Global impact of the new European and American hypertension guidelines: A perspective from Lebanon

1. INTRODUCTION

In 2017 and 2018, the new hypertension (HTN) guidelines of the American Heart Association/American College of Cardiology (AHA/ACC) and those of the European Society of Cardiology/European Society of Hypertension (ESC/ESH) were, respectively, published.1, 2 Both introduced several major novelties that have an important impact on the HTN epidemic worldwide. One of the most important novelties was the change in the definition of HTN by the American guidelines to a blood pressure ≥130/80 mm Hg. The European guidelines, however, maintained the same classification of BP categories and kept the definition of HTN at 140/90 mm Hg and above. The second novelty was in the definition of control. The American guidelines recommended reaching a blood pressure <130/80 mm Hg for all patients, while the European guidelines considered a value of <140/90 mm Hg as adequate, with the goal to reach <130/80 mm Hg in younger patients (<65 years) provided that treatment is well tolerated. The third novelty was the recommendation by both guidelines, to use combination therapy in a single pill, as first‐line treatment for patients with blood pressure ≥140/90 mm Hg.

In countries outside the USA and Europe, especially in those were no local HTN guidelines are available, cardiac societies are faced with the dilemma of which guidelines to follow. This is especially true in countries such as Lebanon, where cardiologists have received advanced training in either the USA or Europe. Local authorities need to assess the impact of these guidelines on the prevalence and on control rate of HTN. Evaluating the impact of the new guidelines in Lebanon is also important, because it may reflect the situation in several other countries belonging to the same group of upper‐middle income countries according to the World Bank classification 3 or in surrounding countries in the Middle East, where the impact of these guidelines has not been evaluated yet.

2. IMPACT OF THE NEW GUIDELINES ON THE HYPERTENSION EPIDEMIC IN LEBANON

In the two most recent surveys performed in Lebanon, the prevalence of HTN was 31.2% and 35.9%, the treatment rate was 49% and 59%, and the control rate 27% and 29%.4, 5 These surveys have used 140/90 mm Hg as the definition of HTN and an on‐treatment blood pressure <140/90 mm Hg as the definition of control.

In order to assess the impact of the new AHA/ACC definition of HTN on Lebanon, we re‐analyzed data from our survey that was performed in 2012‐2013 on 1697 Lebanese citizens aged 21 years and above.4 The global prevalence of HTN increases from 35.9% to 58% if the new AHA/ACC definition is applied. This is mainly due to reclassification of the majority of individuals who were in the normal or high‐normal blood pressure range according to the ESC/ESH classification, into hypertensive (Table 1). The major increase in prevalence occurred in young patients aged 21‐34 years, where it more than doubled from 14.8% to 38%. The increase in prevalence using the 2017 AHA/ACC definition occurred (but less in term of relative increase) in other age brackets, going up from 34.1% to 57.4% for the group of 35‐49 years, from 57.6% to 75.5% for the group of 50‐65 years and from 73.3% to 84.4% in individuals older than 65 years. We cannot evaluate the proportion of patients with a blood pressure between 130‐139/80‐89 who would be eligible for therapy because we do not have data on their 10‐year risk. Control rate using the target of <140/90 mm Hg, was about 50% in treated patients.4, 5 Using a target of <130/80 mm Hg, will make control rate substantially lower, as mean blood pressure in treated patients was 136.5/82.5 mm Hg, well above that target.

Table 1.

Differences of hypertension prevalence in Lebanon according to the ESC/ESH or AHA/ACC definitions

2018 ESC/ESH			2017 AHA/ACC
Systolic and diastolic BP, mm Hg		Prevalence (%)	Systolic and diastolic BP, mm Hg		Prevalence (%)
Optimal	<120/80	33	Normal	<120/80	33
Normal‐high normal	120‐139/80‐89	31	Elevated blood pressure	120‐129/<80	9
Hypertension	≥140/90	36	Hypertension	≥130/80	58

3. WHICH GUIDELINES TO APPLY?

Applying the new AHA/ACC definition of HTN will create a major public health problem in Lebanon, by making the majority of Lebanese hypertensive. From our long clinical experience, and knowing the “culture” of the country, we feel that this would paradoxically minimize the seriousness of the disease, because “everyone has it.” The definition of the “norm” for lay people may not be what physicians recommend, but what is the blood pressure in the majority of the population. We prefer to follow the recommendations of the ESC/ESH and define HTN by 140/90 mm Hg and above. We believe that identifying individuals with blood pressure between 130‐139 mm Hg and/or 80‐89 mm Hg is beyond our limited resources and even if successful in bringing them to therapy, it may not result in significant reduction in cardiovascular outcome. A meta‐analysis of 16 trials did not find in primary prevention, a cardiovascular benefit of additional blood pressure lowering if systolic blood pressure at baseline was <140 mm Hg.6 A better way to deal with the HTN epidemic is to concentrate our efforts on increasing awareness among patients and on teaching physicians to adopt a more aggressive pharmacological approach in their treatment. In our survey, although 72% and 90% of interviewed patients knew that HTN is defined at 140 systolic and 90 diastolic, only 50% of those with HTN were aware of their disease.4 Awareness was the most important predictor of treatment (>90% treatment rate in aware individuals). Thus, organizing screening campaigns for HTN is of uppermost importance. We could not find an independent predictor of control in treated patients. However, physicians “inertia” may be playing an important role. The majority of hypertensive patients were on monotherapy and 10% only were on three or more drugs.4, 5 The new guidelines recommending combination therapy for all patients with blood pressure level ≥140/90 mm Hg are greatly welcomed and will likely result in more important blood pressure reduction and in a better control rate. In addition, targeting blood pressure values <130/80 mm Hg will improve physicians “inertia” because it will decrease the fear that many doctors may have from “excessive blood pressure lowering” and it will thus, encourage them to use more than one drug to reach target level. We believe that by increasing the percentage of hypertensive treated (higher awareness) and by improving blood pressure control with the use of more pills, we can achieve important reductions in blood pressure level and consequently, in morbidity and mortality.

4. CONCLUSION

In conclusion, both European and American guidelines had a huge effect on how cardiologist perceive HTN in Lebanon. Minor blood pressure elevations are no longer downplayed. Aggressive pharmacological treatment with combination therapy aiming at important blood pressure reductions is becoming the standard approach. However, when having to choose between the two, we feel that the Europeans guidelines are more adapted to our country and are in line with our evaluation of the HTN epidemic.

DISCLOSURES

Dr Rabih Azar and Dr Antoine Sarkis have received speaker honoraria from several pharmaceutical companies that manufacture blood pressure lowering drugs, such as Boehringer, Astra‐Zeneca, Merck, MSD, Pfizer, Pharmaline, Algorithm, Sanofi‐Aventis, Novartis, Servier. Dr Antoine Sarkis is the current president of the Lebanese Society of Cardiology

Azar RR, Sarkis A. Global impact of the new European and American hypertension guidelines: A perspective from Lebanon. J Clin Hypertens. 2019;21:684–686. 10.1111/jch.13526