Hypertension - general overview (guidelines )

1. Hypertension - general overview (guidelines) Andrzej Tomaszewski Ass. Prof. M.D. Ph. D. Dept. of Cardiology, Medical University Lublin, Poland CARDIONALE, 26. 11. 2010, Prague

2. History of BP measurement • In 1896 Riva-Rocci described an inflatable cuff that allowed measurement of brachial systolic pressure. • In 1904 Korotkov reported the auscultatory method that allowed measurement of systolic and diastolic pressure.

3. Basis for the lecture:2007 Guidelines for the management of arterial hypertension • The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society 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

4. 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

5. Epidemiology of arterial hypertension • Arterial hypertension is one of the most prevalent cardiovascular diseases. • Arterial hypertension affects 20-50 % of adults in developed countries. • Frequency of arterial hypertension suddenly increases after 50 years of life (>50% of this population). • Worldwide, hypertension affects over 970 milion persons.

6. Definition and classification of blood 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

7. 16 14 12 10 8 6 4 2 0 0 2 4 6 8 10 12 Impact of High-Normal BP on Risk of Major CV Events* in Men High-normal BP (130-139/85-89 mm Hg) Normal BP (120-129/80-84 mm Hg) Cumulative Incidence (%) of Major CV Events Optimal BP (<120/80 mm Hg) Time (y) * 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.

8. Arterial Hypertension as a risk factor • Hypertension is a highly prevalent risk factor for cardiovascular disease • Hypertension plays a major etiologic role in the development of cerebrovascular disease, ischemic heart disease, cardiac and renal failure

9. Assessment of global cardiovascular risk in arterial hypertension • grades of hypertension • total cardiovascular risk (coexistence different risk factors, organ damage, concomitant diseases)

10. Stratification of total CV risk • Four categories : • - Low • - Moderate • - High • - Very high refer to 10 year risk of fatal or non-fatal CV event

11. Diagnostic evaluation in arterialhypertension • Establishing BP values • Identyfying secondary causes of AH • Searching for : • -other risk factors • -subclinical organ damage • -concomitant diseases • -accompanying CV and renal complications

12. Diagnostic procedures in arterial hypertension • repeated BP measurements • family and clinical history • physical examination • laboratory and instrumental investigation

13. Laboratory and instrumental investigation- 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

14. Laboratory and instrumental investigation • 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

15. Left ventricular hypertrophy, parasternal long axis view

16. Left ventricular hypertrophy, parasternal short axis view

17. Left ventricular hypertrophy,four-chamber view

18. Left ventricular hypertrophy, subcostal view

19. Extended laboratory and instrumental investigation • Search for cerebral, cardiac, renal, vascular damage, for secondary hypertension: • measurement of renin, aldosteron,corticosteroids,catecholamines in plasma and/or urine • arteriographies, CT, MRI

20. Secondary causes of AH : • Renal parenchymal disease (most common cause) • Renovascular hypertension (2nd most common cause) • Pheochromocytoma • Primary hyperaldosteronism • Cushing’s syndrome • Obstructive sleep apnea • Coarctation of aorta • Drug-induced hypertension

21. Evidence on the benefit of antihypertensive treatment • Placebo controlled trials provided evidence that BP lowering reduces fatal and non-fatal CV events • Trials comparing different antihypertensive drugs emphasise role of BP lowering of all CV events (stroke, myocardial infarction, heart failure) • BP-independent effects (protection against subclinical organ damage, prevention of high risk condition such as diabetes, renal failure, atrial fibrillation)

22. Benefits of Lowering BP Average reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%

23. Aim of antihypertensive therapy • The primary goal of treatment is to achieve maximum reduction in the long-term total risk of CV disease • For this reason lowering BP therapy (at least < 140/90 mm Hg) and treatment of all reversible risk factors are indicated • In diabetes and in high and very high risk patients BP target should be at least < 130/80 mmHg

24. Treatment guidelines (ESH/ESC 2007) 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

25. Lifestyle changes • smoking cessation • weight reduction • reduction of excessive alkohol intake • physical exercise • reduction of salt intake • increase in fruit and vegetables intake • decrease in saturated and total fat intake

26. Choice of the antihypertensive drugs • Five major classes of these drugs are suitable for initiation and maintenance of treatment, alone or in combination : • thiazide diuretics • calcium antagonists (CA) • ACE-inhibitors (ACEI) • angiotensin receptor blockers (ARB) • beta-blockers (BB)

27. Conditions favouring the use of some antihypertensive drugs versus other • Subclinical organ damage: LVH ACEI, CA, ARB Asymptomatic Atherosclerosis CA, ACEI Microalbuminuria ACEI, ARB Renal dysfunction ACEI, ARB

28. Conditions favouring the use of some antihypertensive drugs versus other • Clinical event: Previous stroke any BP lowering agent Previous MI BB, ACEI, ARB Heart failure diuretics, BB, ACEI, ARB, anti-aldosterone agents Tachyarrhythmias BB Periph.art.disease CA LV dysfunction ACEI

29. Conditions favouring the use of some antihypertensive drugs versus other • Condition : ISH (elderly) diuretics,CA Metabolic syndrome ACEI,ARB,CA Diabetes mellitus ACEI, ARB Pregnancy CA,methyldopa,BB Glaucoma BB

30. Monotherapy versus combination therapy • Monotherapy allows to achieve BP target only in a limited number of patients • Use of more than one agent is necessary to achieve target BP • Initial therapy: monotherapy or combination of two drugs in low doses with subsequent increase in drug doses or number

31. Monotherapy versus combination therapy • Monotherapy in mild BP elevation with low or moderate total CV risk • Two drugs at low doses should be preferred as the first step when BP is in grade 2 or 3 or total CV risk is high or very high with mild hypertension • Fixed combination of two drugs simplify the treatment • If BP control is not achieved by two drugs, combination of three or more drugs is required

32. Possible combinations of different classes of antihypertensive agents Diuretics AT1-receptorblockers β-blockers CCBs α-blockers ACE, angiotensin-converting enzyme AT, angiotensin CCB, calcium-channel blocker ACEinhibitors 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 ESH – ESC Guidelines Committee. J Hypertens 2007; 25: 1105–1187

33. Antihypertensive therapy in special groups • Elderly patients • Diabetic patients • Patients with renal dysfunction • Patients with cerebrovascular disease • Patients with coronary heart disease and heart failure • Patients with atrial fibrillation

34. Hypertension in women • Response to antihypertensive drugs, beneficial effect of BP lowering is similar in men and women • Oral contraceptives • Hormone replacement therapy • Hypertension in pregnancy

35. Resistant 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

36. Unsuspected secondary cause

37. Unsuspected secondary cause

38. Unsuspected secondary cause Coarctation of aorta

39. Unsuspected secondary cause Coarctation of aorta

40. Malignant hypertension • Clear overlap between resistant and malignant hypertension • Severe BP elevation (DBP usually >140 mmHG) with vascular damage (retinal haemorrhage, papilloedema, hypertensive encephalopathy,deterioration in renal function, DIC)

41. Hypertensive 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

42. Echocardiography • Examples of two hypertensive emergencies: - aortic dissection - fatal myocardial infarction

43. Aortic dissection

44. Aortic dissection

45. Chronic aortic dissection

46. Chronic aortic dissection

47. Fatal myocardial infarction

48. Fatal myocardial infarction

49. Fatal myocardial infarction

50. Fatal myocardial infarction