Antihypertensive Drugs Guidelines_ European Society of Cardiology (ESC) Recommendations

Antihypertensive Drugs Guidelines: European Society of Cardiology (ESC) Recommendations

The European Society of Cardiology (ESC), in collaboration with the European Society of Hypertension (ESH), provides comprehensive guidelines for the management of arterial hypertension. These guidelines offer evidence-based recommendations for the diagnosis, evaluation, and treatment of hypertension, including the use of antihypertensive drugs. The most recent major update was published in 2018, with subsequent focused updates addressing specific aspects of hypertension management.

According to the ESC guidelines, the primary goal of antihypertensive treatment is to reduce blood pressure to target levels, which are generally <140/90 mmHg for most patients. For patients aged 18-65 years, the target is 120-130/70-79 mmHg if tolerated. For patients over 65 years, the systolic blood pressure (SBP) target is 130-139 mmHg, with careful monitoring to avoid side effects.

The ESC guidelines recommend five main classes of antihypertensive drugs as first-line and maintenance therapy:

Angiotensin-Converting Enzyme (ACE) Inhibitors

Angiotensin Receptor Blockers (ARBs)

Beta-Blockers

Calcium Channel Blockers (CCBs)

Thiazide and Thiazide-like Diuretics

The guidelines emphasize that all five classes are suitable for the initiation and maintenance of antihpertensive treatment, either as monotherapy or in combinations. This recommendation is based on evidence that the main benefits of antihypertensive treatment are due to blood pressure lowering per se, rather than specific drug effects.

A key recommendation in the ESC guidelines is the use of combination therapy as initial treatment for most patients. This approach is based on the recognition that monotherapy is often insufficient to achieve blood pressure targets. The guidelines suggest starting with a two-drug combination, preferably in a single pill to improve adherence. The recommended combinations are:

An ACE inhibitor or ARB combined with a CCB or diuretic

A CCB combined with a diuretic

Beta-blockers are recommended in specific situations, such as in patients with coronary artery disease, heart failure, or for younger women planning pregnancy.

For resistant hypertension, defined as blood pressure remaining above target despite treatment with optimal doses of three drugs including a diuretic, the guidelines recommend adding spironolactone or, if not tolerated, other diuretics, alpha-blockers, or beta-blockers.

The ESC guidelines also emphasize the importance of a comprehensive approach to cardiovascular risk reduction. This includes lifestyle modifications such as salt restriction, moderation of alcohol consumption, weight loss, regular physical activity, and smoking cessation.

Special considerations are given to specific patient populations:

In patients with diabetes, a SBP target of 130 mmHg or lower is recommended if tolerated.

For patients with chronic kidney disease, the target is <140/90 mmHg, with some patients potentially benefiting from lower targets if tolerated.

In elderly patients (>65 years), careful titration of antihypertensive medication is recommended to avoid adverse effects.

The guidelines stress the importance of monitoring treatment efficacy and tolerability, with regular follow-up and adjustments as needed. They also highlight the value of home blood pressure monitoring and ambulatory blood pressure monitoring in assessing treatment efficacy and identifying white-coat or masked hypertension.

Regarding specific drug choices, the guidelines note that certain comorbidities may favor the use of specific drug classes. For example, ACE inhibitors or ARBs are preferred in patients with proteinuria or microalbuminuria, while beta-blockers are indicated in patients with coronary artery disease or heart failure.