Should hypertensive disorders of pregnancy be considered as a prehypertension state?

Transcription

1 February 2018 Should hypertensive disorders of pregnancy be considered as a prehypertension state? Pr. Jacques Blacher Paris-Descartes University ; AP-HP ; Unité HTA, prévention et thérapeutique cardio-vasculaires, Centre de diagnostic et de thérapeutique, Hôtel-Dieu, Paris, France

2 Disclosures of Jacques Blacher: - No financial interest in the capital of a drug company. - No lasting connection with a business related to drugs (employment contract, regular pay...). - Off interventions related businesses related to drugs (clinical trials, scientific research, scientific committees, expert reports, conferences, seminars, training, participation in various symposia, writing brochures...) and, if applicable, fee billing; and this with the majority of companies selling cardiovascular medicines and other products related to my areas of specialty (Amgen, Astra-Zeneca, Bayer, Boehringer Ingelheim, Bouchara, Daiichi Sankyo, Egis, Ferring, Ipsen, Lilly, Le Quotidien du Médecin, Medtronic, Menarini, MSD, Novartis, Pharmalliance, Pierre Fabre, Pileje, Quantum genomics, Sanofi Aventis, Saint Jude, Servier, Takeda). - HAS, ANSM, CNAM, MGEN

3 Should hypertensive disorders of pregnancy be considered as a prehypertension state? Prehypertension : Stroke risk factor? CHD risk factor? CV mortality risk factor - all-cause mortality risk factor? Which patients? Hypertensive disorders of pregnancy (pre-eclampsia) : Hypertension and renal risk factor? Stroke and CHD risk factor? One more guideline : why? Conclusion

4 Should hypertensive disorders of pregnancy be considered as a prehypertension state? Prehypertension : Stroke risk factor? CHD risk factor? CV mortality risk factor - all-cause mortality risk factor? Which patients? Hypertensive disorders of pregnancy (pre-eclampsia) : Hypertension and renal risk factor? Stroke and CHD risk factor? One more guideline : why? Conclusion

5 Prehypertension and risk of stroke Huang Y et al. Prehypertension and the risk of stroke. Neurology 2014 ; 82 : Pooled data included the results of 762,393 participants from 19 prospective cohort studies. Prehypertension increased the risk of stroke (RR 1.66; 95% CI ) compared with optimal blood pressure (<120/80 mm Hg). After adjusting for multiple cardiovascular risk factors, prehypertension is associated with stroke morbidity. Although the increased risk is largely driven by high-range prehypertension, the risk is also increased in people with low-range prehypertension.

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13 Should hypertensive disorders of pregnancy be considered as a prehypertension state? Prehypertension : Stroke risk factor? CHD risk factor? CV mortality risk factor - all-cause mortality risk factor? Which patients? Hypertensive disorders of pregnancy (pre-eclampsia) : Hypertension and renal risk factor? Stroke and CHD risk factor? One more guideline : why? Conclusion

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25 Should hypertensive disorders of pregnancy be considered as a prehypertension state? Prehypertension : Stroke risk factor? CHD risk factor? CV mortality risk factor - all-cause mortality risk factor? Which patients? Hypertensive disorders of pregnancy (pre-eclampsia) : Hypertension and renal risk factor? Stroke and CHD risk factor? One more guideline : why? Conclusion

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28 Definitions of hypertension during pregnancy Pregnancy-related hypertension SBP 140 mmhg or DBP 90 mmhg Mild to moderate hypertension Severe hypertension SBP mmhg or DBP mmhg SBP 160 mmhg or DBP 110 mmhg

29 Pregnancy-induced hypertension can present as one of the following: Chronic hypertension (preexisting or diagnosed before 20 weeks gestation) Gestational hypertension (onset after 20 weeks gestation) with no proteinuria Preeclampsia defined as onset of hypertension (controlled or not) associated with significant proteinuria after 20 weeks gestation.

30 Severe preeclampsia is associated with at least one of the following: severe hypertension, target organ damage defined by one or more of the following: oliguria <500 ml per 24 hours, or creatininemia >135 µmol/l, or proteinuria >3 g per 24 hours, pulmonary edema, persistent epigastric or right upper quadrant abdominal pain, HELLP syndrome (intravascular hemolysis, hepatic cytolysis and thrombocytopenia), Persistent neurological symptoms (visual disturbances, headache, hyperactive deep-tendon reflexes, seizures), Retro-placental hematoma.

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34 RECOMMENDATION N 20 - (Grade C - Class 2) It is suggested that a dedicated consultation focusing on patient information and announcement of the diagnosis of hypertension should be programed some time after the birth for all patients who experienced hypertension during their pregnancy. The objectives would be: to explain the links between hypertension during pregnancy and the risk of cardiovascular and renal disease; to underline the importance of a coordinated multidisciplinary care-plan, and to ensure that preventive measures are set up, targeting lifestyle measures and the control of cardiovascular and renal risk factors.

35 RECOMMENDATION N 21 (Grade B - Class 1) It is recommended that women who experienced hypertension during a pregnancy should be offered: BP-, creatininemia- and proteinuria-monitoring; An assessment of the etiology of the disease; Evaluation and management of other cardiovascular and renal risk factors; Long-term BP monitoring, even for patients whose BP returns to normal after delivery, because of the persistently elevated risk of cardiovascular and renal outcomes; Adjustment of their antihypertensive treatment if necessary.

36 RECOMMENDATION N 22 - (Grade C - Class 2) It is suggested that women with chronic hypertension or a history of gestational hypertension in a previous pregnancy should be offered a preconception checkup with a view to: assessing and advising the woman about the risks associated with a new pregnancy (recurrence of hypertension or preeclampsia or intrauterine growth retardation, or premature birth); discussing the possibility of researching a possible etiology of the patient s hypertension before beginning a new pregnancy; postponing a new pregnancy in a women with severe hypertension until the disease is controlled; adjusting the antihypertensive drug therapy to the potential new pregnancy; suggesting a specific coordinated care-plan for a new pregnancy; informing the patient whether she needs to take aspirin.

37 Should hypertensive disorders of pregnancy be considered as a prehypertension state? Prehypertension : Stroke risk factor? CHD risk factor? CV mortality risk factor - all-cause mortality risk factor? Which patients? Hypertensive disorders of pregnancy (pre-eclampsia) : Hypertension and renal risk factor? Stroke and CHD risk factor? One more guideline : why? Conclusion

38 Conclusion Prehypertension : cerebrovascular and coronary risk factor Limited to those who will develop hypertension? Hypertensive disorders of pregnancy (pre-eclampsia) : cerebrovascular, coronary and renal risk factor Both situation partly neglected

39 Eclampsia Eclampsia is characterized by the occurrence of convulsions or generalized tonic-clonic seizures in a setting of pregnancy-induced hypertension.

40 Recommendation N 1 It is recommended that BP should be measured with the patient seated, in a medical setting, after at least 5 minutes rest, using an approved electronic brachial blood pressure measuring device. (Grade A - Class 1) For office-measured mild to moderately high BP, hypertension should be confirmed by measurements taken outside the physician s office (HBPM following the rule of 3 or daily average of 24-hour ABPM) to exclude any possible white-coat effect (Grade B - Class 1) (29). SBP 135 mmhg or DBP 85 mmhg, outside the physician s office, is considered pathological. (Grade C - Class 2)

41 Recommendation N 2 - (Grade B - Class 1) It is recommended that proteinuria should be measured at least once a month in all pregnant women by urine collection or by dipstick. A dipstick result greater than 1+ proteinuria requires laboratory confirmation on a morning urine sample or a 24- hour urine collection. Proteinuria >300 mg/24h or a proteinuria/creatininuria ratio 30 mg/mmol (or 300 mg/g) are reliable indicators of disease. If onset occurs after the 20 th week of gestation, it defines preeclampsia in a hypertensive patient, regardless of whether hypertension is controlled.

42 RECOMMENDATION N 3 - (Grade A - Class 1) It is recommended that treatment for severe hypertension (SBP 160 mmhg or DBP 110 mmhg) should be initiated without delay.

43 RECOMMENDATION N 4 - (Grade C - Class 2) Office-measured mild to moderate hypertension (SBP, mmhg or DBP, mmhg), confirmed by HBPM or by the daytime average of ABPM measurements (SBP 135 or DBP 85 mmhg), a history of cardiovascular disease, pregestational diabetes, chronic renal disease or high cardiovascular risk in primary prevention, are all situations where initiation of antihypertensive treatment should be considered.

44 RECOMMENDATION N 5 (Grade A - Class 1) It is recommended that when antihypertensive medication is prescribed, target office BP levels should be DBP between 85 mmhg and 100 mmhg and SBP <160 mmhg.

45 RECOMMENDATION N 6 - (Grade B - Class 2) During pregnancy, it is suggested that any one of the following antihypertensive medications should be used first line (presented in alphabetical order): alpha-methyldopa, labetalol, nicardipine, or nifedipine.

46 RECOMMENDATION N 7 - (Grade A - Class 1) Angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB) and aliskiren must not be used at any time-point of pregnancy and are contraindicated in the 2 nd and 3rd trimesters.

47 RECOMMENDATION N 8 - (Grade C - Class 2) It is suggested that a Personal Pregnancy Care-Plan notebook should be used in patients with hypertension to ensure the best possible use is made of the coordinated healthcare pathway (general practitioner, hypertension specialist, obstetrics team, and pharmacist).

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50 RECOMMENDATION N 15 To prevent the onset of preeclampsia, it is recommended that low-dose ( mg) aspirin should only be prescribed to patients with a history of preeclampsia. This treatment should be initiated before 20 weeks gestation, ideally at the end of the first trimester. (Grade A - Class 1) It is suggested that treatment with aspirin should be continued until at least 35 weeks gestation. (Grade C - Class 2)

51 RECOMMENDATION N 16 - (Grade B - Class 3) Low-dose aspirin is not currently recommended for the prevention of preeclampsia in other high risk populations, i.e., patients with chronic hypertension, obesity, pregestational diabetes, chronic kidney disease, abnormal uterine artery Doppler scan, or those having undergone medically assisted procreation, or screening by different biomarkers during the first trimester.

52 RECOMMENDATION N 17 - (Grade A - Class 3) Low molecular weight heparin, nitric oxide (NO) donors, antioxidants (Vitamins C and E) or physical exercise are not recommended for the prevention of preeclampsia.

53 RECOMMENDATION N 18 - (Grade B - Class 2) It is suggested that the following antihypertensive agents should be selected for women who are breastfeeding: β-blockers: labetalol, propranolol; Calcium channel blockers: nicardipine, nifedipine; Alpha-methyldopa; ACE inhibitors: benazepril, captopril, enalapril or quinapril, except for mothers of premature infants or those with renal failure.

54 RECOMMENDATION N 19 It is recommended that combined hormonal contraceptives should not be prescribed prior to six weeks post-partum because of the elevated risk of venous or arterial thromboembolic disease. (Grade B - Class 1) It is recommended that non-hormonal contraceptive methods should be prescribed for hypertensive patients with inadequate BP control despite appropriate treatment. (Grade B - Class 1) For women who rapidly become normotensive after the birth, progestin-only contraception can be prescribed (pill, implant or intrauterine device). (Grade B - Class 2) For patients who wish to use an intrauterine device, it is recommended that this should be fitted at the post-natal visit. (Grade B Class 2)

55 RECOMMENDATION N 20 - (Grade C - Class 2) It is suggested that a dedicated consultation focusing on patient information and announcement of the diagnosis of hypertension should be programed some time after the birth for all patients who experienced hypertension during their pregnancy. The objectives would be: to explain the links between hypertension during pregnancy and the risk of cardiovascular and renal disease; to underline the importance of a coordinated multidisciplinary care-plan, and to ensure that preventive measures are set up, targeting lifestyle measures and the control of cardiovascular and renal risk factors.

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