Response to ‘Comment on 2018 ESC/ESH Guidelines for the management of arterial hypertension’

This commentary refers to ‘Comment on 2018 ESC/ESH Guidelines for the management of arterial hypertension’, by K.G. Haeusler et al., on page 2092. We thank Haeusler et al. 1 for their interest in clarifying the grey area concerning the management of high blood pressure (BP) in the acute phase of stroke. We agree that there is considerable evidence that, in acute ischaemic or haemorrhagic stroke, high BP is independently associated with poor outcomes, defined by early or late stroke recurrence, death or dependency. In addition, after intracerebral haemorrhage, high BP is related to an expansion of the haematoma and more severe dysfunctional sequelae. As mentioned by Haeusler et al. clinical trials have shown that lowering BP to <140/90 mmHg within 6 h from the acute event reduces the haematoma expansion and improves functional recovery. However, the effect on the primary outcome (disability or death) is not clear. As reviewed by Bath et al.,2 in larger trials (1000 patients or more) on acute haemorrhagic stroke BP lowering did not show an unequivocal benefit. Although some efficacy may have been observed in the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial-2 (INTERACT-2), active BP lowering treatment was neutral in the Antihypertensive Treatment of Acute Cerebral Hemorrhage-2 Trial (ATACH-2), and appeared to be harmful in the subgroup of patients with intracerebral haemorrhage (SCAST-ICH) of the Scandinavian Candesartan Acute Stroke Trial. Moreover, in trials including patients with ischaemic or haemorrhagic stroke, two studies using nitroglycerin/glyceryl trinitrate, the Efficacy of Nitric Oxide in Stroke (ENOS), and the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT) were positive for both stroke types when given early, but use of β-blockers was negative in the β-Blocker Stroke Trial (BEST). Without any clear large randomized trial-based documentation of the BP target to be achieved in these patients, the European hypertension guidelines decided to make a prudent recommendation, namely to achieve at least a systolic BP of <180 mmHg, while awaiting for further evidence.3 This is in line with the independent review of the data and recommendations of the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on hypertension. Regarding the comments on endovascular treatment in acute ischaemic stroke with large vessel occlusion (not addressed by European guidelines), we agree with the recent American Heart Association/American Stroke Association (AHA/ASA) recommendation that, despite lack of data from randomized clinical trials, it seems reasonable to maintain BP ≤185/110 mmHg before the procedure.4 We do not believe that the recommendation to lower BP in patients with transient ischaemic attack and high BP values is in contradiction with the recommendation of the recent AHA/ASA guidelines4 to start or restart antihypertensive medications in the hospital when the patient remains hypertensive and is neurologically stable. In any case, the spirit of our guidelines is that all evidence-based general recommendations have to take into account the specific patient circumstances, i.e. decisions have to be personalized according to the clinical situation. Conflict of interest: none declared.