Opinion
VIEWPOINT
The 2018 European Society of Cardiology/
European Society of Hypertension and 2017
American College of Cardiology/American Heart
Association Blood Pressure Guidelines
More Similar Than Different
Paul K. Whelton, MB, Clinical practice guidelines are an important estab-
MD, MSc lished resource in medicine and public health. Clinical
Department of practice guidelines are particularly well suited to condi-
Epidemiology, Tulane
tions such as high blood pressure (BP) that are com-
University School of
Public Health and mon, result in a substantial disease burden and utiliza-
Tropical Medicine, tion of health care resources, incur individual and societal
New Orleans, cost, demonstrate large variation in practice patterns,
Louisiana; and
Department of
and have enough high-quality evidence to guide deci-
Medicine, Tulane sion-making. Although many BP-related clinical prac-
University School of tice guidelines have been developed by individual coun-
Medicine, New Orleans,
tries and professional societies, few would dispute that
Louisiana.
2 such reports released during the past 12 months—the
Bryan Williams, MD 2017 American College of Cardiology (ACC)/American
UCL Institute of Heart Association (AHA)1 and 2018 European Society of
Cardiovascular Cardiology (ESC)/European Society of Hypertension
Sciences, University
(ESH)2 guidelines—have substantial influence beyond
College London,
London, United their immediate regions of origin.
Kingdom; and National Presentation and publication of these 2 compre-
Institute for Health hensive guidelines have resulted in comparisons and
Research, UCL
Hospitals Biomedical
vigorous debate, with an emphasis on differences3
Research Centre, rather than how their core recommendations can be
London, United implemented to improve the health of the public. This
Kingdom.
may lead to an impression that experts cannot agree or
that the evidence is flawed or insufficient, providing
support for those who are content with the status quo
of lamentable hypertension control globally.4 Against
Editorial page 1757
this backdrop, it is important to recognize that the con-
vergence of the 2017 ACC/AHA (US) and 2018 ESC/ESH
Author Audio (European) guidelines is greater now than ever before.
Interview
The 2 guidelines have much in common (eTable
in the Supplement), including recommendations to
Supplemental (1) base diagnosis and management of hypertension
content on accurate BP measurements; (2) perform out-of-
office BP readings to confirm high office readings and
to recognize “white coat” and “masked” hypertension;
(3) use cardiovascular disease (CVD) risk estimation,
in addition to BP levels, for therapeutic decision-
making; (4) utilize a similar array of drug treatment
and nonpharmacological lifestyle interventions as the
core strategy for BP lowering; (5) add antihyperten-
sive drug treatment to nonpharmacological therapy at
Corresponding
lower BP thresholds than previously recommended;
Author: Paul K. (6) use combination drug therapy, preferably in the
Whelton, MB, MD, MSc, form of a single combination pill, to improve treat-
1440 Canal St, Room
ment adherence; (7) utilize combinations of the same
2015, New Orleans, LA
70112 (pkwhelton classes of antihypertensive drugs for treatment of
@gmail.com). most adults with hypertension (thiazide/thiazide-like
jama.com
© 2018 American Medical Association. All rights reserved.
Downloaded From: by a Univ of Louisiana At Lafayette User on 11/06/2018
diuretics, calcium channel blockers, angiotensin-
converting enzyme inhibitors, and angiotensin recep-
tor blockers), reserving combinations with β-blockers
for specific clinical conditions; (8) use lower BP treat-
ment targets than those previously recommended,
including lower BP targets in older adults, adults with
diabetes, and adults with a variety of comorbid condi-
tions; (9) emphasize functionality rather than chrono-
logical age in managing high BP in older adults; and
(10) use strategies known to improve the control of
hypertension. In addition, both guidelines identify evi-
dence gaps for which additional research is needed to
resolve areas of current uncertainty.
The guidelines vary in the details of their common-
ality but generally encourage greater use of out-of-
office BP measurements, lower BP thresholds for initi-
ating antihypertensive drug therapy, and lower BP
treatment targets, which collectively should lead to a
lower BP and fewer BP-related complications.5 Other re-
cent comprehensive BP clinical practice guidelines from
Canada6 and Australia7 have also recommended lower
BP treatment targets than in previous guidelines.
A key change in both guidelines is the approach to
treatment of BP in older adults, which is closer than ever
to that proposed for younger adults. Emerging evi-
dence that lowering BP seems to protect against cogni-
tive decline8 may help reinforce the importance of im-
proving BP treatment and hypertension control rates,
with no age-related end date and cessation of therapy
only when it is poorly tolerated or the patient experi-
ences functional decline to the point at which treat-
ment is futile.
Despite their similarities, the guidelines take a differ-
ent position in several areas. The most apparent is in clas-
sification of BP. The definition of hypertension in the
European guideline is unchanged, reflecting the level of
BP (ⱖ140/90 mm Hg) at which drug treatment is recom-
mended for all patients. In the US guideline, hyperten-
sion is defined by an average systolic BP of at least
130 mm Hg or diastolic BP of 80 mm Hg or higher, based
on an interpretation of risk and treatment effect. This
results in a different approach to treatment of adults with
a systolic BP of 130 through 139 mm Hg or diastolic BP of
80 through 89 mm Hg, who are classified as having
stage 1 hypertension in the US guideline and high-
normalBPintheEuropeanguideline.TheUSguidelinerec-
ommends nonpharmacological therapy for all adults with
(Reprinted) JAMA November 6, 2018 Volume 320, Number 17 1749
 Opinion Viewpoint

stage 1 hypertension and additional antihypertensive drug therapy for
the approximately 30% in this highly prevalent BP category who are
deemed to be at high risk for atherosclerotic CVD (10-year risk of ath-
erosclerotic CVDⱖ10%). In contrast, the European guideline pre-
dominantly recommends lifestyle interventions, with consideration
of antihypertensive drug therapy only in adults at very high risk,
ie, with established CVD, especially coronary artery disease.
The decision in the US guideline to reclassify hypertension and
base treatment of stage 1 hypertension on CVD risk estimation has
important implications for older adults, many of whom would meet
the risk threshold for drug treatment. Even though BP thresholds
for treatment in older adults have been reduced in the European
guideline, they remain higher than the US recommendations at BP
levels of 140/90 mm Hg or higher for patients older than 65 years
and 160/90 mm Hg or higher for patients older than 80 years who
have not previously been treated.
Both guidelines recommend lower BP targets during com-
bined lifestyle and antihypertensive drug therapy. In the US guide-
line, the target is lower than 130/80 mm Hg in almost all patient
groups, except older adults, among whom the target is systolic BP
lower than 130 mm Hg. In the European guideline, the first objec-
tive is to reduce BP to less than 140/90 mm Hg, with a target of
130/80 mm Hg or lower, if tolerated, in adults younger than 65 years
but not in adults 65 years and older, for whom the target is below
140 to 130/80 mm Hg, if tolerated.
Another difference in BP targets relates to patients with chronic
kidney disease (CKD). The European guideline recommends a target
of less than 140/90 mm Hg, with flexibility for individualized man-
agement depending on treatment tolerance and impact on renal func-
tion and electrolyte levels. The US guideline recommends a target
below 130/80 mm Hg, largely based on the favorable CVD and
all-cause mortality experience in SPRINT participants with CKD at
baseline.9 Both guidelines recommend management of additional
CVD risk factors, but the US guideline generally defers to other
ACC/AHA guidelines, whereas the European guideline provides rec-
ommendations for concomitant treatment with statins in many
patients who have hypertension with a low-moderate or high risk of
CVD. It also recommends antiplatelet therapy and aspirin for second-
ary but not primary prevention of CVD.
Two final differences relate to the process used for guideline
development. The US writing committee had no BP-related com-
mercial relationships and used an independent evidence review
committee, in addition to literature review, to analyze the data for
key questions. The European guideline task force considered the
latter option unnecessary because many relevant systematic
reviews had been published recently in high-quality journals. Both
processes resulted in similar outputs, raising an important question
regarding the value and need for rigorous independent assess-
ments when high-quality systematic reviews are already in the
public domain. Interpretation of the results and considerations of
local factors, policies, and feasibility of implementation was what
led to the guideline differences.
Adoption of the ACC/AHA and ESC/ESH guideline recommen-
dations will be challenging for patients, clinicians, and health care
systems. The fundamental issue is that too many adults have un-
healthy lifestyles that put them at risk for adverse consequences in-
cluding stroke, myocardial infarction, heart failure, and CKD.10 The
best solution is a change to healthier lifestyles but dissemination,
acceptance, and implementation of the ACC/AHA and ESC/ESH core
recommendations for diagnosis and treatment of hypertension will
likely result in substantially better public health.5 It seems unlikely
that current models of care can respond adequately to meet the
guideline recommendations. Potential solutions include minimiz-
ing barriers to accurate diagnosis and management of hyperten-
sion, a progressive shift to team-based care, better application of
strategies for enhanced therapeutic adherence, and greater involve-
ment of patients in their own care. The latter could also reduce the
burden for primary care clinicians.

ARTICLE INFORMATION
Conflict of Interest Disclosures: Dr Whelton
reports having served as chair of the 2017 ACC/AHA
blood pressure guideline committee. Dr Williams
reports receiving grants and personal fees from
Vascular Dynamics Inc, fees from Novartis for
serving on a study advisory board, fees from Daiichi
Sankyo for educational lectures, fees from Servier
for educational lectures, fees from Boehringer
Ingelheim for educational lectures, and fees from
Pfizer for educational lectures outside the
submitted work; and served as chair of the 2018
ESC-ESH Guidelines on Arterial Hypertension
Guideline Task Force, and chair of the ESC Council
on Hypertension, 2016-2018.
Additional Contributions: We thank Robert M.
Carey, MD, and Giuseppe Mancia, MD, PhD, for
valuable suggestions that improved the text.
REFERENCES
1. Whelton PK, Carey RM, Aronow WS, et al. 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/
NMA/PCNA Guideline for the Prevention,
Detection, Evaluation, and Management of High
Blood Pressure in Adults: Executive Summary:
A Report of the American College of
Cardiology/American Heart Association Task Force
on Clinical Practice Guidelines. Hypertension.
2018;71(6):1269-1324. doi:10.1161/HYP
.0000000000000066
2. Williams B, Mancia G, Spiering W, et al; ESC
Scientific Document Group. 2018 ESC/ESH
Guidelines for the management of arterial
hypertension. Eur Heart J. 2018;39(33):3021-3104.
doi:10.1093/eurheartj/ehy339
3. Messerli FH, Bangalore S. The blood pressure
landscape: schism among guidelines, confusion
among physicians, and anxiety among patients.
J Am Coll Cardiol. 2018;72(11):1313-1316. doi:10.1016
/j.jacc.2018.07.026
4. Mills KT, Bundy JD, Kelly TN, et al. Global
disparities of hypertension prevalence and control:
a systematic analysis of population-based studies
from 90 countries. Circulation. 2016;134(6):441-450.
doi:10.1161/CIRCULATIONAHA.115.018912
5. Bundy JD, Mills KT, Chen J, Li C, Greenland P, He
J. Estimating the association of the 2017 and 2014
hypertension guidelines with cardiovascular events
and deaths in US adults: an analysis of national
data. JAMA Cardiol. 2018;3(7):572-581. doi:10.1001
/jamacardio.2018.1240
6. Nerenberg KA, Zarnke KB, Leung AA, et al;
Hypertension Canada. Hypertension Canada’s 2018
Guidelines for Diagnosis, Risk Assessment,
Prevention, and Treatment of Hypertension in
Adults and Children. Can J Cardiol. 2018;34(5):506-
525. doi:10.1016/j.cjca.2018.02.022
7. Gabb GM, Mangoni AA, Anderson CS, et al.
Guideline for the diagnosis and management of
hypertension in adults–2016. Med J Aust. 2016;205
(2):85-89. doi:10.5694/mja16.00526
8. Williamson JD; SPRINT Research Group.
A randomized trial of intensive vs standard systolic
blood pressure control and the risk of mild cognitive
impairment and dementia: results from SPRINT
Mind. Abstract ID: 27525. https://ep70
.eventpilotadmin.com/web/planner.php?id=AAIC18.
9. Wright JT Jr, Williamson JD, Whelton PK, et al;
SPRINT Research Group. A randomized trial of
intensive versus standard blood-pressure control.
N Engl J Med. 2015;373(22):2103-2116. doi:10.1056
/NEJMoa1511939
10. Greenland P. Cardiovascular guideline
skepticism vs lifestyle realism? JAMA. 2018;319(2):
117-118. doi:10.1001/jama.2017.19675

1750 JAMA November 6, 2018 Volume 320, Number 17 (Reprinted) jama.com

© 2018 American Medical Association. All rights reserved.

Downloaded From: by a Univ of Louisiana At Lafayette User on 11/06/2018