To Harmonize or to Hinder... Do We Need Two Sets of European Guidelines in 2024?

Hypertension control remains a significant challenge globally.1 Even in Europe, a region that has produced some of the best science on managing hypertension, the control rates of hypertension is poor, ranging between ~20% and 40% for most countries.2 If this was a simple issue to solve, one could ask - what do we need to ensure that the 60% to 80% of people with hypertension who are at high risk of a stroke, heart attack and other consequences, are not left behind? The first logical response would be that the ~500,000 general practitioners (GPs) in Europe3 should be clear on what the best approach is to diagnose and manage patients with hypertension. With the workload of GPs ever increasing, this guidance should be as simple and clear as possible. In 2018 the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) collaborated to develop a unified guideline for managing hypertension in Europe. These 2018 ESC/ESH Guidelines were well received by the scientific community to judge from the >7,1004 and >2,1005 citations (Scopus) in the two journals in which it was copublished. However, more recently these organizations developed two independent guidelines in 2023 and 2024. The 2024 ESC guidelines have had the benefit of new evidence published since the 2023 ESH guidelines, which have been incorporated into the 2024 ESC guidelines. Most importantly, though, is that the real-world impact of the 2018 guidelines on improving hypertension control rates is not clear. To make new guidelines more relevant, and to make sure they are implemented, guideline developers have become much more vigilant in including GPs and end users on guideline committees and liaising closely with patients in ensuring the implementation of new guidelines are feasible and acceptable for implementation by both providers and patients. [see the full article for more].

Improving prioritization processes for clinical practice guidelines: new methods and an evaluation from the National Heart Foundation of Australia.

BACKGROUND: Releasing timely and relevant clinical guidelines is challenging for organizations globally. Priority-setting is crucial, as guideline development is resource-intensive. Our aim, as a national organization responsible for developing cardiovascular clinical guidelines, was to develop a method for generating and prioritizing topics for future clinical guideline development in areas where guidance was most needed. METHODS: Several novel processes were developed, adopted and evaluated, including (1) initial public consultation for health professionals and the general public to generate topics; (2) thematic and qualitative analysis, according to the International Classification of Diseases (ICD-11), to aggregate topics; (3) adapting a criteria-based matrix tool to prioritize topics; (4) achieving consensus through a modified-nominal group technique and voting on priorities; and (5) process evaluation via survey of end-users. The latter comprised the organization's Expert Committee of 12 members with expertise across cardiology and public health, including two citizen representatives. RESULTS: Topics (n = 405; reduced to n = 278 when duplicates removed) were identified from public consultation responses (n = 107 respondents). Thematic analysis synthesized 127 topics that were then categorized into 37 themes using ICD-11 codes. Exclusion criteria were applied (n = 32 themes omitted), resulting in five short-listed topics: (1) congenital heart disease, (2) valvular heart disease, (3) hypercholesterolaemia, (4) hypertension and (5) ischaemic heart diseases and diseases of the coronary artery. The Expert Committee applied the prioritization matrix to all five short-listed topics during a consensus meeting and voted to prioritize topics. Unanimous consensus was reached for the topic voted the highest priority: ischaemic heart disease and diseases of the coronary arteries, resulting in the decision to update the organization's 2016 clinical guidelines for acute coronary syndromes. Evaluation indicated that initial public consultation was highly valued by the Expert Committee, and the matrix tool was easy to use and improved transparency in priority-setting. CONCLUSION: Developing a multistage, systematic process, incorporating public consultation and an international classification system led to improved transparency in our clinical guideline priority-setting processes and that topics chosen would have the greatest impact on health outcomes. These methods are potentially applicable to other national and international organizations responsible for developing clinical guidelines.

Change in Blood Pressure Variability Among Treated Elderly Hypertensive Patients and Its Association With Mortality.

Background Information is scarce regarding effects of antihypertensive medication on blood pressure variability (BPV) and associated clinical outcomes. We examined whether antihypertensive treatment changes BPV over time and whether such change (decline or increase) has any association with long-term mortality in an elderly hypertensive population. Methods and Results We used data from a subset of participants in the Second Australian National Blood Pressure study (n=496) aged ≥65 years who had 24-hour ambulatory blood pressure recordings at study entry (baseline) and then after a median of 2 years while on treatment (follow-up). Weighted day-night systolic BPV was calculated for both baseline and follow-up as a weighted mean of daytime and nighttime blood pressure standard deviations. The annual rate of change in BPV over time was calculated from these BPV estimates. Furthermore, we classified both BPV estimates as high and low based on the baseline median BPV value and then classified BPV changes into stable: low BPV, stable: high BPV, decline: high to low, and increase: low to high. We observed an annual decline (mean±SD: -0.37±1.95; 95% CI, -0.54 to -0.19; P<0.001) in weighted day-night systolic BPV between baseline and follow-up. Having constant stable: high BPV was associated with an increase in all-cause mortality (hazard ratio: 3.03; 95% CI, 1.67-5.52) and cardiovascular mortality (hazard ratio: 3.70; 95% CI, 1.62-8.47) in relation to the stable: low BPV group over a median 8.6 years after the follow-up ambulatory blood pressure monitoring. Similarly, higher risk was observed in the decline: high to low group. Conclusions Our results demonstrate that in elderly hypertensive patients, average BPV declined over 2 years of follow-up after initiation of antihypertensive therapy, and having higher BPV (regardless of any change) was associated with increased long-term mortality.

Sex-Specific Lifestyle and Biomedical Risk Factors for Chronic Disease among Early-Middle, Middle and Older Aged Australian Adults.

Evidence suggests age and sex differences in risk factors for chronic disease. This study examined lifestyle and biomedical risk factors among men (m) and women (w) in early-middle (25⁻51 years), middle (52⁻64) and older (65+) adulthood. Cross-sectional data from the 2011⁻2012 Australian Health Survey (n = 3024) were analysed. Self-reported dietary, activity, sleep behaviours and collected biomedical data were analysed. Early-middle adults failed to meet fruit, vegetable (95.3%) and sugar-sweetened beverage (SSB, 34.9%) recommendations. Older adults had higher prevalence of overweight/obesity (70%), high blood pressure (38.0%) and fewer met physical activity guidelines (36.3%). Prior to older adulthood, more men consumed SSBs (early-middle m 45.6%, w 24.4%; middle m 26.0%, w 19.3%), and fewer met sedentary behaviour recommendations (early-middle m 43.2%, w 62.1%; middle m 46.4%, w 63.9%). Differences in overweight/obese women in early-middle (44.8%) to middle adulthood (64.7%) were significant. Biomedical risk was greatest in middle age; abnormal cholesterol/lipids increased specifically for women (total cholesterol early-middle 24.9% middle 56.4%; abnormal LDL-cholesterol early-middle 23.1% middle 53.9%). Adherence to lifestyle guidelines was low; particularly among men. While men exhibited greater clinical risk overall, this significantly increased among women in middle-adulthood. Public health strategies to improve lifestyle, monitor and intervene among middle-aged women are warranted.

Relation of Alcohol Consumption to Risk of Heart Failure in Patients Aged 65 to 84 Years With Hypertension.

Although a high level of alcohol consumption is associated with cardiomyopathy, the benefit or risk of moderate alcohol consumption on incident heart failure (HF) is unknown. This study examined the association between alcohol consumption and risk for HF in older adults with hypertension. The study analyzed data from a cohort of 6,083 participants aged 65 to 84 years at baseline (1995 to 2001) followed for a median of 10.8 years during and after the Second Australian National Blood Pressure Study. Frequency and amount of alcohol consumption were self-reported at baseline and during the clinical trial. The percentages of current drinkers, former drinkers, and never-drinkers at baseline were 4,400 (72%), 394 (6%), and 1,289 (21%), respectively. Incident HF was diagnosed in 183 men and 136 women. After adjustment for multiple confounders, alcohol consumption was not significantly associated with HF. Compared with never-drinkers, the adjusted hazard ratios (95% confidence interval) for those who consume 1 to 7, 8 to 14, and >14 drinks/week at baseline were 0.87 (0.59 to 1.30), 0.96 (0.57 to 1.60), and 0.71 (0.25 to 2.02), respectively in women, and 0.81 (0.47 to 1.38), 0.77 (0.43 to 1.38), and 1.04 (0.59 to 1.84), respectively in men. The findings of lack of an association between alcohol consumption and risk of HF persisted in the analyses comparing the risk of HF across each level of drinking at baseline or at follow-up with never-drinkers. In the present study, there was no evidence for benefit or risk of alcohol consumption, reported at baseline or at follow-up, in relation to incident HF in both men and women.

Visit-to-visit (long-term) and ambulatory (short-term) blood pressure variability to predict mortality in an elderly hypertensive population.

OBJECTIVES: To explore the association of different types of blood pressure (BP) variability measures estimated from either short-term ambulatory reading-to-reading or long-term clinic visit-to-visit BP records with long-term survival in an elderly treated hypertensive population. METHODS: A subset of patients (n = 508) aged at least 65-years was studied from the Second Australian National Blood Pressure study. We estimated SBP and DBP BP variability as the SD of ambulatory (24-h, daytime, night-time) and clinic visit-to-visit BP directly from all corresponding on-treatment within-individual BP records. Ambulatory 'weighted day-night' variability was calculated as a weighted mean of daytime and night-time SD. Cox-proportional hazard models adjusted for baseline risk factors (Model 1) and corresponding on-treatment BP (Model 2) or average night-time SBP (best predictive BP measure for outcome) (Model 3) were used to determine the relationship between long-term outcome and BP variability. RESULTS: Over a median of 10.6 years, 101 patients died from any cause, of which 51 deaths were cardiovascular. We observed increase in 'daytime' and 'weighted day-night' SBP/DBP variability was significantly associated with increased all-cause mortality in all models. For cardiovascular mortality, only 'weighted day-night' SBP variability significantly predicted risk in all models (Model 3 hazard ratio: 1.09, 95% confidence interval: 1.00-1.19, P = 0.04). Long-term BP variability was not associated with any outcome. On direct comparison, both 'daytime' and 'weighted day-night' BP variability measures provided similar prognostic information. CONCLUSION: Short-term 'daytime' and 'weighted day-night' SBP variability from ambulatory BP recordings was a better predictor of mortality in elderly treated hypertensive patients than long-term BP variability from visit-to-visit BP recordings.

Prediction of 10-year Risk of Incident Heart Failure in Elderly Hypertensive Population: The ANBP2 Study.

BACKGROUND: Multivariable risk prediction models consisting of routinely collected measurements can facilitate early detection and slowing of disease progression through pharmacological and nonpharmacological risk factor modifications. This study aims to develop a multivariable risk prediction model for predicting 10-year risk of incident heart failure diagnosis in elderly hypertensive population. METHODS: The derivation cohort included 6083 participants aged 65 to 84 years at baseline (1995-2001) followed for a median of 10.8 years during and following the Second Australian National Blood Pressure Study (ANBP2). Cox proportional hazards models were used to develop the risk prediction models. Variables were selected using bootstrap resampling method, and Akaike and Bayesian Information Criterion and C-statistics were used to select the parsimonious model. The final model was internally validated using a bootstrapping, and its discrimination and calibration were assessed. RESULTS: Incident heart failure was diagnosed in 319 (5.2%) participants. The final multivariable model included age, male sex, obesity (body mass index > 30kg/m2), pre-existing cardiovascular disease, average visit-to-visit systolic blood pressure variation, current or past smoking. The model has C-statistics of 0.719 (95% CI: 0.705-0.748) in the derivation cohort, and 0.716 (95% CI: 0.701-0.731) after internal validation (optimism corrected). The goodness-of-fit test showed the model has good overall calibration (χ 2 = 1.78, P = 0.94). CONCLUSION: The risk equation, consisting of variables readily accessible in primary and community care settings, allows reliable prediction of 10-year incident heart failure in elderly hypertensive population. Its application for the prediction of heart failure needs to be studied in the community setting to determine its utility for improving patient management and disease prevention.