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ESH/ESC Guidelines for Themanagement of Arterial European Heart Journal ESH AND ESC GUIDELINES doi:10.1093/eurheartj/eht151 2013 ESH/ESC Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) Authors/Task Force Members: Giuseppe Mancia (Chairperson) (Italy)*, Robert Fagard (Chairperson) (Belgium)*, Krzysztof Narkiewicz (Section co-ordinator) (Poland), Josep Redon (Section co-ordinator) (Spain), Alberto Zanchetti (Section co-ordinator) (Italy), Michael Bo¨ hm (Germany), Thierry Christiaens (Belgium), Renata Cifkova (Czech Republic), Guy De Backer (Belgium), Anna Dominiczak (UK), Maurizio Galderisi (Italy), Diederick E. Grobbee (Netherlands), Tiny Jaarsma (Sweden), Paulus Kirchhof (Germany/UK), Sverre E. Kjeldsen (Norway), Ste´phane Laurent (France), Athanasios J. Manolis (Greece), Peter M. Nilsson (Sweden), Luis Miguel Ruilope (Spain), Roland E. Schmieder (Germany), Per Anton Sirnes (Norway), Peter Sleight (UK), Margus Viigimaa (Estonia), Bernard Waeber (Switzerland), Faiez Zannad (France) ESH Scientific Council: Josep Redon (President) (Spain), Anna Dominiczak (UK), Krzysztof Narkiewicz (Poland), Peter M. Nilsson (Sweden), Michel Burnier (Switzerland), Margus Viigimaa (Estonia), Ettore Ambrosioni (Italy), Mark Caufield (UK), Antonio Coca (Spain), Michael Hecht Olsen (Denmark), Roland E. Schmieder (Germany), Costas Tsioufis (Greece), Philippe van de Borne (Belgium). ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach (Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), He´ctor Bueno (Spain), Veronica Dean (France), Christi Deaton (UK), Cetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai (Israel), Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK), Massimo F. Piepoli (Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera (Poland), Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland). * Corresponding authors: The two chairmen equally contributed to the document. Chairperson ESH: Professor Giuseppe Mancia, Centro di Fisiologia Clinica e Ipertensione, Via F. Sforza, 35, 20121 Milano, Italy. Tel: +39 039 233 3357, Fax: +39 039 322 274. Email: [email protected]. Chairperson ESC: Professor Robert Fagard, Hypertension & Cardiovascular Rehab. Unit, KU Leuven University, Herestraat 49, 3000 Leuven, Belgium. Tel: +32 16 348 707, Fax: +32 16 343 766, Email: [email protected] These guidelines also appear in the Journal of Hypertension, doi: 10.1097/01.hjh.0000431740.32696.cc and in Blood Pressure, doi: 10.3109/08037051.2013.812549. With special thanks to Mrs Clara Sincich and Mrs Donatella Mihalich for their contribution. Other ESC entities having participated in the development of this document: ESC Associations: Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Heart Rhythm Association (EHRA) ESC Working Groups: Hypertension and the Heart, Cardiovascular Pharmacology and Drug Therapy ESC Councils: Cardiovascular Primary Care, Cardiovascular Nursing and Allied Professions, Cardiology Practice The content of these European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines has been published for personal and educational use only. No com- mercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon sub- mission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer. The ESH/ESC Guidelines represent the views of the ESH and ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient’s guardian or carer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription. & The European Society of Hypertension (ESH) and European Society of Cardiology (ESC) 2013. All rights reserved. For permissions please email: [email protected]. Page 2 of 72 ESH and ESC Guidelines Document Reviewers: Denis L. Clement (ESH Review Co-ordinator) (Belgium), Antonio Coca (ESH Review Co-ordinator) (Spain), Thierry C. Gillebert (ESC Review Co-ordinator) (Belgium), Michal Tendera (ESC Review Co-ordinator) (Poland), Enrico Agabiti Rosei (Italy), Ettore Ambrosioni (Italy), Stefan D. Anker (Germany), Johann Bauersachs (Germany), Jana Brguljan Hitij (Slovenia), Mark Caulfield (UK), Marc De Buyzere (Belgium), Sabina De Geest (Switzerland), Genevie`ve Anne Derumeaux (France), Serap Erdine (Turkey), Csaba Farsang (Hungary), Christian Funck-Brentano (France), Vjekoslav Gerc (Bosnia & Herzegovina), Giuseppe Germano (Italy), Stephan Gielen (Germany), Herman Haller (Germany), Arno W. Hoes (Netherlands), Jens Jordan (Germany), Thomas Kahan (Sweden), Michel Komajda (France), Dragan Lovic (Serbia), Heiko Mahrholdt (Germany), Michael Hecht Olsen (Denmark), Jan Ostergren (Sweden), Gianfranco Parati (Italy), Joep Perk (Sweden), Jorge Polonia (Portugal), Bogdan A. Popescu (Romania), Zˇ eljko Reiner (Croatia), Lars Ryde´n (Sweden), Yuriy Sirenko (Ukraine), Alice Stanton (Ireland), Harry Struijker-Boudier (Netherlands), Costas Tsioufis (Greece), Philippe van de Borne (Belgium), Charalambos Vlachopoulos (Greece), Massimo Volpe (Italy), David A. Wood (UK). The affiliations of the Task Force Members are listed in the Appendix. The disclosure forms of the authors and reviewers are available on the respective society websites http://www.eshonline.org and www.escardio.org/guidelines ------------------------------------------------------------------------------------------------------------------------------------------------------ Keywords Hypertension † Guidelines † Antihypertensive treatment † Blood pressure † Blood pressure measurement † Cardiovascular risk † Cardiovascular complications † Device therapy † Follow-up † Lifestyle † Organ damage Table of Contents Abbreviations and acronyms . 4 3.7 Searching for asymptomatic organ damage . 16 1 Introduction . 5 3.7.1 Heart . 16 1.1 Principles . 5 3.7.2 Blood vessels . 18 1.2 New aspects . 5 3.7.3 Kidney . 18 2 Epidemiological aspects . 6 3.7.4 Fundoscopy . 19 2.1 Relationship of blood pressure to cardiovascular and renal 3.7.5 Brain . 19 damage . 6 3.7.6 Clinical value and limitations . 20 2.2 Definition and classification of hypertension . 7 3.7.7 Summary of recommendations on the search for 2.3 Prevalence of hypertension . 7 asymptomatic organ damage, cardiovascular disease, and 2.4 Hypertension and total cardiovascular risk . 7 chronic kidney disease . 20 2.4.1 Assessment of total cardiovascular risk . 7 3.8 Searching for secondary forms of hypertension . 21 2.4.2 Limitations . 8 4 Treatment approach . 21 2.4.3 Summary of recommendations on total cardiovascular 4.1 Evidence favouring therapeutic reduction of high blood risk assessment . 9 pressure . 21 3 Diagnostic evaluation . 9 4.2 When to initiate antihypertensive drug treatment . 22 3.1 Bood pressure measurement . 10 4.2.1 Recommendations of previous Guidelines . 22 3.1.1 Office or clinic blood pressure . 10 4.2.2 Grade 2 and 3 hypertension and high-risk grade 1 3.1.2 Out-of-office blood pressure . 10 hypertension . 22 3.1.3 White-coat (or isolated office) hypertension 4.2.3 Low-to-moderate risk, grade 1 hypertension . 22 and masked (or isolated ambulatory) hypertension . 12 4.2.4 Isolated systolic hypertension in youth . 22 3.1.4 Clinical indications for out-of-office blood pressure . 12 4.2.5 Grade 1 hypertension in the elderly . 22 3.1.5 Blood pressure during exercise and laboratory stress . 13 4.2.6 High normal blood pressure . 23 3.1.6 Central blood pressure . 14 4.2.7 Summary of recommendations on initiation 3.2 Medical history . 15 of antihypertensive drug treatment . 23 3.3 Physical examination . 15 4.3 Blood pressure treatment targets . 24 3.4 Summary of recommendations on blood pressure 4.3.1 Recommendations of previous Guidelines . 24 measurement, history, and physical examination . 15 4.3.2 Low-to-moderate risk hypertensive patients . 24 3.5 Laboratory investigations . 16 4.3.3 Hypertension in the elderly . 24 3.6 Genetics . 16 4.3.4 High-risk patients . 24 ESH and ESC Guidelines Page 3 of 72 4.3.5 The ‘lower the better’ vs. the J-shaped curve 6.10.3 Cognitive dysfunction and white matter lesions . 42 hypothesis . 25 6.10.4 Summary of recommendations on therapeutic 4.3.6 Evidence on target blood pressure from organ damage strategies in hypertensive patients with cerebrovascular studies . 26 disease . 43 4.3.7 Clinic vs. home and ambulatory blood pressure 6.11 Heart disease . 43 targets . 26 6.11.1 Coronary heart disease . 43 4.3.8 Summary of recommendations
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