The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

ABCD
: Appropriate Blood pressure Control in Diabetes
ABI
: ankle–brachial index
ABPM
: ambulatory blood pressure monitoring
ACCESS
: Acute Candesartan Cilexetil Therapy in Stroke Survival
ACCOMPLISH
: Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension
ACCORD
: Action to Control Cardiovascular Risk in Diabetes
ACE
: angiotensin-converting enzyme
ACTIVE I
: Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events
ADVANCE
: Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation
AHEAD
: Action for HEAlth in Diabetes
ALLHAT
: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart ATtack
ALTITUDE
: ALiskiren Trial In Type 2 Diabetes Using Cardio-renal Endpoints
ANTIPAF
: ANgioTensin II Antagonist In Paroxysmal Atrial Fibrillation
APOLLO
: A Randomized Controlled Trial of Aliskiren in the Prevention of Major Cardiovascular Events in Elderly People
ARB
: angiotensin receptor blocker
ARIC
: Atherosclerosis Risk In Communities
ARR
: aldosterone renin ratio
ASCOT
: Anglo-Scandinavian Cardiac Outcomes Trial
ASCOT-LLA
: Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm
ASTRAL
: Angioplasty and STenting for Renal Artery Lesions
A-V
: atrioventricular
BB
: beta-blocker
BMI
: body mass index
BP
: blood pressure
BSA
: body surface area
CA
: calcium antagonist
CABG
: coronary artery bypass graft
CAPPP
: CAPtopril Prevention Project
CAPRAF
: CAndesartan in the Prevention of Relapsing Atrial Fibrillation
CHD
: coronary heart disease
CHHIPS
: Controlling Hypertension and Hypertension Immediately Post-Stroke
CKD
: chronic kidney disease
CKD-EPI
: Chronic Kidney Disease—EPIdemiology collaboration
CONVINCE
: Controlled ONset Verapamil INvestigation of CV Endpoints
CT
: computed tomography
CV
: cardiovascular
CVD
: cardiovascular disease
D
: diuretic
DASH
: Dietary Approaches to Stop Hypertension
DBP
: diastolic blood pressure
DCCT
: Diabetes Control and Complications Study
DIRECT
: DIabetic REtinopathy Candesartan Trials
DM
: diabetes mellitus
DPP-4
: dipeptidyl peptidase 4
EAS
: European Atherosclerosis Society
EASD
: European Association for the Study of Diabetes
ECG
: electrocardiogram
EF
: ejection fraction
eGFR
: estimated glomerular filtration rate
ELSA
: European Lacidipine Study on Atherosclerosis
ESC
: European Society of Cardiology
ESH
: European Society of Hypertension
ESRD
: end-stage renal disease
EXPLOR
: Amlodipine–Valsartan Combination Decreases Central Systolic Blood Pressure more Effectively than the Amlodipine–Atenolol Combination
FDA
: U.S. Food and Drug Administration
FEVER
: Felodipine EVent Reduction study
GISSI-AF
: Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Atrial Fibrillation
HbA1c
: glycated haemoglobin
HBPM
: home blood pressure monitoring
HOPE
: Heart Outcomes Prevention Evaluation
HOT
: Hypertension Optimal Treatment
HRT
: hormone replacement therapy
HT
: hypertension
HYVET
: HYpertension in the Very Elderly Trial
IMT
: intima-media thickness
I-PRESERVE
: Irbesartan in Heart Failure with Preserved Systolic Function
INTERHEART
: Effect of Potentially Modifiable Risk Factors associated with Myocardial Infarction in 52 Countries
INVEST
: INternational VErapamil SR/T Trandolapril
ISH
: Isolated systolic hypertension
JNC
: Joint National Committee
JUPITER
: Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin
LAVi
: left atrial volume index
LIFE
: Losartan Intervention For Endpoint Reduction in Hypertensives
LV
: left ventricle/left ventricular
LVH
: left ventricular hypertrophy
LVM
: left ventricular mass
MDRD
: Modification of Diet in Renal Disease
MRFIT
: Multiple Risk Factor Intervention Trial
MRI
: magnetic resonance imaging
NORDIL
: The Nordic Diltiazem Intervention study
OC
: oral contraceptive
OD
: organ damage
ONTARGET
: ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial
PAD
: peripheral artery disease
PATHS
: Prevention And Treatment of Hypertension Study
PCI
: percutaneous coronary intervention
PPAR
: peroxisome proliferator-activated receptor
PREVEND
: Prevention of REnal and Vascular ENdstage Disease
PROFESS
: Prevention Regimen for Effectively Avoiding Secondary Strokes
PROGRESS
: Perindopril Protection Against Recurrent Stroke Study
PWV
: pulse wave velocity
QALY
: Quality adjusted life years
RAA
: renin-angiotensin-aldosterone
RAS
: renin-angiotensin system
RCT
: randomized controlled trials
RF
: risk factor
ROADMAP
: Randomized Olmesartan And Diabetes MicroAlbuminuria Prevention
SBP
: systolic blood pressure
SCAST
: Angiotensin-Receptor Blocker Candesartan for Treatment of Acute STroke
SCOPE
: Study on COgnition and Prognosis in the Elderly
SCORE
: Systematic COronary Risk Evaluation
SHEP
: Systolic Hypertension in the Elderly Program
STOP
: Swedish Trials in Old Patients with Hypertension
STOP-2
: The second Swedish Trial in Old Patients with Hypertension
SYSTCHINA
: SYSTolic Hypertension in the Elderly: Chinese trial
SYSTEUR
: SYSTolic Hypertension in Europe
TIA
: transient ischaemic attack
TOHP
: Trials Of Hypertension Prevention
TRANSCEND
: Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease
UKPDS
: United Kingdom Prospective Diabetes Study
VADT
: Veterans' Affairs Diabetes Trial
VALUE
: Valsartan Antihypertensive Long-term Use Evaluation
WHO
: World Health Organization

### 1.1 Principles

The 2013 guidelines on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology …

/pdf/2013-esh-esc-guidelines-for-the-management-of-arterial-4ydvs5ifsx.pdf

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).

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

2007 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).

Background End-stage renal disease substantially increases the risks of death, cardiovascular disease, and use of specialized health care, but the effects of less severe kidney dysfunction on these outcomes are less well defined. Methods We estimated the longitudinal glomerular filtration rate (GFR) among 1,120,295 adults within a large, integrated system of health care delivery in whom serum creatinine had been measured between 1996 and 2000 and who had not undergone dialysis or kidney transplantation. We examined the multivariable association between the estimated GFR and the risks of death, cardiovascular events, and hospitalization. Results The median follow-up was 2.84 years, the mean age was 52 years, and 55 percent of the group were women. After adjustment, the risk of death increased as the GFR decreased below 60 ml per minute per 1.73 m2 of body-surface area: the adjusted hazard ratio for death was 1.2 with an estimated GFR of 45 to 59 ml per minute per 1.73 m2 (95 percent confidence interval, 1....

https://www.nejm.org/doi/pdf/10.1056/NEJMoa041031

Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization

Problems in the control of systolic blood pressure

Finerenone in Mild to Severe Chronic Kidney Disease and Type 2 Diabetes: A Fidelity Subgroup Analysis in Patients with Heart Failure

Objective: To evaluate the efficacy of catheter-based renal denervation (RDN) to lower blood pressure (BP) in patients with a history of myocardial infarction or stroke in the Global SYMPLICITY Registry (GSR). Design and method: GSR is a prospective, global, all-comers registry to evaluate the safety and efficacy of catheter-based RDN to lower BP. Patients are enrolled with the intention to receive RDN using either the Symplicity Flex or Symplicity Spyral catheter. Patients are followed at 3, 6, and 12 months, and then annually up to 3 years post-procedure. Office and ambulatory BP are measured at each follow-up and any adverse events are collected. The current post-hoc analysis compares systolic BP (SBP) reduction in patients with and without a history of myocardial infarction as well as with and without history of stroke. Differences in SBP reduction between groups were adjusted for baseline SBP using ANCOVA methods. Results: In March 2021 in GSR, there were 267 patients (10%) with a history of myocardial infarction and 2579 without, and 294 patients with a history of stroke (10%) and 2539 without. Patients with and without a history of myocardial infarction had similar baseline office and ambulatory SBP measurements, whereas patients with a history of stroke had similar office SBP measurements but significantly higher ambulatory SBP (159 ± 22 vs. 154 ± 18, p = 0.005) compared to patients without history of stroke. Office and ambulatory SBP reductions from 6 months to 3 years were similar for patients with and without a history of myocardial infarction after adjusting for differences in baseline SBP (Figure). SBP reductions were also similar for patients with and without a history of stroke except at 6 months for office and ambulatory SBP and at 12 months for ambulatory SBP, when patients with a history of stroke had less BP reduction. Conclusions: Patients with and without a history of stroke or myocardial infarction had similar office and ambulatory SBP reductions after catheter-based RDN, suggesting efficacy of RDN regardless of baseline cardiovascular history.

Blood pressure reduction after catheter-based renal denervation in patients with cardiovascular disease in the global symplicity registry

New approach to measurement of blood pressure in the office

Resistant hypertension is undoubtedly a real clinical challenge, given that it increases cardiovascular events and has no effective treatment. Thus, it is easy to see why renal sympathetic denervation (RDN) has raised expectations among physicians treating patients with this serious disease. The SYMPLICITY HTN-1 trial 1 was a proof-of-principle trial followed by the SYMPLICITY HTN-2 trial, 2 which was a randomized unmasked trial that compared control patients and patients undergoing RDN therapy. Follow-up indicated significant and lasting reductions in blood pressure in the experimental group, thus raising expectations among physicians and patients. In fact, the European Society of Hypertension, the European Society of Cardiology, and an international panel of experts published position papers on RDN. 3–5 In the same period, an RDN registry was set up in Europe with the participation of accredited centers. The registry has already collected data on more than 1500 patients. 6 The recent publication of the SYMPLICITY HTN-3 trial, 7 a single-blind, randomized, sham-controlled trial, confirmed that RDN is safe, but apparently lacks efficacy. Studies on RDN take the SYMPLICITY HTN-3 trial as the reference study and for this reason critics of the technique have suggested that the antihypertensive efficacy of RDN should be reconsidered in the light of its results. We consider that this viewpoint is questionable and analyze the reasons for our position. The SYMPLICITY HTN-3 trial 7 followed an excellent design that randomized patients to RDN or a sham procedure. Analyses were based on the intention-to-treat principle. Thus, the trial included a control group to assess the possibility of a placebo effect. In fact, the SYMPLICITY HTN-1 and HTN-2 trials were accused of simply showing the placebo effect of the treatment on blood pressure. However, the conclusion that RDN lacks efficacy when compared with a sham procedure has been challenged. Firstly, there is insufficient evidence that blood pressure was stable during the RDN procedure in the SYMPLICITY HTN-3 trial in contrast to the SYMPLICITY HTN-1 and HTN-2 trials. 1,2 The latter trials included long-term patients with high stable blood pressures in the months and even years prior to the trials. The SYMPLICITY HTN-3 trial included patients who switched medication in the weeks prior to RDN which, together with better adherence due to participation in the trial, may explain the gradual decrease in blood pressure in both patient groups. This decrease may also have been due to the high percentage of medication changes (40%) during follow-up, which had not been considered in the protocol. 8 This

Resistant Hypertension and Renal Denervation. Considerations on the Results of the Symplicity HTN-3 Trial Hipertension arterial resistente y denervacion renal. Reflexiones tras el estudio Symplicity HTN-3

Luis M. Ruilope

Papers

Problems in the control of systolic blood pressure

Finerenone in Mild to Severe Chronic Kidney Disease and Type 2 Diabetes: A Fidelity Subgroup Analysis in Patients with Heart Failure

Blood pressure reduction after catheter-based renal denervation in patients with cardiovascular disease in the global symplicity registry

New approach to measurement of blood pressure in the office

Resistant Hypertension and Renal Denervation. Considerations on the Results of the Symplicity HTN-3 Trial Hipertension arterial resistente y denervacion renal. Reflexiones tras el estudio Symplicity HTN-3