Purpose: Despite dramatic medical advances over the last few decades, cardiovascular disease remains a leading cause of death globally. High BP is clearly established, but modifiable, risk factor for early disability and death. Although most of the adverse outcomes occur in adulthood it has become clear that high BP is a life course problem that can become evident in early life however, relatively little attention has been paid to the problem of high BP in children and adolescents. Materials and methods: Being aware of the problem and the needs, the Task Force of the ESH Guidelines in children and adolescents took the initiative to move forward in the field, identifying the COST Action program. A proposal, HyperChildNET, was submitted, approved and funded for 4 years starting in October 2020. Results: The aim of the Action has been to establish a European sustainable and multidisciplinary network of researchers, clinicians, early career investigators, health economists, decision-makers, regulatory bodies, and medical devices manufacturers under the umbrella of the European Commission in order to acquire a holistic understanding of those factors affecting high BP in children and adolescents in order to propose and implement preventive and corrective actions. All the activities carried out during the 4 years are described. Conclusions: HyperChildNET offers a European perspective of the issue giving us the opportunity to develop new strategies and objectives moving forward in the field.

1Istanbul University Cerrahpasa Medical Faculty, Istanbul-Turkey, 2Turkish Republic Ministry of Health Sefakoy Village Clinic, Kucukcekmece, Istanbul-Turkey, 3Selcuk University Medical Faculty, Konya-Turkey

1Istanbul University Cerrahpasa Medical Faculty, Istanbul-Turkey, 2Turkish Republic Ministry of Health Sefakoy Village Clinic, Kucukcekmece, Istanbul-Turkey,3Selcuk University Medical Faculty, Konya-Turkey

1Charité, Universitatz Medizin Berlin, Berlin-Germany,2Istanbul University Cerrahpasa School of Medicine, Istanbul-Turkey

Objective: To assess the impact of physician education on blood pressure (BP) control in the primary care setting. Design and Method: Observational study involved 213 primary care physicians from 49 sites countrywide. Physicians received education on the ESH Guidelines before recruiting patients. Patients with newly diagnosed or established hypertension (≥140/90 mmHg), were recruited, and followed-up monthly for 3 months, and then every 3 months until Month 12. Patient data were stored on a central database via an internet-based management system. Data were analyzed and significance (P < 0.05) was determined using Student t-test, chi-square test and logistic regression analysis. Data were expressed as mean±SD or as percentages. Results: A total of 1494 patients (958 females, 536 males) aged 56.99±11.34 years, were recruited. At baseline, systolic BP (SBP)/diastolic BP (DBP) was 148.59±22.72/89.28±13.44 mmHg (male) and 135.86±17.52/82.96±10.99 mmHg (female), respectively. The duration of hypertension in these patients was 6.47±6.38 and 7.18±7.11 years, respectively. High normal BP was recorded in 12.5% and 13.4%, Grade 1 hypertension in 36.0% and 33.9%, Grade 2 hypertension in 25.7% and 24.1%, and Grade 3 hypertension in 15.5% and 15.8%, of male and female patients, respectively. Gender had no effect on BP control (P < 0.2). However, BP control (<140/90 mmHg) reduced with age; with 75.0 % of patients in their second decade, 68.4% in their third, 63.2% in their fourth, 57.3% in their fifth, 51.9% in their sixth, and 33.3% in their seventh decade. Overall, BP control improved between baseline (26.5%) and Month 12 (55.1%) (P < 0.001). BP was poorly controlled as baseline values were higher with Odds Ratio 4.79 for grade 1 HT, 5.93 for grade 2 HT and 11.08 for grade 3 HT. (figure) Conclusion: Higher BP values were associated with poorer BP control. At each grade of BP a significant improvement in BP control has been observed after physician education.

Objective: Several organizations including the ESH, ESC, and NCEP ATP III have risk based guidance for the treatment of cardiovascular risk factors and target organ damage. Each guideline recommends treatment decisions based on patients estimated risk of cardiovascular disease. However, each guideline recommends a different risk assessment tool and sometimes different thresholds for initiating treatments. We compared the proportion of hypertensive patients with additional risk factors participating in the CRUCIAL trial in each cardiovascular risk category according to the ESH charts, the Framingham 10-year total cardiovascular disease risk equation and the SCORE 10-year risk of cardiovascular mortality. Design and Method: CRUCIAL was a prospective, multinational, open-label, cluster-randomized trial to compare a multi-factorial risk factor management strategy based on single-pill amlodipine/atorvastatin with a Usual Care control arm. Eligible patients were aged between 35 and 79 years with hypertension, 3+ additional cardiovascular risk factors, but no history of CHD and baseline total cholesterol 6.5 mmol/L or less and not receiving a statin. The baseline risk of 1461 patients in the CRUCIAL trial were calculated using the ESH charts, the Framingham 10-year CVD risk equation and the SCORE 10-year cardiovascular mortality chart. Results: At baseline the patients’ mean age was 59 years and 52% were male. Using the ESH charts 99.7% of patients were in the high/very high added risk groups compared with 66.7% of patients using the Framingham equation and 34.9% using the SCORE charts (Table).Conclusion: More patients are classified in the high/very high added risk category using the ESH charts compared with the high/very high risk group using the Framingham 10-year CVD risk equation and the SCORE charts. Therefore, the treatment a patient with hypertension and 3+ additional cardiovascular risk factors may receive may differ according to the treatment guidelines and risk assessment tool used.

Objective: To investigate whether a multi-factorial risk factor management strategy based on single-pill amlodipine/atorvastatin (5/10 mg to 10/10 mg) resulted in greater reduction in calculated Framingham 10-year coronary heart disease (CHD) risk compared with usual care after 12 months' treatment. Design and Method: Prospective, multinational, open-label, cluster-randomized trial. Eligible patients aged between 35 and 79 years with hypertension and 3 or more additional cardiovascular risk factors, but no history of CHD and baseline total cholesterol 6.5 mmol/L or less and not receiving a statin, were selected before site randomization. Results: A total of 136 sites contributing 1461 subjects were randomized. Mean baseline age was 59 years, 52% were male, 47% were White, and 36% Asian. Mean baseline age and low-density lipoprotein cholesterol (LDL-C) were comparable in the two treatment arms. Mean baseline blood pressure (150.3/89.7 mm Hg vs. 144.3/86.5 mm Hg) and CHD risk (20.0% vs. 18.1%) were higher in the single-pill amlodipine/atorvastatin arm versus the usual care arm (P < 0.002 for both). At Month 12, mean CHD risk was 12.5% in the single-pill amlodipine/atorvastatin arm and 16.3% in the usual care arm (P < 0.001). The difference was observed at Month 4 and maintained to Month 12 and was driven by significant differences in LDL-C between the two arms (Table). Overall, adverse events were reported in 48.8% of patients in the single-pill amlodipine/atorvastatin arm and 44.0% of patients in the usual care arm. The adverse event profile in the single-pill amlodipine/atorvastatin arm was consistent with previous safety experience for this medication. Peripheral oedema was reported in 6.8% and 1.6% of patients in the single-pill amlodipine/atorvastatin and usual care arms, respectively.Conclusions: A global risk treatment approach, simultaneously targeting both blood pressure and lipids, regardless of individual risk factors per se, is more effective in reducing calculated Framingham 10-year CHD risk than usual care in patients with hypertension and additional risk factors.

Objectives: To assess blood pressure (BP) levels that physicians are satisfied with, concerned with, and would take immediate action at in general hypertensive patients. To gauge physicians' opinions on BP targets recommended by the ESH–ESC guidelines and to test whether these differ from the BP levels that trigger physician concern and action. Design and Methods: Physicians (N = 2629) from across Europe and from a wide range of specialities (including primary and secondary care) completed the interactive Supporting Hypertension Awareness and Research Europe-wide (SHARE) survey. This survey aimed to investigate the current situation in hypertension management. T-tests were used to perform statistical comparisons in an exploratory sense between the BP values selected by physicians and the guideline-recommended BP targets; paired t-tests were used to compare ‘satisfied’, ‘concerned’ and ‘immediate action’ BP levels. Results: Large variations were seen in BP levels that physicians were satisfied with in general hypertensive patients (SBP:110–200mmHg [mean:131.6mmHg]; DBP:70–115mmHg [mean:81.9mmHg]. Figure). In total, 29% and 15% of physicians, respectively, were satisfied with SBP and DBP being above the ESH–ESC targets of <140mmHg and <90mmHg, respectively. Variation was also observed in BP levels that would cause concern or trigger immediate action (Figure). Mean BP levels that would cause concern (SBP:148.8mmHg; DBP:91.6mmHg) were significantly higher than guideline BP targets (p < 0.0001), while mean BP levels that would force physicians to act (SBP:168.2mmHg; DBP:100.1mmHg), were significantly higher than both BP levels that would cause concern (p < 0.0001) and the guideline recommendations (p < 0.0001). 82% of physicians thought that ESH–ESC BP targets were ‘about right’ or ‘not tight enough’, while 18% said they were ‘too tight and not achievable’. Conclusions: Most physicians accept the BP target of < 140/90mmHg recommended by the ESH–ESC guidelines for general hypertensive patients, however in reality, many physicians are satisfied if patient BP exceeds this target. Furthermore, physician inertia delays action being taken until BP is significantly higher than recommended targets thereby increasing patients' cardiovascular risk.

Objective: To identify hypertensive patients with co-existing cardiovascular (CV) risk factors, and to evaluate the effect of these additional CV risk factors on blood pressure (BP) control. Design and Methods: Patients with newly diagnosed or established hypertension were enrolled in an observational study by 213 primary care physicians from 49 sites countrywide. Patients were followed monthly during the first 3 months, and then every 3 months until Month 12. Patient data were automatically stored on a central database via an internet-based management system. Significance was determined using Student t-test, chi-square test, or multiple logistic regression analysis, where P <0.05 was considered significant. Data are given mean ± SD or as a percentage. Results: A total of 1494 patients (36% male) aged 56.99 ± 11.34 years were recruited. At baseline, 17.2% were smokers and BMI was 29.06 ± 4.18 kg/m2 (males) and 31.36 ± 5.38 kg/m2 (females), and waist circumferences were103.64 ± 12.0 cm and 100.75 ± 14.3 cm, respectively. Overall, 11.1% had left ventricular hypertrophy diagnosed by ECG, 85.2% had dyslipidemia, 46.3% had impaired fasting glucose, 13.9% had an impaired oral glucose tolerance test, 73.1% were obese (BMI more than 30 kg/m2), 36.3% had diabetes mellitus (DM), 16.8% a family history of cardiovascular events, and 10.2% had microalbuminuria. BP control (less than 140/90 mmHg) in patients with DM was 57.4%. Patients were classified into the following four groups: 1) no risk factor, 2) 1–2 risk factors, 3) 3 or more risk factors, 4) DM. BP control goal attainment was lower in patients with 3 or more risk factors or DM compared with patients with no additional risk factors, or with 1–2 risk factors (P < 0.007) (Figure). Conclusion: In hypertensive patients, BP control was worse in patients with 3 or more CV risk factors or DM compared with patients with no risk factors or 1–2 additional risk factors.

Objectives: To assess i) the influence of treatment guidelines on prescribing habits, ii) physician familiarity with the ESH–ESC guidelines, and iii) physicians’ opinions on the ESH–ESC guideline-recommended blood pressure (BP) targets and on getting patients to targets in practice. Design and Methods: 2629 physicians from across Europe and from a range of specialities (including primary and secondary care) completed the interactive Supporting Hypertension Awareness and Research Europe-wide (SHARE) survey. This survey aimed to investigate the current situation in hypertension management. T-tests and Chi-Square tests were used to compare responses from office- versus hospital-based physicians. Results: Physicians acknowledge that clinical guidelines and healthcare literature should influence treatment choices more than they currently do, while factors such as hospital and economic directives should influence treatment choices less than at present. In general, hospital-based physicians were most familiar with and rated most highly the ESH-ESC guidelines, whereas office-based physicians were most familiar with their national guidelines (Figure). The majority of physicians (76%) thought that BP targets recommended in the ESH–ESC guidelines were ‘about right’, however a higher number of office- versus hospital-based physicians thought targets were ‘too tight and not achievable’ (24% versus 8%, respectively; p < 0.0001). In total 77% of all physicians found it challenging to get patients to ESH–ESC BP targets, with more office-based than hospital-based physicians finding it a challenge (82% versus 63%, respectively; p < 0.0001). On average physicians said that only 52.6% of their patients achieved BP targets. Conclusions: The ESH–ESC guidelines are respected as a good source of information and play an important role in treatment choices. However, with half of office-based and a third of hospital-based physicians not being familiar with these guidelines it is important to raise awareness about these guidelines in the healthcare community. In general, physicians think that the BP targets recommended by the ESH–ESC guidelines are correct, but find it challenging to get their patients to these targets in practice.

Agreement within Europe abo ut antihypertensive treatment and education – results from the European Society of Hypertension questionnaire Michael H. Olsen, Jean-Michel Mallion, Karl-Heinz Rahn, Serap Erdine, Margus Viigimaa, Stéphane Laurent, Enrico Agabiti-Rosei, Giuseppe Mancia, Roland E. Schmieder, Renata Cifkova, Anna Dominiczak, Sverre E. Kjeldsen, Josep Redon, Alberto Zanchetti, Peter Nilsson, Krzysztof Narkiewicz, on behalf of the ESH Council

Objectives: A ‘Challenging Patient’ is defined as any patient not reaching goal blood pressure (BP) with a minimum target of <140/90 mmHg. The aims of this analysis were to i) compare physicians’ perceptions about the proportion of their patients who are not attaining ESH–ESC recommended BP goals with their perception about the proportion of patients who are ‘Challenging Patients’, and ii) to assess the real resource burden of ‘Challenging Patients’ in terms of the time between examinations. Design and Methods: 2629 physicians from across Europe and from a wide range of specialities (including primary and secondary care) completed the interactive Supporting Hypertension Awareness and Research Europe-wide (SHARE) survey. This survey aimed to investigate the current situation in hypertension management. T-tests and Chi-Square tests were used to compare responses from office- versus hospital-based physicians. Results: On average, European physicians thought that 47% of their patients were not attaining recommended ESH–ESC BP targets, however when asked their opinion on what percentage of their patients were ‘Challenging Patients’ they estimated a much lower value of 34% (p < 0.0001). A higher proportion of office- compared with hospital-based physicians aimed to get their ‘Challenging Patients’ to recommended BP goals (65% versus 38%, respectively). Interestingly, however, a lower proportion of office-based physicians would immediately adjust medication in their ‘Challenging Patients’ in order to get them to BP goal compared with hospital-based physicians (16% versus 39%, respectively; p < 0.001). The majority of physicians (94%) wanted their ‘Challenging Patients’ to return within 1 month for an examination, while only 41% wanted patients with controlled BP to return within this time-frame (Figure) Conclusions: The number of ‘Challenging Patients’ is often underestimated by physicians. ‘Challenging Patients’ are a greater resource burden and are at increased cardiovascular risk than patients whose BP is controlled, therefore by underestimating the number of ‘Challenging Patients’, physicians are also underestimating the true extent of the economic and health burden associated with these patients.

Objective: The CRUCIAL study cluster randomization scheme aimed to recruit and maintain a true “real-life” Usual Care control arm, where treatment was entirely based on the investigators' best clinical judgment. We report the proportion of patients treated with cardiovascular prophylactic medications in the Usual Care control arm at baseline, Months 4, and 12. Design and Method: Eligible patients were aged between 35 and 79 years with treated or untreated hypertension and 3+ additional risk factors, but no history of coronary disease and baseline total cholesterol 6.5 mmol/L or less and not receiving a statin. Patients received 12 months' treatment with single-pill amlodipine/atorvastatin-based treatment or continued usual care. Results: In the Usual Care control arm patients' mean age at baseline was 59.6 years, 50.5% were male, and mean duration of hypertension was 8.7 years. At baseline 94.9% received antihypertensive treatment and mean baseline blood pressure was 144.3/86.5 mm Hg; 5.3% received lipid-lowering treatment and mean LDL-C was 118.0 mg/dL. Mean BMI was 28.9 kg/m2, 36.2% were smokers, and 42.0% had diabetes. The proportion of patients taking 3+ antihypertensive medications increased from 29.5% at baseline to 40.8% at Month 12 (Table). The most frequently prescribed antihypertensives at baseline were ACE-inhibitors/ARBs (69.4%), CCBs (42.3%), beta-blockers (38.1%), diuretics (30.1%), and alpha-blockers (3.5%). This order remained consistent throughout the trial. The proportion of patients taking lipid-lowering medications increased from 5.3% to 31.5%, and the proportion taking aspirin increased from 26.2% to 35.0%. There was a small reduction in calculated 10-year Framingham coronary risk from 18.1% at baseline to 16.3% at Month 12.Conclusions: Patients in the CRUCIAL study Usual Care control arm generally received good cardiovascular risk factor management at baseline. During the 12-month study there was a tendency towards increasing use of antihypertensive and lipid-lowering therapies, resulting in a reduction in calculated Framingham risk, and increasing use of aspirin. The increased use of these medications may, in part, be explained by study participation per se.

The Gemini-AALA (Australia, Asia, Latin America, Africa/Middle East) study evaluated the efficacy and safety of single-pill amlodipine/atorvastatin (Caduet) for the treatment of patients of diverse ethnicity with concomitant hypertension and dyslipidaemia. This was a 14-week, open-label study including patients from 27 countries across the Middle East, Asia-Pacific, Africa and Latin America. Eight dosage strengths of single-pill amlodipine/atorvastatin (5/10, 10/10, 5/20, 10/20, 5/40, 10/40, 5/80 and 10/80 mg) were titrated to improve blood pressure and lipid control. Blood pressure and lipid goals were determined according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP ATP III) guidelines, respectively (blood pressure, <140/90 or <130/80 mm Hg; low-density lipoprotein cholesterol (LDL-C), <4.1 to <2.6 mmol l−1 (<160 to <100 mgdl−1)). Overall, 1649 patients received study medication. Most patients (91.4%) had ⩾1 cardiovascular risk factor (as defined by NCEP ATP III guidelines) in addition to hypertension/dyslipidaemia, and 61.7% had coronary heart disease/risk equivalent. At baseline, mean blood pressure was 146.6/88.3 mm Hg and LDL-C was 3.4 mmol l−1 (130.2 mgdl−1). At week 14, 55.2% of patients reached both blood pressure and lipid goals, 61.3% reached blood pressure goal and 87.1% reached lipid goal (34.0% were at lipid goal at baseline). Mean blood pressure reduction was 20.2/11.4 mm Hg. For patients who were lipid-lowering drug naive at baseline, mean reduction in LDL-C was 41.0%. Treatment-related adverse events led to the discontinuation of 3.6% of patients. Single-pill amlodipine/atorvastatin therapy was well tolerated and effective for the reduction of blood pressure and lipids to recommended goals in patients from diverse ethnic backgrounds.