Φαρµακευτική θεραπεία υπερτασικών ασθενών. Δ. Τσιαχρής, Καρδιολόγος, Α Πανεπιστηµαική Καρδιολογική Κλινική

Transcription

1 Φαρµακευτική θεραπεία υπερτασικών ασθενών Δ. Τσιαχρής, Καρδιολόγος, Α Πανεπιστηµαική Καρδιολογική Κλινική

2 A 42-Year-Old Female with True Severe Resistant Hypertension Female, 42 years old, smoker BMI: 38Kg/m 2 Hypertensive for 4 years Hx: TIA, exertional dyspnoea OBP: 175/105mmHg, 85 bpm Screening for 2ndary hypertension: Negative

3 A 42-Year-Old Female with True Severe Resistant Hypertension Hct: 35%, WBC:9210 egfr: 60ml/min/1.73m 2, ACR: 15mg/g ECHO: Left ventricular hypertrophy (IVS=13mm), diastolic dysfunction 3/12: Coronary angiography : no significant stenosis

4 A 42-Year-Old Female with True Severe Resistant Hypertension OBP: 175/105mmHg, 85 bpm Currently on 7 antihypertensive drugs: Olmesartan/HCTZ 20/25mg OD Lercanidipine 20mg OD Betaxolol 20mg OD Diltiazem 300mg OD Spironolactone 100mg OD Terazosin 2mg BID Other drugs: ASA 100mg/clopidogrel 75 mg

5 Resistant Hypertension Diagnosis Diet Drugs Devices

6 Uncotrolled vs. resistant hypertension Poor compliance Inadequate treatment regimens Secondary hypertension True resistant hypertension

7 1 st step: Confirmation Office BP >140/90 or 130/80 mm Hg in patients with DM/CKD and 3 or more drugs in max tolerated doses or Controlled office BP under 4 or more drugs Circulation 2008;117:

8 2 nd step: Exclude pseudoresistance

9 a. Poor technique for BP measurement 1. Inappropriate conditions 2. Use of smaller cuff size False high BP measurements Κάθισµα µε ευθεία πλάτη Στήριξη βραχίονα στο τραπέζι Κεντρικό µέρος της περιχειρίδας στο ύψος της καρδιάς Τα πόδια στηρίζονται στο έδαφος

10 b. Poor compliance 40% of newly diagnosed hypertensives stop therapy during the first year CMAJ 1999;160: <60% in 5-10 years of follow up keep up with their prescribed therapy J Hypertens 2005;23: Poor compliance in hypertension units is present in only 16% of hypertensives Am J Hypertens. 2005;18:

11 c. White-Coat Effect Equally present in patients with and without resistant hypertension Am J Hypertens. 2001;14: Prevalence between 20% and 30% Hypertension 2005;46: Milder target organ damage Lower CV risk Blood Press Monit. 2003;8:

12 treated hypertensives 12.2% had resistant hypertension (Office BP>140 and/or 90 mm Hg under 3 drugs, including 1 diuretic) Based on ABPM 62.5% had true resistant hypertension 37.5% had white-coat resistance This study did not indicate a better BP control in hypertensives who divided their therapy morning and night

13 A 42-Year-Old Female with True Severe Resistant Hypertension ABPM at baseline 24h SBP :149mmHg 24h DBP : 85 mmhg

14 Resistant Hypertension Diagnosis Diet Drugs Devices

15 3 rd step: Lifestyle Factors Obesity Physical inactivity Alcohol abuse High salt intake Circulation 2008;117:

16 Impact of Lifestyle Changes on BP Lifestyle Changes BP Drop Hypocaloric Diet 5-20 mmhg/10 kg «DASH» Diet 8-14 mmhg Salt Restriction (6 g NaCl/day) 2-8 mmhg Physical Exercice (at least 30 /day) 4-9 mmhg Moderate alcohol consumption 2-4 mmhg

17 Resistant Hypertension Diagnosis Diet Drugs Devices

18 4 th step: discontinuation of drugs that BP NSAIDs Selective COX-2 inhibitors Sympathomimetics (diet pills, decongestants) Contraceptives Cyclosporine Erythropoietin Licorice Ephedra Circulation 2008;117:

19 Circulation 2008;117: th step: Control for secondary hypertension but in whom??? 1. Severe hypertension (SBP>170 and/or DBP>110 mm Hg) 2. Chronically uncontrolled BO 3. Sudden BP increase 4. Adolescents 5. Young <30 non obese patients

20 Anatomical eligibility for RSD Maybe we should perform CT angiography in every resistant hypertensive

21 Sleep apnea: secondary cause or risk factor of hypertension? 60% of OSA patients are hypertensives 20% of hypertensives have OSA Sleep Apnea Severity reduction..does not mean BP reduction In most cases obesity Precedes Sleep Apnea A confounder that always modulates the association From a nosological point of view sleep apnea is a risk factor of hypertension C. Thomopoulos et al. J Clin Hypertens

22 In which cases does BP reduce with CPAP?? Resistant hypertension CPAP compliance ( 5.5 h/night) Severe OSA Sleepy snorers and in which cases does not. Prehypertension Few data in mild hypertension Maybe does not help non-sleepy snorers M. Alajmi et al. Lung 2007 L. Bazzano et al. Hypertension 2007 P. Haentjens et al. Arch Intern Med 2007

23 6 th step: Drug therapy Max doses of diuretics, (HTZ 50mg) Add an aldosterone antagonist 25 mg Spironolactone for 8 weeks Office SBP -5.6mmHg 24h SBP: -9.8mmHg Nighttime SBP : -8.6mmHg Hypertension. 2011;57: Circulation 2008;117:

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25 Resistant Hypertension - ESH Recommendations - on 7 antihypertensive drugs: Olmesartan/HCTZ 20/25mg OD Lercanidipine 20mg OD Betaxolol 20mg OD Diltiazem 300mg OD Spironolactone 100mg OD Terazosin 2mg BID Other drugs: ASA 100mg/clopidogrel 75 mg

26 Cardiovascular (CV) Mortality Risk Doubles with Each 20/10 mmhg Increment in Systolic/Diastolic BP (SBP/DBP)* CV mortality risk 8 6 Our case 8X risk X risk 2X risk 4X risk 115/75 135/85 155/95 175/105 SBP/DBP (mmhg) Lewington et al. Lancet 2002;360: *Individuals aged years

27 Resistant Hypertension Diagnosis Diet Drugs Devices

28 J Hypertens 30: J Hypertens 2012; 30:

29 Severe Resistant hypertension Current indications office BP 160 systolic or 100 mmhg diastolic ( 150/95 mmhg in type 2 diabetes) despite treatment with 3 antihypertensive drugs of different types, including one diuretic.

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31 Anatomical exclusion criteria for RNA Multiple renal arteries (>2mm in diameter) Main renal arteries of less than 4 mm in diameter or less than 20 mm in length Renal artery irregularities (stenosis >30%, aneurysm) History of renal artery intervention (balloon angioplasty or stenting)

32 Renal Denervation Procedure Pre-Procedure Planning Obtain signed informed consent from the patient after a detailed description of the procedure Discontinue all agents that could affect unfavorably the renal function (NSAIDs, metformin) for at least 48h before the procedure Special care on the doses of prescribed diuretics- appropriate hydration prior to procedure Understand the relevant renal artery anatomy through appropriate imaging Select the appropriate guide catheter and the ablation system

33 EnligHTN Renal Denervation System

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35 Ablation with the EnligHTN Catheter

36 Difficult take-off and anatomy of the right renal artery

37 Difficult take-off and anatomy of the right renal artery A guidewire is needed and gentle handling But lack of support when trying to advance the guide catheter deeply

38 Difficult take-off and anatomy of the right renal artery The solution.. Using another 5Fr guiding catheter through the 8 Fr RDC1 we introduced the latter deeply into the stem of the renal artery and.then the EnligHTN

39 Difficult anatomy of RRA

40 Difficult anatomy of RRA Stable position of the expanded basket of the ΕnligHTN catheter during respiration 1 st of 4 ablations

41 Difficult anatomy of RRA The guiding and the ablation catheter are pulled back and the proximal set of 4 ablations is done

42 A 42-Year-Old Female with True Severe Resistant Hypertension ABPM at 1 month post RSD Office BP= 145/90 mmhg 24h SBP :130 mmhg 24h DBP : 74 mmhg

43 A 42-Year-Old Female with True Severe Resistant Hypertension ABPM at 3 months post RSD Office BP= 140/85 mmhg 24h SBP :128 mmhg 24h DBP : 74 mmhg

44 EnligHTN I: Office BP Reduction 3 Months 0-5 PHD (n = 45) Month 1 (n = 46) Month 3 (n = 46) Change in Blood Pressure (mmhg) Systolic BP Diastolic BP -27 * p < % CI -50 Tsioufis C., Worthley S., Worthley M., Sinhal A., Chew D.,, Meredith I., Malaiapan Y., Papademetriou V. ESC Meeting, Munich 2012

45 Renal Denervation Pitfalls There is nothing that tells us that we have really ablated renal nerves (no intraprocedural control on ablation success) No method to visualize renal nerves and identify promising ablation sites No method to identify patients who will not respond to RDN (10-20% of patients are not responders to treatment)

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