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Arterial hypertension

Arterial hypertension. Arterial hypertension. New (1999) WHO-ISH Definitions and Classification of BP Levels. Category Systolic BP Diastolic BP (mm Hg) (mm Hg) Optimal BP <120 <80 Normal BP <130 <85 High-Normal 130-139 85-89 Grade 1 Hypertension (mild) 140-159 90-99

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Arterial hypertension

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  1. Arterial hypertension Arterial hypertension

  2. New (1999) WHO-ISH Definitionsand Classification of BP Levels Category Systolic BP Diastolic BP (mm Hg) (mm Hg) Optimal BP <120 <80 Normal BP <130 <85 High-Normal 130-139 85-89 Grade 1 Hypertension (mild) 140-159 90-99 Subgroup: Borderline 140-149 90-94 Grade 2 Hypertension (moderate) 160-179 100-109 Grade 3 Hypertension (severe) >180 >110 Isolated Systolic Hypertension >140 <90 Subgroup: Borderline 140-149 <90

  3. morbus hypertonicus

  4. What is the Goalof the Practice Guidelines? • To lower blood pressure (BP) and other risk factors in order to reduce the risk of cardiovascular disease (CVD)

  5. Why is Hypertension Management Needed? (1) • 600 million hypertensives in the world • 3 million die annually as a direct result of hypertension

  6. Why is Hypertension Management Needed? (2) • The Rule of Halves • Only 1/2 have been diagnosed • Only 1/2 of those diagnosed have been treated • Only 1/2 of those treated are adequately controlled • Thus, only 12.5% overall are adequately controlled

  7. Why BP <130/85 mm Hgand Not <140/90 mm Hg? (1) • The relationship between CV risk and BP is continuous • Today, more than 50% of all hypertensives have BP >160/90 mm Hg and 75% have BP >140/90 • The major determinant of the risk reduction conferred by antihypertensive therapy is the BP level attained

  8. Why BP <130/85 mm Hgand Not <140/90 mm Hg? (2) • In diabetics, there is a clear benefit of lowering BP <85 mm Hg • The HOT Study showed that lowering BP < 85 mm Hg did not increase CV risk • The goal should be to attain normalBP (<130/85 mm Hg)

  9. What is High Blood Pressure? • BP levels are continuously related to the risk of CVD • Definition of hypertension or raised BP is arbitrary • Even within the normotensive range, people with the lowest BP levels have the lowest rates of CVD

  10. Relative Risk of CHD and Stroke in Relation to Patient’s Usual Diastolic BP

  11. Clinical Evaluation - What Should Be Done? • Confirm elevation of BP • Exclude or identify secondary causes of hypertension • Determine presence of target organ damage and quantify extent • Search for other CV risk factors and clinical conditions that may influence prognosis and treatment

  12. Multiple BP Measurements Recommended • Because BP is characterized by large spontaneous variations, diagnosis should be based on multiple BP measurements taken on several separate occasions

  13. Minimum RoutineInvestigations • Clinical and family history • Full physical examination as described in medical textbooks • Laboratory investigations, including: • urinalyses for blood, protein, and glucose • microscopic examination of the urine • blood chemistry for potassium, creatinine, fasting glucose, and total cholesterol • Electrocardiography (ECG)

  14. “Isolated” Office Hypertension • In some patients office BP is persistently elevated whereas daytime BP outside clinic environment is not. Continuing debate whether “isolated” office hypertension (“white coat hypertension”) is an innocent phenomenon or carries an increased risk of CVD

  15. Ambulatory BP Monitoring • BP values obtained by home measurement or ambulatory monitoring are several mm Hg lower than office measurement • Average 24 hour or home BP values around 125/80 mm Hg = office BP 140/90 mm Hg

  16. Which Factors Influence Prognosis? (1) • Decisions should not be made on BP alone, but also on presence of other risk factors, target organ damage, and concomitant diseases, as well as on other aspects of patients’ personal, medical, social, economic, ethnic, and cultural characteristics

  17. Which Factors Influence Prognosis? (2) • Risk factors of CVD • I. Used for risk stratification • II. Other factors adversely influencing prognosis • Target organ damage (TOD) • Associated clinical conditions (ACC)

  18. Which Factors Influence Prognosis? (3) Risk factors for CVD • I. Used for risk stratification • Levels of systolic and diastolic blood pressure (Grades 1-3) • Men >55 years • Women >65 years • Smoking • Total cholesterol >6.5 mmol/L (250 mg/dl) • Diabetes • Family history of premature cardiovascular disease

  19. Which Factors Influence Prognosis? (4) Risk factors for CVD • II. Other factors adversely influencing prognosis • Reduced HDL cholesterol • Raised LDL cholesterol • Microalbuminuria in diabetes • Impared glucose tolerance • Obesity • Sedentary lifestyle • Raised fibrinogen • High risk socioeconomic group • High risk ethnic group • High risk geographic region

  20. Which Factors Influence Prognosis? (5) Target organ damage (TOD) • Left ventricular hypertrophy (electrocardiogram, echocardiogram, or radiogram) • Proteinuria and/or slight elevation of plasma creatinine concentration 106-177 mmol/L (1.2-2.0 mg/dl) • Ultrasound or radiological evidence of atherosclerotic plaque (carotid, iliac, and femoral arteries, aorta) • Generalised or focal narrowing of the retinal arteries

  21. Which Factors Influence Prognosis? (6) Associated clinical conditions (ACC) • Cerebrovascular disease • Ischaemic stroke • Cerebral haemorrhage • Transient ischaemic attack (TIA) • Heart disease • Myocardial infarction • Angina pectoris • Coronary revascularisation • Congestive heart failure

  22. Which Factors Influence Prognosis? (7) Associated clinical conditions (ACC) • Renal disease • Diabetic nephropathy • Renal failure, plasma creatinine concentration >177 mmol/L (>2.0 mg/dl) • Vascular disease • Dissecting aneurysm • Symptomatic arterial disease • Advanced hypertensive retinopathy • Haemorrhages or exudates • Papilloedema

  23. Stratifying Risk - Quantifying Prognosis

  24. Effects of Antihypertensive Treatment in Randomised Controlled Trials

  25. Management Strategy • Initiate lifestyle measures wherever appropriate in all patients, including those who require drug treatment • Smoking cessation • Weight reduction • Moderation of alcohol consumption • Reduction of salt intake • Increased physical activity

  26. Principles of Drug Treatment (1) • Use a low dose of one drug to initiate therapy • If good response and tolerability but inadequate control increase the dose of the first drug • If little response or poor tolerability change to another drug class

  27. Principles of Drug Treatment (2) • It is often preferrable to add a small dose of a second drug rather than increase the dose of the first drug • Use long-acting drugs providing 24-hour efficacy on a once daily basis. Improves adherence to therapy and minimizes BP variability.

  28. Principles of Drug Treatment (3) • There are six maindrug classes used worldwide - diuretics, beta-blockers, ACE inhibitors, calcium antagonists, alpha blockers, and angiotensin II antagonists.

  29. Principles of Drug Treatment (4) • All 6 classes are suitable for the initiation and maintenance of BP lowering therapy, but the choiceof drugs will be influenced by cost and by many factors for special groupsof patients. In some parts of the world, reserpine and methyldopa arealso used frequently.

  30. Indications Compelling PossibleHeart failure DiabetesElderly patients Systolic hypertension Diuretics Contraindications Compelling PossibleGout Dyslipidaemia Sexually active males

  31. Indications Compelling PossibleAngina Heart failureAfter myocardial infarct PregnancyTachyarrhythmias Diabetes Contraindications Beta-Blockers Compelling PossibleAsthma and Dyslipidaemia Chronic obstructive Athletes and Pulmonary disease Physically activeHeart block (AV 2,3) Patients Peripheral vascular disease

  32. Indications Compelling PossibleAngina PeripheralElderly patients Vascular disease Systolic hypertension Calcium Antagonists Contraindications Compelling PossibleHeart block (AV 2,3) Heart failure* * verapamil or diltiazem

  33. Indications Compelling PossibleHeart failure Left ventricular dysfunctAfter myocardial infarctDiabetic nephropathy ACE Inhibitors Contraindications Compelling PossiblePregnancyBilateral renal artery stenosisHyperkalaemia

  34. ACE inhibitors: • Mech. of eff.: inhibition of the conversion of AT I onto AT II, degradation of bradykine, decrease of PVR and slight venodilatation • vasokonstriction ATII, secretion of aldosterone -natriuresis • regression of hypertrophia of left ventricle and vessel’s wall • heart insufficiency - mortality rate 20-30 % • glom. pressure - proteinuria during DM nephropatia • - cardioprotective, vasoprotective and renoprotective eff. • AE: hypotension after initial dose, renal impairment (acute renal insufficiency, hyperkalaemia, dry cough, angioedema • short acting: captoprile - three times a day • medium term: enalaprile - twice a day • long acting: perindoprile, lisinoprile, quinaprile, ramiprile,spiraprile, trandolaprile

  35. Indications Compelling PossibleProstatic Hypertrophy Glucose intolerance Dyslipidaemia Alpha-Blockers Contraindications Compelling Possible Orthostatic hypotension

  36. - blockers • Central acting - 2, I1 rec. - decrease of sympatic influence • clonidine - 2,I1-agonist - renal hypertension, !sedation, dyssomnia • methyldopa, guanfacine - 2-rec. • moxonidine, rilmenidine - imidazolin I1 rec. • reserpine -depletion of catecholamines - only in combination - NÚ!!! • Combined - urapidile - block of postsyn. 1-rec., activation of 5-HT1Arec. in CNS • Peripheral -blockers • 1 - prazosine, doxazosine, metazosine, terazosine • 1+2 - phentolamine - th. of feochromocytoma • + - labetalol, carvedilol

  37. Indications Compelling PossibleACE-I cough Heart failure Angiotensin II Antagonists Contraindications Compelling PossiblePregnancyBilateral renal Artery stenosisHyperkalaemia

  38. Antagonists of AT II: • Antagonists of AT II • block of AT1 rec., • regression of hypertr. LV, renoprotective eff. • In AE of ACEI • losartan, valsartan, irbesartan, telmisartan,…… • Direct vasodilat. eff.: • hydralazines(endralazine, dihydralazine), minoxidil, sodium nitroprusside • reflex. tachycardia - in combination with -blockers and diuretics

  39. Combination Therapy (1) • In most patients, appropriate combination therapy produces BP reductions that are twice as great as those obtained with monotherapy.

  40. Combination Therapy (2) • Effective drug combinations to treat hypertension are: • diuretic and beta-blocker • diuretic and ACE inhibitor (or Angiotensin II antagonist) • calcium antagonist (dihydropyridine) and beta-blocker • calcium antagonist and ACE inhibitor • alpha-blocker and beta-blocker

  41. Other Drugs to Consider in Hypertension • Aspirin • Cholesterol lowering therapy

  42. Treatment Goal • The goal of antihypertensive treatment should be to achieve “optimal” or “normal” BP in young, middle-aged, or diabetic subjects (below 130/85 mm Hg), and at least “high-normal” BP in elderly patients (below 140/90 mm Hg)

  43. How should hypertensionduring pregnancy be defined? • Hypertension in pregnancy usually defined as: • pre-existing chronic hypertension • de novo diagnosed, gestational hypertension or pre-eclampsia • pre-eclampsia superimposed on chronic hypertension

  44. Antihypertensive drugsmost widely used acutelyduring pregnancy • Nifedipine • Labetalol • Hydralazine

  45. Antihypertensive drugsmost widely used chronicallyduring pregnancy • Beta-blockers: oxprenolol, pindolol, labetalol atenolol, however, is associated with fetal growth retardation when used long-term throughout pregnancy • Methyldopa • Prazosin, hydralazine, nifedipine, and isradipine

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