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## Complete Summary

#### GUIDELINE TITLE

2007 guidelines for the management of arterial hypertension.

#### BIBLIOGRAPHIC SOURCE(S)

Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G,
Grassi G, Heagerty AM, Kjeldsen SE, Laurent S, Narkiewicz K, Ruilope L,
Rynkiewicz A, Schmieder RE, Struijker Boudier HA, Zanchetti A, ESC
Committee for Practice Guidelines (CPG):, Vahanian A, Camm J, De
Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C,
Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M,
Widimsky P, Zamorano JL, ESH Scientific Council:, Kjeldsen SE, Erdine S,
Narkiewicz K, Kiowski W, Agabiti-Rosei E, Ambrosioni E, Cifkova R,
Dominiczak A, Fagard R, Heagerty AM, Laurent S, Lindholm LH, Mancia G,
Manolis A, Nilsson PM, Redon J, Schmieder RE, Struijker-Boudier HA,
Viigimaa M, Document Reviewers:, Filippatos G, Adamopoulos S,
Agabiti-Rosei E, Ambrosioni E, Bertomeu V, Clement D, Erdine S, Farsang
C, Gaita D, Kiowski W, Lip G, Mallion JM, Manolis AJ, Nilsson PM,
O\'brien E, Ponikowski P, Redon J, Ruschitzka F, Tamargo J, van Zwieten
P, Viigimaa M, Waeber B, Williams B, Zamorano JL. 2007 Guidelines for
the management of arterial hypertension: The Task Force for the
Management of Arterial Hypertension of the European Society of
Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur
Heart J 2007 Jun;28(12):1462-536. \[825 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17562668)

#### GUIDELINE STATUS

This is the current release of the guideline.

This updates a previous guideline: 2003 European Society of
Hypertension-European Society of Cardiology guidelines for the
management of arterial hypertension. J Hypertens 2003 Jun;21(6):1011-53.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hypertension

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To offer the best available and most balanced recommendation to all
    health care providers involved in the management of hypertension

-   To provide guidelines that have been prepared on the basis of the
    best available evidence on all issues deserving recommendations, and
    with the consideration that guidelines should have an educational
    purpose more than a prescriptive one

#### TARGET POPULATION

Patients with hypertension

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Repeated blood pressure (BP) measurements

2.  Medical history

3.  Physical examination for evidence of additional risk factors (in
    particular abdominal obesity), for signs suggesting secondary
    hypertension, and for evidence of organ damage

4.  Laboratory and instrumental investigations

    -   Fasting plasma glucose

    -   Serum total cholesterol

    -   Serum low density lipoprotein (LDL)-Cholesterol

    -   Serum high density lipoprotein (HDL)-cholesterol

    -   Fasting serum triglycerides

    -   Serum uric acid

    -   Serum creatinine

    -   Serum potassium

    -   Estimated creatine clearance (Cockroft-Gault formula) or
        glomerular filtration rate (Modification of Diet in Renal
        Disease formula)

    -   Haemoglobin and haematocrit

    -   Urinalysis (complemented by microalbuminuria via dipstick test
        and microscopic examination)

    -   Electrocardiogram

5.  Echocardiogram

6.  Carotid ultrasound

7.  Quantitative proteinuria (if dipstick positive)

8.  Ankle-brachial BP index

9.  Fundoscopy

10. Glucose tolerance test (if fasting plasma glucose \>5.6 mmol/L (100
    mg/dL)

11. Home and 24 hour ambulatory BP monitoring

12. Pulse wave velocity measurement (where available)

13. Searching for subclinical organ damage

**Treatment**

1.  Lifestyle changes including smoking cessation, weight reduction,
    reduction of excessive alcohol intake, physical exercise, reduction
    of salt intake, and increase in fruit and vegetable intake and
    decrease in saturated and total fat intake

2.  Calcium antagonists

3.  Angiotensin-converting enzyme inhibitors

4.  Thiazide diuretics

5.  Beta blockers

6.  Angiotensin receptor antagonist

7.  Alpha-blockers

8.  Monotherapy versus combination therapy

9.  Treatment of associated risk factors

10. Patient follow up

11. Improvement of patient compliance

12. Management of hypertension in patient subgroups (elderly, diabetics,
    patients with renal dysfunction, cerebrovascular disease, coronary
    heart disease and heart failure, women)

#### MAJOR OUTCOMES CONSIDERED

-   Total cardiovascular risk

-   All-cause morbidity and mortality

-   Left ventricular hypertrophy

-   Presence of atherosclerosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Searches were performed of the following resources: PubMed, medical
journals by speciality, the Cochrane Library.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The members of the Guidelines Committee established by the European
Society of Hypertension (ESH) and the European Society of Cardiology
(ESC) have participated independently in the preparation of this
document, drawing on their academic and clinical experience and applying
an objective and critical examination of all available literature.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

**Cost-effectiveness of Antihypertensive Treatment**

Several studies have shown that in high or very high risk patients,
treatment of hypertension is largely cost effective, that is that the
reduction in the incidence of cardiovascular disease and death largely
offsets the cost of treatment despite its lifetime duration. Indeed, it
is likely that the benefit is even greater than that calculated by the
number of events saved per year of treatment and expressed by the so
called number needed to treat or ‚\'NNT\'. 1) In several
placebo-controlled trials a substantial number of patients randomized to
placebo received treatment and a number of patients allocated to active
treatment actually withdrew from it while continuing to be considered in
the original groups according to the intention-to-treat principle; 2)
Some trials show that the difference in event incidence between treated
and placebo groups increases progressively over the few years of the
trial duration, raising the possibility of a greater long-term
protective effect of blood pressure reductions; 3) In younger low risk
hypertensives what appears to be as a relatively small benefit when
calculated over a treatment period of 5 years may translate into a more
substantial number of added life years compared with elderly high risk
hypertensives. This implies that in younger subjects actuarial
information may provide a better assessment of the benefit than data
obtained in trials. In young patients the purpose of treatment is not to
prevent an unlikely morbid or fatal event in the subsequent few years,
but rather to prevent onset and/or progression of organ damage that
will, in the long term, convert the low risk patient into a higher risk
one. Several trials of antihypertensive therapy, foremost the HDFP and
HOT studies, have shown that despite intense blood pressure lowering the
incidence of cardiovascular events remains much higher in high risk
hypertensives or hypertensives with complications than in hypertensives
with initial low or moderate risk. This suggests that some of the major
cardiovascular risk changes may be difficult to reverse, and that
restricting antihypertensive therapy to patients at high or very high
risk may be far from an optimal strategy. Finally, the cost of drug
treatment of hypertension is often contrasted to lifestyle measures,
which are considered cost-free. However, real implementation, and
therefore effectiveness, of lifestyle changes requires behavioural
support, counselling and reinforcement, the cost of which may not be
negligible.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Once the document was finalized and approved by all the experts involved
in the Task Force, it was submitted to outside specialists for review.
In some cases, the document would be presented to a panel of key opinion
leaders in Europe, specialists in the relevant condition at hand, for
discussion and critical review. If necessary, the document was revised
once more and, finally, approved by both the European Society of
Hypertension and the European Society of Cardiology (ESC) Committee for
Practice Guidelines (CPG) and selected members of the board of the ESC.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The following is a brief statement of the practice recommendations for
the management of hypertension. The reader should refer to the original
guideline document for detailed management recommendations and a
critical assessment of the evidence for the recommendations.

**Table 1: Definitions and Classifications of Blood Pressure Levels
(mmHg)**

  -----------------------------------------------------------------------------------------
  **Category**                        **Systolic**          ** **     **Diastolic**
  ----------------------------------- --------------------- --------- ---------------------
  Optimal                             \<120                 and       \<80

  Normal                              120--129              and/or    80--84

  High normal                         130--139              and/or    85--89

  Grade 1 hypertension                140--159              and/or    90--99

  Grade 2 hypertension                160--179              and/or    100--109

  Grade 3 hypertension                [\>]{.underline}180   and/or    [\>]{.underline}110

  Isolated systolic hypertension      [\>]{.underline}140   and       \<90
  -----------------------------------------------------------------------------------------

Isolated systolic hypertension should be graded (1, 2, 3) according to
systolic blood pressure values in the ranges indicated, provided that
diastolic values are \<90 mmHg. Grades 1, 2 and 3 correspond to a
classification in mild, moderate and severe hypertension, respectively.
These terms have now been omitted to avoid confusion with quantification
of total cardiovascular risk.

**Total cardiovascular (CV) risk**

-   Dysmetabolic risk factors and subclinical organ damage are common in
    hypertensive patients.

-   All patients should be classified not only in relation to the grades
    of hypertension but also in terms of the total cardiovascular risk
    resulting from the coexistence of different risk factors, organ
    damage and disease.

-   Decisions on treatment strategies (initiation of drug treatment,
    Blood Pressure (BP) threshold and target for treatment, use of
    combination treatment, need of a statin and other
    non-antihypertensive drugs) all importantly depend on the initial
    level of risk.

-   There are several methods by which total cardiovascular risk can be
    assessed, all with advantages and limitations. Categorization of
    total risk as low, moderate, high, and very high added risk has the
    merit of simplicity and can therefore be recommended. The term
    \'added risk\' refers to the risk additional to the average one.
    (See Figure 1 in the original guideline document: Stratification of
    CV Risk)

-   Total risk is usually expressed as the absolute risk of having a
    cardiovascular event within 10 years. Because of its heavy
    dependence on age, in young patients absolute total cardiovascular
    risk can be low even in the presence of high BP with additional risk
    factors. If insufficiently treated, however, this condition may lead
    to a partly irreversible high risk condition years later. In younger
    subjects treatment decisions should better be guided by
    quantification of relative risk (i.e. the increase in risk in
    relation to average risk in the population).

**Blood pressure (BP) measurement**

When measuring BP, care should be taken to:

-   Allow the patients to sit for several minutes in a quiet room before
    beginning BP measurements.

-   Take at least two measurements spaced by 1--2 minutes, and
    additional measurements if the first two are quite different.

-   Use a standard bladder (12--13 cm long and 35 cm wide) but have a
    larger and a smaller bladder available for fat and thin arms,
    respectively. Use the smaller bladder in children.

-   Have the cuff at the heart level, whatever the position of the
    patient.

-   Use phase I and V (disappearance) Korotkoff sounds to identify
    systolic and diastolic BP, respectively.

-   Measure BP in both arms at first visit to detect possible
    differences due to peripheral vascular disease. In this instance,
    take the higher value as the reference one.

-   Measure BP 1 and 5 minutes after assumption of the standing position
    in elderly subjects, diabetic patients, and in other conditions in
    which postural hypotension may be frequent or suspected.

-   Measure heart rate by pulse palpation (at least 30 sec) after the
    second measurement in the sitting position.

**Ambulatory and home BP measurement**

**Ambulatory BP**

-   Although office BP should be used as reference, ambulatory BP may
    improve prediction of cardiovascular risk in untreated and treated
    patients.

-   Normal values are different for office and ambulatory BP. (See Table
    2 below.)

-   Twenty-four-hour ambulatory BP monitoring should be considered in
    particular, when

    -   Considerable variability of office BP is found over the same or
        different visits.

    -   High office BP is measured in subjects otherwise at low total
        cardiovascular risk.

    -   There is marked discrepancy between BP values measured in the
        office and at home.

    -   Resistance to drug treatment is suspected.

    -   Hypotensive episodes are suspected, particularly in elderly and
        diabetic patients

    -   Office BP is elevated in pregnant women and pre-eclampsia is
        suspected

**Home BP**

-   Self-measurement of BP at home is of clinical value and its
    prognostic significance is now demonstrated. These measurements
    should be encouraged in order to:

    -   Provide more information on the BP lowering effect of treatment
        at trough, and thus on therapeutic coverage throughout the
        dose-to-dose time interval

    -   Improve patient\'s adherence to treatment regimens

    -   There are doubts on technical reliability/environmental
        conditions of ambulatory BP data

-   Self-measurement of BP at home should be discouraged whenever:

    -   It causes anxiety to the patient.

    -   It induces self-modification of the treatment regimen.

-   Normal values are different for office, ambulatory, and home BP (See
    Table 2 below)

**Table 2: Blood Pressure Thresholds (mmHg) for Definition of
Hypertension with Different Types of Measurement**

  -----------------------------------------------------------------------
               **Systolic Blood Pressure    **Diastolic Blood Pressure
               (SBP)**                      (DBP)**
  ------------ ---------------------------- -----------------------------
  Office or    140                          90
  Clinic                                    

  24-hour      125--130                     80

  Day          130--135                     85

  Night        120                          70

  Home         130--135                     85
  -----------------------------------------------------------------------

**Guidelines for family and clinical history**

-   Duration and previous level of high BP

-   Indications of secondary hypertension

    -   Family history of renal disease (polycystic kidney)

    -   Renal disease, urinary tract infection, haematuria, analgesic
        abuse (parenchymal renal disease)

    -   Drug/substance intake: oral contraceptives, liquorice,
        carbenoxolone, nasal drops, cocaine, amphetamines, steroids,
        non-steroidal anti-inflammatory drugs, erythropoietin,
        cyclosporin

    -   Episodes of sweating, headache, anxiety, palpitation
        (phaeochromocytoma)

    -   Episodes of muscle weakness and tetany (aldosteronism).

-   Risk factors

    -   Family and personal history of hypertension and cardiovascular
        disease

    -   Family and personal history of dyslipidaemia

    -   Family and personal history of diabetes mellitus

    -   Smoking habits

    -   Dietary habits

    -   Obesity; amount of physical exercise

    -   Snoring; sleep apnea (information also from partner)

    -   Personality

-   Symptoms of organ damage

    -   Brain and eyes: headache, vertigo, impaired vision, transient
        ischaemic attacks, sensory or motor deficit

    -   Heart: palpitation, chest pain, shortness of breath, swollen
        ankles

    -   Kidney: thirst, polyuria, nocturia, haematuria

    -   Peripheral arteries: cold extremities, intermittent claudication

-   Previous antihypertensive therapy

    -   Drug(s) used, efficacy and adverse effects

-   Personal, family, and environmental factors

**Physical examination for secondary hypertension, organ damage and
visceral obesity**

*Signs suggesting secondary hypertension and organ damage*

-   Features of Cushing syndrome

-   Skin stigmata of neurofibromatosis (phaeochromocytoma)

-   Palpation of enlarged kidneys (polycystic kidney)

-   Auscultation of abdominal murmurs (renovascular hypertension)

-   Auscultation of precordial or chest murmurs (aortic coarctation or
    aortic disease)

-   Diminished and delayed femoral and reduced femoral BP (aortic
    coarctation, aortic disease)

*Signs of organ damage*

-   Brain: murmurs over neck arteries, motor or sensory defects

-   Retina: funduscopic abnormalities

-   Heart: location and characteristics of apical impulse, abnormal
    cardiac rhythms, ventricular gallop, pulmonary rales,  peripheral
    oedema

-   Peripheral arteries: absence, reduction, or asymmetry of pulses,
    cold extremities, ischaemic skin lesions

-   Carotid Arteries: systolic murmurs

*Evidence of visceral obesity*

-   Body weight

-   Increased waist circumference (standing position) M: \> 102 cm; F:
    \> 88 cm

-   Increased body mass index \[body weight (kg)/height (m)^2^\]

-   Overweight [\>]{.underline}25 kg/m^2^; Obesity [\>]{.underline}30
    kg/m2

**Laboratory investigations**

*Routine tests*

-   Fasting plasma glucose

-   Serum total cholesterol

-   Serum LDL-Cholesterol

-   Serum HDL-cholesterol

-   Fasting serum triglycerides

-   Serum potassium

-   Serum uric acid

-   Serum creatinine

-   Estimated creatine clearance (Cockroft-Gault formula) or glomerular
    filtration rate (Modification of Diet in Renal Disease formula)

-   Haemoglobin and haematocrit

-   Urinalysis (complemented by  microalbuminuria via dipstick test and
    microscopic examination)

-   Electrocardiogram

*Recommended tests*

-   Echocardiogram

-   Carotid ultrasound

-   Quantitative proteinuria ( if dipstick test positive)

-   Ankle-brachial BP index

-   Fundoscopy

-   Glucose tolerance test (if fasting plasma glucose \>5.6 mmol/L (100
    mg/dL)

-   Home and 24 hours ambulatory BP monitoring

-   Pulse wave velocity measurement (where available)

*Extended evaluation (domain of the specialist)*

-   Further search for cerebral, cardiac, renal and vascular damage.
    Mandatory in complicated hypertension

-   Search for secondary hypertension when suggested by history,
    physical examination or routine tests: measurement of renin,
    aldosterone, corticosteroids, catecholamines in plasma and/or urine;
    arteriographies; renal and adrenal ultrasound; computer-assisted
    tomography; magnetic resonance imaging

**Searching for subclinical organ damage**

Due to the importance of subclinical organ damage as an intermediate
stage in the continuum of vascular disease and as a determinant of total
cardiovascular risk, signs of organ involvement should be sought
carefully by appropriate techniques:

-   [Heart]{.underline} -- Electrocardiography should be part of all
    routine assessment of subjects with high BP in order to detect left
    ventricular hypertrophy, patterns of \"strain,\" ischaemia and
    arrhythmias. Echocardiography is recommended when a more sensitive
    detection of left ventricular hypertrophy is considered useful.
    Geometric patterns can be defined echocardiographically, of which
    concentric hypertrophy carries the worse prognosis. Diastolic
    dysfunction can be evaluated by transmitral Doppler.

-   [Blood vessels]{.underline} -- Ultrasound scanning of carotid
    arteries is recommended when detection of vascular hypertrophy or
    asymptomatic atherosclerosis is deemed useful. Large artery
    stiffening (leading to isolated systolic hypertension in the
    elderly) can be measured by pulse wave velocity. It might be more
    widely recommended if its availability were greater. A low
    ankle-brachial BP index signals advanced peripheral artery disease.

-   [Kidney]{.underline} -- Diagnosis of hypertension-related renal
    damage is based on a reduced renal function or an elevated urinary
    excretion of albumin. Estimation from serum creatinine of glomerular
    filtration rate (MDRD formula, requiring age, gender, race) or
    creatinine clearance (Cockroft--Gault formula, requiring also body
    weight) should be routine procedure. Urinary protein should be
    sought in all hypertensives by dipstick. In dipstick negative
    patients low grade albuminuria (microalbuminuria) should be
    determined in spot urine and related to urinary creatinine
    excretion.

-   [Fundoscopy]{.underline} -- Examination of eye grounds is
    recommended in severe hypertensives only. Mild retinal changes are
    largely non-specific except in young patients. Haemorrhages,
    exudates and papilloedema, only present in severe hypertension, are
    associated with increased CV risk.

-   [Brain]{.underline} -- Silent brain infarcts, lacunar infarctions,
    microbleeds and white matter lesions are not infrequent in
    hypertensives, and can be detected by magnetic resonance imaging
    (MRI),  or computed tomography (CT). Availability and costs do not
    allow indiscriminate use of these techniques. In elderly
    hypertensives, cognitive tests may help to detect initial brain
    deterioration. (See Table 4 in the original guideline document for a
    summary of the availability, prognostic value and cost of procedures
    to detect subclinical organ damage.)

**Goals of treatment**

-   In hypertensive patients, the primary goal of treatment is to
    achieve maximum reduction in the long-term total risk of
    cardiovascular disease.

-   This requires treatment of the raised BP *per se* as well as of all
    associated reversible risk factors.

-   BP should be reduced to at least below 140/90mmHg
    (systolic/diastolic), and to lower values, if tolerated, in all
    hypertensive patients.

-   Target BP should be at least \<130/80mmHg in diabetics and in high
    or very high risk patients, such as those with associated clinical
    conditions (stroke, myocardial infarction, renal dysfunction,
    proteinuria).

-   Despite use of combination treatment, reducing systolic BP to
    \<140mmHg may be difficult and more so if the target is a reduction
    to \<130mmHg. Additional difficulties should be expected in elderly
    and diabetic patients, and, in general, in patients with
    cardiovascular damage.

-   In order to more easily achieve goal BP, antihypertensive treatment
    should be initiated before significant cardiovascular damage
    develops.

**Lifestyle changes**

-   Lifestyle measures should be instituted, whenever appropriate, in
    all patients, including those who require drug treatment. The
    purpose is to lower BP, to control other risk factors and to reduce
    the number of doses of antihypertensive drugs to be subsequently
    administered.

-   Lifestyle measures are also advisable in subjects with high normal
    BP and additional risk factors to reduce the risk of developing
    hypertension.

-   The lifestyle measures that are widely recognized to lower BP or
    cardiovascular risk, and that should be considered are:

    -   Smoking cessation

    -   Weight reduction (and weight stabilization)

    -   Reduction of excessive alcohol intake

    -   Physical exercise

    -   Reduction of salt intake

    -   Increase in fruit and vegetable intake and decrease in saturated
        and total fat intake

-   Lifestyle recommendations should not be given as lip service but
    instituted with adequate behavioural and expert support, and
    reinforced periodically.

-   Because long-term compliance with lifestyle measures is low and the
    BP response highly variable, patients under non-pharmacological
    treatment should be followed-up closely to start drug treatment when
    needed and in a timely fashion.

**Choice of antihypertensive drugs**

-   The main benefits of antihypertensive therapy are due to lowering of
    BP *per se*.

-   Five major classes of antihypertensive agents -- thiazide diuretics,
    calcium antagonists, angiotensin converting enzymes (ACE)
    inhibitors, angiotensin receptor antagonists and beta-blockers --
    are suitable for the initiation and maintenance of antihypertensive
    treatment, alone or in combination. beta-blockers, especially in
    combination with a thiazide diuretic, should not be used in patients
    with the metabolic syndrome or at high risk of incident diabetes.

-   Because in many patients more than one drug is needed, emphasis on
    identification of the first class of drugs to be used is often
    futile. Nevertheless, there are many conditions for which there is
    evidence in favour of some drugs versus others either as initial
    treatment or as part of a combination.

-   The choice of a specific drug or a drug combination, and the
    avoidance of others, should take into account the following:

    -   The previous favourable or unfavourable experience of the
        individual patient with a given class of compounds

    -   The effect of drugs on cardiovascular risk factors in relation
        to the cardiovascular risk profile of the individual patient

    -   The presence of subclinical organ damage, clinical
        cardiovascular disease, renal disease or diabetes which may be
        more favourably treated by some drugs than others (See
        recommendations on preferred drugs below and Table 6 in the
        original guideline document)

    -   The presence of other disorders that may limit the use of
        particular classes of antihypertensive drugs (See Table 7 in the
        original guideline document)

    -   The possibilities of interactions with drugs used for other
        conditions

    -   The cost of drugs, either to the individual patient or to the
        health provider, but cost considerations should never
        predominate over efficacy, tolerability, and protection of the
        individual patient

-   Continuing attention should be given to side effects of drugs,
    because they are the most important cause of non-compliance. Drugs
    are not equal in terms of adverse effects, particularly in
    individual patients.

-   The BP lowering effect should last 24 hours. This can be checked by
    office or home BP measurements at trough or by ambulatory BP
    monitoring.

-   Drugs which exert their antihypertensive effect over 24 hours with a
    once-a-day administration should be preferred because a simple
    treatment schedule favours compliance.

**Antihypertensive Treatment: Preferred Drugs**

  -------------------------- --------------------------------------------
  ***Subclinical Organ       
  Samage***                  

  LVH                        ACEI, CA, ARB

  Asymptomatic               CA, ACEI
  atherosclerosis            

  Microalbuminuria           ACEI, ARB

  Renal dysfunction          ACEI, ARB

  ***Clinical Event***       

  Previous stroke            Any BP lowering agent

  Previous MI                BB, ACEI, ARB

  Angina pectoris            BB, CA

  Heart failure              Diuretics, BB, ACEI, ARB, antialdosterone
                             agents

  Atrial fibrillation        

  Recurrent                  ARB, ACEI

  Permanent                  BB, non-dihydropyridine CA

  ESRD/proteinuria           ACEI, ARB, loop diuretics

  Peripheral artery disease  CA

  ***Condition***            

  ISH (elderly)              Diuretics, CA

  Metabolic syndrome         ACEI, ARB, CA

  Diabetes mellitus          ACEI, ARB

  Pregnancy                  CA, methyldopa, BB

  Blacks                     Diuretics, CA
  -------------------------- --------------------------------------------

Abbreviations: LVH: left ventricular hypertroph; ISH: isolated systolic
hypertension; ESRD: renal failure; ACEI: ACE inhibitors; ARB:
angiotensin recepter antagonists; CA: calcium antagonists; BB:
beta-blockers

**Monotherapy versus combination therapy**

-   Regardless of the drug employed, monotherapy allows to achieve BP
    target in only a limited number of hypertensive patients.

-   Use of more than one agent is necessary to achieve target BP in the
    majority of patients. A vast array of effective and well tolerated
    combinations is available.

-   Initial treatment can make use of monotherapy or combination of two
    drugs at low doses with a subsequent increase in drug doses or
    number, if needed (See Figures 3 and 4 in the original guideline
    document).

-   Monotherapy could be the initial treatment for a mild BP elevation
    with a low or moderate total cardiovascular risk. A combination of
    two drugs at low doses should be preferred as first step treatment
    when initial BP is in the grade 2 or 3 range or total cardiovascular
    risk is high or very high (Figure 3).

-   Fixed combinations of two drugs can simplify treatment schedule and
    favour compliance.

-   In several patients BP control is not achieved by two drugs, and a
    combination of three of more drugs is required.

-   In uncomplicated hypertensives and in the elderly, antihypertensive
    therapy should normally be initiated gradually. In higher risk
    hypertensives, goal BP should be achieved more promptly, which
    favours initial combination therapy and quicker adjustment of doses.

**Antihypertensive treatment in the elderly**

-   Randomized trials in patients with systolic-diastolic or isolated
    systolic hypertension aged [\>]{.underline}60 years have shown that
    a marked reduction in cardiovascular morbidity and mortality can be
    achieved with antihypertensive treatment.

-   Drug treatment can be initiated with thiazide diuretics, calcium
    antagonists, angiotensin receptor antagonists, ACE inhibitors, and
    beta-blockers, in line with general guidelines. Trials specifically
    addressing treatment of isolated systolic hypertension have shown
    the benefit of thiazides and calcium antagonists but subanalysis of
    other trials also show efficacy of angiotensin receptor antagonists.

-   Initial doses and subsequent dose titration should be more gradual
    because of a greater chance of undesirable effects, especially in
    very old and frail subjects.

-   BP goal is the same as in younger patients (i.e. \<140/90mmHg or
    below if tolerated). Many elderly patients need two or more drugs to
    control BP and reductions to \<140mmHg systolic may be particularly
    difficult to obtain.

-   Drug treatment should be tailored to the risk factors, target organ
    damage and associated cardiovascular and non-cardiovascular
    conditions that are frequent in the elderly. Because of the
    increased risk of postural hypotension, BP should always be measured
    also in the erect posture.

-   In subjects aged 80 years and over, evidence for benefits of
    antihypertensive treatment is as yet inconclusive. However, there is
    no reason for interrupting a successful and well tolerated therapy
    when a patient reaches 80 years of age.

**Antihypertensive treatment in diabetics**

-   Where applicable, intense non-pharmacological measures should be
    encouraged in all diabetic patients, with particular attention to
    weight loss and reduction of salt intake in type 2 diabetes.

-   Goal BP should be \<130/80mmHg and antihypertensive drug treatment
    may be started already when BP is in the high normal range.

-   To lower BP, all effective and well tolerated drugs can be used. A
    combination of two or more drugs is frequently needed.

-   Available evidence indicates that lowering BP also exerts a
    protective effect on appearance and progression of renal damage.
    Some additional protection can be obtained by the use of a blocker
    of the renin-angiotensin system (either an angiotensin receptor
    antagonist or an ACE inhibitor).

-   A blocker of the renin-angiotensin system should be a regular
    component of combination treatment and the one preferred when
    monotherapy is sufficient.

-   Microalbuminuria should prompt the use of antihypertensive drug
    treatment also when initial BP is in the high normal range. Blockers
    of the renin-angiotensin system have a pronounced antiproteinuric
    effect and their use should be preferred.

-   Treatment strategies should consider an intervention against all
    cardiovascular risk factors, including a statin.

-   Because of the greater chance of postural hypotension, BP should
    also be measured in the erect posture.

**Antihypertensive therapy in patients with renal dysfunction**

-   Renal dysfunction and failure are associated with a very high risk
    of cardiovascular events.

-   Protection against progression of renal dysfunction has two main
    requirements:

    -   Strict BP control (\<130/80mmHg and even lower if proteinuria is
        \>1 g/day)

    -   Lowering proteinuria to values as near to normal as possible

-   To achieve the BP goal, combination therapy of several
    antihypertensive agents (including loop diuretics) is usually
    required.

-   To reduce proteinuria, an angiotensin receptor blocker, an ACE
    inhibitor or a combination of both are required.

-   There is controversial evidence as to whether blockade of the
    renin--angiotensin system has a specific beneficial role in
    preventing or retarding nephrosclerosis in non-diabetic
    non-proteinuric hypertensives, except perhaps in Afro-American
    individuals. However, inclusion of one of these agents in the
    combination therapy required by these patients appears well founded.

-   An integrated therapeutic intervention (antihypertensive, statin and
    antiplatelet therapy) has to be frequently considered in patients
    with renal damage because, under these circumstances, cardiovascular
    risk is extremely high.

**Antihypertensive treatment in patients with cerebrovascular disease**

-   In patients with a history of stroke or transient ischemic attacks,
    antihypertensive treatment markedly reduces the incidence of stroke
    recurrence and also lowers the associated high risk of cardiac
    events.

-   Antihypertensive treatment is beneficial in hypertensive patients as
    well as in subjects with BP in the high normal range. BP goal should
    be \<130/80 mmHg.

-   Because evidence from trials suggests that the benefit largely
    depends on BP lowering *per se*, all available drugs and rational
    combinations can be used.  Trial data have been mostly obtained with
    ACE inhibitors and angiotensin receptor antagonists, in association
    with or on the top of diuretic and conventional treatment, but more
    evidence is needed before their specific cerebrovascular protective
    properties are established.

-   There is at present no evidence that BP lowering has a beneficial
    effect in acute stroke but more research is under way. Until more
    evidence is obtained antihypertensive treatment should start when
    post-stroke clinical conditions are stable, usually several days
    after the event. Additional research in this area is necessary
    because cognitive dysfunction is present in about 15% and dementia
    in 5% of subjects aged [\>]{.underline} 65 years.

-   In observational studies, cognitive decline and incidence of
    dementia have a positive relationship with BP values. There is some
    evidence that both can be somewhat delayed by antihypertensive
    treatment.

**Antihypertensive treatment in patients with coronary heart disease and
heart failure**

-   In patients surviving a myocardial infarction, early administration
    of beta-blockers, ACE inhibitors or angiotensin receptor antagonists
    reduces the incidence of recurrent myocardial infarction and death.
    These beneficial effects can be ascribed to the specific protective
    properties of these drugs but possibly also to the associated small
    BP reduction.

-   Antihypertensive treatment is also beneficial in hypertensive
    patients with chronic coronary heart disease. The benefit can be
    obtained with different drugs and drug combinations (including
    calcium antagonists) and appears to be related to the degree of BP
    reduction. A beneficial effect has been demonstrated also when
    initial BP is \<140/90 mmHg and for achieved BP around 130/80 mmHg
    or less.

-   A history of hypertension is common while a raised BP is relatively
    rare in patients with congestive heart failure. In these patients,
    treatment can make use of thiazide and loop diuretics, as well as of
    beta-blockers, ACE inhibitors, angiotensin receptor antagonists and
    antialdosterone drugs on top of diuretics. Calcium antagonists
    should be avoided unless needed to control BP or anginal symptoms.

-   Diastolic heart failure is common in patients with a history of
    hypertension and has an adverse prognosis. There is at present no
    evidence on the superiority of specific antihypertensive drugs.

**Hypertension in women**

***Treatment of hypertension in women***

Response to antihypertensive agents and beneficial effects of BP
lowering appear to be similar in women and in men. However, ACE
inhibitors and angiotensin receptor antagonists should be avoided in
pregnant and pregnancy planning women because of potential teratogenic
effects during pregnancy.

***Oral contraceptives***

Even low oestrogen oral contraceptives are associated with increased
risk of hypertension, stroke and myocardial infarction. The
progestogen-only pill is a contraceptive option for women with high BP,
but influence on cardiovascular outcomes has been insufficiently
investigated.

***Hormone replacement therapy***

There is evidence that the only benefit of this therapy is a decreased
incidence of bone fractures and colon cancer, accompanied, however, by
increased risk of coronary events, stroke, thromboembolism, breast
cancer, gallbladder disease, and dementia. This therapy is not
recommended for cardioprotection in postmenopausal women.

***Hypertension in pregnancy***

-   Hypertensive disorders in pregnancy, particularly pre-eclampsia, may
    adversely affect neonatal and maternal outcomes.

-   Non-pharmacological management (including close supervision and
    restriction of activities) should be considered for pregnant women
    with Systolic BP (SBP) 140 to 149 mmHg or Diastolic BP (DBP) 90 to
    95 mmHg. In the presence of gestational hypertension (with or
    without proteinuria) drug treatment is indicated at BP levels
    [\>]{.underline}140/90 mmHg. SBP levels [\>]{.underline}170 or DBP
    [\>]{.underline} 110 mmHg should be considered an emergency
    requiring hospitalization.

-   In non-severe hypertension, oral methyldopa, labetalol, calcium
    antagonists and (less frequently) beta-blockers are drugs of choice.

-   In pre-eclampsia with pulmonary oedema, nitroglycerine is the drug
    of choice. Diuretic therapy is inappropriate because plasma volume
    is reduced.

-   As emergency, intravenous labetalol, oral methyldopa and oral
    nifedipine are indicated. Intravenous hydralazine is no longer the
    drug of choice because of an excess of perinatal adverse effects.
    Intravenous infusion of sodium nitroprusside is useful in
    hypertensive crises, but prolonged administration should be avoided.

-   Calcium supplementation, fish oil and low dose aspirin are not
    recommended. However, low dose aspirin may be used prophylactically
    in women with a history of early onset pre-eclampsia.

**The metabolic syndrome**

-   The metabolic syndrome is characterized by the variable combination
    of visceral obesity and alterations in glucose metabolism, lipid
    metabolism and BP. It has a high prevalence in the middle age and
    elderly population.

-   Subjects with the metabolic syndrome also have a higher prevalence
    of microalbuminuria, left ventricular hypertrophy and arterial
    stiffness than those without the metabolic syndrome. Their
    cardiovascular risk is high and the chance of developing diabetes
    markedly increased.

-   In patients with a metabolic syndrome diagnostic procedures should
    include a more in-depth assessment of subclinical organ damage.
    Measuring ambulatory and home BP is also desirable.

-   In all individuals with metabolic syndrome, intense lifestyle
    measures should be adopted. When there is hypertension drug
    treatment should start with a drug unlikely to facilitate onset to
    diabetes. Therefore a blocker of the renin-angiotensin system should
    be used followed, if needed, by the addition of a calcium antagonist
    or a low-dose thiazide diuretic. It appears desirable to bring BP to
    the normal range.

-   Lack of evidence from specific clinical trials prevents firm
    recommendations on use of antihypertensive drugs in all metabolic
    syndrome subjects with a high normal BP. There is some evidence that
    blocking the renin-angiotensin system may also delay incident
    hypertension.

-   Statins and antidiabetic drugs should be given in the presence of
    dyslipidemia and diabetes, respectively. Insulin sensitizers have
    been shown to markedly reduce new onset diabetes, but their
    advantages and disadvantages in the presence of impaired fasting
    glucose or glucose intolerance as a metabolic syndrome component
    remain to be demonstrated

**Causes of resistant hypertension**

-   Poor adherence to therapeutic plan

-   Failure to modify lifestyle including:

    -   Weight gain

    -   Heavy alcohol intake (NB: binge drinking)

-   Continued intake of drugs that raise BP (liquorice, cocaine,
    glucocorticoids, non-steroid anti-inflammatory drugs, etc.)

-   Obstructive sleep apnoea

-   Unsuspected secondary cause

-   Irreversible or scarcely reversible organ damage

-   Volume overload due to:

    -   Inadequate diuretic therapy

    -   Progressive renal insufficiency

    -   High sodium intake

    -   Hyperaldosteronism

*Causes of spurious resistant hypertension*

-   Isolated office (white-coat) hypertension

-   Failure to use large cuff on large arm

-   Pseudohypertension

**Treatment of associated risk factors**

*Lipid-lowering agents*

-   All hypertensive patients with established cardiovascular disease or
    with type 2 diabetes should be considered for statin therapy aiming
    at serum total and LDL cholesterol levels of, respectively, \< 4.5
    mmol/l (175 mg/dl) and \< 2.5 mmol/l (100 mg/dl), and lower, if
    possible.

-   Hypertensive patients without overt cardiovascular disease but with
    high cardiovascular risk ([\>]{.underline}20% risk of events in 10
    years) should also be considered for statin treatment even if their
    baseline total and LDL serum cholesterol levels are not elevated.

*Antiplatelet therapy*

-   Antiplatelet therapy, in particular low-dose aspirin, should be
    prescribed to hypertensive patients with previous cardiovascular
    events, provided that there is no excessive risk of bleeding.

-   Low-dose aspirin should also be considered in hypertensive patients
    without a history of cardiovascular disease if older than 50 years,
    with a moderate increase in serum creatinine or with a high
    cardiovascular risk. In all these conditions, the benefit-to-risk
    ratio of this intervention (reduction in myocardial infarction
    greater than the risk of bleeding) has been proven favourable.

-   To minimize the risk of haemorrhagic stroke, antiplatelet treatment
    should be started after achievement of BP control.

*Glycaemic control*

-   Effective glycaemic control is of great importance in patients with
    hypertension and diabetes.

-   In these patients dietary and drug treatment of diabetes should aim
    at lowering plasma fasting glucose to values [\<]{.underline} 6
    mmol/l (108 mg/dl) and at a glycated haemoglobin of \<6.5%.

**Patients\' follow-up**

-   Titration to BP control requires frequent visits in order to modify
    the treatment regimen in relation to BP changes and appearance of
    side effects.

-   Once target BP has been obtained, the frequency of visits can be
    considerably reduced. However, excessively wide intervals between
    visits are not advisable because they interfere with a good
    doctor-patient relationship, which is crucial for patient\'s
    compliance.

-   Patients at low risk or with grade 1 hypertension may be seen every
    6 months and regular home BP measurements may further extend this
    interval. Visits should be more frequent in high or very high risk
    patients. This is the case also in patients under
    non-pharmacological treatment alone due to the variable
    antihypertensive response and the low compliance with this
    intervention.

-   Follow-up visits should aim at maintaining control of all reversible
    risk factors as well as at checking the status of organ damage.
    Because treatment induced changes in left ventricular mass and
    carotid artery wall thickness are slow, there is no reason to
    perform these examinations at less than 1 year intervals.

-   Treatment of hypertension should be continued for life because in
    correctly diagnosed patient\'s cessation of treatment is usually
    followed by return to the hypertensive state. Cautious downward
    titration of the existing treatment may be attempted in low risk
    patients after long-term BP control, particularly if
    non-pharmacological treatment can be successfully implemented.

**How to improve compliance with treatment**

-   Inform the patient on the risk of hypertension and the benefit of
    effective treatment.

-   Provide clear written and oral instructions about treatment.

-   Tailor the treatment regimen to patient\'s lifestyle and needs.

-   Simplify treatment by reducing, if possible, the number of daily
    medicaments.

-   Involve patient\'s partner or family in information on disease and
    treatment plans.

-   Make use of self measurement of BP at home and of behavioural
    strategies such as reminder systems.

-   Pay great attention to side effects (even if subtle) and be prepared
    to change drug doses or types if needed.

-   Dialogue with patient regarding adherence and be informed of his/her
    problems.

-   Provide reliable support system and affordable prices

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for the
possible combination between some classes of hypertensive therapy.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Data was primarily considered from large randomized trials and
meta-analyses, but also made use where necessary of observational
studies and other sources of data, provided they were obtained in
studies meeting a high scientific standard.

These recommendations have been accompanied by relevant references, and
those articles based on large randomized trials, meta-analyses, or large
observational studies have been clearly identified in the original
guideline document.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate management of patients with hypertension

#### POTENTIAL HARMS

Adverse events during anti-hypertensive treatment are not entirely
avoidable because they may have, in part, a psychological nature and
indeed are also reported during administration of placebo. Great effort
should be devoted, however, to limitation of drug-related side effects
and preservation of the quality of life either by switching treatment
from the responsible drug to another agent or by avoiding unnecessary
increases of the dose of the drug employed. Side effects of thiazide
diuretics, beta-blockers and calcium antagonists are dose related
whereas there is little or no dose-dependent increase in side effects
with angiotensin receptor antagonists and angiotensin-converting enzyme
inhibitors (ACE) inhibitors.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

**Table Compelling and Possible Contraindications to use of
Antihypertensive Drugs**

+------------------+------------------------+-------------------------+
| ** **            | **Compelling**         | **Possible**            |
+==================+========================+=========================+
| Thiazide         | Gout                   | -   Metabolic syndrome  |
| diuretics        |                        |                         |
|                  |                        | -   Glucose intolerance |
|                  |                        |                         |
|                  |                        | -   Pregnancy           |
+------------------+------------------------+-------------------------+
| Beta-blockers    | -   Asthma             | -   Peripheral artery   |
|                  |                        |     disease             |
|                  | -   Atrioventricular   |                         |
|                  |     (A-V) block (grade | -   Metabolic syndrome  |
|                  |     2 or 3)            |                         |
|                  |                        | -   Glucose intolerance |
|                  |                        |                         |
|                  |                        | -   Athletes and        |
|                  |                        |     physically active   |
|                  |                        |     patients            |
|                  |                        |                         |
|                  |                        | -   Chronic obstructive |
|                  |                        |     pulmonary disease   |
+------------------+------------------------+-------------------------+
| Calcium          |                        | -   Tachyarrhythmias    |
| antagonists      |                        |                         |
| (d               |                        | -   Heart failure       |
| ihydropyridines) |                        |                         |
+------------------+------------------------+-------------------------+
| Calcium          | -   A-V block (grade 2 |                         |
| antagonists      |     or 3)              |                         |
| (verapamil,      |                        |                         |
| diltiazem)       | -   Heart failure      |                         |
+------------------+------------------------+-------------------------+
| Angiot           | -   Pregnancy          |                         |
| ensin-converting |                        |                         |
| enzyme (ACE)     | -   Angioneurotic      |                         |
| inhibitors       |     oedema             |                         |
|                  |                        |                         |
|                  | -   Hyperkalaemia      |                         |
|                  |                        |                         |
|                  | -   Bilateral renal    |                         |
|                  |     artery stenosis    |                         |
+------------------+------------------------+-------------------------+
| Angiotensin      | -   Pregnancy          |                         |
| receptor         |                        |                         |
| antagonists      | -   Hyperkalaemia      |                         |
|                  |                        |                         |
|                  | -   Bilateral renal    |                         |
|                  |     artery stenosis    |                         |
+------------------+------------------------+-------------------------+
| Diuretics        | -   Renal failure      |                         |
| (                |                        |                         |
| antialdosterone) | -   Hyperkalaemia      |                         |
+------------------+------------------------+-------------------------+

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The Committee avoided a rigid classification of recommendations, by
    the level or strength of scientific evidence. The Committee felt
    this is often difficult to apply and that that it can only apply to
    therapeutic aspects and that strength of a recommendation can be
    judged from the way it is formulated and from reference to relevant
    studies.

-   Guidelines deal with medical conditions in general and therefore
    their role must be educational, not prescriptive or coercive for the
    management of individual patients who may differ widely in their
    personal, medical and cultural characteristics, thus requiring
    decisions different from average one recommended by guidelines.

-   The European Society of Cardiology (ESC) Guidelines represent the
    views of the ESC and were arrived at after careful consideration of
    the available evidence at the time they were written. Health
    professionals are encouraged to take them fully into account when
    exercising their clinical judgment. The guidelines do not, however,
    override the individual responsibility of health professionals to
    make appropriate decisions in the circumstances of the individual
    patients, in consultation with that patient, and where appropriate
    and necessary the patient\'s guardian or carer. It is also the
    health professional\'s responsibility to verify the rules and
    regulations applicable to drugs and devices at the time of
    prescription.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Despite overwhelming evidence that hypertension is a  major
cardiovascular risk factor and that blood pressure lowering strategies
substantially reduce the risk, studies performed on various continents,
as well as in several European countries, consistently show that 1) a
noticeable proportion of hypertensive individuals are unaware of their
condition or, if aware, do not undergo treatment, and 2) goal blood
pressure levels are seldom achieved, regardless of whether treatment is
prescribed and patients are followed by specialists or practitioners.
Systolic blood pressure control is particularly rare, and the lower
values (\<130 mmHg) recommended in diabetics and very high risk patients
almost exceptionally reached. This explains why high blood pressure
remains a leading cause of death and cardiovascular morbidity both
worldwide and in industrialized countries. It also emphasizes the strong
need to extend to a larger fraction of the population the procedures
that allow hypertension to be detected, as well as to \'capture\' for
effective treatment a substantially greater number of patients.

The purpose of the present guidelines is to help achieve this goal.
However, producing guidelines alone is insufficient to address the above
problem. There must be a continuous process of implementation involving
education and audit. The successful implementation of guidelines
requires a concerted effort of medical professionals to realize its full
potential. With regard to hypertension the approach may differ between
European countries. In some countries prevention of cardiovascular
disease, including detection and control of hypertension, is carried out
in the primary care setting under the responsibility of general
practitioners as well as dedicated nurses and other health
professionals. In other countries specialists and hospital physicians
may be more extensively involved. Therefore guidelines issued by an
international expert committee should be adapted at the national level,
depending on local cultural background, socioeconomic situations, and
health care organization.

A broad acceptance of the present guidelines by national hypertension
societies and leagues is a prerequisite to promote management
implementation in practice and improve patient outcomes. In this
context, the present guidelines have been prepared in close cooperation
with the Fourth Joint Task Force of European and other Societies of
Cardiovascular Disease Prevention. Their recommendations are thus
consistent with the recommendations that will appear in the Fourth Joint
Task Force Guidelines which will also be published in 2007. Also
important is that the European Society of Hypertension (ESH) and the
European Society of Cardiology (ESC) are both part of a platform for
Societies interested in the implementation of prevention of
cardiovascular disease in clinical practice in the Joint Prevention
Committee. The other partners in that platform are: the European
Atherosclerosis Society, the European Association for the Study of
Diabetes, the International Diabetes Federation-Europe, WONCA-Europe
(European Society of General Practice/Family Medicine), the European
Heart Network and the International Society of Behavioural Medicine.
This partnership is crucial because general practitioners are more
likely to accept and to use guidelines when these are developed with the
involvement of those known to them.

Successful implementation of guidelines requires awareness of the
barriers interposed between recommendations and practice. The first
barrier is knowledge and acceptance by physicians. Knowledge is hampered
by the high number of guidelines doctors receive, by their duplication
by too many scientific societies, local organizations, health providing
agencies. Confusion is raised by even small differences in the
recommendations, and the suspicion is cultivated that some guidelines
may be excessively influenced by the scientific biases of the experts,
or by extrinsic influences such as those of the pharmaceutical industry
or of private or public health providers. Furthermore, doctors are
correctly aware that their task is to manage individuals, so often
different from each other, while guidelines, by necessity, are dealing
with a medical condition in general. This aspect was carefully
considered when the 2003 ESH-ESC Guidelines were prepared, and the
choice of making them widely informative and minimally prescriptive has
likely been an important reason for their acceptance. This choice has
been reiterated when preparing the current guidelines.

Barriers to implementation relate not only to the clinician but also to
the patient. Adherence to lifestyle changes and longterm compliance with
multiple drugs are major problems. Lifestyle changes have too often been
conceived as an object of preaching rather than an approach to be
implemented, and as a cheap alternative to the costs of drug therapy,
while a costly professional approach guided by experts in behavioural
medicine is often needed.

Besides the doctor and the patient, the health care system by itself may
be a barrier. Indeed, health providers sometimes wrongly consider the
management of hypertension as the matter of few minute visits, and
reimburse doctors accordingly. They often see guidelines as an
instrument to reduce cost and limit reimbursement to high risk
conditions defined by arbitrary cutoffs. Therefore policy makers and all
those responsible for the organization of the system should be involved
in the development of a comprehensive preventive programme.

The Committee is well aware of the fact that issuing these guidelines on
its own may not make the difference, but it can be helpful as part of a
more comprehensive strategy of evidence based preventive medicine where
it may serve as:

-   A consensus among all partners involved in detection and control of
    arterial hypertension

-   A basis for education and training

-   A template for national joint task forces to adopt and/or adapt
    these guidelines in accord with national health policies and
    available resources

-   A reference point based on scientific evidence to identify the most
    appropriate management tools for hypertension control

-   A good basis for health economic purposes

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Personal Digital Assistant (PDA) Downloads\
Pocket Guide/Reference Cards

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G,
Grassi G, Heagerty AM, Kjeldsen SE, Laurent S, Narkiewicz K, Ruilope L,
Rynkiewicz A, Schmieder RE, Struijker Boudier HA, Zanchetti A, ESC
Committee for Practice Guidelines (CPG):, Vahanian A, Camm J, De
Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C,
Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M,
Widimsky P, Zamorano JL, ESH Scientific Council:, Kjeldsen SE, Erdine S,
Narkiewicz K, Kiowski W, Agabiti-Rosei E, Ambrosioni E, Cifkova R,
Dominiczak A, Fagard R, Heagerty AM, Laurent S, Lindholm LH, Mancia G,
Manolis A, Nilsson PM, Redon J, Schmieder RE, Struijker-Boudier HA,
Viigimaa M, Document Reviewers:, Filippatos G, Adamopoulos S,
Agabiti-Rosei E, Ambrosioni E, Bertomeu V, Clement D, Erdine S, Farsang
C, Gaita D, Kiowski W, Lip G, Mallion JM, Manolis AJ, Nilsson PM,
O\'brien E, Ponikowski P, Redon J, Ruschitzka F, Tamargo J, van Zwieten
P, Viigimaa M, Waeber B, Williams B, Zamorano JL. 2007 Guidelines for
the management of arterial hypertension: The Task Force for the
Management of Arterial Hypertension of the European Society of
Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur
Heart J 2007 Jun;28(12):1462-536. \[825 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17562668)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Jun (revised 2007)

#### GUIDELINE DEVELOPER(S)

European Society of Cardiology - Medical Specialty Society\
European Society of Hypertension - Disease Specific Society

#### SOURCE(S) OF FUNDING

European Society of Cardiology

#### GUIDELINE COMMITTEE

Task Force for the Management of Arterial Hypertension

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: Giuseppe Mancia, Co-Chairperson (Italy); Guy De
Backer, Co-Chairperson (Belgium); Anna Dominiczak (UK); Renata Cifkova
(Czech Republic); Robert Fagard (Belgium); Giuseppe Germano (Italy);
Guido Grassi (Italy); Anthony M. Heagerty (UK); Sverre E. Kjeldsen
(Norway); Stephane Laurent (France); Krzysztof Narkiewicz (Poland); Luis
Ruilope (Spain); Andrzej Rynkiewicz (Poland); Roland E. Schmieder
(Germany); Harry A.J. Struijker Boudier (Netherlands); Alberto Zanchetti
(Italy)

*European Society of Cardiology (ESC) Committee for Practice Guidelines
Members*: Alec Vahanian, Chairperson (France); John Camm (United
Kingdom); Raffaele De Caterina (Italy); Veronica Dean (France); Kenneth
Dickstein (Norway); Gerasimos Filippatos (Greece); Christian
Funck-Brentano (France); Irene Hellemans (Netherlands); Steen Dalby
Kristensen (Denmark); Keith McGregor (France); Udo Sechtem (Germany);
Sigmund Silber (Germany); Michal Tendera (Poland); Petr Widimsky (Czech
Republic); Jose Luis Zamorano (Spain)

*European Society of Hypertension (ESH) Scientific Council*: Sverre E.
Kjeldsen, President (Norway); Serap Erdine, Vice-President (Turkey);
Krzysztof Narkiewicz, Secretary (Poland); Wolfgang Kiowski, Treasurer
(Switzerland); Enrico Agabiti-Rosei (Italy); Ettore Ambrosioni (Italy);
Renata Cifkova (Czech Republic); Anna Dominiczak (United Kingdom);
Robert Fagard (Belgium); Anthony M. Heagerty; Stephane Laurent (France);
Lars H. Lindholm (Sweden); Giuseppe Mancia (Italy); Athanasios Manolis
(Greece); Peter M. Nilsson (Sweden); Josep Redon (Spain); Roland E.
Schmieder (Germany); Harry A.J. Struijker-Boudier (The Netherlands);
Margus Viigimaa (Estonia)

*Document Reviewers*: Gerasimos Filippatos (CPG Review Coordinator)
(Greece); Stamatis Adamopoulos (Greece); Enrico Agabiti-Rosei (Italy);
Ettore Ambrosioni (Italy); Vicente Bertomeu (Spain); Denis Clement
(Belgium); Serap Erdine (Turkey); Csaba Farsang (Hungary); Dan Gaita
(Romania); Wolfgang Kiowski (Switzerland); Gregory Lip (UK); Jean-Michel
Mallion (France); Athanasios J. Manolis (Greece); Peter M. Nilsson
(Sweden); Eoin O\'Brien (Ireland); Piotr Ponikowski (Poland); Josep
Redon (Spain); Frank Ruschitzka (Switzerland); Juan Tamargo (Spain);
Pieter van Zwieten (Netherlands); Margus Viigimaa (Estonia); Bernard
Waeber (Switzerland); Bryan Williams (UK); Jose Luis Zamorano (Spain)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Disclosure forms are available on the respective society Web Sites.

#### ENDORSER(S)

Albanian Society of Cardiology - Medical Specialty Society\
British Cardiac Society - Medical Specialty Society\
Cyprus Society of Cardiology - Medical Specialty Society\
Czech Society of Cardiology - Medical Specialty Society\
Finnish Cardiac Society - Medical Specialty Society\
Georgian Association of Cardiology - Medical Specialty Society\
German Society of Cardiology - Medical Specialty Society\
International Society of Hypertension\
Italian Federation of Cardiology - Medical Specialty Society\
Lithuanian Society of Cardiology - Medical Specialty Society\
Polish Cardiac Society - Medical Specialty Society\
Portuguese Society of Cardiology - Medical Specialty Society\
Romanian Society of Cardiology - Medical Specialty Society\
San Marino Society of Cardiology - Medical Specialty Society\
Spanish Society of Cardiology - Medical Specialty Society\
Turkish Society of Cardiology - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

This updates a previous guideline: 2003 European Society of
Hypertension-European Society of Cardiology guidelines for the
management of arterial hypertension. J Hypertens 2003 Jun;21(6):1011-53.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[European Society of Cardiology (ESC) Web
site](http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/arterial-hypertension.aspx).

Print copies: Available from Oxford University Press, Great Clarendon
Street, Oxford, OX2 6DP, UK, Tel: +44 (0) 1865 353263, Fax: +44 (0) 1865
353774, Web site: <http://www.eurheartj.oxfordjournals.org/>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Management of arterial hypertension. Pocket guideline. Electronic
    copies: Available from the [European Society of Cardiology (ESC) Web
    site](http://www.escardio.org/guidelines-surveys/products/pocket/Pages/AH.aspx).
    Also available for PDA download from the [ESC Web
    site](http://pocketgram.net/escardio/).

-   Recommendations for guidelines production. A document for Task Force
    Members responsible for the production and updating of ESC
    guidelines. 2006 Jun 28. 21 p. Available from the [ESC Web
    site](http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx).

Print copies: Available from Oxford University Press, Great Clarendon
Street, Oxford, OX2 6DP, UK, Tel: +44 (0) 1865 353263, Fax: +44 (0) 1865
353774, Web site: <http://www.eurheartj.org/>.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on May 12, 2004. The information
was verified by the guideline developer on July 29, 2004. This NGC
summary was updated by ECRI Institute on October 3, 2007. The updated
information was verified by the guideline developer on November 15,
2007.

#### COPYRIGHT STATEMENT

This summary is based on the original guideline, which is subject to the
guideline developer\'s restrictions.

The content of the European Society of Cardiology (ESC) Guidelines and
their derivative products has been made available for personal and
educational use only. No commercial use is authorized. No part of the
ESC Guidelines and their derivative products may be translated or
reproduced in any form without written permission from the ESC.

The ESC Guidelines or their derivative products can be: viewed, printed
or downloaded for individual use, linked to from external websites or
online media. In order to benefit from updates and additional sources of
information, the ESC recommends linking to the relevant ESC Guidelines
pages, instead of linking directly to documents themselves.

The ESC does not allow for the insertion of its Guidelines and
derivative products (full or partial) in external websites, pages,
portals or servers, unless specific exceptional permission has been
granted for such.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008