Hipertensión enmascarada. Alejandro de la Sierra Hospital Mútua Terrassa Universitat de Barcelona

Transcription

1 Hipertensión enmascarada Alejandro de la Sierra Hospital Mútua Terrassa Universitat de Barcelona

2 HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento

3 HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento

4 Definitions Masked hypertension Untreated subjects presenting with normal BP in the office but elevated ABP (or HBP) Masked uncontrolled hypertension (MUCH) Treated patients controlled at the office but uncontrolled at home or by ABPM

5 Definición Prevalencia Características clínicas Riesgo derivado HTA enmascarada Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento

6 Distribution of hypertension phenotypes in untreated patients from the Spanish ABPM Registry Office BP mmhg 26.2% 50.2% Normotension Sustained hypertension White-coat hypertension Masked hypertension 140/ % 8.1% 130/80 24-hour ambulatory BP mmhg

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8 Prevalence of MH and MUCH depending on guidelines criteria and the circadian period selected Prevalence of MH, n (%) (N=3477) ESH proposed criteria Prevalence of MUCH, n (%) (N=5934) Daytime BP 135 or 85 mmhg 497 (14.3%) 881 (14.8%) 24-hour BP 130 or 80 mmhg 671 (19.3%) 1204 (20.3%) Night-time BP 120 or 70 mmhg 977 (28.1%) 2149 (36.2%) Any of the above 1147 (33.0%) 2349 (39.6%) ACC/AHA proposed criteria Daytime BP 130 or 80 mmhg 1033 (29.7%) 1682 (28.3%) 24-hour BP 125 or 75 mmhg 1337 (38.5%) 2302 (38.8%) Night-time BP 110 or 65 mmhg 1919 (55.2%) 3730 (62.9%) Any of the above 2094 (60.2%) 3956 (66.7%) De la Sierra et al. Circulation 2018

9 Other isssues on MH prevalence ESHWG recommends diagnosis of MH or MUCH when either daytime BP, nighttime BP, or 24-hour BP are elevated O Brien E, et al. J Hypertens % of patients with MUCH were due to isolated nocturnal BP elevation Banegas JR, et al. Eur Heart J 2014 Nocturnal period should be tailored to patient s dairy.

10 HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento

11 Prevalence of MH decreases with age Conen D, et al. Hypertension 2014

12 Clinical variables associated with MH or MUCH Young age Male gender Smoking Normal weight LVH or microalbuminuria Overt CV or renal disease Banegas et al. Eur Heart J 2014 De la Sierra et al. Circulation 2018

13 Some typical circumstances Mental stress at work Typical among physicians and nurses High variability of office BP measurements Combined normal and elevated BP recordings Sleep disorders, especially sleep apnea High normal office BP with documented TOD

14 HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento

15 Increased TOD in MH Increased prevalence of LVH Increased carotid IMT Increased prevalence of CKD Reduced forearm FMD (increased endothelial dysfunction)

16 Definición Prevalencia Características clínicas Riesgo derivado HTA enmascarada Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Tratamiento

17 Reproducibility of MH diagnosis after 1 year without pharmacological intervention 50 47, ,7 33,3 NT WCH MH SH ,6 0 MH at baseline

18 HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Tratamiento

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20 Figure S4 Panel A All-cause mortality P<0.001 Masked hypertension Masked uncontrolled hypertension Sustained hypertension White-coat hypertension P=0.774 Sustained uncontrolled hypertension White-coat uncontrolled hypertension Normotension P=0.811 Controlled hypertension P=0.655 Risk of MH and MUCH Number at risk Normotension Controlled hypertension White-coat hypertension White-coat uncontrolled hypertension Masked hypertension Masked uncontrolled hypertension Sustained hypertension Sustained uncontrolled hypertension Banegas, Ruilope, de la Sierra, et al. NEJM 2018

21 Risk of MH and MUCH Banegas, Ruilope, de la Sierra, et al. NEJM 2018

22 Risk of MUCH vs CH Pierdomenico SD, et al. Hypertension 2018

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24 HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento

25 Screening and diagnosis of hypertension Williams B, et al. Eur Heart J 2018

26 Management of masked hypertension Recommendations In masked hypertension, lifestyle changes are recommended to reduce CV risk, with regular follow-up, including periodic out-of-office BP monitoring. Antihypertensive drug treatment should be considered in masked hypertension to normalize the out-of-office BP based on the prognostic importance of out-of-office BP elevation. Antihypertensive drug up-titration should be considered in treated patients whose out-of-office BP is not controlled (i.e. masked uncontrolled hypertension), because of the high CV risk of these patients. I IIa IIa C C C Williams B, et al. Eur Heart J 2018

27 Detection of White Coat Hypertension or Masked Hypertension in Patients Not on Drug Therapy Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring.

28 Detection of White Coat Effect or Masked Uncontrolled Hypertension in Patients on Drug Therapy Detection of white coat effect or masked uncontrolled hypertension in patients on drug therapy Office BP at goal Yes No Increased CVD risk or target organ damage Office BP 5 10 mm Hg above goal on 3 agents Yes No Yes No Screen for masked uncontrolled hypertension with HBPM (Class IIb) Screening not necessary (No Benefit) Screen for white coat effect with HBPM (Class IIb) Screening not necessary (No Benefit) HBPM BP above goal HBPM BP at goal Yes Masked uncontrolled hypertension: Intensify therapy (Class IIb) ABPM BP above goal No Continue current therapy (Class IIa) White coat effect: Confirm with ABPM (Class IIa) Continue titrating therapy Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring. Yes No

29 Management Although there is no evidence-based data, it seems reasonable to treat MH patients to reduce their CV risk. Future clinical trials should consider ABPM and phenotype distribution when assessing the protective effect of antihypertensive treatment Office BP is not useful for follow-up and treatment titration in MH or MUCH patients. HBPM or yearly ABPM are the methods of choice