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Impact of the European and American guidelines on hypertension prevalence, treatment, and cardiometabolic goals

Gijón-Conde, Teresaa,b; Sánchez-Martínez, Mercedesa,c; Graciani, Auxiliadoraa; Cruz, Juan J.a; López-García, Esthera; Ortolá, Rosarioa; Rodríguez-Artalejo, Fernandoa; Banegas, José R.a

doi: 10.1097/HJH.0000000000002065

Objectives: Unlike the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guideline, the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline has recommended a shift in hypertension definition from blood pressure (BP) 140/90–130/80 mmHg. Further, they proposed somewhat different indications for antihypertensive medication. No data are available on the comprehensive impact of these guidelines in European countries, where physicians do not always follow guidelines from their own continent. We estimated the prevalence of hypertension, recommendations for antihypertensive medication, and cardiometabolic goals achieved in Spain using the ESC/ESH versus ACC/AHA guidelines.

Methods: We analyzed data from a national survey on 12074 individuals representative of the population aged at least 18 years in Spain. BP was measured with standardized procedures.

Results: According to the ESC/ESH and ACC/AHA guidelines, hypertension prevalence was 33.1% (95% confidence interval: 32.2–33.9%) and 46.9% (46.0–47.8%), respectively, and antihypertensive medication was recommended for 33.5% (32.7–34.3%) and 37.2% (36.3–38.1%) of adults, respectively. This represents 5.3 more million hypertensive patients and 1.4 more million candidates for medication (for a 40-million-adults’ country) using the ACC/AHA versus the ESC/ESH guideline. Participants who were hypertensive under the ACC/AHA but not the ESC/ESH guideline achieved less frequently some cardiometabolic goals (e.g. nonsmoking, reduced salt consumption, LDL cholesterol if hypercholesterolemic, lifestyle medical advice, and treatment with renin–angiotensin-system blockers where indicated) than those who were hypertensive under the ESC/ESH guideline.

Conclusion: The implementation of the ACC/AHA versus the ESC/ESH guideline would result in a substantial increase in the prevalence of hypertension and the number of adults who should receive medication. There is room for improvement in lifestyles and cardioprotective treatment in individuals with BP of 130–9/80–9 mmHg whether they are called hypertensive (ACC/AHA) or not (ESC/ESH). We suggest that clinical-practice guidelines should consider the public health and costs implications, and not only the evidence on effectiveness and cost-effectiveness, of their recommendations.

aDepartment of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ – CIBER in Epidemiology and Public Health (CIBERESP)

bMadrid Health Service, Centro de Salud Universitario Cerro del Aire, Madrid

cDepartmental Area of Health Science, Universidad Católica ‘Santa Teresa de Jesús’ de Ávila, Ávila, Spain

Correspondence to José R. Banegas, Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Arzobispo Morcillo 4, 28029 Madrid, Spain. Tel: +34 91 4975425; e-mail:

Abbreviations: ACC/AHA, 2017 American College of Cardiology/American Heart Association guideline; BRAS, blockers of the renin–angiotensin system; eGFR, estimated glomerular filtration rate; ESC/ESH, 2018 European Society of Cardiology/European Society of Hypertension guideline; SCORE, Systematic Coronary Risk Evaluation

Received 3 November, 2018

Revised 23 December, 2018

Accepted 15 January, 2019

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