hypertension - general overview (guidelines ) hypertension - general overview (guidelines ) andrzej...

Hypertension - general Hypertension - general

overview (guidelinesoverview (guidelines) )

Andrzej Tomaszewski Ass. Prof. M.D. Ph. D.Andrzej Tomaszewski Ass. Prof. M.D. Ph. D.

Dept. of Cardiology, Medical University Lublin, Dept. of Cardiology, Medical University Lublin, PolandPoland

CARDIONALE, 26. 11. 2010, Prague CARDIONALE, 26. 11. 2010, Prague

History of BP measurementHistory of BP measurement

• In 1896 Riva-Rocci described an In 1896 Riva-Rocci described an inflatable cuff that allowed inflatable cuff that allowed measurement of brachial systolic measurement of brachial systolic pressure.pressure.

• In 1904 Korotkov reported the In 1904 Korotkov reported the auscultatory method that allowed auscultatory method that allowed measurement of systolic and measurement of systolic and diastolic pressure. diastolic pressure.

Basis for the lecture:2007 Guidelines for the management of arterial hypertension

• The Task Force for the Management of Arterial Hypertension of theEuropean Society of Hypertension (ESH) and of the EuropeanSociety of Cardiology (ESC)

• Authors/Task Force Members: Giuseppe Mancia, Co-Chairperson (Italy), Guy De Backer, Co-Chairperson (Belgium), Anna Dominiczak (UK), Renata Cifkova (Czech Republic), Robert Fagard (Belgium), Giuseppe Germano (Italy), Guido Grassi (Italy), Anthony M. Heagerty (UK), Sverre E. Kjeldsen (Norway), Stephane Laurent (France), Krzysztof Narkiewicz (Poland), Luis Ruilope (Spain), Andrzej Rynkiewicz (Poland), Roland E. Schmieder (Germany), Harry A.J. Struijker Boudier (Netherlands), Alberto Zanchetti (Italy)

• European Heart Journal 2007;28:1462-1536

Basis for the lecture:Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document 2009

• Giuseppe Mancia, Stephane Laurent, Enrico Agabiti-Rosei, Ettore Ambrosioni, Michel Burnier, Mark J. Caulfield,

Renata Cifkova,Denis Cle´ment, Antonio Coca, Anna Dominiczak, Serap Erdine,Robert Fagard, Csaba Farsang, Guido Grassi, Hermann Haller,Antony Heagerty, Sverre E. Kjeldsen, Wolfgang Kiowski, Jean Michel Mallion,Athanasios Manolis, Krzysztof Narkiewicz, Peter Nilsson, Michael H. Olsen,Karl Heinz Rahn, Josep Redony Jose´ Rodicio, Luis Ruilopea,Roland E. Schmiedera, Harry A.J. Struijker-Boudiera, Pieter A. van Zwietena,Margus Viigimaaa and Alberto Zanchettia

• Journal of Hypertension 2009, Vol 27,2121-58

Epidemiology of arterial hypertensionEpidemiology of arterial hypertension

• Arterial hypertension is one of the most prevalent Arterial hypertension is one of the most prevalent cardiovascular diseases. cardiovascular diseases.

• Arterial hypertension affects 20-50 % of adults in Arterial hypertension affects 20-50 % of adults in developed countries. developed countries.

• Frequency of arterial hypertension suddenly Frequency of arterial hypertension suddenly increases after 50 years of life (>50% of this increases after 50 years of life (>50% of this population).population).

• Worldwide, hypertension affects over 970 milion Worldwide, hypertension affects over 970 milion

persons.persons.

Definition and classification ofDefinition and classification of blood blood

pressure levels (mmHg)pressure levels (mmHg)

• Category Systolic Diastolic

• Optimal <120 and <80• Normal 120–129 and/or 80–84• High normal 130–139 and/or 85–89• Grade 1 hypertension 140–159 and/or 90–99• Grade 2 hypertension 160–179 and/or 100–

109• Grade 3 hypertension ≥180 and/or ≥110• Isolated syst. ≥140 and <90• hypertension

* Defined as death due to CV disease; recognized myocardial infarction (MI), stroke, or congestive heart failure (CHF).

Adapted from Vasan RS. N Engl J Med. 2001;345:1291-1297.

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Optimal BP(<120/80 mm Hg)

Normal BP(120-129/80-84 mm Hg)

High-normal BP(130-139/85-89 mm Hg)

Impact of High-Normal BP on Risk of Impact of High-Normal BP on Risk of Major CV Events* in MenMajor CV Events* in Men

Arterial Hypertension as a risk factorArterial Hypertension as a risk factor

• Hypertension is a highly prevalent risk Hypertension is a highly prevalent risk factor for cardiovascular diseasefactor for cardiovascular disease

• Hypertension plays a major etiologic role Hypertension plays a major etiologic role in the development of cerebrovascular in the development of cerebrovascular disease, ischemic heart disease, cardiac disease, ischemic heart disease, cardiac and renal failureand renal failure

Assessment Assessment of of global cardiovascular global cardiovascular risk in arterial hypertensionrisk in arterial hypertension

• grades of hypertension grades of hypertension

• total cardiovascular risk (coexistence total cardiovascular risk (coexistence different risk factors, organ damage, different risk factors, organ damage, concomitant diseases)concomitant diseases)

Stratification of total CV riskStratification of total CV risk

• Four categories :Four categories :

• - Low- Low

• - Moderate- Moderate

• - High- High

• - Very high- Very high

refer to 10 year risk of fatal or non-fatal CV refer to 10 year risk of fatal or non-fatal CV eventevent

Diagnostic Diagnostic evaluationevaluation in arterial in arterial hypertensionhypertension

• Establishing BP values Establishing BP values

• Identyfying secondary causes of AH Identyfying secondary causes of AH

• Searching for :Searching for :

• -other risk factors-other risk factors

• -subclinical organ damage-subclinical organ damage

• -concomitant diseases-concomitant diseases

• -accompanying CV and renal -accompanying CV and renal complicationscomplications

Diagnostic procedures in arterial Diagnostic procedures in arterial hypertensionhypertension

• repeated BP measurementsrepeated BP measurements

• family and clinical historyfamily and clinical history

• physical examinationphysical examination

• laboratory and instrumental investigationlaboratory and instrumental investigation

Laboratory and instrumental Laboratory and instrumental investigation- routine testsinvestigation- routine tests

• Fasting plasma glucose• Serum total cholesterol, LDL-cholesterol, HDL-cholesterol• Fasting serum triglycerides• Serum potassium• Serum uric acid• Serum creatinine• Estimated creatinine clearance• Haemoglobin and haematocrit• Urinalysis • Electrocardiogram

Laboratory and instrumental Laboratory and instrumental investigationinvestigation

• Echocardiogram

• Carotid ultrasound

• Quantitative proteinuria

• Fundoscopy

• Glucose tolerance test (if fasting plasma glucose>5.6 mmol/L (100 mg/dL)

• Home and 24 h ambulatory BP monitoring

Left ventricular hypertrophy, Left ventricular hypertrophy, parasternal long axis viewparasternal long axis view

Left ventricular hypertrophy, Left ventricular hypertrophy, parasternal short axis viewparasternal short axis view

Left ventricular hypertrophy,Left ventricular hypertrophy,four-chamber viewfour-chamber view

Left ventricular hypertrophy, Left ventricular hypertrophy, subcostal viewsubcostal view

Extended laboratory and instrumental Extended laboratory and instrumental investigationinvestigation

• Search for cerebral, cardiac, renal, vascular Search for cerebral, cardiac, renal, vascular damage, for secondary hypertension: damage, for secondary hypertension:

• measurement of renin, measurement of renin, aldosteron,corticosteroids,catecholamines aldosteron,corticosteroids,catecholamines in plasma and/or urinein plasma and/or urine

• arteriographies, CT, MRIarteriographies, CT, MRI

Secondary causes of AH :Secondary causes of AH :

• Renal parenchymal disease (most Renal parenchymal disease (most common cause)common cause)

• Renovascular hypertension (2nd most Renovascular hypertension (2nd most common cause)common cause)

• Pheochromocytoma Pheochromocytoma • Primary hyperaldosteronismPrimary hyperaldosteronism• Cushing’s syndromeCushing’s syndrome• Obstructive sleep apneaObstructive sleep apnea• Coarctation of aortaCoarctation of aorta• Drug-induced hypertensionDrug-induced hypertension

Evidence on the benefit of Evidence on the benefit of antihypertensive treatmentantihypertensive treatment

• Placebo controlled trials provided evidence Placebo controlled trials provided evidence that BP lowering reduces fatal and non-that BP lowering reduces fatal and non-fatal CV eventsfatal CV events

• Trials comparing different Trials comparing different antihypertensive drugs emphasise role of antihypertensive drugs emphasise role of BP lowering of all CV events (stroke, BP lowering of all CV events (stroke, myocardial infarction, heart failure)myocardial infarction, heart failure)

• BP-independent effects (protection against BP-independent effects (protection against subclinical organ damage, prevention of subclinical organ damage, prevention of high risk condition such as diabetes, renal high risk condition such as diabetes, renal failure, atrial fibrillation)failure, atrial fibrillation)

Benefits of Lowering BPBenefits of Lowering BP

Average reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

Aim of antihypertensive therapyAim of antihypertensive therapy

• The primary goal of treatment is to The primary goal of treatment is to achieve maximum reduction in the long-achieve maximum reduction in the long-term total risk of CV diseaseterm total risk of CV disease

• For this reason lowering BP therapy (at For this reason lowering BP therapy (at least least

< 140/90 mm Hg) and treatment of all < 140/90 mm Hg) and treatment of all reversible risk factors are indicatedreversible risk factors are indicated

• In diabetes and in high and very high risk In diabetes and in high and very high risk patients BP target should be at least < patients BP target should be at least < 130/80 mmHg 130/80 mmHg

Treatment guidelines (ESH/ESC 200Treatment guidelines (ESH/ESC 20077))

Average risk Low added risk Moderate added risk High added risk Very high added risk

ESH – ESC Guidelines Committee. J Hypertens 2007; 25: 1105–1187

Lifestyle changesLifestyle changes

• smoking cessationsmoking cessation

• weight reductionweight reduction

• reduction of excessive alkohol intakereduction of excessive alkohol intake

• physical exercisephysical exercise

• reduction of salt intakereduction of salt intake

• increase in fruit and vegetables intakeincrease in fruit and vegetables intake

• decrease in saturated and total fat intakedecrease in saturated and total fat intake

Choice of the antihypertensive Choice of the antihypertensive drugsdrugs

• Five major classes of these drugs are suitable for initiation Five major classes of these drugs are suitable for initiation and maintenance of treatment, and maintenance of treatment, alone or in combination :alone or in combination :

• thiazide diuretics thiazide diuretics

• calcium antagonists (CA)calcium antagonists (CA)

• ACE-inhibitors (ACEI)ACE-inhibitors (ACEI)

• angiotensin receptor blockers (ARB)angiotensin receptor blockers (ARB)

• beta-blockers (BB)beta-blockers (BB)

Conditions favouring the use of some Conditions favouring the use of some antihypertensive drugs versus otherantihypertensive drugs versus other

• Subclinical organ damage:Subclinical organ damage:

LVH ACEI, CA, ARBLVH ACEI, CA, ARB

Asymptomatic Atherosclerosis CA, ACEIAsymptomatic Atherosclerosis CA, ACEI

Microalbuminuria ACEI, ARBMicroalbuminuria ACEI, ARB

Renal dysfunction ACEI, ARBRenal dysfunction ACEI, ARB


• Clinical event:Clinical event:

Previous stroke any BP lowering agentPrevious stroke any BP lowering agent

Previous MI BB, ACEI, ARBPrevious MI BB, ACEI, ARB

Heart failure diuretics, BB, ACEI, Heart failure diuretics, BB, ACEI,

ARB, anti-aldosterone agentsARB, anti-aldosterone agents

Tachyarrhythmias BBTachyarrhythmias BB

Periph.art.disease CAPeriph.art.disease CA

LV dysfunction ACEILV dysfunction ACEI


• Condition :Condition :

ISH (elderly) diuretics,CAISH (elderly) diuretics,CA

Metabolic syndrome ACEI,ARB,CAMetabolic syndrome ACEI,ARB,CA

Diabetes mellitus ACEI, ARBDiabetes mellitus ACEI, ARB

Pregnancy CA,methyldopa,BBPregnancy CA,methyldopa,BB

Glaucoma BBGlaucoma BB

Monotherapy versus combination Monotherapy versus combination therapytherapy

• Monotherapy allows to achieve BP target Monotherapy allows to achieve BP target only in a limited number of patientsonly in a limited number of patients

• Use of more than one agent is necessary Use of more than one agent is necessary to achieve target BPto achieve target BP

• Initial therapy: monotherapy or Initial therapy: monotherapy or combination of two drugs in low doses combination of two drugs in low doses with subsequent increase in drug doses or with subsequent increase in drug doses or numbernumber

Monotherapy versus combination Monotherapy versus combination therapytherapy

• MonotherapyMonotherapy in mild BP elevation with in mild BP elevation with low or moderate total CV risklow or moderate total CV risk

• TwoTwo drugs at low doses should be drugs at low doses should be preferred as the first step when BP is in preferred as the first step when BP is in grade 2 or 3 or total CV risk is high or grade 2 or 3 or total CV risk is high or very high with mild hypertensionvery high with mild hypertension

• Fixed combination ofFixed combination of two two drugs simplify drugs simplify the treatmentthe treatment

• If BP control is not achieved by If BP control is not achieved by twotwo drugs, drugs, combination of combination of three or morethree or more drugs is drugs is requiredrequired

Possible combinations of different Possible combinations of different classes of antihypertensive agentsclasses of antihypertensive agents

The preferred combinations in general hypertensive population are represented as thick lines. The frames indicate classes of agents proven to be beneficial

in controlled interventional trials

Diuretics

AT1-receptorblockers

β-blockers

α-blockers CCBs

ACE inhibitorsACE, angiotensin-converting enzymeAT, angiotensinCCB, calcium-channel blocker

ESH – ESC Guidelines Committee. J Hypertens 2007; 25: 1105–1187

Antihypertensive therapy in special Antihypertensive therapy in special groupsgroups

• Elderly patientsElderly patients

• Diabetic patientsDiabetic patients

• Patients with renal dysfunctionPatients with renal dysfunction

• Patients with cerebrovascular diseasePatients with cerebrovascular disease

• Patients with coronary heart disease Patients with coronary heart disease and heart failureand heart failure

• Patients with atrial fibrillationPatients with atrial fibrillation

Hypertension in womenHypertension in women

• Response to antihypertensive drugs, Response to antihypertensive drugs, beneficial effect of BP lowering is beneficial effect of BP lowering is similar in men and womensimilar in men and women

• Oral contraceptivesOral contraceptives

• Hormone replacement therapyHormone replacement therapy

• Hypertension in pregnancyHypertension in pregnancy

Resistant hypertensionResistant hypertension

• Poor adherence to therapeutic plan• Failure to modify lifestyle including: weight

gain, heavy alcohol intake • Intake of drugs that raise blood pressure• Obstructive sleep apnoea• Unsuspected secondary cause• Irreversible or scarcely reversible organ

damage• Volume overload due to:inadequate diuretic

therapy, progressive renal insufficiency, high sodium intake, hyperaldosteronism

Unsuspected secondary cause

Unsuspected secondary cause Coarctation of aorta Coarctation of aorta

Malignant hypertensionMalignant hypertension

• Clear overlap between resistant and Clear overlap between resistant and malignant hypertensionmalignant hypertension

• Severe BP elevation (DBP usually Severe BP elevation (DBP usually >140 mmHG) with vascular damage >140 mmHG) with vascular damage (retinal haemorrhage, papilloedema, (retinal haemorrhage, papilloedema, hypertensive hypertensive encephalopathy,deterioration in encephalopathy,deterioration in renal function, DIC)renal function, DIC)

Hypertensive emergiencesHypertensive emergiences

• Hypertensive encephalopathy• Hypertensive left ventricular failure• Hypertension with myocardial infarction• Hypertension with unstable angina• Hypertension and dissection of the aorta• Severe hypertension associated with subarachnoid haemorrhage or cerebrovascular accident• Crisis associated with phaeochromocytoma• Use of recreational drugs such as amphetamines,

LSD, cocaine or ecstasy• Hypertension perioperatively• Severe pre-eclampsia or eclampsia

EchocardiographyEchocardiography

• Examples of two hypertensive Examples of two hypertensive emergencies:emergencies:

- aortic dissectionaortic dissection

- fatal myocardial infarctionfatal myocardial infarction

Aortic dissectionAortic dissection

Chronic aortic Chronic aortic dissectiondissection

Chronic aortic dissectionChronic aortic dissection

Fatal myocardial Fatal myocardial infarctioninfarction

Fatal myocardial infarctionFatal myocardial infarction

Fatal myocardial Fatal myocardial infarction,cardiac tamponadeinfarction,cardiac tamponade

Hypertension – treatment of Hypertension – treatment of associated risk factorsassociated risk factors

• Lipid lowering agents:Lipid lowering agents:

- all hypertensive pts with CV disease or - all hypertensive pts with CV disease or diabetes should be considered for statin diabetes should be considered for statin therapy aiming total cholesterol < 175 therapy aiming total cholesterol < 175 mg/dl and LDL < 100mg/dl mg/dl and LDL < 100mg/dl

- pts with high CV risk should be - pts with high CV risk should be considered for statin therapy, even if total considered for statin therapy, even if total and LDL cholesterol are not elevatedand LDL cholesterol are not elevated

Hypertension – treatment of Hypertension – treatment of associated risk factorsassociated risk factors

• Antiplatelet therapy (low dose aspirin):Antiplatelet therapy (low dose aspirin):

-for pts with previous CV events-for pts with previous CV events -for pts without history of CV disease if older -for pts without history of CV disease if older

than 50 y., with moderate increase in serum than 50 y., with moderate increase in serum creatinine or with high CV riskcreatinine or with high CV risk

• Glycemic control :Glycemic control : - lowering fasting plasma glucose to 108 - lowering fasting plasma glucose to 108

mg/dl, glycated hemoglobin of <6,5%mg/dl, glycated hemoglobin of <6,5%

Reappraisal of European guidelines on hypertension management: a ESH Task Force document, 2009

What is new today after reappraisal 2009 ?What is new today after reappraisal 2009 ?

1/Some of new studies have reinforced the evidence on

which the recommendations of the 2007 ESH/ESC guidelines were based 2/Other studies have widened the information

available in 2007 3/Modifying some of the previous concepts 4/New evidence-based recommendations could be

appropriate.

New evicence-based recommendations:New evicence-based recommendations:

- blood pressure goals of treatmentblood pressure goals of treatment

- indications for starting antihypertensive - indications for starting antihypertensive pharmacotherapy pharmacotherapy



• Blood pressure goals of treatment:Blood pressure goals of treatment:

there is sufficient evidence to recommend that SBP be lowered below 140mmHg (and DBP below 90mmHg) in all hypertensive patients, both those at low moderate risk and those at high risk.

The recommendation of previous guidelines to aim at a lower goal SBP (<130mmHg) in diabetic patients and in patients at very high cardiovascular risk (previous cardiovascular events) may be wise, but it is not consistently supported by trial evidence.


• Blood pressure goals of treatmentBlood pressure goals of treatment::

on the basis of current data, it may be prudent to recommend lowering SBP/DBP to values within the range 130–139/80–85mmHg, and possibly close to lower values in this range, in all hypertensive patients.


• Indications for starting Indications for starting antihypertensive pharmacotherapyantihypertensive pharmacotherapy

In the vast majority of hypertensive patients, effective BP control can only be achieved by combination of at least two antihypertensive drugs.


•Recommended combinations for priority use:

•Diuretic + ACEI•Diuretic + ARB•Diuretic + CA•ACEI + CA•ARB +CA


• Not recommended combinationsNot recommended combinations::

• Beta-blocker + diuretic combination favors Beta-blocker + diuretic combination favors the development of diabetesthe development of diabetes

• ACE inhibitor + angiotensin receptor ACE inhibitor + angiotensin receptor antagonist combination presents dubious antagonist combination presents dubious potentiation of benefits with a serious side potentiation of benefits with a serious side efectsefects


• In no less than 15–20% of patients, BP control cannot be achieved by a two-drug combination.

• The most rational combination of three drugs appears to be a blocker of the renin–angiotensin system, a calcium antagonist, and a diuretic at effective doses.

• β-blocker or an α-blocker, may be included in a multiple approach, depending on the clinical circumstances.

Thank you for your attentionThank you for your attention

hypertension - general overview (guidelines ) hypertension - general overview (guidelines ) andrzej...

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