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Highlights from the European Society of Cardiology (ESC) Congress, Munich, Germany, 25–29 August, 2018

Highlights from the European Society of Cardiology (ESC) Congress, Munich, Germany, 25–29 August, 2018
  • Cardiometabolic
  • Hypertension

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International meeting
2018 ESC/ESH guidelines
ASCOT Legacy trial. atrial fibrillation

The major highpoint in the field of hypertension at the ESC 2018 Congress was the detailed presentation of the new 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines for the management of arterial hypertension. Other important presentations in the hypertension field included the results of the ASCOT Legacy trial and presentations related to the burden of hypertension and the risk for atrial fibrillation and the targets for hypertension treatment in atrial fibrillation.

2018 ESC/ESH Guidelines

The 2018 European guidelines were presented by Professor Bryan Williams (University College London, UK) and Professor Giuseppe Mancia (University of Milano-Bicocca, Milan, Italy) and published simultaneously in the European Heart Journal.1 The new guidelines did not follow the 2017 American guidelines in changing the definition of hypertension but retained the previous level of office blood pressure (BP) ≥140/90 mm Hg as the cut-off level for hypertension and the general threshold for treatment. For those aged ≥80 years, the threshold for treatment was office systolic BP ≥160 mm Hg Ambulatory BP monitoring and home BP monitoring were recommended for confirming the diagnosis of hypertension and monitoring the response to therapy. The usual lifestyle interventions of smoking cessation, sodium restriction, alcohol moderation, regular exercise and weight reduction were emphasized for all patients.  
  
Nonetheless, the new guidelines did recommend a more aggressive approach in the treatment of hypertension with a treatment target for office BP of <140/90 mm Hg for all patients and a target of ≤130/80 mm Hg if treatment is well-tolerated in patients <65 years of age. 

There was a strong recommendation to start treatment in most patients with a combination of two drugs, preferably used as a single pill combination. A simplified drug treatment algorithm was provided as a practical approach to hypertension management. A two-in-one combination tablet containing an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) along with a calcium channel blocker (CCB) or thiazide/thiazide-like diuretic was recommended. Initiating treatment with monotherapy should be reserved for patients with BP close to their recommended target or very old patients, and frail elderly patients.

The second-line treatment should be a triple combination pill containing an ACEI or ARB in combination with a CCB and a diuretic. The next step recommended as third-line treatment was the triple combination pill along with spironolactone or another diuretic, an alpha-blocker or a beta-blocker. Beta-blockers were no longer recommended as a general first-line treatment but should be considered at any treatment step when there is a specific indication for their use, such as heart failure, angina, post-MI atrial fibrillation, or younger women with or planning pregnancy.

Statin therapy was recommended for hypertensive patients with established cardiovascular disease or high cardiovascular risk and low dose aspirin was recommended for secondary prevention but not primary prevention in hypertensive patients.

The ASCOT Legacy trial

The results of the ASCOT Legacy trial were presented by Dr Ajay Gupta (William Harvey Research Institute, Queen Mary University of London, UK) and published simultaneously in The Lancet.2  

The mortality outcomes after 16 years of follow-up of the UK participants in the original ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) study were reported. Among the UK-based patients in the blood pressure-lowering arm (BPLA), there was no overall difference in all-cause mortality between those assigned to atenolol-based treatment and those assigned to amlodipine-based treatment (adjusted hazard ratio [HR] 0.90, 95% CI 0.81-1.01, P=0.0776). However, there were significantly fewer deaths from stroke (adjusted HR 0.71, 0.53-0.97, P=0.0305) in the amlodipine-based treatment group compared with the atenolol-based treatment group. In the 3975 patients who were not in the lipid-lowering arm (LLA) of ASCOT, there were fewer cardiovascular deaths (adjusted HR 0.79, 0.67-0.93, P=0.0046) among those assigned to amlodipine-based treatment compared with atenolol-based treatment (P=0.022 for the test for interaction between the two blood pressure treatments and allocation to LLA or not). Statin treatment was associated with significantly fewer cardiovascular deaths (HR 0.85, 0.72-0.99, P=0.0395) compared with placebo in the LLA.

The findings show that patients on amlodipine-based treatment had fewer stroke deaths and patients on atorvastatin had fewer cardiovascular deaths more than 10 years after the end of the trial, supporting the notion that interventions for blood pressure and cholesterol are associated with long-term benefits on cardiovascular outcomes.

Blood pressure exposure as a risk for atrial fibrillation (AF) and targets for hypertension treatment in AF.

Dr Ekaterina Sharashova (The Arctic University of Norway, Tromsø, Norway) presented results from the population-based Tromsø study in North Norway.3 Five long-term systolic blood pressure (SBP) trajectory groups were identified between 1986 and 2001 in subjects who were followed up for incident atrial fibrillation (AF) through 2013. In men, groups 1 and 2 were normotensive throughout the period, group 3 had mild hypertension with a tendency to increase SBP, groups 4 and 5 were hypertensive throughout, but group 4 increased and group 5 decreased their SBP substantially. Groups 3 and 4 were associated with significantly increased risk of AF.

In women, SBP trajectory groups 1 and 2 were similar to those seen in men, groups 3 and 4 were hypertensive throughout, but SBP increased in group 3 and decreased in group 4, and group 5 had the highest SBP throughout with no tendency to decrease. The risk of AF was significantly increased in groups 3, 4 and 5. The findings suggest the cumulative exposure to elevated SBP was associated with increased risk of AF.

Daehoon Kim (Yonsei University College of Medicine, Seoul, Korea) presented an analysis of the ideal BP threshold for the management of hypertension in patients with AF from 298,374 non-valvular AF adults from the entire Korean population cohort. Compared with patients who were non-hypertensive according to the 2017 ACC/AHA guideline (<130/80 mmHg), those with hypertension had significantly greater risks of major cardiovascular events, ischemic stroke, intracranial hemorrhage and heart failure admission. In the patients with AF having hypertension treatment, a U-shaped relationship for major cardiovascular events was evident, with 120–129/<80 mmHg as the optimal BP treatment target. They concluded that the new BP threshold and target defined by the 2017 ACC/AHA guideline may be beneficial for AF patients.

These two studies suggest that increased BP burden increases the risk of developing AF and in patients with AF and hypertension, the optimal target for SBP may be 120-129 mm Hg. 


References

  1. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018;39:3021-104.
  2. Gupta A, Mackay J, Whitehouse A, et al. Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial. Lancet 2018 Aug 24;pii:S0140-6736(18)31776-8. 
  3. E Sharashova, T Wilsgaard, I Njolstad, et al. 6168. Long-term systolic blood pressure trajectories predict risk of incident atrial fibrillation in a general population cohort study. Eur Heart J 2018;39(suppl_1):1275-76. 
  4. Kim D, Yang PS, Kim TH, et al. 2181. What is the ideal blood pressure threshold and target for the management of high blood pressure in patients with atrial fibrillation? Nationwide cohort data covering the entire Korean population. Eur Heart J 2018;39(suppl_1):436. 

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