ESC/ESH guideline 2013

Dr atma gunawan
(consultant of hypertension
and nephrology)

TheTask Force for the management of arterial

hypertension of the European Society of
Hypertension (ESH) and of the European
Society of Cardiology (ESC)
List of 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), Stephane 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), and Faiez Zannad (France)
24 countries, 735 literature, within the last 6 years
Previous guideline : 2003 and 2007

Levels of Evidence

Classes of
recommendations

Denitions and classication of office BP levels (mmHg)*

Hypertension:
SBP >140 mmHg DBP >90 mmHg
Category

Systolic

Diastolic

Optimal

<120

and

<80

Normal

120129

and/or

8084

High normal

130139

and/or

8589

Grade 1 hypertension

140159

and/or

9099

Grade 2 hypertension

160179

and/or

100109

Grade 3 hypertension

180

and/or

110

Isolated systolic hypertension

140

and

<90

* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated
systolic hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.

Office BP measurement
Sit for 35 minutes
Sitting position
At least two BP measurements
Repeated measurements in patients with arrhythmias
Use a standard bladder (1213 cm wide and 35 cm long), but have a larger and
a smaller bladder available for large (arm circumference >32 cm) and thin arms,
respectively
Cuff at the heart level
Phase I and V (disappearance) Korotkoff sounds to identify systolic and
diastolic BP
Measure BP in both arms at first visit, take the arm with the higher value as the
reference
In elderly,diabetic, other conditions in which orthostatic hypotension may be
frequent or suspected : at first visit measure BP 1 and 3 min after assumption
of the standing
BP, blood pressure.

Who should measure BP ?

Mancia,et.al, Hypertension 1987;9;209

Variations in the measurement of blood

pressure between doctors and nurses
Frequency distribution of systolic
blood pressure

Frequency distribution of diastolic

blood pressure

J. Roy. Coll. gen. Practit., 1971, 21, 698

Circadian BP rhythm in normotensive (lower curve)

and hypertensive (upper curve) individuals

Melatonin circadian

Blood pressure monitoring

Home BP : measured at 7 AM
and 7 PM, at least 3 days

ABPM (ambulatory blood

pressure monitoring)

2013 ESH/ESC Guidelines for the management of arterial hypertension

Definitions of hypertension by office and out-of-office BP levels

Category

Systolic BP
(mmHg)

Diastolic BP
(mmHg)

Office BP

140

and

90

Daytime (or awake)

135

and/or

85

Nighttime (or asleep)

120

and/or

70

24-h

130

and/or

80

135

and/or

85

Ambulatory BP

Home BP
BP, blood pressure.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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White coat hypertension

Office BP persistently 140/90mmHg

Normal daytime ambulatory (<130135/85mmHg) or
home (<135/85 mmHg) BP

Cumulative hazard for stroke in the 3 groups

(normotensive subjects, WCH, and ambulatory
hypertension).

Paulo,Grian. Hypertension 2005;45;203-208

Masked hypertension
Office BP persistently normal (<140/90mmHg)
Elevated ambulatory ( 130/80mmHg) or home
( 135/85mmHg) BP
10 to 40 percent of patients who are
normotensive by conventional clinic
measurement

Treatment strategies in white-coat

and masked hypertension

Non-dipping
hypertensio
n
Nocturnal BP is
approximately 15
percent lower than
daytime values
(normals and
hypertensive)
Failure of the BP to
fall by at least 10
percent during
sleep is called
nondipping

11-year risk of cardiovascular mortality for

10mm Hg increase in office, home, and
ambulatory BP (Pamela Study, n= 1412)

Circulation 2005, 111:1777-1783

Clinical indications for HBPM or ABPM

Clinical indications for HBPM or ABPM

Suspicion of white-coat hypertension
Identification of white-coat effect in hypertensive
patients
Grade I hypertension or high normal BP in the office
Suspicion of masked hypertension
Normal office BP in individuals with asymptomatic organ
damage or at high total CV risk
Suspicion of nocturnal hypertension or absence of
dipping, such as in patients with sleep apnoea, CKD, or
diabetes
Autonomic, postural, post-prandial, siesta- and druginduced hypotension
Identification of true and false resistant hypertension

The concept of Hypertension

and total cardiovascular risk
Only a small fraction of the hypertensive
population has an elevation of BP alone
Majority exhibiting additional CV risk factors
BP and other CV risk factors may potentiate each
other, leading to a total CV risk that is greater
than the sum of its individual components
In high-risk individuals, BP control is more difficult
and more frequently requires the combination of
antihypertensive drugs with other therapies, such
as aggressive lipid-lowering treatments

Factorsother than office BPinfluencing prognosis

(used for stratification of total CV risk )
Risk factors
Male sex
Age (men 55 years; women 65 years)
Smoking
Dyslipidaemia
- Total cholesterol >4.9 mmol/L (190 mg/dL), and/or
- Low-density lipoprotein cholesterol >3.0 mmol/L (115 mg/dL), and/or
- High-density lipoprotein cholesterol: men <1.0 mmol/L (40 mg/dL),
women <1.2 mmol/L (46 mg/dL), and/or
- Triglycerides >1.7 mmol/L (150 mg/dL)
Fasting plasma glucose 5.66.9 mmol/L (102125 mg/dL)
Abnormal glucose tolerance test
Obesity [BMI 30 kg/m 2 (height2)]
Abdominal obesity (waist circumference: men 102 cm;
women 88 cm) (in Caucasians)
Family history of premature CVD (men aged <55 years;
women aged <65 years
Diabetes Mellitus
Fasting plasma glucose 7.0 mmol/L (126 mg/dL) on two repeated
measurements, and/or
HbA1c >7% (53 mmol/mol), and/or
Post-load plasma glucose >11.0 mmol/L (198 mg/dL)

Asymptomatic organ damage

Pulse pressure (in the elderly) 60 mmHg
Electrocardiographic LVH (SokolowLyon index >3.5 mV; RaVL >1.1
mV; Cornell voltage duration product >244 mV*ms), or
Echocardiographic LVH [LVM index: men >115 g/m 2; women >95 g/m2
(BSA)]a
Carotid wall thickening (IMT >0.9 mm) or plaque
Carotid-femoral PWV >10 m/s
Ankle/brachial BP index <0.9
CKD with eGFR 3060 ml/min/1.73 m2 (BSA)
Microalbuminuria (30300 mg/24 h), or albumincreatinine ratio
(30300 mg/g; 3.434 mg/mmol) (preferentially on morning spot urine)

Established CV or renal disease

Cerebrovascular disease: ischaemic stroke; cerebral haemorrhage;
transient ischaemic attack
CHD: myocardial infarction; angina; myocardial revascularization with
PCI or CABG
Heart failure, including heart failure with preserved EF
Symptomatic lower extremities peripheral artery disease
CKD with eGFR <30 mL/min/1.73m 2 (BSA); proteinuria (>300 mg/24 h)
Advanced retinopathy: haemorrhages or exudates, papilloedema

BMI, body mass index; BP, blood pressure; BSA, body surface area; CABG, coronary artery bypass graft; CHD, coronary heart disease; CKD,
chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; EF, ejection fraction; eGFR, estimated glomerular filtration rate;
HbA1c, glycated haemoglobin; IMT, intima-media thickness; LVH, left ventricular hypertrophy; LVM, left ventricular mass; PCI, percutaneous
coronary intervention; PWV, pulse wave velocity.
a
Risk maximal for concentric LVH: increased LVM index with a wall thickness/radius ratio of 0.42.

2013 ESH/ESC Guidelines for the management of arterial hypertension

Initiation of lifestyle changes and antihypertensive drug treatment

Blood pressure (mmHg)
Other risk factors,
asymptomatic organ
damage or disease

High normal SBP

130139
or DBP 8589

Grade 1 HT
Grade 2 HT
SBP 140159 or
SBP 160179
DBP 9099
or DBP 100109

Grade 3 HT
SBP 180
or DBP 110

No other RF

No BP intervention

Lifestyle changes for

several months
Then add BP drugs
targeting <140/90

Lifestyle changes for

several weeks
Then add BP drugs
targeting <140/90

Lifestyle changes
Immediate BP
drugs targeting
<140/90

12 RF

Lifestyle changes
No BP intervention

Lifestyle changes for

several weeks
Then add BP drugs
targeting <140/90

Lifestyle changes for

several weeks
Then add BP drugs
targeting <140/90

Lifestyle changes
Immediate BP
drugs targeting
<140/90

3 RF

Lifestyle changes
No BP intervention

Lifestyle changes for

several weeks
Then add BP drugs
targeting <140/90

Lifestyle changes
BP drugs targeting
<140/90

Lifestyle changes
Immediate BP
drugs targeting
<140/90

OD, CKD stage 3 or diabetes

Lifestyle changes
No BP intervention

Lifestyle changes
BP drugs targeting
<140/90

Lifestyle changes
BP drugs targeting
<140/90

Lifestyle changes
Immediate BP
drugs targeting
<140/90

Symptomatic CVD, CKD stage

4 or diabetes with OD/RFs

Lifestyle changes
No BP intervention

Lifestyle changes
BP drugs targeting
<140/90

Lifestyle changes
BP drugs targeting
<140/90

Lifestyle changes
Immediate BP
drugs targeting
<140/90

BP, blood pressure; CKD, chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; DBP, diastolic blood pressure; HT,
hypertension; OD, organ damage; RF, risk factor; SBP, systolic blood pressure.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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Initiation of antihypertensive drug

treatment

Blood pressure goals in hypertensive patients

Recommendations
SBP goal for most
Patients at lowmoderate CV risk
Patients with diabetes
Consider with previous stroke or TIA
Consider with CHD
Consider with diabetic or non-diabetic CKD

<140 mmHg

SBP goal for elderly

Ages <80 years
Initial SBP 160 mmHg

140-150 mmHg

SBP goal for fit elderly

Aged <80 years

<140 mmHg

SBP goal for elderly >80 years with SBP

160 mmHg

140-150 mmHg

DBP goal for most

<90 mmHg

DB goal for patients with diabetes

<85 mmHg

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.

Lifestyle changes for hypertensive patients

Recommendations to reduce BP and/or CV risk factors
Salt intake

Restrict 5-6 g/day

Moderate alcohol intake

Limit to 20-30 g/day men,

10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal

25 kg/m2

Waist circumference goal

Men: <102 cm (40 in.)*

Women: <88 cm (34 in.)*

Exercise goals

30 min/day, 5-7 days/week

(moderate, dynamic exercise)
Quit smoking

* Unless contraindicated. BMI, body mass index.

Compelling indications for hypertension treatment

Class

Contraindications
Compelling

Possible

Diuretics
(thiazides)

Gout

Metabolic syndrome
Glucose intolerance
Pregnancy
Hypercalcemia
Hypokalaemia

Beta-blockers

Asthma
AV block (grade 2 or 3)

Metabolic syndrome
Glucose intolerance
Athletes and physically active patients
COPD (except for vasodilator beta-blockers)

Calcium antagonists
(dihydropyridines)

Tachyarrhythmia
Heart failure

Calcium antagonists
(verapamil, diltiazem)

AV block (grade 2 or 3, trifascicular block)

Severe LV dysfunction
Heart failure

ACE inhibitors

Pregnancy
Angioneurotic oedema
Hyperkalaemia
Bilateral renal artery stenosis

Women with child bearing potential

Angiotensin receptor blockers

Pregnancy
Hyperkalaemia
Bilateral renal artery stenosis

Women with child bearing potential

Mineralocorticoid
receptor antagonists

Acute or severe renal failure (eGFR <30 mL/min)

Hyperkalaemia

A-V, atrio-ventricular; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; LV, left
ventricular.

Preferred hypertension treatment in specific conditions

Condition

Drug

Asymptomatic organ damage

LVH

LVH ACE inhibitor, calcium antagonist, ARB

Asymptomatic atherosclerosis

Calcium antagonist, ACE inhibitor

Microalbuminuria

ACE inhibitor, ARB

Renal dysfunction

ACE inhibitor, ARB

Clinical CV event
Previous stroke

Any agent effectively lowering BP

Previous myocardial infarction

BB, ACE inhibitor, ARB

Angina pectoris

BB, calcium antagonist

Heart failure

Diuretic, BB, ACE inhibitor, ARB, mineralocorticoid receptor antagonists

Aortic aneurysm

BB

Atrial fibrillation, prevention

Consider ARB, ACE inhibitor, BB or mineralocorticoid receptor antagonist

Atrial fibrillation, ventricular rate control

BB, non-dihydropyridine calcium antagonist

ESRD/proteinuria

ACE inhibitor, ARB

Peripheral artery disease

ACE inhibitor, calcium antagonist

Other
ISH (elderly)

Diuretic, calcium antagonist

Metabolic syndrome

ACE inhibitor, ARB, calcium antagonist

Diabetes mellitus

ACE inhibitor, ARB

Pregnancy

Methyldopa, BB, calcium antagonist

Blacks

Diuretic, calcium antagonist

ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BB, beta-blocker; BP, blood pressure; CV, cardiovascular; ESRD, end-stage renal
disease;
ISH, isolated systolic hypertension; LVH, left ventricular hypertrophy.

2013 ESH/ESC Guidelines for the management of arterial hypertension

Monotherapy vs. drug combination strategies to achieve target BP

Choose between

Mild BP elevation
Low/moderate CV risk

Single agent

Marked BP elevation
High/very high CV risk

Twodrug combination

Switch
to different agent

Previous agent
at full dose

Full dose
monotherapy

Two drug
combination
at full doses

Previous combination
at full dose

Switch
to different twodrug
combination

Add a third drug

Three drug
combination
at full doses

Moving from a less intensive to a more intensive therapeutic strategy

should be done whenever BP target is not achieved.
BP, blood pressure; CV, cardiovascular.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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Combination Versus Monotherapy

for Blood Pressure Reduction

The American Journal of Medicine (2009) 122,

290-300

2013 ESH/ESC Guidelines for the management of arterial hypertension

Possible combinations of classes of antihypertensive drugs

Thiazide diuretics

-blockers

Angiotensin-receptor
blockers

Other
antihypertensives

Calcium
antagonists

ACE inhibitors
Green continuous lines: preferred combinations; green dashed line: useful combination (with some
limitations); black dashed lines: possible but less well tested combinations; red continuous line: not
recommended combination. Although verapamil and diltiazem are sometimes used with a beta-blocker to
improve ventricular rate control in permanent atrial fibrillation, only dihydropyridine calcium antagonists should
normally be combined with beta-blockers.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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Hypertension treatment options

Clinical scenario

Recommendations

Initiation and maintenance treatment

Monotheray or in combination

Diuretics (thiazides, chlorthalidone,

indapamide)
BBs
CCBs
ACE-I
ARBs

Consider two-drug combination therapy in patient with:

High baseline BP
High CV risk

Combination of two RAS antagonists

Not recommended

Consider other drug combinations for BP reduction

Most preferable option may be

combinations successfully used in trial

Combination therapy with fixed doses of two drugs in a

single tablet

May be recommended due to potential

for improved adherence

BB, beta-blocker; CCB, calcium channel blockers; ACE-I, angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; OD, organ damage; BP,
blood pressure; CV, cardiovascular; RAS, reninangiotensin system.

Hypertension treatment for people with diabetes

Recommendations
Mandatory: initiate drug treatment in patients
with SBP 160 mmHg

Additonal considerations
Strongly recommended: start drug treatment
when SBP 140 mmHg

SBP goals for patients with diabetes: <140 mmHg

DBP goals for patients with diabetes: <85 mmHg
All hypertension treatment agents are
recommended and may be used in patients with
diabetes

RAS blockers may be preferred

Especially in presence of preoteinuria or
microalbuminuria

Choice of hypertension treatment must take comorbidities into account

Coadministration of RAS blockers not
recommended

Avoid in patients with diabetes

SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, reninangiotensin system.

Hypertension treatment for people with nephropathy

Recommendations

Additonal considerations

Consider lowering SBP to <140 mmHg

Consider SBP <130 mmHg with overt proteinuria

Monitor changes in eGFR

RAS blockers more effective to reduce

albuminuria than other agents

Indicated in presence of microalbuminuria or

overt proteinuria

Combination therapy usually required to reach

BP goals

Combine RAS blockers with other agents

Combination of two RAS blockers

Not recommended

Aldosterone antagonist not recommended in

CKD

Especially in combination with a RAS blocker

Risk of excessive reduction in renal function,
hyperkalemia

SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, reninangiotensin system.

Hypertension treatment for people with heart disease

Recommendations

Additonal considerations

SBP goals for hypertensive patients with CHD: <140 mmHg

BBs for hypertensive patients with recent MI

Other CHD: other antihypertensive agents can

be used; BBs, CCBs preferred

Diuretics, BBs, ACE-I, ARBs, and/or

mineralcorticoid receptor antagonist for patients
with heart failure or severe LV dysfunction

Reduce mortality and hospitalization

No evidence that any hypertension drug

beneficial for patients with heart failure and
preserved EF

However, in these patients and patients with

hypertension and systolic dysfunction:
consider lowering SBP to 140 mmHg
Guide treatment by symptom relief

Consider ACE-I and ARBs (and BBs and mineralcorticoid receptor antagonist in coexisting
heart failure) in patients at risk of new or recurrent AF
Antihypertensive therapy in all patients with LVH

Initiate treatment with an agent with greater

ability to regress LVH (ACE-I, ARBs, CCBs)

SBP, systolic blood pressure; BB, beta-blocker; MI, myocardial infarction; ACE-I, angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; LV,
left ventricular; EF, ejection fraction; CHD, coronary heart disease; CCB, calcium channel blockers; AF, atrial fibrillation; LVH, left ventricular hypertrophy.

Hypertension treatment for people with cerebrovascular disease

Recommendations

Additonal considerations

Do not introduce antihypertensive treatment

during first week after acute stroke

Irrispective of BP level
Use clinical judgment with very high SBP

Introduce antihypertensive treatment in patients

with history of stroke or TIA

Even when initial SBP is 140-159 mmHg

SBP goals for hypertensive patients with history of stroke or TIA: <140 mmHg
Consider higher SBP goal in elderly with previous stroke or TIA
All drug regimens recommended for stroke
prevention
TIA, transient ischaemic attack; SBP, systolic blood pressure; BP, blood pressure.

Provided BP is effectively reduced

Hypertension treatment for people with resistant hypertension

Recommendations

Additonal considerations

Withdraw any drugs in antihypetensive treatment regimen that have absent or minimal effect
Consider mineralocorticoid receptor antagonists,
amiloride, and the alpha-1-blocker doxazosin
should be considered (if no contraindication
exists)

If no contraindications exist

Invasive approaches: renal denervation and

baroreceptor stimulation may be considered

If drug treatment ineffective

No long-term efficay, safety data for renal denervation, baroreceptor stimulation only
experienced clinicians should use
Diagnosis and follow-up should be restricted to hypertension Centres
Invasive approaches only for truly resistant
hypertensive patients
SBP, systolic blood pressure; DBP, diastolic blood pressure; BP, blood pressure.

Clinic values: SBP 160 mmHg or DBP 110

mmHg with BP elevation confirmed by ABPM

Renal Denervation

Renal denervation- ESH/ECS

2013
Simply labeled as "promising" therapy
In studies conducted so far, renal
denervation has been associated with
relatively consistent blood pressure
declines in the range of 26 to 32 mm Hg
systolic and 6 to 17 mm Hg diastolic at 6
months.
Yet to establish safety and efficacy against
the best possible drug regimens
Will it translate into reductions in
cardiovascular morbidity and mortality ?

Obstructive sleep apneu

At least 10 apneic and hypopneic episodes (min 10 seconds) per sleep hour
10% of 30-60 years of age (5% of woman and 15% of men)

Obstructive Sleep Apnea

(OSA)
Acute hypercapnia or hypoxia separately
increase plasma aldosterone
10% of 30-60 years of age (5% of woman
and 15% of men)
OSA responsible for a large proportion of
cases of BP increase or absence of BP
reduction at night-time
A few prospective studies have linked
severe OSA to fatal and nonfatal CV events
and all-cause mortality

Association Between Treated and Untreated Obstructive Sleep Apnea and Risk of Hypertension
JAMA. 2012;307(20):2169-2176. doi:10.1001/jama.2012.3418

OSA indicates obstructive sleep apnea. Severity of OSA was defined by the apnea-hypopnea index (AHI) as mild OSA (AHI, 5.014.9), moderate OSA (AHI, 15.0-29.9), and severe OSA (AHI, 30.0). P value reflects an overall log-rank 23 test, providing an
overall survival difference among the 4 study groups.

Drug
Resistant
Htn

Stroke or
TIA

CHF

All Htn

CAD

Javaheri

Nieto

Shafer

Basetti
Sleep,
1999

JAMA
2000

Card 1999

Logan

Circ 1999

J Htn 2001

Superimposed recordings of the electrooculogram (EOG),

electroencephalogram (EEG), electromyogram (EMG), ECG (EKG),
sympathetic nerve activity (SNA), respiration (RESP), and blood
pressure (BP) during REM sleep in a patient with OSA

Treatment of sleep apnea

Behavioral factors :
- weight loss
- no alcohol and sedatives
before sleep
- avoidance of supine sleep
position
Nasal CPAP Continuous
positive airway pressure
Oral dental devices
Surgical procedures :
UPP, nasal
surgery,,tonsilectony,LAUP
Maxiofacial
surgery,tracheostomy

Can antihypertensive medications

be
reduced or stopped?

Patients in effective BP control for an

extended period, it may be possible to
reduce the number and dosage of drugs.
Reduction of medications should be made
gradually
BP control is accompanied by healthy
lifestyle
BP should be checked frequently because
of the risk of reappearance of hypertension.

Discontinuation of antihypertensive
therapy
N : 2765

Medical Research Council Working Party of Mild

Hypertension, Br Med J 1986; 293:988.

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