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.......................................................................................................... ABPM and HBPM BP targets are extrapolated from observational data. A treated office SBP of 130 mmHg likely corresponds to a 24-h SBP of 125 mmHg and home SBP <130 mmHg.4

4.7.5.4 Drug treatment of hypertension The most important driver of benefit is the magnitude of BP lowering. Single-drug therapy will rarely achieve optimal BP control.

Initial therapy with a combination of two drugs should be considered usual care for hypertension.560563,565,581 The only exceptions would be patients with a baseline BP close to the recommended target, who might achieve that target with a single drug, or very old (>80 years) or frail patients who may better tolerate a more gentle reduction of BP. Initial combination therapy, even low-dose combination therapy, is more effective at lowering BP than monotherapy,560,561,565 and will reduce BP faster and reduce heterogeneity in response.560,565 Moreover, initial combination therapy does not increase risk of adverse effects.560563,565 Initiating therapy with two drugs will also help overcome treatment inertia where patients remain on one drug long term despite inadequate BP control.562

Single-pill strategy to treat hypertension: poor adherence to BP-lowering medication is a major cause of poor BP control rates, and is directly related to the number of pills.581 Single-pill combination therapy (if available) is the preferred strategy. This strategy will control BP in most patients.560565

Recommended drug therapy and treatment algorithm: five major classes of BP-lowering drug therapy have shown benefit in reducing CV events; angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics.582 A recommended treatment algorithm based on best available evidence, pragmatic considerations (e.g. combination pill availability), and pathophysiological reasoning is shown in Figure 16.4 A combination of an ACE inhibitor or ARB with a CCB or thiazide/thiazide-like diuretic is the preferred initial therapy for most patients with hypertension.566569 For those in whom treatment requires escalation to three drugs, a combination of an ACE inhibitor or ARB with a CCB and a thiazide/thiazide-like diuretic should be used.563,570,571 Betablockers should be used when there is a specific indication (e.g. angina, post myocardial infarction, arrythmia, HFrEF, or as an alternative to an ACE inhibitor or ARB in women of child-bearing potential).582 Combinations of an ACE inhibitor and an ARB are not recommended because of no added benefit on outcomes and increased risk of harm.575,576 Specific modifications to the treatment algorithm are recommended for patients with CHD, CKD, HF, and AF.4

4.7.6. Resistant hypertension Resistant hypertension is defined as BP being uncontrolled despite treatment with optimal or best-tolerated doses of three or more drugs including a diuretic, and confirmed by ABPM or HBPM. The prevalence of resistant hypertension is likely to be <10% of treated hypertensive patients. Spironolactone is the most effective drug for lowering BP in resistant hypertension when added to existing treatment; however, the risk of hyperkalaemia is increased in patients with CKD and eGFR <45 mL/min/m2 and blood potassium levels >4.5 mmol/L.555,572 Potassium-binding drugs reduce the risk of hyperkalaemia.573 When spironolactone is not tolerated, amiloride, alphablockers, beta-blockers, or centrally acting drugs, such as clonidine, have evidence supporting their use.555,572,574 Renal denervation and device-based therapy may be considered for specific cases, and are discussed in the 2018 ESC/ESH hypertension guidelines.4

4.7.7. Management of hypertension in women The diagnosis and treatment of hypertension in women is similar to that in men, except for women of child-bearing potential or during pregnancy, because of potential adverse effects of some drugs on the foetus, especially in the first trimester. In addition, the effect of oral contraceptive pills on the risk of developing or worsening hypertension should be considered.4

4.7.8. Duration of treatment and follow-up Treatment of hypertension is usually maintained indefinitely because cessation of treatment usually results in a return of BP to pretreatment levels. In some patients with successful lifestyle changes, it may be possible to gradually reduce the dose or number of drugs. After BP is stable and controlled, visits should be scheduled at least annually, and include the control of other risk factors, renal function, and HMOD, as well as reinforce lifestyle advice. When there is a loss of BP control in a previously well-controlled patient, non-compliance with therapy should be considered. Self-measurement of BP using HBPM helps engage the patient in their own management and can improve BP control. HBPM is essential to monitor BP control in patients with a significant ‘white-coat effect’ or masked hypertension. Supervision of patient follow-up increasingly involves nurses and pharmacists and is likely to become increasingly supported by telemedicine and app-based technologies.

4.8 Diabetes mellitus

Recommendations for the treatment of patients with diabetes mellitus

Recommendations Classa Levelb

Screening When screening for DM in individuals with or without ASCVD, assessment of HbA1c (which can be done non-fasting) or fasting blood glucose should be considered.583 IIa A Lifestyle Lifestyle changes including smoking cessation, a low saturated fat, high-fibre diet, aerobic PA, and strength training are recommended.584 I A Reduction in energy intake is recommended to patients, to help achieve lower body weight or prevent or slow weight gain.584 I B For those motivated to try, considerable weight loss with use of low-calorie diets followed by food reintroduction and weight-maintenance phases early after diagnosis can lead to DM remission and should be considered.585,586 IIa A

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