1 esc/eas 2011 guidelines for the management of dyslipidemias 2564-12-2011
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ESC/EAS 2011 GuidelinesESC/EAS 2011 Guidelinesfor the management of for the management of dyslipidemias dyslipidemias
2564-12-2011
2
European Heart Journal Advance Access Published June 28, 2011
3
Classes of recommendations
Classes of recommendations Definition Suggested wording to use
Class I‘Everybody agrees’
Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective.
Is recommended/is indicated
Class II‘Not everybody agrees’
Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure.
Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy. Should be considered
Class IIb Usefulness/efficacy is less well established by evidence/opinion. May be considered
Class III‘Everybody agrees’
Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful.
Is not recommended
Classes of recommendations
4
Levels of evidence
Levels of evidence
Level of Evidence AData derived from multiple randomizedclinical trialsor meta-analyses.
Level of Evidence BData derived from single randomizedclinical trialsor large non-randomized studies.
Level of Evidence C Consensus of opinion of the experts and/or small studies, retrospective studies, registries.
5
Risque de maladies cardiovasculaires fatalesRisque à dix ans de maladies cardiovasculaires fatales pour la Belgique en fonction du sexe, de l’âge,
de la pression systolique, du cholestérol et du statut tabagique
Femme Homme
6
This chart may be used to show younger people at low absolute risk that, relative to others in their age group, their risk may be many times higher than necessary. This may help to motivate decisions about avoidance of smoking, healthy nutrition and exercise, as well as flagging those who may become candidates for medication.
Please note that this chart shows RELATIVE not absolute risk. The risks are RELATIVE to 1 in the bottom left. Thus a person in the top right hand box has a risk that is 12 times higher than a person in the bottom left.
Relative Risk Chart < 40y
ESC 2007
8
Recommendations for treatment targets for LDL-C
Recommendations Classa Levelb Refc
In patients at VERY HIGH CV risk (established CVD, type 2 diabetes, type 1 diabetes with target organ damage, moderate to severe CKD or a SCORE level ≥10%) the LDL-C goal is <1.8 mmol/L (less than ~70 mg/dL) and/or ≥ 50% LDL-C reduction when target level cannot be reached.
I A 15,32,33
aClass of recommendation. bLevel of evidence.cReferences.
CKD= chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease; LDL-C = low-density lipoprotein-cholesterol
9
Recommendations for treatment targets for LDL-C
Recommendations Classa Levelb Refc
In patients at HIGH CV risk (markedly elevated single risk factors, a SCORE level ≥5 to <10%) an LDL-C goal <2.5 mmol/L (less than ~100 mg/dL) should be considered.
IIa A 15,16,17
In subjects at MODERATE risk (SCORE level >1 to ≤5%) an LDL-C goal < 3.0 mmol/L (less than ~115 mg/dL) should be considered.
IIa C -
aClass of recommendation. bLevel of evidence.cReferences.
CKD= chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease; LDL-C = low-density lipoprotein-cholesterol
10
*In patients with MI, statin therapy should be considered irrespective of LDL-C levels.aClass of recommendation.bLevel of evidence.
Intervention strategies as a function of total CV risk and LDL-C level
CV = cardiovascular; LDL-C = low-density lipoprotein-cholesterol; MI = myocardial infarction.
TOTAL CV risk (SCORE) %
LDL-C levels<70 mg/dL
<1.8 mmol/L70 to <100 mg/dL
1.8 to <2.5 mmol/L100 to <155 mg/dL2.5 to < 4.0 mmol/L
155 to < 190 mg/dL4.0 to < 4.9 mmol/L
>190 mg/dL>4.9 mmol/L
<1 No lipid intervention
No lipid intervention
Lifestyle intervention
Lifestyle intervention
Lifestyle intervention, consider drug if uncontrolled
Classa/Levelb I/C I/C I/C I/C IIa/A
≥ 1 to < 5 Lifestyle intervention
Lifestyle intervention
Lifestyle intervention, consider drug if uncontrolled
Lifestyle intervention, consider drug if uncontrolled
Lifestyle intervention, consider drug if uncontrolled
Classa/Levelb I/C I/C IIa/A IIa/A I/A
>5 to <10, or high risk
Lifestyle intervention, consider drug*
Lifestyle intervention, consider drug*
Lifestyle intervention, and immediate drug intervention
Lifestyle intervention, and immediate drug intervention
Lifestyle intervention, and immediate drug intervention
Classa/Levelb IIa/A IIa/A IIa/A I/A I/A
≥10 or very high risk
Lifestyle intervention, consider drug*
Lifestyle intervention, and immediate drug intervention
Lifestyle intervention, and immediate drug intervention
Lifestyle intervention, and immediate drug intervention
Lifestyle intervention, and immediate drug intervention
Classa/Levelb IIa/A IIa/A I/A I/A I/A
11
Addendum II. Practical approach to reach LDL-C goal
Percentage reduction of LDL-C requested to achieve goals as a function of the starting value
Starting LDL-C % Reduction to reach LDL-C
mmol/L ~mg/mL <1.8 mmol/L(~70mg/dL)
<2.5 mmol/L(~100mg/dL)
<3 mmol/L(~115mg/dL)
>6.2 >240 >70 >60 >55
5.2-6.2 200-240 65-70 50-60 40-55
4.4-5.2 170-200 60-65 40-50 30-45
3.9-4.4 150-170 55-60 35-40 25-30
3.4-3.9 130-150 45-55 25-35 10-25
2.9-3.4 110-130 35-45 10-25 <10
2.3-2.9 90-110 22-35 <10 -
1.8-2.3 70-90 <22 - -
12
LDL-
C
13
LDL-C: Percentage Change from Baseline at Week 6 (n=2240)
LS m
ean
% c
hang
e fr
om b
asel
ine
-60
-50
-40
-30
-20
-10
010 20 40 80
Dose (mg)
Log scale
rosuvastatin atorvastatin simvastatin pravastatin
Jones et al. Am J Cardiol 2003: 93: 152-160
14
SCORE2011
WomenHighRisk
15
0
2
4
6
8
10
12
10 20 40 80Dose (mg)
LS m
ean
% c
hang
e fr
om b
asel
ine
Log scale
HDL-C: Percentage Change from Baseline at Week 6 (n= 2240)
Jones et al. Am J Cardiol 2003: 93: 152-160
rosuvastatin atorvastatin simvastatin pravastatin
16
TauxHDL-C, mg/dl 30 38 46 54 62 70Femme x 1,8 x 1,5 x 1,2 x 1 x 0,8 x 0,7Homme x 1,3 x 1,1 x 1 x 0,9 x 0,8 x 0,7
l’effet du cholestérol associé aux lipoprotéinesde haute densité (HDL-C) sur le risque CV global
17
Statins are among the most studied drugs in CV prevention, and dealing with single studies is beyond the scope of the present guidelines.
A number of large-scale clinical trials have demonstrated that statins substantially reduce CV morbidity and mortality in both primary and secondary prevention. Statins have also been shown to slow the progression or even promote regression of coronary atherosclerosis.
StatinsEfficacy in clinical studies
18
Current available evidence suggests that the clinical benefit is largely independent of the type of statin but depends on the extent of LDL-C lowering; therefore, the type of statin used should reflect the degree of LDL-C reduction that is required to reach the target LDL-C in a given patient. More details on this are provided in Addendum II to these guidelines.
Statins Meta-analyses
19
The recent finding that the incidence of diabetes may increase with statins should not discourage institution of treatment; the absolute reduction in the risk of CVD in high risk patients outweighs the possible adverse effects of a very small increase in the incidenceof diabetes.
StatinsMeta-analyses - Type 2 Diabetes
20
Cholesterol absorption inhibitorsEfficacy in clinical studies
Ezetimibe can be used as second-line therapy in association with statins when the therapeutic target is not achieved at maximal tolerated statin dose or in patients intolerant of statins or with contraindications to these drugs.
21
Management of hypertriglyceridaemiaPharmacological therapy
As statins have significant effects on mortality as well as most CVD outcome parameters, these drugs are the first choice to reduce both total CVD risk and moderately elevated TG levels. More potent statins (atorvastatin, rosuvastatin, and pitavastatin) demonstrate a robust lowering of TG levels, especially at high doses and in patients with elevated TG.
23
Le risque sera également plus élevé qu’indiquédans les tableaux pour :
• Les personnes socialement défavorisées ; les privations induisent denombreux autres facteurs de risque.• Les sujets sédentaires et ceux présentant une obésité abdominale ;ces caractéristiques déterminent de nombreux autres aspects desrisques énumérés ci-dessous.• Les personnes diabétiques : une nouvelle analyse de la base de donnéesSCORE indique que les personnes présentant un diabète avéré ont unrisque nettement plus élevé ; cinq fois plus élevé pour les femmes ettrois fois plus élevé pour les hommes.• Les personnes ayant un faible taux d’HDL-C ou d’apolipoprotéine A1(apo A1), des taux élevés de TG, de fibrinogène, d’homocystéine,d’ apolipoprotéine B (apo B) et de lipoprotéine(a) (Lp(a)), une hypercholestérolémie familiale (HF) ou un taux élevé de hs-CRP ;ces facteurs indiquent un niveau de risque accru pour les deux sexes, pour toutes les tranches d’âge et pour tous les niveaux de risque.
24
• Les personnes asymptomatiques présentant des signes précliniques
d’athérosclérose, par exemple la présence de plaques ou un
épaississement de l’intima–média carotidienne détecté lors d’une
échographie carotidienne.
• Les personnes atteintes d’insuffisance rénale.
• Les personnes ayant des antécédents familiaux de MCV précoce dont
on considère qu’ils multiplient le risque par 1,7 chez les femmes et par
2,0 chez les hommes.
• À l’inverse, le risque peut être inférieur à celui indiqué chez les
personnes ayant des taux très élevés d’HDL-C ou des antécédents
familiaux de longévité.
25
Risk factor management in coronary Risk factor management in coronary patients – results from a European patients – results from a European
wide survey wide survey EUROASPIRE IIIEUROASPIRE III
Professor David A Woodon behalf of the EUROASPIRE Investigators
26
0
10
20
30
40
50
60
70
80
90
100
Survey 1 24,9 59,3 47,8 25,6 25,6 25,8 23,0
Survey 2 25,2 59,4 48,1 24,8 27,8 26,1 21,2
Survey 3 23,1 60,9 40,6 28,3 49,8 9,9 12,0
Women Mean ageAge < 60
yrs CABG PTCA AMI ISCHAEMIA
Distribution of Age, Gender and Diagnostic Category
(%) (%) (%) (%) (%) (%)(years)
Gender Age Diagnostic category
27
Prevalence of Smoking*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 22,0% 12,8% 25,0% 16,8% 23,3% 18,6% 31,8% 13,3% 20,3%
Survey 2 19,3% 21,6% 24,2% 16,8% 30,1% 15,1% 28,3% 14,6% 21,2%
Survey 3 22,2% 16,8% 24,8% 18,4% 18,3% 14,0% 15,1% 12,0% 18,2%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.64
S2 vs. S1 : P=0.83S3 vs. S2 : P=0.37S3 vs. S1 : P=0.48
* Self-reported smoking or CO in breath > 10 ppm
28
Prevalence of Overweight*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 81,3% 79,3% 75,8% 82,4% 71,0% 81,4% 70,5% 73,8% 76,8%
Survey 2 87,0% 78,4% 79,7% 82,7% 79,2% 71,7% 78,5% 78,7% 79,9%
Survey 3 84,6% 77,2% 77,1% 85,3% 85,6% 81,3% 78,9% 84,4% 82,7%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.04
S2 vs. S1 : P=0.15S3 vs. S2 : P=0.22S3 vs. S1 : P=0.02
* Body mass index ≥ 25 kg/m²
29
Prevalence of Obesity*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 31,4% 29,6% 33,4% 23,0% 23,3% 22,4% 18,9% 19,2% 25,0%
Survey 2 40,1% 33,6% 37,5% 30,6% 36,8% 23,6% 28,2% 28,0% 32,6%
Survey 3 37,9% 26,4% 36,8% 43,1% 49,3% 29,4% 26,5% 39,1% 38,0%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.0006
S2 vs. S1 : P=0.009S3 vs. S2 : P=0.051S3 vs. S1 : P=0.0002
* Body mass index ≥ 30 kg/m²
30
Prevalence of Raised Blood Pressure (1)*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 60,1% 56,1% 48,4% 58,4% 50,6% 55,3% 54,0% 55,1% 54,6%
Survey 2 46,9% 52,0% 55,5% 67,0% 40,4% 50,8% 54,4% 62,8% 54,0%
Survey 3 62,5% 67,1% 48,1% 50,9% 46,3% 60,5% 59,6% 55,1% 55,2%
Czech Rep.
Finland France Germany Hungary ItalyNether lands
Slovenia ALL
P=0.79
S2 vs. S1 : P=0.83S3 vs. S2 : P=0.51S3 vs. S1 : P=0.65
* SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg
31
Therapeutic Control of Blood Pressure*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 34,4% 39,1% 47,9% 39,7% 44,0% 41,0% 43,3% 37,7% 41,0%
Survey 2 47,2% 43,4% 36,7% 29,1% 55,0% 45,7% 43,5% 31,1% 41,2%
Survey 3 30,1% 29,1% 44,1% 45,2% 44,1% 34,8% 35,3% 41,4% 38,7%
Czech Rep. Finland France Germany Hungary Italy Netherlands Slovenia ALL
P=0.57
S2 vs. S1 : P=0.98S3 vs. S2 : P=0.36S3 vs. S1 : P=0.37
* SBP/DBP < 140/90 mmHg for non-diabetics or < 130/80 mmHg for diabetics
32
Prevalence of Raised Total Cholesterol*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 94,2% 93,7% 91,5% 94,3% 97,4% 96,9% 97,1% 95,5% 94,5%
Survey 2 86,1% 63,8% 79,3% 83,4% 54,5% 72,5% 66,7% 82,2% 76,7%
Survey 3 47,1% 28,2% 40,8% 49,4% 57,0% 48,8% 33,1% 41,8% 46,2%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P<0.0001S2 vs. S1 : P<0.0001S3 vs. S2 : P<0.0001S3 vs. S1 : P<0.0001
* Total cholesterol ≥ 4.5 mmol/L
33
Therapeutic Control of Total Cholesterol*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 4,6% 6,8% 14,2% 9,6% 4,8% 0,0% 7,9% 8,1% 8,4%
Survey 2 17,3% 46,2% 23,4% 20,5% 31,4% 31,1% 40,0% 22,0% 28,7%
Survey 3 55,8% 72,6% 62,4% 54,0% 48,7% 53,2% 68,9% 60,3% 57,3%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P<0.0001S2 vs. S1 : P<0.0001S3 vs. S2 : P<0.0001S3 vs. S1 : P<0.0001
* Total cholesterol < 4.5 mmol/L
34
Prevalence of Diabetes*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 21,8% 15,4% 16,7% 13,5% 26,6% 17,2% 10,3% 17,4% 17,4%
Survey 2 21,5% 18,7% 27,5% 13,5% 21,1% 21,8% 13,2% 23,8% 20,1%
Survey 3 30,8% 19,1% 34,2% 22,6% 44,8% 21,7% 20,6% 18,8% 28,0%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.004
S2 vs. S1 : P=0.21S3 vs. S2 : P=0.02S3 vs. S1 : P=0.001
* Self-reported history of diagnosed diabetes
35
Therapeutic Control of Diabetes*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 38,7% 34,4% 15,1% 71,4% 48,6% 39,1%
Survey 2 29,9% 30,8% 20,4% 26,9% 42,3% 53,2% 70,7% 72,7% 42,1%
Survey 3 17,2% 40,0% 27,8% 18,7% 25,4% 10,2% 33,3% 20,0% 21,5%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.04
S2 vs. S1 : P=0.82S3 vs. S2 : P=0.03S3 vs. S1 : P=0.08
* Fasting glucose < 7 mmol/L in patients with history of diabetes
36
Medication Use: Antiplatelets
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 85,2% 82,2% 82,1% 82,9% 72,0% 86,1% 77,5% 79,4% 80,8%
Survey 2 87,6% 81,9% 85,7% 86,3% 75,1% 91,5% 81,0% 82,3% 83,6%
Survey 3 92,5% 96,4% 98,1% 91,8% 86,1% 98,0% 95,7% 92,4% 93,2%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P<0.0001
S2 vs. S1 : P=0.29S3 vs. S2 : P=0.0002S3 vs. S1 : P<0.0001
37
Medication Use: Beta-Blockers
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 65,3% 77,8% 56,3% 43,6% 57,7% 49,2% 46,8% 51,8% 56,0%
Survey 2 73,7% 87,9% 60,4% 68,1% 84,3% 61,2% 48,2% 65,7% 69,0%
Survey 3 91,3% 95,8% 74,4% 85,0% 85,9% 87,6% 74,6% 87,0% 85,5%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P<0.0001S2 vs. S1 : P=0.001S3 vs. S2 : P=0.0002S3 vs. S1 : P<0.0001
38
Medication Use: ACE Inhibitors & Angiotensin II RA
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 28,1% 17,3% 33,8% 31,4% 46,3% 31,8% 27,4% 31,2% 31,0%
Survey 2 47,1% 31,0% 43,7% 50,6% 58,6% 53,5% 42,9% 63,0% 49,2%
Survey 3 76,1% 59,3% 78,9% 72,8% 80,6% 70,9% 66,5% 83,0% 74,6%
Czech Rep. Finland France Germany Hungary ItalyNether-
landsSlovenia ALL
P<0.0001
S2 vs. S1 : P<0.0001S3 vs. S2 : P<0.0001S3 vs. S1 : P<0.0001
39
Medication Use: Statins
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 6,3% 34,9% 20,2% 31,1% 6,7% 6,8% 14,0% 23,2% 18,1%
Survey 2 38,8% 62,6% 61,0% 65,6% 45,2% 57,0% 75,1% 56,3% 57,3%
Survey 3 88,1% 95,2% 89,1% 85,4% 76,7% 90,0% 91,4% 90,1% 87,0%
Czech Rep. Finland France Germany Hungary ItalyNether-
landsSlovenia ALL
P<0.0001S2 vs. S1 : P<0.0001S3 vs. S2 : P<0.0001S3 vs. S1 : P<0.0001
40
Medication Use: Diuretics
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Survey 1 15,7% 12,0% 18,7% 14,5% 15,9% 17,6% 13,7% 14,3% 15,3%
Survey 2 22,7% 12,4% 13,2% 32,7% 23,9% 16,3% 12,6% 14,3% 18,8%
Survey 3 36,3% 10,8% 19,2% 33,8% 52,6% 20,4% 23,2% 29,1% 31,1%
Czech Rep. Finland France Germany Hungary Italy Nether-lands Slovenia ALL
P=0.006
S2 vs. S1 : P=0.30S3 vs. S2 : P=0.02S3 vs. S1 : P=0.002
41
No change in blood pressure control despite increased use of anti-hypertensive medications
61% above therapeutic target (BP < 140/90 mmHg)
Continuing improvement in lipid control with increased use of statins
42% above the 2003 therapeutic target (TC < 4.5 mmol/l)
Conclusions
42ESH - ESC Guidelines, J Hypertens 2003ESH - ESC Guidelines, J Hypertens 2003
-BP < 140/90 mmHg in all hypertensive patients
< 130/80 mmHg in hypertensive patients with diabetes or renal disease
-Control of all cardiovascular risk factors
-BP < 140/90 mmHg in all hypertensive patients
< 130/80 mmHg in hypertensive patients with diabetes or renal disease
-Control of all cardiovascular risk factors
Goals of treatmentGoals of treatment
43
Sympathetic nervous systemRenin-angiotensin systemTotal body sodium
Sympathetic nervous systemRenin-angiotensin systemTotal body sodium
Patient 1 Patient 2 Patient 3Patient 1 Patient 2 Patient 3
44
Percentage of patients with normal blood pressure
Percentage of patients with normal blood pressure
Drug ADrug A
0 20 40 60 801000 20 40 60 80100
%%Drugs CDrugs C
Drug BDrug B
45
Achieved BP: <140/90 mmHg Achieved BP: <140/90 mmHg
Dickerson et al, Lancet, 1999Dickerson et al, Lancet, 1999
During monotherapy(diuretic, -blocker, ACE inhibitor or Ca antagonist)
During monotherapy(diuretic, -blocker, ACE inhibitor or Ca antagonist)
%% 39 39
00
2020
4040
6060
8080
BP control rate during antihypertensive monotherapy
46
Percentage of patients with normal blood pressure
Percentage of patients with normal blood pressure
Drug ADrug A
0 20 40 60 801000 20 40 60 80100
%%Drugs A + BDrugs A + B
Drug BDrug B
47
SystolicDiastolicSystolicDiastolic
0
-5
-10
-5
0
-5
-10
-5
Effects of two different drugs on BP separately and in combination
(119 randomized placebo controlled trials)
Effects of two different drugs on BP separately and in combination
(119 randomized placebo controlled trials)P
lace
bo-
subt
ract
ed B
P
resp
onse
. m
mH
g
Pla
cebo
-su
btra
cted
BP
re
spon
se.
mm
Hg
Law et al, BMJ 2003
Law et al, BMJ 2003
"First" drug alone
"First" drug alone
"Second" drug alone
"Second" drug alone
Combination
Combination
48
Advantages of fixed versus liberal combinations of two antihypertensive
drugs
Advantages of fixed versus liberal combinations of two antihypertensive
drugsFixed
Liberal
Simplicity of treatment +-
Compliance +-
Efficacy ++
Tolerability +*-
Price +-
Flexibility -+
Risk of administering +-
contraindicated drug
FixedLiberal
Simplicity of treatment +-
Compliance +-
Efficacy ++
Tolerability +*-
Price +-
Flexibility -+
Risk of administering +-
contraindicated drug
* lower doses generally used in fixed-dose combinations* lower doses generally used in fixed-dose combinations
49
Pharmacological treatment of hypertensionPharmacological treatment of hypertension
Consider :Blood pressure level before treatmentAbsence or presence of TOD and risk factors
Consider :Blood pressure level before treatmentAbsence or presence of TOD and risk factors
2003 European Society of Hypertension - European Society of Cardiology Guidelines for the Management of Arterial Hypertension, J Hypertens, 2003
2003 European Society of Hypertension - European Society of Cardiology Guidelines for the Management of Arterial Hypertension, J Hypertens, 2003
Two-drug combination at low dose
Two-drug combination at low dose
Choose between :Choose between :
Single agent at low dose
Single agent at low dose
If goal BP not achieved :If goal BP not achieved :
Previous agent at full dose
Previous agent at full dose
Switch to different agent at low dose
Switch to different agent at low dose
Previous combination at full
dose
Previous combination at full
dose
Add a third drug
at low dose
Add a third drug
at low doseIf goal BP not achieved :If goal BP not achieved :
Two-three drug combination
Two-three drug combination
Two-three drug combination
Two-three drug combination
50
Stage 1 hypertension (SBP 140-159 or DBP 90-99
mmHg)
Thiazide-type diuretics for most, consider ACE inhibitor, ARB, -blocker, CCB, or combination
Stage 1 hypertension (SBP 140-159 or DBP 90-99
mmHg)
Thiazide-type diuretics for most, consider ACE inhibitor, ARB, -blocker, CCB, or combination
Stage 2 hypertension (SBP ≥160 mmHg or DBP ≥100
mmHg)
2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or -blocker or CCB)
Stage 2 hypertension (SBP ≥160 mmHg or DBP ≥100
mmHg)
2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or -blocker or CCB)
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACE inhibitor, ARB, -blocker, CCB) as needed
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACE inhibitor, ARB, -blocker, CCB) as needed
Not at goal BPNot at goal BP
Lifestyle modificationsLifestyle modifications
Algorithm for treatment of hypertensionAlgorithm for treatment of hypertension
The JNC VII Report, 2003The JNC VII Report, 2003
Not at goal BP (<140/90 mmHg or <130/80 mmHg for those with diabetes or chronic kidney disease)
Not at goal BP (<140/90 mmHg or <130/80 mmHg for those with diabetes or chronic kidney disease)
Initial drug choicesInitial drug choices
Hypertension with compelling indicationsHypertension with compelling indicationsHypertension without compelling indicationsHypertension without compelling indications
Optimize dosages or add additional drugs until goal BP is achievedConsider consultation with hypertension specialist
Optimize dosages or add additional drugs until goal BP is achievedConsider consultation with hypertension specialist
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SATISFACTIONSATISFACTION
Normalization of BP
Normalization of BP
Goodtolerability
Goodtolerability
Simple drug regimen
Simple drug regimen
Day-to-day compliance Day-to-day compliance Long-term compliance Long-term compliance
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