2024 ESH临床实践指南：高血压的管理

指南心血管内科· 高血压 · 2024

Authors

1. Introduction

The European Society of Hypertension (ESH) reported in 2023 its current Guidelines for the management of arterial hypertension [1] . Following their aim to summarize the best available evidence for all aspects of hypertension management, the Task Force of the 2023 Guidelines generated a comprehensive document covering almost 200 pages including 1736 references [1] . This document thus provides a valuable and comprehensive source of information for hypertension management. However, due to the length of the text and its complexity, not only primary care providers (e.g. family physicians, general physicians/internists), who represent the group of physicians that manages the vast majority of patients, but also specialists may find it challenging to navigate through the extensive guidelines with its numerous recommendations. Therefore, the ESH decided to provide with its 2024 Clinical Practice Guidelines a novel concise format that supports the dissemination of the most important information of the Guidelines for the management of the general hypertensive population and its implementation into clinical practice. To this end, the ESH developed a MASTERplan for the management of hypertension (Fig. 1 ). For aspects that are (intentionally) not covered in this document and for the supporting literature readers are referred to the full text of the 2023 ESH Guidelines [1] .

2. Measure blood pressure-diagnose

The accurate measurement of blood pressure (BP) is the cornerstone for the diagnosis and management of hypertension. The measurement of BP to diagnose hypertension therefore represents the first pivotal step of the ESH MASTERplan for the management of hypertension.

• Conventional attended office BP measurement (OBPM) is the most well-studied method for assessing BP and the one by which the diagnosis of hypertension, BP classification, the role of BP as a cardiovascular (CV) risk factor, the protective effect of antihypertensive treatment and the BP thresholds and targets of therapeutic interventions have been established.a; CCB, calcium channel blocker; CV, cardiovascular; CVD, cardiovascular disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; COVID-19, Coronavirus Disease 2019 (COVID-19); COX-2, cyclooxygenase 2; DASH, dietary approaches to stop hypertension; DBP, diastolic blood pressure; ECG, electrocardiogram; eGFR, estimated glomerular filtration rate; ESH, European Society of Hypertension; FU, follow-up; HbA1c, hemoglobin A 1c ; HBPM, home blood pressure monitoring; HDL, high density lipoprotein; HDP, hypertensive disorders in pregnancy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HMOD, hypertension-mediated organ damage; ISH, isolated systolic hypertension; LDL, low density lipoprotein; Lp(a), lipoprotien (a); LV, left ventricle; LVH, left ventricular hypertrophy; MMSE, mini mental state examination; MRA, mineralocorticoid receptor antagonist; MRI, magnetic resonance imaging; NSAIDS, non-steroidal anti-inflammatory drugs; NsMRA, non-steroidal mineralocorticoid receptor antagonist; OSA, obstructive sleep apnea; OBPM, office blood pressure monitoring; OTC, over the counter medications; PWV, pulse wave velocity; SCORE2, Systematic COronary Risk Evaluation model 2; SCORE2-OP, Systematic COronary Risk Evaluation model 2 for Older People; SBP, systolic blood pressure; SPC, single pill combination; SGLT2i, sodium-glucose cotransporter type 2 inhibitors; TIA, transient ischemic attack; T/TL-diuretic, thiazide/thiazide-like diuretic; UACR, urinary albumin-creatinine ratio. • Ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) are important methods for out-of-office BP monitoring, that provide important additional information for the management of Abbreviations: ACEi, angiotensin-converting-enzyme inhibitor; ABPM, ambulatory blood pressure monitoring; ADL, activity of daily living; AF, atrial fibrillation; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprylisin inhibitor; BB, beta blocker; BP, blood pressure; BMI, body mass index; bpm, beats per minute; BSA, body surface area; CCB, calcium channel blocker; CV, cardiovascular; CVD, cardiovascular disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; COVID-19, Coronavirus Disease 2019 (COVID-19); COX-2, cyclooxygenase 2; DASH, dietary approaches to stop hypertension; DBP, diastolic blood pressure; ECG, electrocardiogram; eGFR, estimated glomerular filtration rate; ESH, European Society of Hypertension; FU, follow-up; HbA1c, hemoglobin A 1c ; HBPM, home blood pressure monitor ypertensive disorders in pregnancy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HMOD, hypertension-mediated organ damage; ISH, isolated systolic hypertension; LDL, low density lipoprotein; Lp(a), lipoprotien (a); LV, left ventricle; LVH, left ventricular hypertrophy; MMSE, mini mental state examination; MRA, mineralocorticoid receptor antagonist; MRI, magnetic resonance imaging; NSAIDS, non-steroidal anti-inflammatory drugs; NsMRA, non-steroidal mineralocorticoid receptor antagonist; OSA, obstructive sleep apnea; OBPM, office blood pressure monitoring; OTC, over the counter medications; PWV, pulse wave velocity; SCORE2, Systematic COronary Risk Evaluation model 2; SCORE2-OP, Systematic COronary Risk Evaluation model 2 for Older People; SBP, systolic blood pressure; SPC, single pill combination; SGLT2i, sodium-glucose cotransporter type 2 inhibitors; TIA, transient ischemic attack; T/TL-diuretic, thiazide/thiazide-like diuretic; Clinical indications that support the use of HBPM or ABPM are summarized in Table 1 .

3. Assess patient

A thorough patient work-up aims to gather essential information about the patient's personal and medical history, any other relevant factors and co-morbidities that may impact their BP, CV risk and management. This information is critical in determining the initiation of the most appropriate treatment approach and the follow-up strategy.

3.1. Basic assessment

Due to the high prevalence of hypertension and thus the large number of individuals that will be managed by primary care providers, it is essential to prioritize the basic assessment to investigations that are effective and feasible in this setting, allowing widespread implementation. The recommended pathway shown in Fig. 3 should be adapted according to the severity of hypertension, clinical circumstances and individual needs of patients.

The basic assessment includes personal and medical history, physical examination, lab tests and the recording of a 12-lead resting electrocardiogram (ECG) (Fig. 3 ). The recommended evaluation allows the diagnosis and staging of chronic kidney disease (CKD), by assessing estimated glomerular filtration rate (eGFR) and urinary albumincreatinine ratio (UACR), and of left ventricular hypertrophy (LVH) by ECG (although with limited sensitivity).

An extended list of factors to be considered in the evaluation of patient's history is shown in Table 2 .

An extended list of factors that influence CV risk in patients with hypertension is shown in Table 3 .

Further details for a comprehensive physical examination for patients with hypertension are summarized in Table 4 .

The specific assessment of patients older than 80 years should include the analysis of their functional capacities/autonomy status as shown in Table 5 .

Table 6 shows selected basic and extended laboratory tests for assessment of hypertensive patients

3.2. Extended assessment

The extended assessment of hypertension mediated organ damage (HMOD) can be executed as deemed necessary and available to physicians (Fig. 3 ).

3.3. When to refer a patient

Basic and extended assessment of patients should support decision making about when a patient should be referred to a hypertension specialist or a hospital (including the need for inpatient treatment). Criteria that influence these decisions are summarized in Fig. 3 . Additional information on the incidence of selected forms of secondary hypertension according to age that can guide clinical decision making when to refer a patient with suspected secondary hypertension for further work-up is shown in Fig. 4 . as increasing the efficacy of BP-lowering therapy, improving overall CV health and reducing the risk of other chronic diseases. They are important in the prevention of hypertension and may control BP when used alone already in a fraction of patients, i.e. in patient with mildly elevated grade 1 hypertension with systolic BP (SBP) and diastolic BP (DBP) < 150/95 mmHg and low CV risk. However, most patients with hypertension should be treated with a combination of both lifestyle interventions and pharmacological treatment. The strategy for the initial management of hypertension with the aim to control BP within 3 months according to the risk of patients is shown in Fig. 5 .

4. Select therapy

4.1. General aspects

Lifestyle interventions have been shown to be effective in reducing BP in hypertensive patients and can also have additional benefits, such

The initial management as well as follow-up strategies should be executed according to the risk of patients as summarized in Fig. 6 .

4.2. Lifestyle interventions

The recommended lifestyle interventions together with their relevance and prescribing patterns are shown in Fig. 7 .

4.3. Pharmacological treatment

The general treatment strategy for patients with hypertension is shown in Fig. 8 . The recommended major BP-lowering drug classes include angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), beta-blockers (BB), calcium channel blockers (CCB) and thiazide/thiazide-like diuretics (T/TL-diuretics). Additional therapies can be considered in patients with true resistant hypertension, heart failure and CKD as shown. Furthermore, renal denervation can be considered in true-resistant hypertension (Fig. 8 ) and in patients who have uncontrolled BP despite the use of antihypertensive drug combination therapy, or if drug treatment elicits serious side effects and poor quality of life (if eGFR > 40 ml/min/1.73m 2 ).

The general strategy for pharmacological treatment shown in Fig. 8 applies to a large number of patients including patients with diabetes, after a stroke or with peripheral artery disease. Further specific treatment algorithms for true resistant hypertension and important comorbidities including coronary heart disease, heart failure with preserved ejection fraction, atrial fibrillation, and CKD are shown in suppl. Figs. 1 2 3 4 5 .

The general BP treatment targets for office SBP and DBP are also shown in Fig. 8 along with additional comments that indicate the need to adjust these targets, e.g. in certain patient populations.

The recommended strategy in older persons according to their functional capacities/autonomy status is summarized in Fig. 9 .

5. Evaluate response

It is important to evaluate the BP response after treatment initiation (3 months) as well as during short-term and long-term follow-up in patients with hypertension in order to monitor the effectiveness of the treatment and make any necessary adjustments. To aim first for BP control with SBP and DBP below 140 and 80 mmHg in most patients in the general hypertensive population and subsequently for optimal BP control achieving the individual BP targets is the important goal that should be evaluated (Fig. 8 ). However, the evaluation of possible side effects (tolerability) and safety parameters, e.g. eGFR and serum potassium levels, in response to treatment and changes in the risk factor Practice Guidelines profile, HMOD or co-morbidities is also important. Fig. 10 summarizes important aspects that should be evaluated and considered during the initiation phase, short-term and long-term follow up.

6. Conclusions

The successful implementation of the guideline recommendations for the treatment of hypertension depends on many factors, including national/regional opportunities and challenges in healthcare systems. The ESH hopes that this MASTERplan will make a meaningful contribution to the further development and improvement of hypertension care.

Declaration of competing interest

The conflict of interest declaration of authors are compiled into one file that can be found on the ESH website: https://www.eshonline.or g/guidelines/2023-guidelines/. ESH received no financial support for the generation of this guidelines. Practice Guidelines

ort for the generation of this guidelines. Practice Guidelines

|Conditions| |---|

|Personal history| |---|

|• Time of the first diagnosis of hypertension, including records of any previous medical screening, hospitalization|

|• Stable or rapidly increasing BP|

|• Recordings of current and past HBPM values|

|• Current/past antihypertensive medications including their effectiveness and intolerance|

|• Adherence to therapy|

|• Previous hypertension in pregnancy/preeclampsia Risk factors a|

|Parameter for risk stratification, which are included in SCORE2 and SCORE2-OP|| |---|---|

|Sex (men > women)||

|Age Level of SBP a||

|Smoking -current or past history||

|Non-HDL cholesterol||

|Established and suggested novel factors||

|Family or parental history of early onset hypertension||

|Personal history of malignant hypertension||

|Family history of premature CVD (men aged < 55 years; women aged < 65 years)||

|Heart rate (resting values > 80 bpm)||

|Low birth weight||

|Sedentary lifestyle||

|Overweight or Obesity||

|Diabetes||

|Dyslipidemia||

|Lp(a)||

|Uric acid||

|Adverse outcomes of pregnancy (recurrent pregnancy loss, preterm delivery, hypertensive disorders, gestational diabetes)||

|Early-onset menopause||

|Frailty, functional capacities and autonomy status||

|Psychosocial and socioeconomic factors||

|Migration||

|Environmental exposure to air pollution or noise||

|Additional clinical conditions or comorbidities||

|True resistant hypertension||

|Sleep disorders (including OSA)||

|COPD||

|Gout||

|Chronic inflammatory diseases||

|Metabolic dysfunction-associated fatty liver disease||

|Chronic infections (including long COVID-19)||

|Migraine||

|Depressive syndromes||

|Erectile dysfunction||

|Hypertension-mediated organ damage (HMOD)||

|Increased large artery stiffness||

|Pulse pressure (in older people) ≥60 mmHg||

|and > 95/m 2 in women|2 in men|

|Moderate increase of albuminuria 30-300 mg/24 h or elevated UACR (preferably in morning spot urine) 30 -300 mg/g CKD stage 3 with eGFR 30-59 ml/min/1.73 m 2||

|Ankle-brachial index < 0.9||

|Advanced retinopathy: hemorrhages or exudates, papilledema||

|Established cardiovascular and kidney disease||

|Cerebrovascular disease: ischemic stroke, cerebral hemorrhage, TIA||

|Coronary artery disease: myocardial infarction, angina, myocardial revascularization||

|Presence of hemodynamically significant atheromatous plaque (stenosis) on imaging||

|Heart failure||

|Peripheral artery disease||

|Atrial fibrillation||

|Severe albuminuria > 300 mg/24 h or UACR (preferably in morning spot urine) > 300 mg/g CKD stage 4 and 5, eGFR < 30 mL/min/1.73m 2||

|a DBP is not included in the SCORE2/SCORE2-OP tool to estimate CV risk.||

|Adapted with permission from Wolters Kluwer Health, Inc.: [Mancia G, Kreutz R, Brunstrom M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH Guidelines for||

|the management of||

||Group 1|Group 2|Group 3| |---|---|---|---|

|||autonomous for|dependent|

|||most activities||

||and|Groups 1 and 3|≤2|

||-absence of clinically||or|

||significant dementia||-severe|

||(MMSE > 20)||dementia|

||and||(MMSE|

||-routine walking||≤10)|

||activities||or|

||||chronic|

||||bedridden|

||||or|

||||-end of life|

|ADL: Activities of Daily Living (Katz Index) scaled rated from 0 (completely||||

|dependent) to 6 (completely autonomous).||||

|This scale comprises 6 ADL: Bathing, Dressing, Toileting, Transferring, Feeding||||

|and Continence.||||

|For each ADL '0′ means that the person is unable to do it without assistance, 0.5||||

|need of some assistance, 1 no need of any assistance.|need of some assistance, 1 no need of any assistance.|need of some assistance, 1 no need of any assistance.||

|MMSE: Mini mental state examination. Score 0-30, 30 best, 0-10 severe de-||||

|mentia, 11-20 moderate dementia, 21-30 absence of clinically significant de-||||

|mentia. The assessment is used to guide treatment as shown in Fig. 9.|mentia. The assessment is used to guide treatment as shown in Fig. 9.|mentia. The assessment is used to guide treatment as shown in Fig. 9.|mentia. The assessment is used to guide treatment as shown in Fig. 9.|

|Adapted with permission from Wolters Kluwer Health, Inc.: [Mancia G, Kreutz R,||||

|Brunstrom M, Burnier M, Grassi G, Januszewicz A, et al. 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||||

|International Society of Hypertension (ISH) and the European Renal Association||||

|(ERA). Journal of hypertension 2023; 41:1874-2071. https://doi.org/10.10||||

|97/hjh.0000000000003480].||||

|Body habitus| |---|

|• Weight and height measured on a calibrated scale, with calculation of BMI|

|• Waist circumference|

|Signs of hypertension-mediated organ damage|

|• Neurological examination and cognitive status|

|• Fundoscopic examination for hypertensive retinopathy in emergencies|

|• Auscultation of heart and carotid arteries|

|• Palpation of carotid and peripheral arteries|

|• Ankle-brachial index|

|Signs of secondary hypertension|

|• Skin inspection: cafe-au-lait patches of neurofibromatosis (pheochromocytoma)|

|• Kidney palpation for signs of renal enlargement in polycystic kidney disease|

|• Auscultation of heart and renal arteries for murmurs or bruits indicative of aortic coarctation, or renovascular hypertension|

|• Signs of Cushing's disease or acromegaly|

|• Signs of thyroid disease|

Acknowledgements

Clinical indications for home and ambulatory BP monitoring*.

• Assessment of nocturnal BP and dipping status (e.g. sleep apnea, CKD, diabetes, endocrine hypertension, or autonomic dysfunction) • Patients incapable or unwilling to perform reliable HBPM, or anxious with self-measurement • Evaluation of patients considered for renal denervation • Children • Pregnancy Specific indications for HBPM rather than ABPM • Long-term follow-up of treated individuals to improve adherence with treatment and hypertension control • Patients unwilling to perform ABPM, or with considerable discomfort during the recording Indications

Medical and family history a .

Adapted with permission from Wolters Kluwer Health, Inc.: [Mancia G, Kreutz R, Brunstrom M, Burnier M, Grassi G, Januszewicz A, et al. 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 International Society of Hypertension (ISH) and the European Renal Association (ERA). Journal of hypertension 2023; 41:1874-2071. https://doi.org/10.1097/hjh .0000000000003480].

Factors that influence CV risk in patients with hypertension. arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). Journal of hypertension 2023; 41:1874-2071. https://doi.org/10.1097/hjh .0000000000003480].

Assessment of functional capacities/autonomy status in hypertensive patients older than 80 years.

Comprehensive physical examination for hypertension a . Can be adapted according to the clinical circumstance. Adapted with permission from Wolters Kluwer Health, Inc.: [Mancia G, Kreutz R, Brunstrom M, Burnier M, Grassi G, Januszewicz A, et al. 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 International Society of Hypertension (ISH) and the European Renal Association (ERA). Journal of hypertension 2023; 41:1874-2071. https://doi.org/10.1097/hjh .0000000000003480]. Selected standard laboratory tests for work-up of hypertensive patients a . Can be adapted according to the clinical circumstance. Adapted with permission from Wolters Kluwer Health, Inc.: [Mancia G, Kreutz R, Brunstrom M, Burnier M, Grassi G, Januszewicz A, et al. 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 International Society of Hypertension (ISH) and the European Renal Association (ERA). Journal of hypertension 2023; 41:1874-2071. https://doi.org/10.1097/hjh .0000000000003480].

Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ejim.2024.05.033.

References

引用 / 出处

2024 ESH临床实践指南：高血压的管理. 2024.