La Prise en Charge de l’Hypertension Artérielle

Objectives

The guidance aims to reduce ischaemic and haemorrhagic stroke, heart failure and other vascular disease by improving detection, assessment and sustained control of arterial hypertension. It sets differentiated blood-pressure targets according to cerebro-cardiovascular risk, age, frailty and treatment tolerance, while excluding acute stroke and pregnancy from its general scope.[1][2]

• Achieve blood pressure of no more than 14/9 cmHg in the general population, and no more than 13/8 cmHg for people at high cerebro-cardiovascular risk when treatment is tolerated.[1]
• Apply a cautious target of no more than 14/9 cmHg for older or frail people at high risk, while considering 13/8 cmHg where this is achieved without dizziness, fatigue or other adverse effects.[1][3]
• Consider pharmacological treatment for blood pressure between 13/8 and 14/9 cmHg where it is well tolerated; use initial monotherapy for this range, while considering low-dose dual therapy when initial pressure exceeds 14/9 cmHg.[2][3]
• Prioritise lifestyle modification, cardiovascular and renal risk assessment, and evidence-based antihypertensive therapy as integrated elements of hypertension management.[3][4]
• Use four medicine classes with favourable evidence on morbidity and mortality: thiazide and related diuretics, renin-angiotensin-system medicines, calcium-channel blockers and beta-blockers.[5]
• Reserve alpha-1 blockers, including prazosin and terazosin, and centrally acting antihypertensives for last-line treatment when response to other medicines is insufficient, owing to limited outcome evidence and potential serious adverse effects.[6][7]
• Exclude aliskiren because it has not shown cardiovascular morbidity or mortality benefit and may cause potentially serious adverse effects; recognise methyldopa as principally used for hypertension during pregnancy.[7]

Implementation

Implementation is centred on patient-specific clinical assessment, accurate blood-pressure measurement, lifestyle support, tailored medicine selection, follow-up monitoring and safety surveillance. Clinicians and patients are the principal operational participants; the guidance was developed by a multidisciplinary Vascular Risks Working Group with representation from relevant health bodies, but it does not specify a wider delivery model, financing plan or formal system-level implementation structure.[1][2][8]

• Measure blood pressure at the start of the clinical examination, in both arms, at rest and with the arm at heart level; use a wider cuff for people with obesity.[1]
• Assess control through repeated conventional measurements, 24-hour ambulatory averages or daytime ambulatory averages, using respective reference values below 14/9 cmHg, 13.0/8.0 cmHg and 13.5/8.5 cmHg.[2]
• Use unattended automated measurement or home self-measurement where appropriate, recognising that unattended measurement reduces the white-coat effect and may not be directly comparable with earlier studies.[2]
• Support home monitoring by asking patients to take four measurements daily at regular intervals during the three days before consultation, and retain records of methods and systolic and diastolic readings.[1][2]
• Use 24-hour ambulatory recording where resistant or white-coat hypertension, variable readings, nocturnal hypertension, treatment-related hypotension, autonomic dysfunction or high vascular risk is suspected.[3]
• Discuss smoking cessation, dietary adaptation for overweight or obesity, regular physical activity and salt reduction after diagnosis; salt reduction lowers blood pressure, although no reduction in cerebro-cardiovascular events is identified.[3][4]
• Perform electrocardiography, creatinine testing and urine testing for proteinuria in every person with hypertension, and tailor further target-organ investigations to age, symptoms, comorbidities and response to treatment.[4]
• Select medicines case by case according to initial pressure, comorbidities, age, concurrent medicines, tolerability and long-term exposure risks.[4]
• Use thiazide-related diuretics, particularly indapamide and chlortalidone, for uncomplicated hypertension and isolated systolic hypertension in older people; use renin-angiotensin-system medicines for left-ventricular dysfunction or albuminuria, and offer angiotensin-II receptor blockers when angiotensin-converting enzyme inhibitors cause persistent cough.[5]
• Use beta-blockers for angina, post-myocardial-infarction care, atrial fibrillation and heart failure alongside other medicines; consider calcium-channel blockers for older people with systolic hypertension or stable angina.[6]
• Consider calcium-channel blockers and diuretics preferentially for people of African origin, for whom these classes are described as more effective than other pharmacological classes.[6]
• Escalate to low-dose combinations of two or three medicines when response is inadequate or strict control is needed, avoid combining an angiotensin-converting enzyme inhibitor with an angiotensin-II receptor blocker, and weigh improved adherence from fixed-dose combinations against reduced flexibility for dose adjustment.[6]
• Monitor people with systolic pressure of 13.0 to 13.9 cmHg and diastolic pressure of 8.5 to 8.9 cmHg at least annually, and review white-coat hypertension every three to six months.[1][2]
• Check regularly for new or changing skin lesions in people taking hydrochlorothiazide alone or in combination, arrange assessment of suspicious lesions, advise ultraviolet protection, and consider changing treatment for those with a history of non-melanoma skin cancer.[5]
• Maintain governance through the Vascular Risks Working Group, which included neurology, cardiology and general-practice specialists and representatives of the Scientific Council, Directorate of Health and Medical Control of Social Security; members declared potential conflicts of interest and the Scientific Council provided secretariat support.[8]

Monitoring & Evaluation

Monitoring centres on repeated blood-pressure measurement, clinical assessment of cardiovascular and renal risk, treatment tolerability, and safety surveillance for selected medicines. Formal population-level indicators, reporting systems, surveillance arrangements, evaluation schedules, and accountability mechanisms are not specified.[1][2][3][4][5][6][7][8]

• Measure blood pressure at the start of the clinical examination, in both arms, at rest and with the arm positioned at heart level; use an appropriately wider cuff for people with obesity.[1]
• Assess blood-pressure control using repeated conventional measurements, 24-hour ambulatory averages, daytime ambulatory averages, unattended automated measurement, or self-measurement where appropriate. Reference thresholds include below 14/9 cmHg for conventional measurement, 13.0/8.0 cmHg for 24-hour ambulatory averages, and 13.5/8.5 cmHg for daytime ambulatory averages.[2]
• Record home-monitoring measurements in detail, including the measurement method and systolic and diastolic values; patients undertaking home monitoring are advised to take four measurements daily at regular intervals during the three days before consultation.[1][2]
• Monitor people with systolic pressure of 13.0 to 13.9 cmHg and diastolic pressure of 8.5 to 8.9 cmHg at least annually, as approximately half are expected to develop hypertension within two years.[1]
• Review people with white-coat hypertension every three to six months, because more than half are expected to develop hypertension within six months.[1][2]
• Use 24-hour ambulatory recording where resistant hypertension, white-coat hypertension, variable readings, nocturnal hypertension, treatment-related hypotension, autonomic dysfunction, or high vascular risk is suspected.[3]
• Assess cardiovascular and renal status in every person with hypertension through at least electrocardiography, serum creatinine measurement, and urine testing for proteinuria; tailor further investigation for target-organ damage to age, symptoms, comorbidities, and response to treatment.[4]
• Adapt treatment targets to individual tolerance, particularly for older or frail people, and avoid lower blood-pressure targets where dizziness, fatigue, or other adverse intolerance occurs.[1][3]
• Monitor dermatological safety in people receiving hydrochlorothiazide alone or in combination by checking for new or changing skin lesions, arranging assessment of suspicious lesions, and advising limitation of ultraviolet exposure and adequate sun protection.[5]
• Consider changing antihypertensive therapy for people with a history of non-melanoma skin cancer.[5]

Costing & Financing

No costs, budgets, funding allocations, financing sources, resource-mobilisation measures, funding gaps, or economic assumptions are specified for hypertension diagnosis, monitoring, treatment, or guideline implementation.[1][2][3][4][5][6][7][8]

• Identify clinical resource implications only indirectly through the recommended use of blood-pressure measurement equipment, ambulatory monitoring, electrocardiography, renal and urine testing, antihypertensive medicines, and dermatological assessment; no associated unit costs, quantities, or funding arrangements are provided.[1][2][3][4][5][6]
• Specify no budgetary provision for the Vascular Risks Working Group, Scientific Council secretariat support, conflict-of-interest processes, dissemination, implementation, or evaluation.[8]