ΑΡΥΙΚΗ ΠΡΟΔΓΓΙΗ ΤΠΔΡΣΑΙΚΟΤ ΑΘΔΝΟΤ Μ.Β.Παπαβαζιλείοσ Καρδιολόγος FESC - Γιεσθύνηρια ιζμανόγλειον ΓΝΑ Clinical Hypertension Specialist ESH
Hypertension Co-Morbidities
HTN Commonly Clusters with Other Risk Factors Kaiser Permanente Northwest database; N=57,573 aged > 35 years with HTN and no CVD HTN + 3 other risk factors 3 14 HTN + 2 other risk factors 44 HTN only HTN + 1 other risk factor 39 Other risk factors: obesity,* hyperlipidemia, and diabetes *Body mass index >30 kg/m 2 Weycker D et al. Am J Hypertens. 2007;20:599-607
Consequences of Hypertension: Subclinical and Organ Damage Hypertension Transient ischemic attack, stroke LVH, CHD, CHF Retinopathy Carotid IMT Peripheral arterial disease Albuminuria and Chronic kidney disease CHF=congestive heart failure; CHD=coronary heart disease; LVH=left ventricular hypertrophy. Chobanian AV et al. JAMA. 2003;289:2560-2572.
(Goodman and Gilman s 1993) * *
High normal HTN - PreHTN Orthostatic hypertension
Cumulative CVD incidence during 12 years of followup by prehypertension and diabetes status in the Strong Heart Study cohort Segura J, Ruilope L M Dia Care 2009;32:S284-S289
Patient Evaluation Evaluation of patients with documented HTN has three objectives: A. Assess lifestyle and identify other CV risk factors or concomitant disorders that affect prognosis and guides treatment. B. Reveal identifiable causes of high BP (secondary HTN) C. Assess the presence or absence of target organ damage and CVD.
A. CVD Risk Factors Hypertension** Cigarette smoking Obesity** (BMI >30 kg/m 2 ) Central obesity W/m>102 W/w>88cm Physical inactivity Dyslipidemia** Diabetes mellitus** Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65) *Components of the metabolic syndrome (ESH 2007)
Metabolic Syndrome Increases Risk for CHD and Type 2 Diabetes new Metabolic Syndrome HYPERTENSION UBCLINICAL ORGAN DAMAGE Type 2 Diabetes 3-6 φορες σψηλοτερος κινδσνος 2-4 φορες σψηλοτερος κινδσνος Coronary Heart Disease GUIDELINES 2007 ESH-ESC
Cumulative Hazard, % Adverse Cardiovascular Prognosis in Metabolic Syndrome Population-Based Observational Study in 1209 Men 15 Cardiovascular Disease Mortality 10 RR (95% Cl), 3.55 (1.98-6.43) 5 Metabolic Syndrome Yes No 0 0 2 4 6 8 10 12 Follow-up, y Lakka et al. JAMA 2002;288:2709-2716
Carotid IMT
Stratification of CV risk in four categories (Blood pressure - mmhg) Other risk factors, TOD or disease Normal SBP 120-129 or DBP 80-84 High normal SBP 130-139 or DBP 85-89 Grade 1 HT SBP 140-159 or DBP 90-99 Grade 2 HT SBP 160-179 or DBP 100.109 Grade 3HT SBP 180 or DBP 110 No other risk factors Average risk Average risk Low added risk Moderate added risk High added risk 1-2 risk factors Low added risk Low added risk Moderate added risk Moderate added risk Very high added risk 3 or more risk factors, TOD, DM or MS Moderate added risk High added risk High added risk High added risk Very high added risk Established CV or renal disease Very high added risk Very high added risk Journal of Hypertension 2007;25:1105-1187 Very high added risk Very high added risk Very high added risk European Society of Hypertension, European Society of Cardiology
Prevalence of LVH in hypertension Stage 3: SBP 180; DBP 110 90% Stage of hypertension 12% 30% Stage 2: SBP = 160 179; DBP = 100 110 3% 8% Stage 1: SBP = 140 159; DBP = 90 99 10 20 30 80 90 100 Hypertensive patients (%) Tedesco MA et al. Clin Cardiol 2001;24:603 7. Schmieder RE et al. J Hum Hyperten 2000;14:597 604. Kahan T. J Hypertens 1998;16(suppl 7):23 29.
Regression of LVH predicts 100 Probability of event-free survival (%) prognosis Rate of events (per 100 patient-years) 7 90 80 70 60 50 Regressors (n = 52) p = 0.002 Non-regressors (n = 60) 6 5 4 3 2 1 40 0 100 200 300 400 500 Time to event (weeks) Regressors Non- Regressors Verdecchia P et al. Circulation 1998;97:48 54. 0
B. Identifiable Causes of Hypertension Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease
Renal failure >50%
Treatment Overview 1. Goals of therapy 2. Lifestyle modification 3. Pharmacologic treatment Algorithm for treatment of hypertension 4. Classification and management of BP for adults 5. Follow-up and monitoring Seventh Joint USA National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - JNC 7, JAMA, May 21, 2003, and USA Government Printing Office publication.
Estimated 24-Hour Urinary Excretion of Sodium and Composite of Cardiovascular Death, Stroke, Myocardial Infarction, and Hospitalization for Congestive Heart Failure Martin J. O'Donnell et al JAMA 2011
ESH 2009
Renin inhibitor - Aliskiren : 2009 guidelines
First line anti-hypertensive drugs ACE-I AT-1 DIURETIC CA-ANTAGONISTS B-BLOCKERS JNC 7 + + + + + NSH + + + + - AHA + + + + - ESH/ESC + + + + + WHO + + + + -
JNC7- ESH/ESC Guidelines 2007
Compelling and possible contraindications to use of antihypertensive drugs Compelling Possible Thiazide diuretics Beta-blockers Calcium antagonists (dihydropiridines) Calcium antagonists (verapamil, dilitazem) ACE inhibitors AT1 blockers Diuretics (antialdosterone) Gout Asthma A-V block (grade 2 or 3) A-V block (grade 2 or 3) Heart failure Pregnancy Angioneurotic oedema Hyperkalaemia Bilateral renal artery stenosis Pregnancy Hyperkalaemia Bilateral renal artery stenosis Renal failure Hyperkalaemia Metabolic syndrome Glucose intolerance Pregnancy Peripheral artery disease Metabolic syndrome Glucose intolerance Athletes and physically active patients Chronic obstructive pulmonary disease Tachyarrhythmias Heart failure
2007-2009 ESC/ESH Guidelines: Προηεινόμενοι ζσνδσαζμοί 2007 ESH/ESC Guidelines Combinations between Some Classes of Antihypertensive Drugs Thiazide diuretics Thiazide diuretics ß- blockers AT 1 - receptor antagonists ACCOMPLISH ADVANCE HYVET ASCOT ONTARGET AT 1 - receptor antagonists α-blockers Calcium antagonists Calcium antagonists ACE inhibitors ACE inhibitors Pronounced antihypertensive effect CV protection Optimal tolerability J hypertension 2009;27:2121 58
HYVET Trial >80y
Relationship between odds of (A) all-cause mortality, (B) cardiovascular mortality, (C) myocardial infarction, (D) stroke, (E) serious adverse events, and (F) nephropathy and final achieved systolic pressure (SBP) in the intensive group. all-cause mortality cardiovascular mortality subjects with type 2 diabetes mellitus/ impaired fasting glucose MI stroke nephropathy Bangalore S et al. Circulation 2011
Population-Based Strategy SBP Distributions After Intervention Before Intervention Reduction in BP Reduction in SBP mmhg Whelton, P. K. et al. JAMA 2002;288:1882-1888 2 3 5 % Reduction in Mortality Stroke CHD Total 6 4 3 8 5 4 14 9 7