In direct contrast to JNC 7, the European guidelines state that emphasis on a preferred class of drugs for "first-line therapy" is probably outdated, given the need to use 2 or more drugs in combination in order to achieve goal blood pressure. Taking into account baseline blood pressure and the presence or absence of complications, the guidelines recommend initiating therapy either with an adequate dose of a single agent or with a low-dose combination of 2 agents.

Drug combinations found to be effective and well tolerated include:

1. Diuretic and beta-blocker
2. Diuretic and ACE inhibitor or ARB
3. CCB (dihydropyridine) and beta-blocker
4. CCB and ACE inhibitor or ARB
5. CCB and diuretic
6. Alpha-blocker and beta-blocker
7. Other combinations (eg, with centrally acting agents, including alpha2-adrenoceptor agonists and imidazoline-I2 receptor modulators, or ACE inhibitors or ARBs) can be used, if necessary.
8. In many cases, 3 or 4 drugs may be necessary.

There are advantages and disadvantages associated with both monotherapy and combination therapy, the guidelines state. A disadvantage of combination therapy is the potential exposure of patients to unnecessary drugs, but control of blood pressure and its complications is more likely. Use of low-dose combinations are more likely to be free of side effects, and fixed-dose combinations available in Europe are likely to have the practical advantage of optimizing compliance. The decision as to which approach should be prescribed in which patients will likely depend on the initial blood pressure, risk factors, and the presence or possibility of TOD.

Other Aspects of the Guidelines

As well as detailed sections on treatment of special populations, other hypertension treatment areas covered in the guidelines include the present status of genetic analysis, relative benefits of ambulatory/home blood pressure, follow-up strategies, the importance of long-acting agents, evaluation of adverse effects, and implementation/compliance/adherence. Treatments for associated risk factors include lipid-lowering agents, antiplatelet therapy, and glycemic control.

Implementation of Guidelines

The importance of closing the gap between experts' recommendations and the poor blood pressure control seen in European medical practice is emphasized in the new guidelines. It is hoped that translations of the guidelines into the many European languages will be sanctioned by the national hypertension societies and leagues, so that the guidelines can be widely disseminated to improve blood pressure control in Europe.

编辑 郑麓薇