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How to implement the new 2018 ESH/ESC guidelines for the management of arterial hypertension in patients with metabolic syndrome and diabetes?

Blood pressure (BP) control in hypertensive patients remains poor worldwide, particularly in high-risk patients with hypertension and diabetes. New ESH/ESC guidelines recommend more stringent BP targets (on-treatment values of ≤ 130/80 mm Hg in the general population and ≤ 140/90 mm Hg in older hypertensive people), which will make the achievement of BP control even more challenging. The most effective evidence-based treatment strategy to improve BP control is one that: encourages the use of combination treatment, enables the use of single-pill combination (SPC) therapy for most patients to improve adherence to treatment, with the use of SPC therapy as initial therapy. The combination of perindopril with thiazide-like diuretic indapamide is one of the widely tested SPC in multicentre clinical trials for diabetic patients. Studies suggested that two-drug combination therapy will control BP in approximately two-thirds of patients. For patients whose BP is not controlled by two-drug combination therapy, the logical option is to increase treatment to three-drug combination therapy: usually a RAS blocker, a CCB and a diuretic. The combination of perindopril with indapamide and amlodipine is particularly recommended in population of hypertensive patients with metabolic complications because of favourable, neutral effect on blood glucose and cholesterol level. This combination has proven hypotensive effect in group of patients with difficult-to-control hypertension.