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Highlights of the October issue

Mancia, Giuseppe

doi: 10.1097/HJH.0000000000001899
Editor's Corner
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Università Milano-Bicocca, Milan, Italy

Correspondence to Prof. Giuseppe Mancia, MD, Università Milano-Bicocca, P.za dei Daini, 4-20126 Milano, Italy. Tel: +39 3474327142; e-mail: giuseppe.mancia@unimib.it

Received 11 July, 2018

Accepted 11 July, 2018

The October issue of the Journal of Hypertension devotes most of its space to the new hypertension guidelines jointly prepared by the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) (pp. 1953–2041). As for the past guidelines of the two Societies, the process that has led to the publication has been long and complex. The first step has been the selection of a 25-member Task Force, half appointed by the ESC and half by the ESH to be representative of expertise in the multiple areas covered by hypertension. Two chairmen were then appointed, one by the ESC and one by the ESH, and Task Force members were assigned specific writing tasks. This was followed by an about 2-year period during which the chairmen and Task Force members met several times and corresponded with one another constantly. The results were a text which was sent out to reviewers, selected by both the ESC and the ESH, with which the Task Force interacted for three successive rounds to refine the text, sharpen the recommendations and include in the guidelines all aspects of hypertension management of practical relevance. For the first time, the reviewing process was extended to representatives of the European national hypertension and cardiology societies, which made the overall number of reviewers quite high, but ensured that geographically different viewpoints were considered.

The new ESC/ESH hypertension guidelines deal with all important epidemiological, diagnostic and treatment aspects of hypertension. They follow the previous guidelines insofar they (1) explain in the text the reasons for the recommendations, to make the guidelines not prescriptive but educational and (2) make use of simple and short recommending sentences to combine the inevitable length and complexity of the explanations with the simplicity of the advice to be given to the practicing physician. Compared with the ESH/ESC guidelines published in 2013, the 2018 recommendations include many elements of novelty. Antihypertensive drug treatment, for example, is extended to clinically important conditions for which drug administration was previously regarded of uncertain or no benefit, such as grade 1 hypertension with a low or moderate cardiovascular risk, grade 1 hypertension of the elderly (patients aged 65 years or above) and individuals with high-normal blood pressure (BP) in whom cardiovascular risk is very high because of a previous cardiovascular event. In addition, compared with previous guidelines, lower target BP values are recommended in both the general and the elderly hypertensive population, namely less than 130/80 rather than less than 140/90 mmHg in the former case and less than 140/90 rather than less than 150/90 mmHg in the latter. Finally, treatment algorithms are substantially different in the 2018 guidelines, which recommend drug treatment to start with two drugs rather than with monotherapy in most hypertensive patients, using single pill combinations whenever possible. This recommendation originates from the evidence that in medical practice initial monotherapy faces barriers such as therapeutic inertia and low adherence to the prescribed treatment regimen, which limits use of drug combinations, that is the universally accepted best treatment for hypertension, in many patients. This may be, at least in part, avoided by starting treatment with two drugs, the hope being to help reducing the high percentage of treated patients in whom BP remains uncontrolled, and thus downgrade hypertension from its position as the first cause of death worldwide.

The remaining part of the October issue of the Journal includes an ESH position paper and original research contributions on epidemiological, pathophysiological and treatment aspects of hypertension. The ESH position paper (Schmieder et al., pp. 2042–2048) revises a document published years ago on use of renal denervation for the treatment of resistant hypertension. Information provided by recent trials is critically reviewed, with the conclusion that, as mentioned by the 2018 European guidelines, evidence does not allow this device-based therapy to be recommended for routine use but it makes further studies worthwhile, especially if directed to the unanswered questions that the position paper duly lists and comments. Aljuraiban et al. (pp. 2049–2058) report that in the INTERMAP study assumption of low-fat dairy products was associated with lower SBP and DBP values (−2.3 mmHg for both) than whole fat dairy products, which is in line with the notion that BP and lipid metabolism are interconnected, and fat may have a relationship with the severity of hypertension as well as for its development. Xiong et al. (pp. 2059–2067) show that the autoptically quantified number and volume of renal nerves are markedly greater in dogs and human beings who had hypertension than in those who were normotensive, a finding that is consonant with the well established association between sympathetic hyperactivity and high BP, adding to previous evidence, however, that in the kidney this has an anatomical basis. Jacob et al. (pp. 2068–2076) provide a description of the autonomic characteristics of a small number of women with a so called ‘constitutional’ hypotension, that is a largely asymptomatic low BP status. Compared with a control group, women with a SBP less than 105 mmHg (mean 97/54 mmHg) exhibited lower values of several indirect markers of sympathetic tone. They also exhibited, however, an increased baroreflex sensitivity as well as a greater serum concentration of plasma renin activity and aldosterone, leading to the conclusion that ‘constitutional hypotension’ may be characterized by low sympathetic activity caused a higher inhibitory baroreflex drive, with, as a reactive phenomenon, a stimulation of the renin–angiotensin–aldosterone system.

The October issue of the Journal is completed by three articles on obesity, and two on pregnancy and BP. As far as obesity is concerned, Chau et al. (pp. 2077–2084) show that in a multivariable linear model central obesity is associated, over a remarkably long (20 years) follow-up, with an accelerated stiffening of the aorta, an observation that scores in favour of a so far poorly documented role of body weight for vascular aging. Xie et al. (pp. 2085–2091) provide evidence that in the large number (more than 12 000) of hypertensive people recruited for the Chinese Stroke Primary Prevention Trial, an increase in BMI was accompanied by an increased risk of chronic kidney disease. South et al. (pp. 2092–2101) report that in adolescents with a history of preterm birth vasodilator peptides are lower and angiotensin II/A (1–7) ratio higher than in controls, which means a shift of the activity of the peptide systems that modulate vasomotor tone towards its vasoconstrictor component. This finding extends the already impressive body of evidence that pregnancy as well as birth abnormalities can have long-term adverse consequences and thus alter the function and structure of the cardiovascular system in adulthood, representing a mechanistic component that cannot be forgotten in studies on the genesis of cardiovascular disease.

The two articles on pregnancy focus on its hemodynamic and treatment aspects. O’ Callaghan et al. (pp. 2102–2108) provide a detailed description of the changes in peripheral and central BP that occur during pregnancy. Perhaps the most interesting observation, however, is that a normal pregnancy is accompanied by a reduction of pulse wave velocity which does not disappear after adjustment for concomitant BP and heart rate changes. Thus, despite the potential stiffening effect of some other factors (e.g. the pregnancy-induced increase of body fluids, which at the arterial wall level should favour stiffening), large arteries become more distensible in normal pregnancies. This represents valuable information also for studies on the effect of abnormal pregnancies on arterial distensibility. Lastly, Hoeltzenbein et al. (pp. 2109–2117) report on the assumption of bisoprolol in pregnant women, using a large number of untreated pregnant women as controls. When the drug was administered during the third trimester there was no increased risk of major birth defects or abortion, although a somewhat higher risk of reduced foetal growth was detected with a more prolonged administration of the drug. Studies on the effects of antihypertensive drugs in pregnancy are highly meritorious because this is an area in which considerable uncertainty persists and old data still dominate guidelines.

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