Hypertension

Updated ESC Hypertension Guidelines 2024: Intensified Blood Pressure Targets and New Categories – Eur Heart J

31 Aug, 2024 | 19:54h | UTC

Introduction:

The 2024 ESC Guidelines for managing elevated blood pressure (BP) and hypertension were developed by the European Society of Cardiology (ESC) and endorsed by the European Society of Endocrinology (ESE) and the European Stroke Organisation (ESO). These guidelines introduce significant updates to BP management, including more intensive treatment targets and the introduction of a new category for “Elevated BP.”

Key Points:

1 – New Intensive BP Target: For most patients receiving BP-lowering medication, the guidelines now recommend a systolic BP treatment target range of 120-129 mmHg. This marks a significant shift from previous guidelines, which suggested a less aggressive initial target.

2 – New ‘Elevated BP’ Category: The guidelines introduce a new category, “Elevated BP,” defined as a systolic BP of 120-139 mmHg and/or diastolic BP of 70-89 mmHg. This aims to identify more patients at risk of cardiovascular events, such as heart attacks and strokes, before they meet the traditional threshold for hypertension.

3 – Pragmatic BP Management: For patients who cannot tolerate the intensive BP target, the guidelines recommend aiming for a BP that is “as low as reasonably achievable” (ALARA), particularly in frail or older individuals.

4 – Lifestyle Modifications: The guidelines emphasize lifestyle interventions, including dietary changes like potassium supplementation and new exercise recommendations, as first-line strategies for managing BP.

5 – Renal Denervation: For the first time, the guidelines include recommendations on the use of renal denervation—a procedure for patients with resistant hypertension that has not responded to standard treatments. This is not recommended as a first-line treatment but may be considered in specific high-risk cases.

Conclusion:

These new guidelines represent a major update in the management of hypertension, particularly in promoting more aggressive BP targets to reduce cardiovascular risks. The inclusion of a new BP category and recommendations for renal denervation highlight the guidelines’ focus on early intervention and advanced treatment options.

Reference: European Society of Cardiology (2024). “2024 ESC Guidelines for the management of elevated blood pressure and hypertension.” European Heart Journal. https://doi.org/10.1093/eurheartj/ehae178

RCT: No Difference in Postoperative Complications Between Continuation and Discontinuation of Renin-Angiotensin System Inhibitors Before Major Surgery – JAMA

31 Aug, 2024 | 19:12h | UTC

Study Design and Population: This multicenter randomized clinical trial included 2,222 patients who had been treated with renin-angiotensin system inhibitors (RASIs) for at least 3 months and were scheduled for major noncardiac surgery at 40 hospitals in France between January 2018 and April 2023. The participants were randomly assigned to either continue RASIs until the day of surgery or to discontinue them 48 hours before surgery.

Main Findings: The trial found no significant difference in the primary outcome—a composite of all-cause mortality and major postoperative complications within 28 days—between the continuation and discontinuation groups (22% in both groups, RR 1.02, 95% CI 0.87-1.19). However, the continuation group experienced a higher incidence of intraoperative hypotension (54% vs. 41%, RR 1.31, 95% CI 1.19-1.44).

Implications for Practice: Continuation of RASIs before major noncardiac surgery does not increase the risk of postoperative mortality or major complications, but it does elevate the risk of intraoperative hypotension. Clinicians should weigh these risks when deciding whether to continue or discontinue RASIs before surgery.

Reference: Legrand M, Falcone J, Cholley B, et al. (2024). Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery: The Stop-or-Not Randomized Clinical Trial. JAMA. https://doi.org/10.1001/jama.2024.17123

Meta-Analysis: Renal Denervation Modestly Reduces Blood Pressure in Uncontrolled Hypertension – J Am Heart Assoc

17 Aug, 2024 | 16:14h | UTC

Study Design and Population: This updated meta-analysis evaluated 15 randomized clinical trials, encompassing 2,581 patients, to assess the efficacy and safety of catheter-based renal denervation (RDN) in patients with uncontrolled hypertension. The trials included both patients on antihypertensive medications (ON-Med) and those off medications (OFF-Med), with comparisons made between RDN and sham or standard therapy.

Main Findings: RDN led to a modest but statistically significant reduction in blood pressure across both ON-Med and OFF-Med groups. In the OFF-Med group, 24-hour ambulatory systolic BP was reduced by 3.7 mm Hg (95% CI, -5.41 to -2.00). In the ON-Med group, the reduction was 2.23 mm Hg (95% CI, -3.56 to -0.90). Sham-controlled trials reinforced these findings, showing consistent BP reductions, thus validating the effect of RDN. However, the degree of BP reduction is modest and may be clinically limited.

Implications for Practice: While RDN appears to have a favorable safety profile and provides consistent BP reductions, the modest nature of these reductions suggests that its clinical utility may be more limited. Further research is needed to identify which patient populations might benefit the most from RDN and to optimize procedural techniques for greater efficacy.

Reference: Mufarrih et al. (2024). Randomized Trials of Renal Denervation for Uncontrolled Hypertension: An Updated Meta-Analysis. Journal of the American Heart Association, 13(e034910). DOI: 10.1161/JAHA.124.034910.

RCT: Dietary Acid Reduction with Fruits and Vegetables Slows CKD Progression and Lowers CVD Risk in Hypertensive Patients – Am J Med

17 Aug, 2024 | 15:49h | UTC

Study Design and Population: This five-year randomized control trial included 153 hypertensive patients with macroalbuminuria and normal kidney function. Participants were randomly assigned to one of three groups: a diet rich in base-producing fruits and vegetables, oral sodium bicarbonate (NaHCO3), or Usual Care. The primary objective was to assess the effects of dietary acid reduction on chronic kidney disease (CKD) progression and cardiovascular disease (CVD) risk.

Main Findings: The study found that both fruits and vegetables and NaHCO3 slowed CKD progression compared to Usual Care, with significantly higher estimated glomerular filtration rates in the intervention groups. However, only the fruits and vegetables group showed significant reductions in systolic blood pressure, LDL cholesterol, and body mass index, leading to greater improvements in CVD risk indices.

Implications for Practice: The results support using fruits and vegetables as a foundational treatment for hypertension to reduce CKD progression and lower CVD risk, potentially with reduced reliance on pharmacological interventions.

Reference: Goraya, N., Madias, N. E., Simoni, J., Kahlon, M., Aksan, N., & Wesson, D. E. (2024). Kidney and Cardiovascular Protection Using Dietary Acid Reduction in Primary Hypertension: A Five-Year, Interventional, Randomized, Control Trial. The American Journal of Medicine, 000(000), 1-14. DOI: https://doi.org/10.1016/j.amjmed.2024.06.006.

New AHA Guidelines for Managing Elevated Blood Pressure in Acute Care Settings – Hypertension

13 Aug, 2024 | 13:13h | UTC

Introduction:

The American Heart Association (AHA) has released a scientific statement focusing on the management of elevated blood pressure (BP) in acute care settings. This guideline addresses the significant variation in practice due to a lack of robust evidence for managing BP in such environments, particularly in emergencies or when elevated BP is asymptomatic.

Key Points:

1 – Classification of Elevated BP: Elevated BP in acute care settings is categorized into asymptomatic elevated BP and hypertensive emergency, the latter requiring immediate treatment due to acute target-organ damage.

2 – Hypertensive Emergency: Immediate treatment is necessary for patients with BP >180/110–120 mm Hg and evidence of new or worsening target-organ damage, typically using intravenous antihypertensive medications in a closely monitored environment.

3 – Asymptomatic Elevated BP: In cases where elevated BP is present without symptoms or target-organ damage, the use of antihypertensive medications should be approached cautiously. Recent studies suggest potential harm from aggressive treatment, highlighting the importance of verifying BP readings and identifying reversible causes before intervention.

4 – Proper BP Measurement: Accurate BP measurement is crucial. The guidelines stress using recently calibrated devices and following correct measurement techniques to avoid unnecessary treatment due to erroneous readings.

5 – PRN Orders: The use of “as needed” (PRN) antihypertensive medications for asymptomatic elevated BP is discouraged due to the risks of overtreatment and variability in BP control, which can lead to adverse outcomes.

6 – Treatment Thresholds: The guidelines recommend a high threshold for initiating or intensifying antihypertensive treatment in asymptomatic patients, emphasizing the need for repeated measurements and assessment of underlying causes.

7 – Post-Discharge Care: It is crucial to maintain prehospital antihypertensive regimens and avoid intensification at discharge unless clearly indicated. Effective care coordination and patient education are vital for successful transitions from hospital to home care.

Conclusion:

These guidelines represent a significant step toward standardizing BP management in acute care settings. By focusing on accurate measurement, cautious treatment of asymptomatic elevated BP, and proper follow-up, clinicians can reduce unnecessary interventions and improve patient outcomes.

Guideline Reference: Bress, A.P., et al. (2024). “The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement from the American Heart Association.” Hypertension, 81–e106.

M-A: Effects of long-term salt substitution on cardiovascular mortality and events – Ann Intern Med

5 May, 2024 | 15:10h | UTC

This systematic review and meta-analysis assessed the impact of long-term salt substitution on cardiovascular outcomes by analyzing data from 16 randomized controlled trials (RCTs). The primary investigation focused on mortality, major cardiovascular events (MACE), and adverse events with a study period of six months or longer. Key findings include a potential reduction in all-cause mortality (rate ratio [RR] of 0.88) and cardiovascular mortality (RR of 0.83), based on low-certainty evidence from studies predominantly conducted in China or Taiwan among older adults or those at higher cardiovascular risk. Results also indicated a slight reduction in MACE (RR of 0.85) with very low certainty. Evidence suggests no significant increase in serious adverse events. Limitations include the dominance of a single large RCT and limited generalizability of results to Western populations. The study concludes that while salt substitution could reduce mortality, the effects on cardiovascular events remain uncertain, with more robust evidence needed for broader demographic applicability.

Reference (link to abstract – $ for full-text):

Hannah Greenwood et al. (2024). Long-Term Effect of Salt Substitution for Cardiovascular Outcomes: A Systematic Review and Meta-Analysis. Annals of Internal Medicine, Volume 178, Pages 23-31. DOI: 10.7326/M23-2626.

Cohort Study: Increased fracture risk linked with initiation of antihypertensive medication in older veterans

26 Apr, 2024 | 12:29h | UTC

Study Design and Population:
This retrospective cohort study evaluated the association between antihypertensive medication initiation and fracture risk among older long-term care nursing home residents within the Veterans Health Administration. Conducted from 2006 to 2019 with data analysis spanning 2021 to 2023, the study utilized target trial emulation techniques and included 29,648 residents. A 1:4 propensity score-matched method was employed to compare medication initiators with non-initiators.

Main Findings:
Out of the matched cohort of 64,710 residents, those who initiated antihypertensive medication showed a higher incidence of fractures (5.4 per 100 person-years) compared to controls (2.2 per 100 person-years). The adjusted hazard ratio for fractures was 2.42. Notably, higher risks were observed in subgroups with dementia or elevated blood pressure thresholds (systolic ≥140 mm Hg or diastolic ≥80 mm Hg). Risks for severe falls and syncope were also elevated in the medication-initiating group.

Implications for Practice:
The study indicates a significant association between the initiation of antihypertensive medications and increased fracture risks among older, frail nursing home residents. Given these findings, clinicians should exercise caution and consider enhanced monitoring and preventive strategies when prescribing these medications to this vulnerable population.

Reference (link to abstract – $ for full-text):
Dave, C. V. et al. (2024). Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents. JAMA Intern Med, Published online April 22, 2024. DOI:10.1001/jamainternmed.2024.0507.

Pragmatic Cluster-Randomised Trial: Efficacy of a Fixed-Dose Polypill in Reducing Cardiovascular Disease Risk in Rural Iran

21 Apr, 2024 | 21:05h | UTC

Study Design and Population: The PolyPars Study was structured as a two-arm pragmatic cluster-randomised trial within the larger PARS cohort study. It targeted residents aged over 50 in a district in southern Iran, dividing 91 villages into two groups: one receiving a once-daily polypill (containing two antihypertensives, a statin, and aspirin) alongside non-pharmacological interventions, and the other receiving only the non-pharmacological interventions. The trial included 4,415 participants aged 50-75 years, with the primary endpoint being the first occurrence of major cardiovascular events.

Main Findings: Over a median follow-up of 4.6 years, adherence to the polypill was high at 86%. The intervention arm showed a significant reduction in the incidence of the primary outcome, with only 4.0% (88 participants) experiencing major cardiovascular events compared to 8.0% (176 participants) in the control arm. This translates to a hazard ratio of 0.50, indicating a 50% reduction in risk, and an absolute risk reduction of 4.0%.

Implications for Practice: The study demonstrates the significant potential of fixed-dose combination therapy with the polypill to halve the risk of major cardiovascular diseases in a population-level intervention. This finding supports the polypill as a safe and effective strategy for both primary and secondary prevention of cardiovascular diseases, particularly in settings where access to individual medications and consistent medical supervision might be limited.

Reference: Fatemeh Malekzadeh et al. (2024). Effectiveness of polypill for primary and secondary prevention of cardiovascular disease: a pragmatic cluster-randomised controlled trial (PolyPars). Heart, heartjnl-2023-323614. DOI: 10.1136/heartjnl-2023-323614.

RCT: Quadruple quarter-dose hypertension medication versus monotherapy for ambulatory blood pressure control

20 Mar, 2024 | 18:00h | UTC

Study Design and Population: This randomized clinical trial investigated the efficacy of a combination of four ultra-low-dose blood pressure medications (quadpill) compared to standard monotherapy in adults with hypertension. A total of 591 participants, either untreated or currently on monotherapy for hypertension, were enrolled and randomly assigned to receive either the quadpill (irbesartan 37.5 mg, amlodipine 1.25 mg, indapamide 0.625 mg, and bisoprolol 2.5 mg) or a monotherapy control (irbesartan 150 mg).

Main Findings: At 12 weeks, the quadpill group demonstrated significantly lower mean 24-hour ambulatory systolic and diastolic blood pressure (SBP and DBP) by 7.7 mmHg and 5.3 mmHg, respectively, compared to the monotherapy group, with similar reductions observed during daytime and night-time. Additionally, the rate of blood pressure control (24-hour average BP < 130/80 mmHg) was significantly higher in the quadpill group (77% vs. 50%). The study highlighted the quadpill’s effectiveness in reducing blood pressure variability and enhancing control rates across a 24-hour period.

Implications for Practice: The findings from this study support the superior efficacy of an ultra-low-dose quadruple medication strategy over monotherapy in managing ambulatory blood pressure among hypertensive patients. These results suggest that a quadpill approach could offer a more effective means for clinicians to achieve and maintain blood pressure control in hypertensive patients, potentially improving cardiovascular outcomes.

Reference: Janis M Nolde et al. (2024). Ambulatory blood pressure after 12 weeks of quadruple combination of quarter doses of blood pressure medication vs. standard medication. J Hypertens, 2024 Feb 29. DOI: 10.1097/HJH.0000000000003683. Access the study here: [Link]

Crossover RCT | Using one-size cuff results in major inaccuracy in BP readings across varying arm sizes

11 Aug, 2023 | 15:41h | UTC

Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial – JAMA Internal Medicine (free for a limited period)

Commentaries:

When it comes to blood pressure cuffs, size matters – MedicalResearch.com

One-size-fits-all blood pressure cuffs ‘strikingly inaccurate,’ study says – CNN

[News release – not published yet] Study finds blood pressure cuff size matters, affects blood pressure readings

Commentary on Twitter

Using a regular blood pressure (BP) cuff regardless of individual’s arm size resulted in 3.6 mmHg lower systolic BP when a regular cuff was one size too-large, and 4.8 and 19.5 mmHg higher when a regular cuff was one and two sizes too small. https://t.co/ZKnGfWc9fy

— JAMA Internal Medicine (@JAMAInternalMed) August 7, 2023

News Release: Routinely drinking alcohol may raise blood pressure even in adults without hypertension – AHA Newsroom

Review | Revisiting resistant hypertension

1 Aug, 2023 | 14:16h | UTC

Revisiting resistant hypertension: a comprehensive review – Internal Medicine Journal

Podcast: #390 Resistant Hypertension – The Curbsiders

M-A | Various exercise training modes reduce resting blood pressure, isometric exercise most effective

31 Jul, 2023 | 14:35h | UTC

Exercise training and resting blood pressure: a large-scale pairwise and network meta-analysis of randomised controlled trials – British Journal of Sports Medicine

News Release: Static isometric exercise, such as wall sits, best for lowering blood pressure – BMJ Newsroom

Commentary: Wall squats and planks best at lowering blood pressure – BBC

Systematic Review | Insufficient evidence for ACEi/ARB’s impact on early non-diabetic CKD

24 Jul, 2023 | 12:56h | UTC

Angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers for adults with early (stage 1 to 3) non‐diabetic chronic kidney disease – Cochrane Library

Summary: Blood pressure lowering medication for adults with early stages of chronic kidney disease (without diabetes) – Cochrane Library

Phase 1 Trial | Zilebesiran demonstrates potential as prolonged-action hypertension therapeutic

21 Jul, 2023 | 13:32h | UTC

Zilebesiran, an RNA Interference Therapeutic Agent for Hypertension – New England Journal of Medicine (link to abstract – $ for full-text)

Commentary: Experimental Shot Given Every Six Months Controlled High Blood Pressure in Early Trial – HealthDay

Self-measured blood pressure telemonitoring programs: a pragmatic how-to guide

19 Jul, 2023 | 14:33h | UTC

Self-Measured Blood Pressure Telemonitoring Programs: A Pragmatic How-to Guide – American Journal of Hypertension

Nationwide Cohort Study | Adolescent hypertension linked with increased stroke risk in young adulthood

18 Jul, 2023 | 13:49h | UTC

Adolescent Hypertension Is Associated With Stroke in Young Adulthood: A Nationwide Cohort of 1.9 Million Adolescents – Stroke

Commentary: The Relationship Between Adolescent Hypertension and Stroke Risk After Age 40 Years – Neurology Advisor

M-A | First-line thiazide diuretics show reduced cardiovascular events, comparable mortality vs. other antihypertensive drugs

14 Jul, 2023 | 12:55h | UTC

First‐line diuretics versus other classes of antihypertensive drugs for hypertension – Cochrane Library

Summary: What are the benefits and harms of diuretics given as a first treatment compared to other drug classes for hypertension (high blood pressure)? – Cochrane Library

M-A | The effect of blood pressure lowering medications on the prevention of episodic migraine

12 Jul, 2023 | 13:50h | UTC

The effect of blood pressure lowering medications on the prevention of episodic migraine: A systematic review and meta-analysis – Cephalalgia

News Release: New study shows common blood pressure meds underused for migraine – George Institute for Global Health

Cohort Study | Hypertensive disorders of pregnancy linked to a 66% higher stroke risk in U.S. black women

10 Jul, 2023 | 13:31h | UTC

Hypertensive Disorders of Pregnancy and Risk of Stroke in U.S. Black Women – NEJM Medicine

Commentary: Black women with history of hypertensive disorders of pregnancy have 66% increased risk of stroke, study finds – News Medical

2023 ESH Guidelines for the management of arterial hypertension

3 Jul, 2023 | 14:34h | UTC

2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension Endorsed by the European Renal Association (ERA) and the International Society of Hypertension (ISH) – Journal of Hypertension

Review | Hypertension management in patients with cardiovascular comorbidities

27 Jun, 2023 | 13:39h | UTC

Hypertension management in patients with cardiovascular comorbidities – European Heart Journal