A “20/20” Match: ACC/AHA 2017 versus ESC/ESH 2018 Guidelines for Management of Hypertension

Hypertension, the commonest noncommunicable disease globally, is an important risk factor for cardiovascular disease and renal failure. Theoretically, while it is easy to diagnose and manage by simple measures, practically it has been observed that not only treatment but also diagnosis and its preventive measures are inadequate in developing as well as developed nations. Several guidelines by various international organizations are available to guide clinicians for hypertension management. Though the basic principles of hypertension management are similar in all the guidelines, subtle differences are there. In this article, we compare the two most widely accepted guidelines for hypertension, that is, American College of Cardiology/American Heart Association 2017 Hypertension Guidelines and 2018 European Society of Cardiology and European Society of Hypertension Guidelines on Hypertension. Both the differences and similarities between these two widely followed guidelines are presented.

Prevalence and Risk Factors for Hypertension in Adolescents Aged 12 to 17 Years: A School-Based Study in China

Hypertension in adolescents has attracted increasing attention. However, large, well-designed studies accurately demonstrating epidemiological characteristics of adolescent hypertension remain insufficient. We, therefore, conducted a population-based multicenter study with repeated blood pressure visits to offer precise prevalence of it. We randomly recruited 42 025 adolescents aged 12 to 17 years in 6 centers throughout China from 2018 to 2019. The initial hypertension was estimated in all centers through one blood pressure measurement visit. Confirmed hypertension was evaluated in 3 blood pressure visits in 2 of 6 centers including 16 220 subjects. Hypertension was defined using American and Chinese guidelines and standardized by sex and age using 2010 China population census data. Standardized prevalence of initial and confirmed hypertension were 18.6% (95% CI, 17.3%–20.0%) and 5.9% (95% CI, 4.7%–7.2%) using 2017 American Association Pediatrics hypertension guidelines, respectively and which were 24.5% (95% CI, 23.0%–25.9%) and 8.8% (95% CI, 7.3%–10.3%) using 2018 Chinese hypertension guidelines. Male (odds ratio [OR], 1.275 [95% CI, 1.070–1.520]), parental hypertension history (OR, 1.387 [95% CI, 1.159–1.660]), higher heart rate (OR, 1.043 [95% CI, 1.037–1.049]), higher waist circumference (OR, 1.036 [95% CI, 1.027–1.046]), and adiposity indexes including overweight (OR, 2.211 [95% CI, 1.781–2.745]), and obesity (OR, 3.085 [95% CI, 2.330–4.084]) were identified as risk factors. In conclusion, the prevalence of hypertension was quite high evaluated by both guidelines with several risk factors, and a single blood pressure measurement visit leads to an overestimation of hypertension prevalence among adolescents.

Comparison of ESHG2016 and AAP2017 hypertension guidelines in adolescents between the ages of 13 and 16: effect of body mass index on guidelines

Objective: The diagnosis of hypertension in adolescents aged ≥13 and <16 years is based on the percentile according to age, gender, and height in the European Society of Hypertension guidelines guideline; whereas, the American Academy of Pediatrics guideline uses blood pressure above 130/80 mmHg as a single criterion. Therefore, this study aimed to evaluate the compatibility of these two guidelines in adolescents aged ≥13 and <16 years. Methods: This study was designed by retrospectively screening the records of 395 adolescents with both office and 24-hour ambulatory blood pressure measurements. Each blood pressure measurement was classified according to both the ESGH2016 and AAP2017 guidelines. Patients were divided into three subgroups according to body mass index. Cohen’s kappa analysis was used to evaluate the agreement between the two guidelines. Results: The majority of adolescents were normotensive according to both guidelines, 55.9% by ESHG2016 and 43.1% by AAP2017. For the whole group, the frequency of hypertension was 32.4% with ESHG2016 and 34.4% with AAP2017; while, in obese patients, hypertension frequencies were 38.8% and 43.3%, respectively. The diagnosis of hypertension was demonstrated with the two guidelines, and there was significant agreement at a substantial level, both for the obese subgroup and the whole study group (kappa value = 0.738 and 0.785, respectively). The frequency of white-coat hypertension was higher with the AAP2017 guideline (28.1% versus 16.2%, p < 0.001). Conclusion: With our experience in this single-centre study, it seems that both the AAP2017 and the ESHG2016 guidelines can be used in the diagnosis of hypertension in adolescents.

The factors influencing clinician use of hypertension guidelines in different resource settings: a qualitative study investigating clinicians’ perspectives and experiences

Background Hypertension accounts for the greatest burden of disease worldwide, yet hypertension awareness and control rates are suboptimal, especially within low- and middle-income countries. Guidelines can enable consistency of care and improve health outcomes. A small body of studies investigating clinicians’ perceptions and implementation of hypertension guidelines exists, mostly focussed on higher income settings. This study aims to explore how hypertension guidelines are used by clinicians across different resource settings, and the factors influencing their use. Methods A qualitative approach was employed using convenience sampling and in-depth semi-structured interviews. Seventeen medical doctors were interviewed over video or telephone call from March to August 2020. Two clinicians worked in low-income countries, ten in middle-income countries, and five in high-income countries. Interviews were recorded, transcribed, and coded inductively. Reflexive thematic analysis was used. Results Themes were generated at three levels at which clinicians perceived influencing factors to be operating: healthcare worker, healthcare worker interactions with patients, and the wider health system. Within each level, influencing factors were described as barriers to and facilitators of guideline use. Variation in factors occurred across income settings. At the healthcare worker level, usability of guidelines, trust in guidelines, attitudes and views about guidelines’ purpose, and relevance to patient populations were identified as themes. Influencing factors at the health system level were accessibility of equipment and medications, workforce, and access to healthcare settings. Influences at the patient level were clinician perceived patient motivation and health literacy, and access to, and cost of treatment, although these represented doctors’ perceptions rather than patient perceived factors. Conclusions This study adds a high level global view to previous studies investigating clinician perspectives on hypertension guideline use. Guidelines should be evidence-based, regularly updated and attention should be given to increasing applicability to LMICs and a range of healthcare professionals.