The Latest on the European Blood Pressure Guidelines from ESC

Maciej S. Tomaszewski, FRCP;  Richard McManus, MA PhD MBBS FRCGP FRCP


August 30, 2018

Prof Tomaszewski: Hello everyone. We're here today with Medscape UK, ESC 2018. And I have the pleasure of interviewing Professor Richard McManus, professor of primary care and practising GP to solicit his views on the recent European Society of Hypertension, European Society of Cardiology guidelines [1]. My name is Maciej Tomaszewski. I'm a professor of cardiovascular medicine at the University of Manchester.

So Richard, welcome. It's wonderful to have you on board. And we've got so much to discuss. There's a lot of excitement about the new guidelines, in particular in relation to the new definition of hypertension. We've seen some development compared to the previous guidelines. We've got probably more ways to diagnose hypertension than before, according to the new guidelines. So what does it mean for us practising clinicians and those in primary care.

Prof McManus: So I think for colleagues in the UK, since 2011 and the NICE guidance [2], we've been thinking about the use of out of office measurement, particularly ambulatory and home monitoring for the diagnosis of hypertension. And slowly the world has caught up with us and we had the Americans last year, the Japanese earlier than that, the Canadians and now Europe have come on board and agreed that it's reasonable, as well as the traditional clinic monitoring, which will look very familiar to anyone with multiple measurements on multiple occasions. They've included specifically the use of either ambulatory or home monitoring in the diagnostic process, both to diagnose hypertension and I think, also importantly, to diagnose specifically masked hypertension in those just below the threshold, and thinking carefully about white coat hypertension in those who are maybe only just in a stage 1 hypertension.

Prof Tomaszewski: And I think that's very important since the reviews of home-based blood pressure monitoring and 24 hour ambulatory blood pressure monitoring in these guidelines go beyond, as you say, the diagnosis of hypertension. White coat high hypertension and masked hypertension have received very prominent coverage in those guidelines, and as we know it's absolutely critical for us to have the out of office measurement to diagnose both.

It's obviously also interesting and important that it's probably for the first time where we see some quite clear guidance on how we should treat both conditions. And I wonder what is your opinion on the introduction of drug therapy to masked hypertension? It received, I think, a level of support to ‘A’, which is quite strong already. What do you think about this?

Prof McManus: So I think at the moment we're in the situation where there are ongoing trials, the one I know about is Gianfranco Perotti's trial which is looking specifically, in a randomised manner, at the treatment of masked hypertension.

But we know clearly from the epidemiological evidence that people whose blood pressure, whilst being normal in the clinic, is raised in the out of office time, ie most of the time, that those people do worse. And they have a risk approaching those who have definitive high blood pressure. And so given that blood pressure is really probably the best intermediate outcome of anything else in, in, in any field, that it seems not unreasonable, particularly in those people with evidence of high cardiovascular risk, or evidence of what used to be called end organ damage, and now we're going to perhaps talk about the new name for this: hypertension mediated organ damage. But people who you can see maybe with eye signs or renal problems and so on, it seems entirely reasonable to treat them on the basis of the blood pressure which they have most of the time, as opposed to the blood pressure they have for a few minutes when they see their doctor.

Prof Tomaszewski: So it's clear from the guidelines that these are not innocent conditions, in particular masked hypertension, but even people with white coat hypertension, they receive a bit of attention in the new guidelines and there is an opportunity to introduce pharmacological treatment in them as well. It appears that those who created the guidelines suggested that there is a particular situation where you might wish to introduce medications in those patients as well even if they do not fit the full picture of typical hypertension.

Prof McManus: Sure. I should have said that for both masked and white coat hypertension it is very clear that we should do lifestyle interventions because, in fact we should do those for everyone, but we should do those.

I think what we know about white coat hypertension is if you look at that out of office blood pressure, it is definitely higher on average than those people who have normotension definitively. And so what that means is that over time, those people are much more likely to become hypertensive. So if you look at them over a 5 year period, they really have very little difference in risk to someone with normotension. But as you go on in time, over longer periods of time, they are more likely to develop hypertension. And so if you have someone who is again, particularly at high risk, or even has some evidence of end organ damage, then those are specific circumstances where it would be reasonable to treat white coat hypertension. But the guideline is pretty clear that, in general, treatment is not recommended unless there's some good reason to.

Prof Tomaszewski: The guidelines mention the importance of precision in taking blood pressure measurements, and that's reassuring, in particular in the spirit of exclusion of pseudo-resistant hypertension. So it's very clear from the new guidelines that the blood pressure should be taken in a very particular way using an appropriately sized cuff. And they recognise that a lot of, a lot of problems with pseudo-resistant hypertension stems from inappropriate technique of blood pressure measurements, and is it something that you see a lot in clinical practice?

Prof McManus: So actually, we've done some interesting work where we recruited a group of patients to be mystery shoppers [3] for us and we asked them the next time they had their blood pressure measured just to make a little note of what happened, and how many times they had their blood pressure measured. And it was very interesting. I mean, largely, people get their blood pressure measured on multiple occasions if the blood pressure's raised. But if the blood pressure's fairly normal the first time, they often only get one measurement. What the guideline is seeking to do is to try and replicate in a clinic, and it's obviously largely in hypertension clinics in Europe, that blood pressure is measured in a similar way to how it might be measured in a trial. Because we know that if you measure blood pressure once or twice in a busy clinical setting, it really is not going to be the same as a trial, and therefore the danger is, as you say, you end up treating someone's blood pressure to a level that then ends up with them having side effects because you're over treating them. 

Prof Tomaszewski: The diagnosis of essential hypertension, diagnosis of hypertension, so well covered in the guidelines, is followed by specific recommendations about hypertension mediated organ damage. It's a new term that we have been introduced to. It will replace previously used target organ damage, and the guidelines give a very clear recommendation and how we should be screening for target organ damage, what tests are available, and there's a lot of emphasis on those that have prognostic implications, those with clear validation as predictive of cardiovascular mortality and morbidity. Do you think the new guidelines will change the way we assess target organ damage in clinical practice in the UK?

Prof McManus: I don't think that the guidelines will be seen as particularly controversial. I think there was, in the discussions around the guideline, that there was quite a lot of effort made not to do very high-tech investigations on everyone, because it's clear that in a number of settings, even in Europe, that these investigations just aren't available - but to try and get the basic things done on everyone. And then where there's a signal that may be an issue to, you know, to perhaps go on to the to the more what, what as a primary care physician, I would say the more complex things which might require specialists, such as echocardiography.

Prof Tomaszewski: And what about the new targets of treatment? There's a lot of discussion here at the conference and in the community about the introduction of a stepwise approach to the targets of treatment, and perhaps quite interesting, the range for the target rather than traditional below a value, and I think that that sounds very appealing to me personally, but I wonder whether you could perhaps comment on firstly about these new targets that have been introduced, and secondly, about the range for the motivation behind that.

Prof McManus: Yeah. So I think that the new targets in essence are not so different from the old targets and the rationale behind them is firstly to get everyone below 140/90. The problem being that if you just have a target of 140/90 and you leave it at that, then what happens is that quite a significant proportion of the population, and we think about, you know, in the UK there are about 7 million people on hypertension registers. So it's a really big population of people. And so the rationale is to think well, let's firstly get everyone below 140/90. We've also got the evidence from SPRINT [4] suggesting that lower targets may be better, but of course the controversy about how blood pressure was measured in that, in that trial, and so the rationale is to try and get everyone below 140/90, then for younger patients to be aiming for a lower target which is believed that they will be tolerated of, provided that they are tolerant. The only real difference in terms of 140/90 would be in the very elderly, in those over 80, and that's really going back to think about the HYVET [5] evidence and going for targets, a threshold of treatment of 160. But everyone else's is pretty much 140.

The other new thing is the data suggesting if you go too low it might be a bad thing and so pretty much 120 for sure is the lower limit, and then in in older people, maybe even 130.

Prof Tomaszewski: And even for diastolic blood pressure there's also clear limitation that you shouldn't go below 70 mm mercury, which is quite sensible in particular for patient with CAD. 

Prof McManus: Yeah and with a lower target of 80 in those people who tolerate it as well.

Prof Tomaszewski: So in terms of the treatment of hypertension and quite a few new concepts quite, perhaps not so new from the perspective of being available, but being in the guidelines. The major one that I find particularly appealing is the use of fixed dose combinations, or single pill combinations as they are called in the guidelines. There is a clear motivation and both scientific data and clinical experience beyond that. How do you think the community of physicians and GPs in the UK will take the message that to start hypertension treatment in the majority of patients we should use single pill combinations?

Prof McManus: Yeah, so I think that the issue in the UK historically has been the combination drugs are much more expensive than the single drugs. But now really, there is no excuse for not having generic multiple combinations in drugs. And indeed, there are companies that are starting to make these.

The rationale behind this, and I think this may be a time we can perhaps talk a little bit about the work that your group does, we know very clearly, and I saw you presenting in the meeting that we're at, some nice data showing that the more drugs that you have someone on, the less likely they are to take them. And I think there are some clear data showing that is at least in part to do with the number of tablets and the tablet burden. I don't know if you'd like to comment?


Prof Tomaszewski: I completely agree and I think that one of the major emphases of these guidelines is adherence. It's one of the key five new concepts introduced in the guidelines and it's wonderful to see that it's increasingly recognised as a major obstacle to blood pressure control. And I completely agree with you the polypharmacy is one of the major reasons why people do not adhere to treatment. And we've provided [6] evidence using the objective way of measuring adherence through biochemical analysis of urine that the more medications patients are prescribed, the less likely they are to take them on a regular basis. So this and seeing a clear emphasis of replacing 2 or 3 medications by a single tablet is very appealing to me. And I think it will be also to many colleagues in the UK.

Prof McManus: And the thing that we know about hypertension is it's one of the few conditions where it is actually cost-saving to treat someone's blood pressure. And that's because the medication is relatively cheap, but the thing that you're trying to prevent, which is strokes and heart disease largely, and also renal disease, and so on, is so expensive to treat. And this has such a profound effect on quality of life of the individuals who are unfortunate enough to suffer those.

We know that really quite high proportions of people, despite treatment, are not controlled, and so I think this emphasis on adherence is really key to try and get the people who are identified and treated to the targets, which will mean that they get the benefit from the treatment that they are taking.

Prof Tomaszewski: I completely agree with you. And perhaps one of those points where you see the convergence of the emphasis on adherence and out of office measurements, which I consider one of those two most important messages of the guidelines, comes very clearly is a new definition of resistant hypertension. And I think it's very specific, it's very clear that you have to exclude the state of pseudo resistant to treatment that effectively covers both non-adherence to treatment and white coat effect, white coat hypertension. So I think it also will be very helpful for us in the UK to look at the guidelines and to see how we define resistant hypertension.

Prof McManus: Yeah, and we know that now that we have good data, and I'm pleased to say that my group has published [7] on this, showing that if you use out of office measurement, particularly home monitoring to guide treatment, GPs can do this to titrate their patients against home measurements, you can really get good control of blood pressure. And unlike previous studies, we've actually shown now in randomised controlled trials that you can get significantly lower blood pressure using out of office measurement, and that means that you're treating those people who need the treatment and those people who have got white coat hypertension or white coat effects are not getting unnecessary treatment.

Prof Tomaszewski:  I think that's very important. Thank you, Richard, for joining us this afternoon. It was wonderful to have you here and thank you for your important insights.

I would like to thank the audience for joining this interview. Please leave your feedback, we’ll be delighted to hear from you.


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