What are the differences between American College of Cardiology (ACC)/American Heart Association (AHA) and European Society of Cardiology (ESC) guidelines for hypertension treatment?

Key Differences in Hypertension Treatment Between ACC/AHA and ESC/ESH Guidelines

The most significant difference between ACC/AHA and ESC/ESH guidelines is the definition of hypertension and treatment thresholds, with ACC/AHA recommending more intensive treatment starting at lower blood pressure levels (130/80 mm Hg) compared to ESC/ESH's higher threshold (140/90 mm Hg). 1

Definition and Classification of Hypertension

• ACC/AHA (2017):

  • Defines hypertension as BP ≥130/80 mm Hg
  • Two stages of hypertension:
    • Stage 1: 130-139/80-89 mm Hg
    • Stage 2: ≥140/90 mm Hg

• ESC/ESH (2018):

  • Defines hypertension as BP ≥140/90 mm Hg
  • Three stages of hypertension:
    • Grade 1: 140-159/90-99 mm Hg
    • Grade 2: 160-179/100-109 mm Hg
    • Grade 3: ≥180/110 mm Hg
  • Classifies BP 130-139/85-89 mm Hg as "high normal" rather than hypertension 1

Treatment Initiation Thresholds

• ACC/AHA:

  • Recommends drug therapy for:
    • BP ≥140/90 mm Hg for all adults
    • BP 130-139/80-89 mm Hg with cardiovascular disease (CVD) or 10-year atherosclerotic CVD risk ≥10%

• ESC/ESH:

  • Recommends drug therapy for:
    • BP ≥140/90 mm Hg for all adults
    • Only considers drug therapy for BP 130-139/85-89 mm Hg in very high-risk patients, especially those with coronary artery disease 1

Blood Pressure Targets

• ACC/AHA:

  • Single target of <130/80 mm Hg for most adults
  • For older adults (≥65 years): SBP <130 mm Hg if tolerated

• ESC/ESH:

  • Stepped approach:
    • First target <140/90 mm Hg for all
    • Then target 130-139 mm Hg SBP if tolerated (for patients 18-65 years)
    • For older adults (≥65 years): target 130-139 mm Hg SBP
  • Identifies safety boundaries: not below 120/70 mm Hg (130 mm Hg SBP in CKD) 1

Initial Treatment Approach

• ACC/AHA:

  • Recommends single-pill combinations when possible
  • Suggests combination therapy for patients >20/10 mm Hg above goal

• ESC/ESH:

  • Places stronger emphasis on single-pill combinations
  • Recommends initial combination therapy for all patients with BP ≥140/90 mm Hg 1

Treatment of Other Cardiovascular Risk Factors

• ACC/AHA:

  • References other ACC/AHA guidelines for specific details on managing other risk factors

• ESC/ESH:

  • Includes detailed recommendations within the guideline for statin and aspirin therapy 1

Medication Selection

Both guidelines share similar core strategies:

• First-line medications include thiazide/thiazide-like diuretics, ACE inhibitors/ARBs, and calcium channel blockers
• Both recommend combination therapy for most adults with hypertension
• Both restrict beta-blockers as first-line therapy except for specific indications
• Both recommend initial 2-drug combination of diuretic or calcium channel blocker plus ACE inhibitor or ARB 1, 2

Practical Implications

• The ACC/AHA guideline classifies more individuals as having hypertension and recommends more aggressive treatment
• The ESC/ESH guideline takes a more conservative approach to diagnosis and a more stepped approach to treatment
• Both guidelines emphasize accurate BP measurement, out-of-office readings, and lifestyle modifications
• Both recommend lower BP targets compared to previous guidelines 1

Common Pitfalls to Avoid

• Don't overlook accurate BP measurement: Both guidelines emphasize proper technique and out-of-office readings
• Don't ignore lifestyle modifications: Both guidelines strongly recommend non-pharmacological approaches
• Don't use beta-blockers as first-line therapy unless specific indications exist (e.g., coronary heart disease)
• Don't underestimate the value of combination therapy: Both guidelines recommend combination therapy for most patients
• Don't forget to assess overall cardiovascular risk when making treatment decisions 1, 3

Despite their differences, both guidelines aim to improve hypertension control and reduce cardiovascular morbidity and mortality, with greater congruity between them than their predecessors 1.