Giuseppe Mancia, MD, PhD, Discusses the 2003 ESH/ESC Hypertension Guidelines
Giuseppe Mancia, MD, PhD, Discusses the 2003 ESH/ESC Hypertension Guidelines
Professor Giuseppe Mancia, MD, PhD, University of Milan-Bicocca (Milan, Italy) and S Gerardo Hospital (Monza, Italy); Chairman of the Organizing Committee, 13th European Meeting on Hypertension, June 13-17, 2003, Milan, Italy; and Chairman of the ESH-ESC Guidelines Committee
The new European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines for the management of arterial hypertension were presented at the 2003 ESH meeting in Milan and published simultaneously in the Journal of Hypertension [see related links]. In an exclusive interview with Medscape Cardiology, the Chairman of the Guidelines Committee, Professor Giuseppe Mancia, explained the rationale for the guidelines, their most important features, and how doctors in Europe can make use of the guidelines. He also criticized some aspects of the recently released US guidelines, JNC 7, from which the European guidelines have diverged since issuance of JNC 6.
The Rationale for New Guidelines
Prior to the publication of the new ESH guidelines, both the ESH and the ESC had simply endorsed the guidelines formulated by the International Society of Hypertension (ISH) and the World Health Organization (WHO). However, the Europeans had come to believe that they needed to issue their own guidelines, according to Professor Mancia, because the WHO/ISH guidelines, last published in 1999, were concerned with a global vision and dealt largely with issues concerning the developing world, where the health problems are different from those pertaining only to Europe. Thus, what Europeans may find unacceptable in terms of blood pressure thresholds, targets, diagnostic procedures, and drugs may be the only options in low-income countries, he explained. For instance, in low-income countries, it would not be possible to talk about diagnosing subclinical organ damage by echocardiography, and conversely, diuretics could be the best choice of treatment in these countries whereas more recently developed (and often more expensive) drugs may represent better therapeutic options in Europe.
Since most parts of Europe have well-developed health systems, European physicians felt they should have a new set guidelines, separate from those issued by WHO/ISH, that more nearly reflected the European realities. The WHO/ISH will continue to update their guidelines, but they have also called for the creation of more regional guidelines, and the new European guidelines have been formally endorsed by the ISH.
Importance of the Guidelines
An important aspect of the guidelines, Professor Mancia emphasized, is that they underline the relevance of calculating the so-called "global cardiovascular risk." This is a multifactorial risk assessment that incorporates the blood pressure values, associated risk factors, and risk of future organ damage, on which so many aspects of the decision-making process depend, including the timing, aggressiveness, and associated elements of treatment, as well as the target blood pressure values to be reached with therapy. This is emphasized in the new ESH guidelines, at variance from the JNC 7 guidelines, in which little attention was given to the calculation or quantification of the global cardiovascular risk, according to Professor Mancia.
Mancia also noted that a further important aspect of the ESH strategy is that there is no single value dividing normotension from hypertension. The threshold for initiation of blood pressure treatment is flexible, and should be seen as flexible, depending on the global cardiovascular risk.
(As an important aside, Professor Mancia noted that if a patient's overall risk profile is not high, then it should not be said that the patient is "at low risk"; rather the correct terminology should be "low added risk" because it is an increase in relative risk compared with "no additional risk.")
The advantage of this strategy for categorizing risk is that it is very simple. The disadvantage, Professor Mancia acknowledged, is the possible compromise on accuracy, because it does not take into account, for example, the duration of the disease. Patients with diabetes and hypertension are automatically at high risk, but having diabetes for 20 years is different from having diabetes for 2 years. At the same time, however, it must be noted that epidemiology is an inexact science, Professor Mancia admitted.
No European "Prehypertensives"
Professor Mancia disapproves of the term "prehypertensive," as used in JNC 7. "Words are stones," Professor Mancia warned, quoting Italian writer Carlo Levi (Le Parole Sono Pietre, 1955). Would we, for example, call a healthy subject "prediseased"? he asked. It is difficult to tell a patient, "You are prehypertensive, but don't do anything about it. Of course the patient is going to think that something is wrong and that he should see the doctor more frequently. He is going to go around asking for medical exams more frequently and he may want to have drugs anyway."
However, it is not only the word "prehypertensive" Professor Mancia objects to. According to JNC 7, the category of prehypertensive pools all subjects with SBP 120-139 mm Hg and DBP 80-89 mm Hg together. But to date, there is evidence of therapeutic benefit in this so-called high normal range only if the patient has a high or a very high additional risk. If a patient has a blood pressure of 122/82 mm Hg, for example, there is no evidence that the patient should get any form of pharmacologic treatment. However, if there is evidence that a patient with blood pressure 120/80 mm Hg is at high risk (eg, has diabetes and family history of hypertension), then this patient should in fact be assigned to drug treatment.
First Choice for Drug Treatment
Another point of deviation from JNC 7, which the European guidelines take a firm position on, is the issue of which drugs should be assigned, or in which order, once it is determined that drug therapy is warranted. According to the Europeans, the evidence from clinical trials shows that a number of different drugs and drug classes are protective in the hypertensive patient, and therefore the obvious interpretation of the scientific data is that the largest fraction of the benefit comes from reduction of blood pressure per se. If this is the case, then the logical course should be to record the various agents that are available and leave physicians free to use whichever agent is appropriate and beneficial for the individual patient.
"We should not forget that guidelines deal with the disease and physicians deal with individual patients, and these can be quite different situations," Professor Mancia said. Thus, the ESH/ESC guidelines delineate the major indications for which a benefit has been demonstrated in clinical trials and then allow the physician to make a choice from a large number of diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers that are available and approved for use.
Another important point that should not be forgotten is that in the vast majority of the hypertensive population, good blood pressure control can be obtained only by combination treatment, Professor Mancia pointed out. This makes this insistence on the choice of first drug, as in JNC 7, somewhat obsolete, he believes, because it does not really matter which drug the patient is taking for the first 2-3 weeks if the patient will most likely be taking 2 or 3 drugs for the rest of his/her life.
Professor Mancia described the attitude of the European guidelines as a liberal one, because, he says, this is what the scientific evidence supports. This does not mean that the choice is totally blind, however; there are some criteria for selection, as detailed in the guidelines. For example, a patient's previous experience with a drug or the presence or absence of organ damage, diabetes, associated conditions, etc, must be taken into account. Some drugs have been shown to be better in some specific conditions or in some specific groups, and cost is also a factor. However --
Different Classes of Drugs
Professor Mancia pointed out that it is also important for the physician to consider adverse effects. This should be done in a very accurate manner because adverse effects are the major cause of noncompliance, a phenomenon that is disturbing to all hypertensionologists in Europe, where the number of patients with good blood pressure control is a small fraction of the hypertensive population, sometimes as low as 1 in 4. "If we want to improve this condition, then obviously physicians have to pay a great deal of attention to adverse effects, and question their patients about the presence or absence of adverse effects." Sometimes patients do not tell their doctor or they cannot interpret the adverse effects, and physicians can only identify any problems after very careful questioning, Mancia noted.
Combination Treatment
The importance of combination treatment is emphasized in both the European and the JNC 7 guidelines. However, the ESH/ESC guidelines have a new element, in that they say that since combination treatment is so important and so prevalent, physicians should be given the option to start with combination treatment. So one of the flow charts in the guidelines gives 2 options, monotherapy or low-dose combination, and the advantages and disadvantages of each option are outlined.
An obvious disadvantage of starting with a low-dose combination is that some patients may be on 2 drugs even though they could get their blood pressure under control with 1. The advantage is faster blood pressure control, which has favorable psychological reflection on both the patient and the physician. Low dose means probably less chance of side effects and better compliance.
The new guidelines also outline the criteria for when the doctor may want to start with a low-dose combination or with monotherapy -- for example, the blood pressure level. If the blood pressure is quite high, the patient is going to require 2 or 3 drugs eventually, and it may seem like a waste of time to start the patient on a single drug. Then again, if the patient is at high risk (even with a more moderate blood pressure), he/she needs blood pressure control quickly, and it seems unnecessary to wait 3-5 months before achieving control.
Professor Mancia believes that these criteria could endorse physicians' preference to combination treatment as the first step. Furthermore, as he pointed out, underuse of combination treatment by physicians has been shown to be one of the possible reasons for poor blood pressure control. The guidelines mention that fixed-dose combinations could increase compliance by simplifying treatment, but otherwise they take no firm position about whether these fixed combinations should be the regular strategy.
Avoid Switching
Both the European and JNC 7 guidelines discourage switching from one drug regimen to another. This practice, which used to be known as sequential monotherapy, takes a very long time and has a negative impact on the patient. In addition, the chance of achieving blood pressure control is not high. As a result, switchers are patients whose blood pressure is not controlled, and they are the ones who tend to become noncompliant.
Professor Mancia pointed out that because patients responding to drug A are not always the same as patients responding to drug B, a doctor may think that theoretically if he is persistent, he may be able to find a single antihypertensive drug that is effective. In practice, however, this does not happen, because blood pressure is a multiregulated variable and it takes several points of attack to control it and also to prevent compensating mechanisms. As a result, combination treatment is probably going to be more effective. There are instances in which sequential monotherapy is inevitable, however, Professor Mancia admitted. For example, if a drug is not effective at all, then it is useless to keep it on board; or if the patient develops a side effect, then the drug must be changed. In other words, switching cannot be prevented completely, but it should not be the regular strategy, as this is a bad policy, Professor Mancia believes.
Diagnosing and Treating Hypertension in Europe
To improve the present low control rates for hypertension in Europe, doctors should improve the way they treat hypertension, Professor Mancia believes. This means that they should not diagnose hypertension too quickly; otherwise they will see what could be a transient increase in blood pressure due to an alerting reaction and treat patients who may not be really truly hypertensive. Rather, they should diagnose hypertension more accurately, according to Mancia. They should also be more persevering in the way they treat patients. "One concept that we would like to put through is that blood pressure should definitely be reduced below 140/90 mm Hg in all subjects, and doctors should not stop their efforts to lower blood pressure before they have reached the target," Professor Mancia said, adding that patient compliance is extremely important. However, he cautioned that there is an inherent limitation in the hypertension condition, which is that patients do not have an immediate benefit.
Professor Mancia added that this "delayed benefit" is why appreciation of subclinical organ damage is important in the guidelines. Subclinical organ damage - eg, left ventricular hypertrophy, microalbuminuria, modest reduction in renal function, carotid artery wall thickening, or arterial sclerotic plaques - can all be slowed or reversed by antihypertensive treatment, and these data give a measure of long-term protection. They can also serve the doctors in terms of improving compliance, Professor Mancia believes, because doctors can use the measures of subclinical organ damage to demonstrate to patients that things are going well. Using these measures, the physician can report "progress" because arteries remain thin and the heart maintains its weight and shape. This gives the patients something positive to think about and a way to receive positive feedback so that their attitude toward treatment may change.
National Support Needed
Professor Mancia strongly believes that the national health services need to have a long-term perspective about hypertension and must not try to save money in the short term. For example, diuretics are effective drugs, especially in combination treatment, without which we would not know how to control blood pressure, he said. However, to try to save money by saying that the drug to be used in most patients should be a diuretic (as is advocated in JNC 7) does not take into account a number of factors, for example, that the diuretics cause diabetes much more frequently than other drugs. Making a patient diabetic in the long term increases cardiovascular risk, in addition to increasing the number of medical visits and additional treatments. Thus, the short-term economy turns into the long-term cost. Unfortunately, physicians often get the impression that public health providers are more keen on saving money in the short term and they do not think about the consequences in the long term, Professor Mancia complained.
Dissemination of European Guidelines
Describing another variance from the JNC 7 Guidelines Committee, Professor Mancia said that the European committee believed that it had to produce the full report first, explaining the reasons for its recommendations, and then produce the simple version later. (The JNC 7 guidelines have appeared only in an "express" version in the spring of 2003, with the full version not expected until later in the year.)
It is Professor Mancia's opinion that most countries will translate and make use of these new European guidelines. A pocket version will be available, in English, in summer of 2003, and Mancia hopes that the guidelines will be translated into many languages, as there is no copyright on the main guidelines. (However, each version should be checked and sanctioned by the relevant national hypertension society, in order to retain quality and accuracy.)
Professor Mancia acknowledged the difficulties in persuading European general practitioners to adopt even the simplified guidelines, given the limited amount of time they have to spend with each patient (estimated recently as 6 minutes per patient in the United Kingdom). "Studies show that most physicians do not really assess global cardiovascular risk and when they do, they underestimate it," Professor Mancia admitted. "This will have to change in the future if we really want to improve treatment and cardiovascular prevention."
Third Joint Task Force of European and Other Societies on Coronary Prevention
The present guidelines were prepared in concert with Third Joint European Societies' Task Force on Cardiovascular Disease Prevention, of which Professor Mancia is a member. The Task Force includes representation from the European societies of cardiology, atherosclerosis, hypertension, family physicians, and diabetology. Professor Mancia told Medscape that the Task Force's comprehensive guidelines will be announced at the next annual meeting of the ESC in Vienna (August 29-September 3). Some parts of the WHO/ISH 1999 guidelines will be retained in these guidelines, but they will be cross-referenced to the ESH/ESC guidelines.
References
Professor Giuseppe Mancia, MD, PhD, University of Milan-Bicocca (Milan, Italy) and S Gerardo Hospital (Monza, Italy); Chairman of the Organizing Committee, 13th European Meeting on Hypertension, June 13-17, 2003, Milan, Italy; and Chairman of the ESH-ESC Guidelines Committee
The new European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines for the management of arterial hypertension were presented at the 2003 ESH meeting in Milan and published simultaneously in the Journal of Hypertension [see related links]. In an exclusive interview with Medscape Cardiology, the Chairman of the Guidelines Committee, Professor Giuseppe Mancia, explained the rationale for the guidelines, their most important features, and how doctors in Europe can make use of the guidelines. He also criticized some aspects of the recently released US guidelines, JNC 7, from which the European guidelines have diverged since issuance of JNC 6.
The Rationale for New Guidelines
Prior to the publication of the new ESH guidelines, both the ESH and the ESC had simply endorsed the guidelines formulated by the International Society of Hypertension (ISH) and the World Health Organization (WHO). However, the Europeans had come to believe that they needed to issue their own guidelines, according to Professor Mancia, because the WHO/ISH guidelines, last published in 1999, were concerned with a global vision and dealt largely with issues concerning the developing world, where the health problems are different from those pertaining only to Europe. Thus, what Europeans may find unacceptable in terms of blood pressure thresholds, targets, diagnostic procedures, and drugs may be the only options in low-income countries, he explained. For instance, in low-income countries, it would not be possible to talk about diagnosing subclinical organ damage by echocardiography, and conversely, diuretics could be the best choice of treatment in these countries whereas more recently developed (and often more expensive) drugs may represent better therapeutic options in Europe.
Since most parts of Europe have well-developed health systems, European physicians felt they should have a new set guidelines, separate from those issued by WHO/ISH, that more nearly reflected the European realities. The WHO/ISH will continue to update their guidelines, but they have also called for the creation of more regional guidelines, and the new European guidelines have been formally endorsed by the ISH.
Importance of the Guidelines
An important aspect of the guidelines, Professor Mancia emphasized, is that they underline the relevance of calculating the so-called "global cardiovascular risk." This is a multifactorial risk assessment that incorporates the blood pressure values, associated risk factors, and risk of future organ damage, on which so many aspects of the decision-making process depend, including the timing, aggressiveness, and associated elements of treatment, as well as the target blood pressure values to be reached with therapy. This is emphasized in the new ESH guidelines, at variance from the JNC 7 guidelines, in which little attention was given to the calculation or quantification of the global cardiovascular risk, according to Professor Mancia.
Mancia also noted that a further important aspect of the ESH strategy is that there is no single value dividing normotension from hypertension. The threshold for initiation of blood pressure treatment is flexible, and should be seen as flexible, depending on the global cardiovascular risk.
|
For example, if a patient has a small elevation in blood pressure and his/her overall risk profile is not high, then physicians can afford simply to monitor the patient and wait to see whether these blood pressure values are persistent. Thus, if a patient's blood pressure level is in the range of SBP 120-139 mm Hg/DBP 80-89 mm Hg, he or she can afford not to begin drug treatment, although nonpharmacologic interventions should always be advised. On the other hand, if this same patient has an additional risk factor and a blood pressure of 132/86 mm Hg, then he should be put on drug treatment and blood pressure should be lowered to below 130/80 mm Hg. If the risk is high, however - eg, the patient has target organ damage or additional risk factors, such as diabetes, or the patient has already had a myocardial infarction or a stroke -- then not only should treatment be promptly started, but the target goal pressures should be lower. |
(As an important aside, Professor Mancia noted that if a patient's overall risk profile is not high, then it should not be said that the patient is "at low risk"; rather the correct terminology should be "low added risk" because it is an increase in relative risk compared with "no additional risk.")
The advantage of this strategy for categorizing risk is that it is very simple. The disadvantage, Professor Mancia acknowledged, is the possible compromise on accuracy, because it does not take into account, for example, the duration of the disease. Patients with diabetes and hypertension are automatically at high risk, but having diabetes for 20 years is different from having diabetes for 2 years. At the same time, however, it must be noted that epidemiology is an inexact science, Professor Mancia admitted.
No European "Prehypertensives"
Professor Mancia disapproves of the term "prehypertensive," as used in JNC 7. "Words are stones," Professor Mancia warned, quoting Italian writer Carlo Levi (Le Parole Sono Pietre, 1955). Would we, for example, call a healthy subject "prediseased"? he asked. It is difficult to tell a patient, "You are prehypertensive, but don't do anything about it. Of course the patient is going to think that something is wrong and that he should see the doctor more frequently. He is going to go around asking for medical exams more frequently and he may want to have drugs anyway."
However, it is not only the word "prehypertensive" Professor Mancia objects to. According to JNC 7, the category of prehypertensive pools all subjects with SBP 120-139 mm Hg and DBP 80-89 mm Hg together. But to date, there is evidence of therapeutic benefit in this so-called high normal range only if the patient has a high or a very high additional risk. If a patient has a blood pressure of 122/82 mm Hg, for example, there is no evidence that the patient should get any form of pharmacologic treatment. However, if there is evidence that a patient with blood pressure 120/80 mm Hg is at high risk (eg, has diabetes and family history of hypertension), then this patient should in fact be assigned to drug treatment.
First Choice for Drug Treatment
Another point of deviation from JNC 7, which the European guidelines take a firm position on, is the issue of which drugs should be assigned, or in which order, once it is determined that drug therapy is warranted. According to the Europeans, the evidence from clinical trials shows that a number of different drugs and drug classes are protective in the hypertensive patient, and therefore the obvious interpretation of the scientific data is that the largest fraction of the benefit comes from reduction of blood pressure per se. If this is the case, then the logical course should be to record the various agents that are available and leave physicians free to use whichever agent is appropriate and beneficial for the individual patient.
"We should not forget that guidelines deal with the disease and physicians deal with individual patients, and these can be quite different situations," Professor Mancia said. Thus, the ESH/ESC guidelines delineate the major indications for which a benefit has been demonstrated in clinical trials and then allow the physician to make a choice from a large number of diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers that are available and approved for use.
Another important point that should not be forgotten is that in the vast majority of the hypertensive population, good blood pressure control can be obtained only by combination treatment, Professor Mancia pointed out. This makes this insistence on the choice of first drug, as in JNC 7, somewhat obsolete, he believes, because it does not really matter which drug the patient is taking for the first 2-3 weeks if the patient will most likely be taking 2 or 3 drugs for the rest of his/her life.
Professor Mancia described the attitude of the European guidelines as a liberal one, because, he says, this is what the scientific evidence supports. This does not mean that the choice is totally blind, however; there are some criteria for selection, as detailed in the guidelines. For example, a patient's previous experience with a drug or the presence or absence of organ damage, diabetes, associated conditions, etc, must be taken into account. Some drugs have been shown to be better in some specific conditions or in some specific groups, and cost is also a factor. However --
|
Although cost is acknowledged as important in the ESH/ESC guidelines, both to the individual and to the health provider, the guidelines also insist that cost should not be given consideration above the patient's welfare and protection. Ethically, physicians must always put patients' interests before cost. |
Different Classes of Drugs
Professor Mancia pointed out that it is also important for the physician to consider adverse effects. This should be done in a very accurate manner because adverse effects are the major cause of noncompliance, a phenomenon that is disturbing to all hypertensionologists in Europe, where the number of patients with good blood pressure control is a small fraction of the hypertensive population, sometimes as low as 1 in 4. "If we want to improve this condition, then obviously physicians have to pay a great deal of attention to adverse effects, and question their patients about the presence or absence of adverse effects." Sometimes patients do not tell their doctor or they cannot interpret the adverse effects, and physicians can only identify any problems after very careful questioning, Mancia noted.
Combination Treatment
The importance of combination treatment is emphasized in both the European and the JNC 7 guidelines. However, the ESH/ESC guidelines have a new element, in that they say that since combination treatment is so important and so prevalent, physicians should be given the option to start with combination treatment. So one of the flow charts in the guidelines gives 2 options, monotherapy or low-dose combination, and the advantages and disadvantages of each option are outlined.
An obvious disadvantage of starting with a low-dose combination is that some patients may be on 2 drugs even though they could get their blood pressure under control with 1. The advantage is faster blood pressure control, which has favorable psychological reflection on both the patient and the physician. Low dose means probably less chance of side effects and better compliance.
The new guidelines also outline the criteria for when the doctor may want to start with a low-dose combination or with monotherapy -- for example, the blood pressure level. If the blood pressure is quite high, the patient is going to require 2 or 3 drugs eventually, and it may seem like a waste of time to start the patient on a single drug. Then again, if the patient is at high risk (even with a more moderate blood pressure), he/she needs blood pressure control quickly, and it seems unnecessary to wait 3-5 months before achieving control.
Professor Mancia believes that these criteria could endorse physicians' preference to combination treatment as the first step. Furthermore, as he pointed out, underuse of combination treatment by physicians has been shown to be one of the possible reasons for poor blood pressure control. The guidelines mention that fixed-dose combinations could increase compliance by simplifying treatment, but otherwise they take no firm position about whether these fixed combinations should be the regular strategy.
Avoid Switching
Both the European and JNC 7 guidelines discourage switching from one drug regimen to another. This practice, which used to be known as sequential monotherapy, takes a very long time and has a negative impact on the patient. In addition, the chance of achieving blood pressure control is not high. As a result, switchers are patients whose blood pressure is not controlled, and they are the ones who tend to become noncompliant.
Professor Mancia pointed out that because patients responding to drug A are not always the same as patients responding to drug B, a doctor may think that theoretically if he is persistent, he may be able to find a single antihypertensive drug that is effective. In practice, however, this does not happen, because blood pressure is a multiregulated variable and it takes several points of attack to control it and also to prevent compensating mechanisms. As a result, combination treatment is probably going to be more effective. There are instances in which sequential monotherapy is inevitable, however, Professor Mancia admitted. For example, if a drug is not effective at all, then it is useless to keep it on board; or if the patient develops a side effect, then the drug must be changed. In other words, switching cannot be prevented completely, but it should not be the regular strategy, as this is a bad policy, Professor Mancia believes.
Diagnosing and Treating Hypertension in Europe
To improve the present low control rates for hypertension in Europe, doctors should improve the way they treat hypertension, Professor Mancia believes. This means that they should not diagnose hypertension too quickly; otherwise they will see what could be a transient increase in blood pressure due to an alerting reaction and treat patients who may not be really truly hypertensive. Rather, they should diagnose hypertension more accurately, according to Mancia. They should also be more persevering in the way they treat patients. "One concept that we would like to put through is that blood pressure should definitely be reduced below 140/90 mm Hg in all subjects, and doctors should not stop their efforts to lower blood pressure before they have reached the target," Professor Mancia said, adding that patient compliance is extremely important. However, he cautioned that there is an inherent limitation in the hypertension condition, which is that patients do not have an immediate benefit.
|
"With hypertension, the reward for treatment comes 20 years later and there are no positive measures of reward, only negative measures. That is, you treat your blood pressure because you reduce your risk of having a stroke. You do not know whether you are going to be the lucky one or the unlucky one, however." |
Professor Mancia added that this "delayed benefit" is why appreciation of subclinical organ damage is important in the guidelines. Subclinical organ damage - eg, left ventricular hypertrophy, microalbuminuria, modest reduction in renal function, carotid artery wall thickening, or arterial sclerotic plaques - can all be slowed or reversed by antihypertensive treatment, and these data give a measure of long-term protection. They can also serve the doctors in terms of improving compliance, Professor Mancia believes, because doctors can use the measures of subclinical organ damage to demonstrate to patients that things are going well. Using these measures, the physician can report "progress" because arteries remain thin and the heart maintains its weight and shape. This gives the patients something positive to think about and a way to receive positive feedback so that their attitude toward treatment may change.
National Support Needed
Professor Mancia strongly believes that the national health services need to have a long-term perspective about hypertension and must not try to save money in the short term. For example, diuretics are effective drugs, especially in combination treatment, without which we would not know how to control blood pressure, he said. However, to try to save money by saying that the drug to be used in most patients should be a diuretic (as is advocated in JNC 7) does not take into account a number of factors, for example, that the diuretics cause diabetes much more frequently than other drugs. Making a patient diabetic in the long term increases cardiovascular risk, in addition to increasing the number of medical visits and additional treatments. Thus, the short-term economy turns into the long-term cost. Unfortunately, physicians often get the impression that public health providers are more keen on saving money in the short term and they do not think about the consequences in the long term, Professor Mancia complained.
Dissemination of European Guidelines
Describing another variance from the JNC 7 Guidelines Committee, Professor Mancia said that the European committee believed that it had to produce the full report first, explaining the reasons for its recommendations, and then produce the simple version later. (The JNC 7 guidelines have appeared only in an "express" version in the spring of 2003, with the full version not expected until later in the year.)
It is Professor Mancia's opinion that most countries will translate and make use of these new European guidelines. A pocket version will be available, in English, in summer of 2003, and Mancia hopes that the guidelines will be translated into many languages, as there is no copyright on the main guidelines. (However, each version should be checked and sanctioned by the relevant national hypertension society, in order to retain quality and accuracy.)
Professor Mancia acknowledged the difficulties in persuading European general practitioners to adopt even the simplified guidelines, given the limited amount of time they have to spend with each patient (estimated recently as 6 minutes per patient in the United Kingdom). "Studies show that most physicians do not really assess global cardiovascular risk and when they do, they underestimate it," Professor Mancia admitted. "This will have to change in the future if we really want to improve treatment and cardiovascular prevention."
Third Joint Task Force of European and Other Societies on Coronary Prevention
The present guidelines were prepared in concert with Third Joint European Societies' Task Force on Cardiovascular Disease Prevention, of which Professor Mancia is a member. The Task Force includes representation from the European societies of cardiology, atherosclerosis, hypertension, family physicians, and diabetology. Professor Mancia told Medscape that the Task Force's comprehensive guidelines will be announced at the next annual meeting of the ESC in Vienna (August 29-September 3). Some parts of the WHO/ISH 1999 guidelines will be retained in these guidelines, but they will be cross-referenced to the ESH/ESC guidelines.
References
Mancia G. Presentation of the ESH-ESC Guidelines for the management of arterial hypertension. Program and abstracts of the 13th European Meeting on Hypertension; June 13-17, 2003; Milan, Italy.
Guidelines Committee. 2003 European Society of Hypertension -- European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens. 2003;21;1011-1053. Available online at:
http://www.eshonline.org/ documents/2003_guidelines.pdf
US Department of Health and Human Services. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Available on the NHLBI Web site at http://www.nhlbi.nih.gov or from the NHLBI Health Information Center, PO Box 30105, Bethesda, MD 20824-0105. Phone 301-592-8573 or 240-629-3255 (TTY); Fax: 301-592-8563.
Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 report. JAMA. 2003;289:3560-3572.
Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure (JNC VI). Arch Intern Med. 1997;157:2413-2446.
Guidelines Sub-Committee. 1999 World Health Organization -- International Society of Hypertension guidelines for the management of hypertension. J Hypertens. 1999;17:151-183.
