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2013 ESH/ESC Hypertension Guidelines. Guías de HTA 2013 ESH/ESC. Evaluación diagnóstica. Confirmación del diagnóstico de HTA Detección de causas de HTA secundaria Valoración del RCV, LOD asintomática y condiciones clínicas concomitantes.
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2013 ESH/ESC Hypertension Guidelines Guías de HTA 2013 ESH/ESC
Evaluación diagnóstica • Confirmación del diagnóstico de HTA • Detección de causas de HTA secundaria • Valoración del RCV, LOD asintomática y condiciones clínicas concomitantes
Factores (además de PA clínica) queinfluyen en el pronósticopara la estratificación de RCV total Sin cambios
Estratificación del RCV en categorías: bajo, moderado, alto y muy alto riesgo
Valoración y estratificación del RCV total • En la estratificación, además de la HTA: • Otros FRCV • LOD asintomática • Diabetes • Enfermedad renal o CV establecida
Definición de HTA a través de los niveles de PA clínica y no clínica
Evaluación diagnóstica: Variables derivadas del MAPA • Ratio Noche-Día • Categorías según el patrón dipper: • La mayoría de marcadores de LOD se correlacionan de forma más estrecha con la PA ambulatoria • PA ambulatoria es un predictor más sensible de los eventos clínicos CV coronarios e ictus tanto fatales como no fatales que la PA clínica • La PA nocturna es un predictor más robusto de la morbi-mortalidad que la PA diurna • La incidencia de eventos CV es mayor en pacientes con menor o ausencia de descenso de la presión arterial nocturna
Recomendaciones en la evaluación diagnóstica a nivel cardíaco, arterial, renal, retiniano y cerebral
Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónica Sin cambios
Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónica Sin cambios
Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónica Sin cambios
Inicio de los cambios en el estilo de vida y tratamientoantiHTA
Modificación del estilo de vida • Restricción de sal • Moderación del consumo de alcohol • Reducción y mantenimiento del peso • Ejercicio físico regular • Cese del tabaquismo Sin cambios
Objetivos de PA • A SBP < 140 mmHg recommended/considered, regardless the level of risk • Low/moderate risk (IB) • Diabetes (IA) • Diabetic/nondiabetic CKD (IIaB) • Patients with CHD/previous stroke or TIA (IIaB) • A DBP < 90 mmHg recommended PA < 140/90 mmHg
BP goals in hypertension - Exception to the general rule • In patients with diabetes DBP values < 85 mmHg are recommended (IA) • In elderly hypertensives (< 80 years old) there is solid evidence to recommend reducing SBP between 150-140 mmHg (IA)Consider a SBP <140 mmHg in fit elderlies • Same SBP target in individuals older than 80 years (IB)It Applies to octogenarians in good physical/mental conditions
Choice of antihypertensive drugs - Conclusions from 2013 (and 2003 and 2007) Guidelines • The main benefits of antihypertensive treatment are due to lowering BP “per se” and are largely independent of the drug employed • Although meta-analyses occasionally claim superiority of one class for some outcomes this largely depends on selection bias of trials. The largest meta-analyses do not show clinically relevant between-class differences • Current Guidelines reconfirm that the following drugs classes are all suitable for initiation and maintenance of antihypertensive treatment either as monotherapy or in some combinations with each other (IA) • Diuretics (thiazides / chlorthalidone / indapamide) • Beta-blockers • Calcium antagonists • ACE-inhibitors • Angiotensin receptor blockers
Estrategias de tratamiento en condicionesespeciales • HTA de bata blanca • HTA enmascarada • Ancianos • Adultos jóvenes • Mujeres • Diabetes mellitus • Síndrome metabólico • SAHS • Cardiopatía • Aterosclerosis /Arteriosclerosis / Enfermedad arterial periférica • Disfunción eréctil • HTA resistente • HTA maligna • Emergencias / urgencias hipertensivas • Manejo de la HTA en el perioperatorio • HTA renovascular • Aldosteronismo primario
Two drug combinations as initial treatment • Cons • One of the two drugs may be ineffective • Ascribing side effects more difficult • Pros • When one agent ineffective, finding an alternative monotherapy may be a painstaking process, adversely affecting compliance • Prompter response in a larger number of patients (benefit in high risk patients?) • Lower drop-out rate
Possible combinations of antihypertensive drug classes Green/continuous: preferred Green/dashed: useful (with some limitations) Black/dashed: possible but less well tested Red/continuous: not recommended No doble bloqueo del SRAA Only dihydropyridines to be combined with -blockers (except for verapamil or diltiazem for rate control in AF) Thiazides + -blockers increase risk of new onset DM ACEI + ARB combination discouraged (IIIA)
Follow-up of hypertensive patients • After treatment initiation see patients at 2-4 week intervals • Once the target is reached, a visit interval of a few months (3 or 6) is reasonable • Depending on local organization and health resources later visits may be performed by non-physician health workers • For stable patients Home BP and electronic communication may provide an acceptable alternative • It is advisable to assess risk factors and OD at least every 2 years
Can antihypertensive medications be stopped? • In some patients in whom treatment is accompanied by an effective BP control for an extended period it may be possible to reduce the number/dosage of drugs • This may be particularly the case if BP control is accompanied by healthy lifestyle changes, removing the environmental pressor influences • Medication reduction should be gradual and patients should be frequently checked Intentar reducciones farmacológicas tras buen control largo tiempo
Treatment strategies in hypertensive patients with resistant hypertension
Treatment strategies in hypertensive patients with heart disease COMO ANTES
Treatment strategies in hypertensive patients with cerebrovascular disease
Treatment strategies in hypertensive patients with atherosclerosis, arteriosclerosis, and peripheral artery disease PA <140/90 mmHg
Treatment strategies in hypertensive patients with nephropathy • PAS < 130-140 mmHg • Si proteinuria bloqueadores de SRAA
Treatment strategies in hypertensive patients with metabolic syndrome PA < 140/90 mmHg De elección: Bloqueadores SRAA Calcio-antagonistas
Diabetes Mellitus - Key Issues • High BP is common / masked HT not infrequent • Marked CV risk increase with HT-DM association • Major benefit of antihypertensive therapy on macrovascular and renal complications • No clear effect of antihypertensive therapy on retinopathy and neuropathy (several studies)
Treatment strategies in patients with diabetes PA < 140/85 mmHg
Young Hypertensive Adults • Isolated DBP elevation possible • Long-term CV risk possibly more closely related to DBP than SBP • Drug treatment may be considered prudent with BP target < 140/90 mmHg • Selective SBP elevation sometimes associated with normal central SBP – Because there is no evidence on drug effects, close FU / lifestyle changes advisable 18516 M