2018 ESC/ESH Guidelines for the management of arterial hypertension.

Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Hector Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.

https://www.zora.uzh.ch/id/eprint/162475/1/document.pdf

2018 ESC/ESH Guidelines for the management of arterial hypertension : The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension

Authors/Task Force Members: Bryan Williams* (ESC Chairperson) (UK), Giuseppe Mancia* (ESH Chairperson) (Italy), Wilko Spiering (The Netherlands), Enrico Agabiti Rosei (Italy), Michel Azizi (France), Michel Burnier (Switzerland), Denis L. Clement (Belgium), Antonio Coca (Spain), Giovanni de Simone (Italy), Anna Dominiczak (UK), Thomas Kahan (Sweden), Felix Mahfoud (Germany), Josep Redon (Spain), Luis Ruilope (Spain), Alberto Zanchetti (Italy), Mary Kerins (Ireland), Sverre E. Kjeldsen (Norway), Reinhold Kreutz (Germany), Stephane Laurent (France), Gregory Y. H. Lip (UK), Richard McManus (UK), Krzysztof Narkiewicz (Poland), Frank Ruschitzka (Switzerland), Roland E. Schmieder (Germany), Evgeny Shlyakhto (Russia), Costas Tsioufis (Greece), Victor Aboyans (France), Ileana Desormais (France)

[2018 ESC/ESH Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH)].

A comparison of the contribution of systolic versus diastolic blood pressure to risk of coronary heart disease and the role of mean arterial pulse pressure and systolic lability have been examined prospectively in 5,127 men and women during 14 years of biennial follow-up studies. Similar gradients of risk of subsequent coronary heart disease were observed whether persons were classified by their systolic or diastolic pressure, and no “safe” or critical level could be identified. Assessment of the net effect of each, employing discriminant analysis, indicated a stronger association of systolic than diastolic pressure with risk of coronary heart disease. Neither the systolic and diastolic pressure measurements in combination nor the pulse pressure and the mean arterial pressure measurements alone discriminated better than the systolic measurement alone. Systolic lability did not predict incidence of coronary heart disease independently of the associated level of blood pressure. There was a trend of declining relative importance of diastolic and a corresponding increase in the importance of systolic pressure with advancing age. Only in those under 45 was diastolic pressure predominant. The level of casually obtained blood pressure was a good predictor of coronary heart disease. The current practice of assessing the importance of blood pressure at all ages largely on the basis of diastolic pressure and the commonly held view concerning the innocuous nature of an elevated level of systolic pressure in the elderly requires reevaluation.

Systolic Versus Diastolic Blood Pressure and Risk of Coronary Heart Disease???The Framingham Study

Summary


Aim: To determine the effects of imperfect adherence (i.e. occasionally missing prescribed doses), and the influence of rate of loss of antihypertensive effect during treatment interruption, on the predicted clinical effectiveness of antihypertensive drugs in reducing mean systolic blood pressure (SBP) and cardiovascular disease (CVD) risk.



Method:  The effects of imperfect adherence to antihypertensive treatment regimens were estimated using published patterns of missed doses, and taking into account the rate of loss of antihypertensive effect when doses are missed (loss of BP reduction in mmHg/day; the off-rate), which varies between drugs. Outcome measures were the predicted mean SBP reduction and CVD risk, determined from the Framingham Risk Equation for CVD.



Results:  In patients taking 75% of prescribed doses (typical of clinical practice), only long-acting drugs with an off-rate of ∼1 mmHg/day were predicted to maintain almost the full mean SBP-lowering effect throughout the modelled period. In such patients, using shorter-acting drugs (e.g. an off-rate of ∼5–6 mmHg/day) was predicted to lead to a clinically relevant loss of mean SBP reduction of > 2 mmHg. This change also influenced the predicted CVD risk reduction; in patients with a baseline 10-year CVD risk of 27.0% and who were taking 75% of prescribed doses, a difference in off-rate from 1 to 5 mmHg/day led to a predicted 0.5% absolute increase in 10-year CVD risk.



Conclusions:  In patients who occasionally miss doses of antihypertensives, modest differences in the rate of loss of antihypertensive effect following treatment interruption may have a clinically relevant impact on SBP reduction and CVD risk. While clinicians must make every effort to counsel and encourage each of their patients to adhere to their prescribed medication, it may also be prudent to prescribe drugs with a low off-rate to mitigate the potential consequences of missing doses.

Effects on blood pressure and cardiovascular risk of variations in patients' adherence to prescribed antihypertensive drugs: role of duration of drug action

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Effects on blood pressure and cardiovascular risk of variations in patients' adherence to prescribed antihypertensive drugs: role of duration of drug action