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Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines.

ABSTRACT: The 2017 American College of Cardiology/American Heart Association and 2018 European Society of Cardiology/European Society of Hypertension clinical practice guidelines for management of high blood pressure/hypertension are influential documents. Both guidelines are comprehensive, were developed using rigorous processes, and underwent extensive peer review. The most notable difference between the 2 guidelines is the blood pressure cut points recommended for the diagnosis of hypertension. There are also differences in the timing and intensity of treatment, with the American College of Cardiology/American Heart Association guideline recommending a somewhat more intensive approach. Overall, there is substantial concordance in the recommendations provided by the 2 guideline-writing committees, with greater congruity between them than their predecessors. Additional harmonization of future guidelines would help to underscore the commonality of their core recommendations and could serve to catalyze changes in practice that would lead to improved prevention, awareness, treatment, and control of hypertension, worldwide.

SUBMITTER: Whelton PK

PROVIDER: S-EPMC9470378 | biostudies-literature | 2022 Sep

REPOSITORIES: biostudies-literature

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Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines.

Whelton Paul K PK Carey Robert M RM Mancia Giuseppe G Kreutz Reinhold R Bundy Joshua D JD Williams Bryan B

European heart journal 20220901 35

The 2017 American College of Cardiology/American Heart Association and 2018 European Society of Cardiology/European Society of Hypertension clinical practice guidelines for management of high blood pressure/hypertension are influential documents. Both guidelines are comprehensive, were developed using rigorous processes, and underwent extensive peer review. The most notable difference between the 2 guidelines is the blood pressure cut points recommended for the diagnosis of hypertension. There a ...[more]

PMID: 36100239

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Project description:ImportanceClinical decisions are ideally based on evidence generated from multiple randomized controlled trials (RCTs) evaluating clinical outcomes, but historically, few clinical guideline recommendations have been based entirely on this type of evidence.ObjectiveTo determine the class and level of evidence (LOE) supporting current major cardiovascular society guideline recommendations, and changes in LOE over time.Data sourcesCurrent American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) clinical guideline documents (2008-2018), as identified on cardiovascular society websites, and immediate predecessors to these guideline documents (1999-2014), as referenced in current guideline documents.Study selectionComprehensive guideline documents including recommendations organized by class and LOE.Data extraction and synthesisThe number of recommendations and the distribution of LOE (A [supported by data from multiple RCTs or a single, large RCT], B [supported by data from observational studies or a single RCT], and C [supported by expert opinion only]) were determined for each guideline document.Main outcomes and measuresThe proportion of guideline recommendations supported by evidence from multiple RCTs (LOE A).ResultsAcross 26 current ACC/AHA guidelines (2930 recommendations; median, 121 recommendations per guideline [25th-75th percentiles, 76-155]), 248 recommendations (8.5%) were classified as LOE A, 1465 (50.0%) as LOE B, and 1217 (41.5%) as LOE C. The median proportion of LOE A recommendations was 7.9% (25th-75th percentiles, 0.9%-15.2%). Across 25 current ESC guideline documents (3399 recommendations; median, 130 recommendations per guideline [25th-75th percentiles, 111-154]), 484 recommendations (14.2%) were classified as LOE A, 1053 (31.0%) as LOE B, and 1862 (54.8%) as LOE C. When comparing current guidelines with prior versions, the proportion of recommendations that were LOE A did not increase in either ACC/AHA (median, 9.0% [current] vs 11.7% [prior]) or ESC guidelines (median, 15.1% [current] vs 17.6% [prior]).Conclusions and relevanceAmong recommendations in major cardiovascular society guidelines, only a small percentage were supported by evidence from multiple RCTs or a single, large RCT. This pattern does not appear to have meaningfully improved from 2008 to 2018.

Project description:The American College of Cardiology (ACC) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) have recently published recommendations for the use of proprotein convertase subtilisin/kexin-9 (PCSK9) inhibitors in situations of very high risk. We aim to assess in the real world the suitability of PCSK9 inhibitors for acute coronary syndromes.We analyzed a prospective Swiss cohort of 2023 patients hospitalized for acute coronary syndromes between 2009 and 2014 with available data for low-density lipoprotein cholesterol and lipid-lowering therapy at 1 year. Clinical familial hypercholesterolemia was defined using the Dutch Lipid Clinic Network algorithm as unlikely, possible, probable, or definite. We simulated a fixed relative reduction of 24% in low-density lipoprotein cholesterol levels at 1 year in all patients not treated with ezetimibe, irrespective of the low-density lipoprotein cholesterol levels and statin regimen. At 1 year, 94.3% of patients were treated with statin, 5.8% with ezetimibe, and 35.8% of patients had on-target low-density lipoprotein cholesterol levels (<1.8 mmol/L); 25.6% met criteria for possible or probable/definite familial hypercholesterolemia. After a simulation of the lipid-lowering effect of ezetimibe, the proportion of patients who would be eligible for PCSK9 inhibitors at 1 year was 13.4% using American College of Cardiology criteria and 2.7% using European Society of Cardiology/European Atherosclerosis Society criteria. Patients with possible or probable/definite familial hypercholesterolemia were more eligible for PCSK9 inhibitors compared with their non-familial hypercholesterolemia counterparts: 27.6% versus 8.8% according to American College of Cardiology criteria and 6.6% versus 1.8% according to European Society of Cardiology/European Atherosclerosis Society criteria (P<0.001).Recommendations made by the American College of Cardiology guidelines would lead to 5-fold higher eligibility rates for PCSK9 inhibitors compared to the European Society of Cardiology/European Atherosclerosis Society consensus statement in acute coronary syndrome patients.

Project description:ImportanceThe 2017 American College of Cardiology and American Heart Association (ACC/AHA) blood pressure (BP) guidelines redefined hypertension using a BP threshold of 130/80 mm Hg or greater and applied a treatment target of less than 130/80 mm Hg.ObjectiveTo evaluate the potential change in the diagnosis, treatment, and control of hypertension in a Canadian cohort of patients with hypertension attending primary care practices using the ACC/AHA guidelines.Design, setting, and participantsThis cross-sectional study used primary care practices across Canada electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network, extracted as of June 30, 2015. Adults with at least 1 primary care encounter in the previous 2 years (July 1, 2013, to June 30, 2015) were included in the study. Those with current hypertension were identified using a validated definition consisting of diagnoses, billing codes, and/or antihypertensive medication from within the primary care electronic medical record. Data analysis was conducted from December 2017 to July 2018.Main outcomes and measuresProportion of individuals with a diagnosis of hypertension, prescribed antihypertensive medication, and meeting treatment BP targets.ResultsOf the 594 492 Canadian participants included in the study, 144 348 (24.2%) had hypertension (45.6% male; mean [SD] age, 65.5 [14.5] years). On applying the ACC/AHA guidelines, 252 279 individuals (42.4%) were considered hypertensive and half (51.0%; 95% CI, 50.8%-51.2%) were prescribed an antihypertensive medication. Individuals who were not previously considered to have hypertension but were reclassified as having elevated BP using the lower cutoff of 130/80 mm Hg or greater tended to be younger and were at lower cardiovascular risk. There was a shift toward more individuals requiring antihypertensive treatment, particularly in the lower-risk categories. The crude prevalence of hypertension increased from 13.3% to 32.0% in those aged 18 to 64 years, and of those aged 65 years and older, 16.6% more individuals were reclassified as having hypertension (from 55.2% to 71.8%). Only 12.3% of those who were considered at high risk were reclassified as hypertensive.Conclusions and relevanceAdoption of the ACC/AHA BP guidelines would result in a near doubling in the prevalence of hypertension in Canada. The changes would largely affect individuals who are younger and at low to moderate cardiovascular risk.

Project description:Background The impact of the new 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline on dementia risk at the population level has not been evaluated. Methods and Results We studied dementia-free participants in the ARIC (Atherosclerosis Risk in Communities) Study cohort in 1987 to 1989. Hypertension was defined by 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2017 ACC/AHA guidelines using blood pressure measured at baseline. Dementia was defined using adjudicated consensus diagnoses, informant telephone interviews, and discharge codes from hospitalizations and death certificates. Cox regression estimated hazard ratios (HRs) for dementia and 95% CIs by hypertension categories, adjusting for confounders. Population attributable fraction of dementia was calculated by hypertension categories. Among 13 971 participants followed up for a median of 23 years, 1381 dementia cases were identified. Prevalence of hypertension was 34% and 48%, according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and ACC/AHA criteria, respectively. HRs (95% CIs) compared with normal blood pressure, according to ACC/AHA categories, were 1.35 (1.12-1.61) for elevated blood pressure, 1.28 (1.07-1.52) for hypertension stage 1, and 1.36 (1.18-1.57) for hypertension stage 2. Population attributable fractions (95% CIs) of dementia from blood pressure categories were 3% (1%-5%), 3% (1%-5%), and 9% (4%-14%), respectively. Population attributable fractions (95% CIs) using the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure categories were 6% (3%-9%) for prehypertension, 0% (-2% to 2%) for hypertension stage 1, and 9% (5%-13%) for hypertension stage 2. Conclusions Risk of dementia increased across hypertension categories defined by ACC/AHA guidelines. The population impact on dementia incidence using ACC/AHA categories was similar to the impact of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Project description:ImportanceHypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality. The impact of applying recent guideline definitions for nonpregnant adults to pregnant women is unclear.ObjectiveTo determine whether reclassification of hypertensive status using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline definition better identifies women at risk for preeclampsia or eclampsia and adverse fetal/neonatal events compared with the current American College of Obstetricians and Gynecologists (ACOG) definition of hypertension.Design, setting, and participantsThis cohort study used electronic medical record data of women who delivered singleton infants between 2009 and 2014 at a large US regional health system. Data analysis was performed from July 2020 to September 2020.ExposureApplication of ACC/AHA and ACOG guidelines for the definition of chronic and gestational hypertension.Main outcomes and measuresThe primary maternal end point was the development of preeclampsia or eclampsia, and the primary fetal/neonatal end point was a composite of preterm birth, small for gestational age, and neonatal intensive care unit admission within 28 days of delivery. Net reclassification indices were calculated to examine how well the lower ACC/AHA diagnostic threshold reclassifies outcomes of pregnancy compared with the current ACOG definition of hypertension.ResultsApplying the ACC/AHA criteria to 137 389 pregnancies of women (mean [SD] age at time of delivery, 30.1 [5.8] years) resulted in a 14.3% prevalence of chronic hypertension (19 621 pregnancies) and a 13.8% prevalence of gestational hypertension (18 998 pregnancies). A 17.8% absolute increase was found in the overall prevalence of hypertension from 10.3% to 28.1%. The 2.1% of women who were reclassified with chronic rather than gestational hypertension had the highest risk of developing preeclampsia compared with women without hypertension by either criterion (adjusted risk ratio, 13.58; 95% CI, 12.49-14.77). Overall, the use of the ACC/AHA criteria to diagnose hypertension resulted in a 20.8% improvement in the appropriate identification of future preeclampsia, but only a 3.8% improvement of appropriate fetal/neonatal risk classification.Conclusions and relevanceUsing the lower diagnostic threshold for hypertension recommended in the 2017 ACC/AHA guideline increased the prevalence of chronic and gestational hypertension, markedly improved the appropriate identification of women who would go on to develop preeclampsia, and was associated with the identification of adverse fetal/neonatal risk.

Project description:Background Impaired endothelial function is thought to contribute to the increased cardiovascular risk associated with above-normal blood pressure (BP). However, the association between endothelial function and BP classified by 2017 American College of Cardiology/American Heart Association guidelines is unknown. Our objective was to determine if endothelial function decreases in midlife/older adults across the 2017 American College of Cardiology/American Heart Association guidelines BP classifications and identify associated mechanisms of action. Methods and Results A retrospective analysis of endothelial function (brachial artery flow-mediated dilation) from 988 midlife/older adults (aged 50+ years) stratified by BP status (normal BP; elevated BP; stage 1 hypertension; stage 2 hypertension) was performed. Endothelium-independent dilation (sublingual nitroglycerin), reactive oxygen species-mediated suppression of endothelial function (∆brachial artery flow-mediated dilation with vitamin C infusion), and endothelial cell and plasma markers of oxidative stress and inflammation were assessed in subgroups. Compared with normal BP (n=411), brachial artery flow-mediated dilation was 12% (P=0.04), 15% (P<0.01) and 20% (P<0.01) lower with elevated BP (n=173), stage 1 hypertension (n=248) and stage 2 hypertension (n=156), respectively, whereas endothelium-independent dilation did not differ (P=0.14). Vitamin C infusion increased brachial artery flow-mediated dilation in those with above-normal BP (P≤0.02) but not normal BP (P=0.11). Endothelial cell p47phox (P<0.01), a marker of superoxide/reactive oxygen species-generating nicotinamide adenine dinucleotide phosphate oxidase, and circulating interleukin-6 concentrations (P=0.01) were higher in individuals with above-normal BP. Conclusions Vascular endothelial function is progressively impaired with increasing BP in otherwise healthy adults classified by 2017 American College of Cardiology/American Heart Association guidelines. Impaired endothelial function with above-normal BP is mediated by excessive reactive oxygen species signaling associated with increased endothelial expression of nicotinamide adenine dinucleotide phosphate oxidase and circulating interleukin-6.

Dataset Information

Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines.

Publications

Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines.

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