This was a joint session between the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) that was co-chaired by ESC Congress Chair, Professor Keith Fox (Edinburgh, GB).
Dr. Giuseppe Mancia (Milano, IT) spoke on the global impact of hypertension: is it the same disease worldwide? Hypertension is a deadly non-communicable disease that affects one billion people across the world and is one of the most important modifiable risk factors for global cardiovascular morbidity and mortality. Hypertension disproportionately affects populations in low- and middle-income countries where health systems have fewer resources to manage the problem. Dr. Mancia stressed that the ethnography of hypertension needs to be considered in targeting treatment strategies with a focus on patient compliance, clinical inertia and health care structure. He highlighted the variable treatment response to hypertension management in Asian and non-Asian populations. Dr. Mancia noted that target blood pressure levels are difficult to reach even in countries where the cost of medication is not an issue. He presented data from Lombardy where he noted patient noncompliance at a population level, looking at the number of patients who actually refilled drug prescriptions within 90 days. Patient adherence to treatment may have a far greater impact on the health of the population than any improvement in specific medical treatments.
Dr. Sidney Smith (Chapel Hill, US) spoke on what is ‘resistant hypertension’ which is usually defined as a blood pressure ≥ 140/90 mmHg at baseline (≥ 130/80 mmHg if diabetes/renal insufficiency) with the use of ≥ 3 antihypertensive medications, including a diuretic. The prevalence of resistant hypertension has been increasing over time and is associated with a poorer prognosis than nonresistant hypertension. Dr. Smith highlighted the ESC Hypertension guidelines and the recommendations from the JAMA 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults, Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) that was published in February 2014. A multifaceted treatment approach incorporating accurate diagnosis, identification, and removal of substances that interfere with blood pressure, dietary and lifestyle management, and treatment with combination drug therapy can be effective in management. Newer pharmacologic and interventional therapies are under study and may hold future promise.
Dr. Valentin Fuster (New York, US) spoke on ‘The concept of the polypill: hypertension versus secondary prevention.’ Globally, there is room for improvement in the secondary prevention of heart disease, especially in nations with limited resources. The use of a polypill fixed dose drug combination which include key medications for hypertension and secondary prevention has been suggested to improve accessibility, adherence and decrease cardiovascular events. Dr. Fuster highlighted the FOCUS trial that will analyze the impact of a fixed-dose polypill strategy for secondary prevention and medication adherence in postmyocardial infarction patients. He noted that further research on the polypill is needed to address the global challenges of noncommunicable diseases. Major trials are underway that will provide further evidence on the efficacy of the polypill in reducing cardiovascular events in a cost-effective manner.
Dr. Murray Esler (Melbourne, AU) spoke on ‘Renal denervation: will it work and will it have a wide place in the world? The sympathetic nervous system plays an important role in the pathogenesis of hypertension as the renal sympathetic nerves pass to the kidneys in the adventitia of the renal arteries within reach of radiofrequency or ultrasound energy released in the renal artery lumen. Dr. Esler’s research on the sympathetic nerves of the kidneys in hypertension provided the theoretical basis for the development of renal sympathetic denervation as a potential management tool. Renal denervation has been studied as potential treatment for severe drug-resistant hypertension but the degree of denervation may have been sub-optimal in trials. Planned future studies will need to incorporate denervation testing as renal denervation may be incomplete and non-uniform between patients. Utilization of higher radiofrequency and ultrasonic energy doses in the future is envisaged and energy may need to be delivered to both the aortic and the distal ends of the renal artery to target both sympathetic and afferent nerves. Patient selection will remain problematic until the influence on the responder status of the two determinants, effectiveness of denervation and hypertension pathophysiology can be discriminated.
Hypertension: a planetary view provided an outstanding overview on the pathophysiology and epidemiology of hypertension as it may be seen in various countries worldwide and promoted understanding of new modalities of treatment and their applicability. This joint ESC/ACC session featured world leaders in their respective fields who stressed the burgeoning public health challenge of noncommunicable diseases and the need to develop innovative solutions to address the global challenge of hypertension.