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The 2018 ESC-ESH guidelines for the management of arterial hypertension leave clinicians facing a dilemma in half of the patients.Emmanuelle Vidal-Petiot1,2*, Thomas F. Lüscher3,4, Kim M. Fox3, and Philippe Gabriel Steg2,3,51Physiology Department, AP-HP, H?pital Bichat, and Inserm U1149, Paris, France; 2Paris Diderot University, Sorbonne Paris Cité, Paris, France; 3NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK; 4Center for Molecular Cardiology, Zurich and Zurich Heart House, Zurich, Switzerland; 5Cardiology department, AP-HP, Hopital Bichat, FACT (French Alliance for Cardiovascular Trials), an F-CRIN network, and INSERM U1148, Paris, France*Corresponding author:Tel+331-40-25-84-08; Fax+331-40-25-88-56Email: emmanuelle.vidal-petiot@aphp.frWord count: 678 The 2018 ESC-ESH guidelines for the management of arterial hypertension [Williams et al, Eur Heart J, 2018] lowered the blood pressure (BP) targets to below 130/80 mmHg, in line with the 2017 ACC/AHA guideline on high blood pressure, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OU5bJxso","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":1457,"uris":[""],"uri":[""],"itemData":{"id":1457,"type":"article-journal","title":"2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines","container-title":"Journal of the American College of Cardiology","page":"e127-e248","volume":"71","issue":"19","source":"PubMed","DOI":"10.1016/j.jacc.2017.11.006","ISSN":"1558-3597","note":"PMID: 29146535","shortTitle":"2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults","journalAbbreviation":"J. Am. Coll. Cardiol.","language":"eng","author":[{"family":"Whelton","given":"Paul K."},{"family":"Carey","given":"Robert M."},{"family":"Aronow","given":"Wilbert S."},{"family":"Casey","given":"Donald E."},{"family":"Collins","given":"Karen J."},{"family":"Dennison Himmelfarb","given":"Cheryl"},{"family":"DePalma","given":"Sondra M."},{"family":"Gidding","given":"Samuel"},{"family":"Jamerson","given":"Kenneth A."},{"family":"Jones","given":"Daniel W."},{"family":"MacLaughlin","given":"Eric J."},{"family":"Muntner","given":"Paul"},{"family":"Ovbiagele","given":"Bruce"},{"family":"Smith","given":"Sidney C."},{"family":"Spencer","given":"Crystal C."},{"family":"Stafford","given":"Randall S."},{"family":"Taler","given":"Sandra J."},{"family":"Thomas","given":"Randal J."},{"family":"Williams","given":"Kim A."},{"family":"Williamson","given":"Jeff D."},{"family":"Wright","given":"Jackson T."}],"issued":{"date-parts":[["2018",5,15]]}}}],"schema":""} 1 but did not modify the definition of hypertension (>140/90 mmHg) when the US guideline also lowered the threshold defining hypertension down to 130/80 mmHg. In practice however, this important difference in the definition of hypertension does not translate into a significant difference in the clinical management of patients. On the one hand, the US guideline recommended pharmacological treatment in patients with BP 130-139/80-89 only when they are at high cardiovascular risk, whereas the European guidelines recommended to consider drug treatment in patients with “high-normal BP” (130-139/85-89 mmHg) in “very high risk patients with cardiovascular disease, especially coronary artery disease (CAD)”. Therefore, at least in patients with CAD, the only subtle difference is the threshold of diastolic BP for drug initiation (80 vs 85 mmHg). This being said, the European guideline introduced a major novelty compared to both previous European and US guidelines, namely lower BP thresholds, below which patients should not be treated, both for the systolic and diastolic components of BP, thus defining BP target ranges rather than just upper limits of BP targets. More specifically, the diastolic BP treatment target range is 70-79 mmHg in all patients, while the systolic BP should be “130 mmHg or lower if tolerated” but “not <120 mmHg”, hence 120-130 mmHg, in patients younger than 65 years, and 130-139 mmHg in patients older than 65 years. The authors justify this recommendation to avoid excessive lowering of BP by the higher incidence of serious adverse events and treatment discontinuation associated with lower on-treatment BP values, and by the lower level of evidence in favor of lower BP targets in several subgroups of patients (such as diabetes and CAD). The optimal lower BP thresholds will certainly generate just as heated debates as the optimal higher thresholds, but this word of caution against excessive lowering of BP is evidence-based, and conceptually, indicating a BP range rather than just an upper limit is undoubtedly a step forward in the management of hypertension.Unfortunately, as clinical experience has long taught us, systolic BP and diastolic BP cannot be regulated independently and consequently, targeting optimal BP ranges for both components of BP will inevitably leave the clinician facing a dilemma having to choose between targeting an optimal systolic or an optimal diastolic BP; for instance when systolic BP is above the upper target but diastolic BP is below 70 mmHg.In order to evaluate the prevalence of such situations in clinical practice, we analyzed BP levels at inclusion in the prospective observational longitudinal registry of patients with stable CAD (CLARIFY) which includes 32 703 outpatients receiving standard care from 45 countries. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ggpdqPF7","properties":{"formattedCitation":"{\\rtf \\super 2\\nosupersub{}}","plainCitation":"2"},"citationItems":[{"id":1459,"uris":[""],"uri":[""],"itemData":{"id":1459,"type":"article-journal","title":"Rationale, design, and baseline characteristics of the CLARIFY registry of outpatients with stable coronary artery disease","container-title":"Clinical Cardiology","page":"797-806","volume":"40","issue":"10","source":"PubMed","abstract":"BACKGROUND: Despite major advances in prevention and treatment, coronary artery disease (CAD) remains the leading cause of death worldwide. Whereas many sources of data are available on the epidemiology of acute coronary syndromes, fewer datasets reflect the contemporary management and outcomes of stable CAD patients.\nHYPOTHESIS: A worldwide contemporary registry would improve our knowledge about stable CAD. The main objectives are to describe the demographics, clinical profile, contemporary management and outcomes of outpatients with stable CAD; to identify gaps between evidence and treatment; and to investigate long-term prognostic determinants.\nMETHODS: CLARIFY (ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) is an ongoing international observational longitudinal registry. Stable CAD patients from 45 countries in Europe, Asia, America, Middle East, Australia and Africa were enrolled between November 2009 and June 2010. The inclusion criteria were previous myocardial infarction, evidence of coronary stenosis >50%, proven symptomatic myocardial ischemia or prior revascularization procedure. The main exclusion criteria were serious non-cardiovascular disease, conditions interfering with life expectancy or severe other cardiovascular disease (including advanced heart failure). Follow-up visits were planned annually for up to 5 years, interspersed with 6-month telephone calls.\nRESULTS: Of the 32,703 patients enrolled, most (77.6%) were male, age (mean ± SD) was 64.2 ± 10.5 years, and 71.0% were receiving treatment for hypertension; mean ± SD resting heart rate was 68.2 ± 10.6 bpm. Patients were enrolled based on a history of myocardial infarction >3 months earlier (57.7%), having at least one stenosis >50% on coronary angiography (61.1%), proven symptomatic myocardial ischemia on non-invasive testing (23.1%), or history of percutaneous coronary intervention or coronary artery bypass graft (69.8%). Baseline characteristics were similar across the four subgroups identified by the four inclusion criteria.\nCONCLUSION: CLARIFY will provide a useful resource for understanding the current epidemiology of stable CAD.","DOI":"10.1002/clc.22730","ISSN":"1932-8737","note":"PMID: 28561986\nPMCID: PMC5697615","journalAbbreviation":"Clin Cardiol","language":"eng","author":[{"family":"Sorbets","given":"Emmanuel"},{"family":"Greenlaw","given":"Nicola"},{"family":"Ferrari","given":"Roberto"},{"family":"Ford","given":"Ian"},{"family":"Fox","given":"Kim M."},{"family":"Tardif","given":"Jean-Claude"},{"family":"Tendera","given":"Michal"},{"family":"Steg","given":"Philippe Gabriel"},{"literal":"CLARIFY Investigators"}],"issued":{"date-parts":[["2017",10]]}}}],"schema":""} 2 In these patients with CAD, as detailed above, BP levels requiring drug treatment and BP targets recommended by the European guidelines are unambiguous, and almost identical to those recommended by the US guidelines except for the lower thresholds. We included all patients with a history of hypertension, as well as those considered as normotensive, but with either systolic BP≥130 or diastolic BP≥85 mmHg, hence 27310 patients requiring antihypertensive drug treatment according to both European and US guidelines. The Table indicates the number of patients in each systolic/diastolic BP category (divided as below, at, or above BP target range for each component). In 46 % of patients younger than 65 years and 51 % of patients older than 65 years, clinicians will be facing a conflicting situation where a choice will have to be made whether to target an optimal systolic BP or an optimal diastolic BP.In future, recommendations indicating ranges of target BP should also indicate a hierarchical priority between both components of BP whilst treading the narrow balance between benefit and risk. As data to guide the optimal strategy when BP components are dissociated are lacking, the recent European guidelines highlight another remaining gap in evidence and the saga of the BP targets is not over.Declaration of interestsEVP reports non-financial support and personal fees from Servier outside the submitted work. KMF reports personal fees from Servier, non-financial support from Servier, during the conduct of the study; personal fees from Servier, AstraZeneca, TaurX, and CellAegis, non-financial support from Armgo, personal fees and non-financial support from Broadview Ventures, outside the submitted work; and is Director of Vesalius Trials Ltd. PGS reports research grants from Bayer, Merck, Sanofi, and Servier; speaking or consulting fees from Amarin, Amgen, AstraZeneca, Bayer/Janssen, Boehringer Ingelheim, Bristol-Myers Squibb, Lilly, Merck, Novartis, Novo-Nordisk, Pfizer, Regeneron, Sanofi, and Servier.REFERENCES: ADDIN ZOTERO_BIBL {"custom":[]} CSL_BIBLIOGRAPHY 1. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127–e248. 2. Sorbets E, Greenlaw N, Ferrari R, Ford I, Fox KM, Tardif J-C, Tendera M, Steg PG, CLARIFY Investigators. Rationale, design, and baseline characteristics of the CLARIFY registry of outpatients with stable coronary artery disease. Clin Cardiol 2017;40:797–806. Table: Baseline BP measurements in patients with stable CAD from the CLARIFY registry, classified according to optimal upper and lower BP limits as recommended by the 2018 ESC-ESH guidelines for the management of arterial hypertension. Panel A: patients<65 years. Panel B: patients≥65 years.The number of patients is indicated in each cell. Green cells indicate cases when the target BP ranges are concordant for each component (for instance systolic BP and diastolic BP are too low in 573 patients <65 years: treatment should be reduced). Red cells indicate complete discordance (treatment should be intensified according to one component and reduced according to the other). Orange cells indicate partial discordance (one component is within the optimal range while the other is not). ................
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