to 140-150mmHg I A
- >80y to 140-150mmHg I B
Fit elderly <80y keep SBP <140mmHg II b C
Diastolic BP <90mmHg for all & for DM <85mmHg.
I A
40

41. Lifestyle modification for treating
HTN
41

42. Lifestyle changes
 Equivalent to monotherapy.
 Adherence is a major factor.
 Smoking cessation.
 Regular exercise. 3/2.4mmHg
 Salt reduction.
 Wt. reduction. 0.7mmHg/kg
 BMI < 25 kg/m2.
 Waist men < 108 cm in men. women <88cm
 Reduce Alcohol. 1/0.7mmHg.
men <140 gm/ wk. women 80 gm/wk in females.
 Do your best to convince your patient.
42

43. Recommendation for Lifestyle and level of evidence
Recommendations Class Level
Low salt 5-6gm/day I A
Moderate Alcohol I A
DASH diet I A
Decrease Wt. I A
30min exercise 5-7 days I A
Advice to stop smoking I A
43

44. Medication treatment
44

45. Recommendation for Antihypertensive drug therapy
Recommendations Class Level
HTN Grade 2 & 3. I A
HTN Grade I & high CV risk. I B
HTN Grade I not improve after life style. II a B
Elderly with SBP > 160mmHg. I A
Elderly (<80y) SBP 140-159mmHg. II b C
High Normal. III A
Young with isolated high systolic. III A
45

46. Pharmaceutical treatment
 Reducing BP rather than selection of drug is most
important.
 ANY drug group could be used.
 Diuretics.
 Beta blockers.
 RAAS.
 Certain therapeutic indications are more favorable.
46

47. Beta blockers
 Total mortality and CV events: less favorable than Ca blockers.
 Stroke: less favorable than Ca blockers and RAS.
 Recent MI and Heart failure: Highly effective.
 Preventing Coronary outcome: Equally effective.
 Reducing central pressure and pulse pressure: Lower effect
 Regressing target organ as LVH, Aortic stiffness,
small art. remodeling, & carotid IMT. Less effective
 More side effects.
47

48. Beta blockers
Wiyonge CS, Bradley HA, Volmink J, Mayosi BM, Mbenin A, Opie LH. Cochrane
Database Syst Rev 2012, Nov 14,11:CD002003.doi.
Bradley HA, Wiyonge CS, Volmink VA, Mayosi BM, Opie LH. How strong is the
evidence for use of beta-blockers as first line therapy for hypertension? J Hypertens
2006; 24:2131–2141.
Williams B, Lacy PS, Thom SM, Cruickshank K, Stanton A, Collier D,et al.
Differential impact of blood pressure-lowering drugs on central aortic pressure and
clinical outcomes: principal results of the Conduit Artery Function Evaluation
(CAFE) study. Circulation 2006; 113:1213–1225.
Boutouyrie P, Achouba A, Trunet P, Laurent S. Amlodipine-valsartan combination
decreases central systolic blood pressure more effectively than the amlodipine-
atenolol combination: the EXPLOR study. Hypertension 2010; 55:1314–1322
48

49. Beta blockers
 Increased wt.
 Increase incidence of DM.
49
Sharma AM, Pischon T, Hardt S, Kruz I, Luft FC. Hypothesis: Betaadrenergic
receptor blockers and weight gain: A systematic analysis. Hypertension 2001;
37:250–254.
Elliott WJ, Meyer PM. Incident diabetes in clinical trials of antihypertensive
drugs: a network meta-analysis. Lancet 2007; 369:201–207.

50. Beta blockers
Carvidelol, Nebivolol and Celiprolol have favorable
metabolic profile.
Reduce Mortality in COPD patients.
50
Rutten FH, Zuithoff NP, Halk F, Grobbee DE, Hoes AW. Beta-Blockers may reduce
mortality and risk of exacerbations in patients with chronic obstructive pulmonary
disease. Arch Intern Med 2010;170:880–887.
Kampus P, Serg M, Kals J, Zagura M, Muda P, Karu K, et al. Differential effects of
nebivolol and metoprolol on central aortic pressure and left ventricular wall
thickness. Hypertension 2011; 57:1122–1128.
Bakris GL, Fonseca V, Katholi RE, McGill JB, Messerli FH, Phillips RA et al.
Metabolic effects of carvedilol vs metoprolol in patients with type 2 diabetes
mellitus and hypertension: a randomized controlled trial. JAMA 2004; 292:2227–
2236.

51. Diuretics
 Classified as the first choice since 1977 JNC I.
 ACCOMPLISH: inferior to Ca blocker in combinaiton
with ACE inh.
 Clorthalidon and Indapamide rather than HCTZ.
51
Report of the Joint National Committee on Detection, Evaluation and Treatment
of High Blood Pressure. A co-operative study. JAMA 1977;237:255–261.
Jamerson K, Weber MA, Bakris GL, Dahlof B, Pitt B, Shi V, et al. Benazepril plus
amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N
Engl J Med 2008; 359:2417–2428
Roush GC, Halford TR, Guddati AK. Chlortalidone compared with
hydrochlorothiazide in reducing cardiovascular events: systematic review and
network meta-analyses. Hypertension 2012; 59:1110–1117.

52. Diuretics
 Spironolactone favorable effect in heart failure and in
Primary hyperaldosteronism.
 Eplerinone is effective in heart failure.
52
Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. The effect of
spironolactone on morbidity and mortality in patients with severe heart failure.
Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999; 341:709–717.
Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, et al.,
EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure and mild
symptoms. N Engl J Med 2011; 364:11–21.

53. Ca channel Blockers
 Superior to other agents in prevention stroke.
 Similar to other agents in prevention of heart failure.
 Superior to Betablocker in reducing carotid
atherosclerosis and LVH.
53
Verdecchia P, Reboldi G, Angeli F, Gattobigio R, Bentivoglio M, Thijs L, et al.
Angiotensin-Converting Enzyme Inhibitorsand Calcium Channel Blockers for
Coronary Heart Disease and Stroke Prevention. Hypertension 2005; 46:386–392
Poole-Wilson PA, Lubsen J, Kirwan BA, van Dalen FJ, Wagener G, Danchin N, et al.
Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients
with stable angina requiring treatment (ACTION trial): randomised controlled trial.
Lancet 2004; 364:849–857.
Fagard RH, Celis H, Thijs L, Wouters S. Regression of left ventricular mass by
antihypertensive treatment: a meta-analysis of randomized comparative studies.
Hypertension 2009; 54:1084–1091.

54. ACE inh and ARB
 ACE inh and ARB are similar in CV outcome
including major cardiac outcome, stroke and all
cause death.
 No evidence of association of ARB with Cancer.
 Combination is contraindicated.
54
Mann JF, Schmieder RE, McQueen M, Dyal L, Schumacher H, Pogue J, et al. Renal outcomes with
telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a
multicentre, randomised, double-blind, controlled trial. Lancet 2008; 372:547–553.
ARB Trialists collaboration. Effects of telmisartan, irbesartan, valsartan, candesartan and
losartan on cancers in 15 trials enrolling 138 769 individuals. J Hypertens 2011; 29:623–
635.

55. Renin Inh.
 Useful as single agent or in combination.
 No studies on mortality and morbidity in HTN.
 Combination with other RAS contraindicated because
of the high CV morbidity shown in ALTITUDE trial.
(Aliskiren Trial in Type 2 Dm using Cardio-renal Endpoint)
No beneficial effect on mortality or hospitalization for
heart failure.
55
Parving HH, Brenner BM, McMurray JJV, de Zeeuw D, Haffer SM, Solomon SD. Cardiorenal endpoints in a
trial of aliskiren for type 2 diabetes. N Engl J Med 2012; 367:2204–2213.
Gheorghiade M, Bohm M, Greene SJ, Fonarow GC, Lewis EF, Zannad F, et al., for the ASTRONAUT
Investigators and Co-ordinators. Effect of Aliskiren on Postdischarge Mortality and Heart Failure
Readmissions Among Patients Hospitalized for Heart Failure. The ASTRONAUT Randomized Trial. JAMA
2013; 309:1125–1135.

56. Contraindication of Anti Hypertension medications
56

57. Drugs preferred in specific conditions
57

58. Treatment diagram
58

59. Monotherapy versus combination
59

60. Preferable Combinations
60

61. Treatment Strategies and choice for therapy
Recommendations Class Level
Any drug could be started I A
Target organ specific treatment II a C
Combination drugs for high BP and CV II b C
RAAS combinations III A
Consider combination II a C
Fixed tab combination II b B
61

62. Hypertension in diabetic patients
Recommendations Class Level
 Start drug treatment with BP >140 mmHg I A
 Systolic BP Goal <140 mmHg I A
 Diastolic BP Goal <85 mmHg I A
 RAS preferred for Proteinuria otherwise any drug could be used.
I A
 Therapy should consider comorbid condition I C
 Double RAS blockade. III B
62

63. Hypertension in Metabolic syndrome patients
Recommendations Class Level
 Lifestyle changes I B
 RAS and Ca blocker are preferable,
Betablocker are only supplementary. II a C
 Use medication with BP >140/90 mmHg I B
 Medication not needed in high normal BP. III B
63

64. White Coat and Masked Hypertension
Recommendations Class Level
Lifestyle modification if no CV risk II a C
Drug treatment if with higher CV risk II b C
Medication and lifestyle in masked HTN II a C
64

65. Other Subpopulation
Elderly.
Women.
Peripheral vascular disease.
Nephropathy.
IHD.
Stroke.
Resistant Hypertension.
65

66. Treating other CV Risk factors
 Recommendations Class Level
 Statin:
 With moderate risk LDL <3 (115) I A
 With CHD LDL < 1.8 ( 70) I A
 Antiplatelet with Cv events I A
 ASA in Cv with CKD or Cv risk II a B
 ASA not recommended with low- moderate risk III A
 HBA1C < 7 in DM I B
 Elderly fragile DM HbA1C 7-8 II a C
66

67. Conclusion for 2013 guidelines
 Grade the level of the scientific evidence.
 Enforce out of office BP monitoring.
 Cv risk assessment in the approach to
patients.
 Emphasizing the significance of Target
organ damage.
 Target BP < 140/90mmHg .
67

68. Conclusion for 2013 guidelines
 Liberal approach to initial therapy.
 No drug ranking purpose for first line.
 Revised two drug combination priority.
 Address HTN in certain subpopulation.
68

69. 1- When Can we see a Gulf or Middle East
CVD risk scoring or HTN guidelines ???
2- Why, all the times, we are following
other countries and when can we depend
on ourselves ???
69
Take home questions?

70. www.eshonline.org
Mancia et. al, 2013 ESH/ESC Guidelines for the management of arterial
hypertension. Journal of Hypertension. Vol31. No. 7 . July 2013 70

71. See you in Athens!
www.hypertension2014.org

72. See you in Athens!
www.hypertension2014.org
Topics:
The Burden of Hypertension in the Gulf and Middle East
Countries.
Cardiovascular Risk factors in the Gulf region.
Do we need regional Hypertension guidelines?
Cardiovascular Mortality and Morbidity in the Middle East
and the Gulf.
Gulf Hypertension and
Cardiovascular Session
Athens, Greece.