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

Sin cambios Factores (además de PA clínica) que influyen en el pronóstico para la estratificación de RCV total Sin cambios Data taken from European cardiovascular disease statistics 2008

Estratificación del RCV en categorías: bajo, moderado, alto y muy alto riesgo Data taken from European cardiovascular disease statistics 2008

Valoración y estratificación del RCV total En la estratificación, además de la HTA: Otros FRCV LOD asintomática Diabetes Enfermedad renal o CV establecida Recomendaciones Clase Nivel Asintomáticos hipertensos sin ECV, DM , mínimos requerimientos I B Hay evidencias de que la LOD predice el riesgo de muerte CV independientemente del SCORE por lo que se debe valorar sobre todo en individuos de riesgo moderado IIa Se recomienda que las decisiones del tratamiento dependan del nivel inicial de RCV total Data taken from European cardiovascular disease statistics 2008

Definición y clasificación de los niveles de PA clínica Data taken from European cardiovascular disease statistics 2008

Definición de HTA a través de los niveles de PA clínica y no clínica Data taken from European cardiovascular disease statistics 2008

PA ambulatoria

Evaluación diagnóstica: Variables derivadas del MAPA Categoría Ratio Noche/día Ausencia de dipping >1.0 Dipping leve >0.9 y ≤ 1.0 Dipping >0.8 y ≤ 0.9 Dipping extremo ≤ 0.8 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

Definiciones según presión arterial clínica y ambulatoria Office BP(mmHg) PAS < 140 y PAD < 90 PAS ≥ 140 o PAD ≥ 90 PA ambulatoria diurna o Home BP(mmHg) PAS < 135 y PAD < 85 Normotensión verdadera HT de bata blanca PAS ≥ 135 y PAD ≥ 85 HT enmascarada HT sostenida

Indicaciones de la medición de la PA ambulatoria Data taken from European cardiovascular disease statistics 2008

Recomendaciones en la evaluación diagnóstica a nivel cardíaco, arterial, renal, retiniano y cerebral

Sin cambios Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónica Data taken from European cardiovascular disease statistics 2008 Sin cambios

Sin cambios Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónica Sin cambios Data taken from European cardiovascular disease statistics 2008

Sin cambios Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónica Data taken from European cardiovascular disease statistics 2008 Sin cambios

Objetivos de PA

Objetivos de presión arterial Data taken from European cardiovascular disease statistics 2008

Estrategias de tratamiento

Inicio de los cambios en el estilo de vida y tratamiento antiHTA Data taken from European cardiovascular disease statistics 2008

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

PA < 140/90 mmHg 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 Data taken from European cardiovascular disease statistics 2008

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 Data taken from European cardiovascular disease statistics 2008

Initiation of antihypertensive drug treatment Data taken from European cardiovascular disease statistics 2008

Inicio de tratamiento farmacológico Grado 2-3 Recomendado (precoz) IA Grado I (alto RCV) Recomendado IB Grado I (bajo RCV) Debe considerarse IIaB Ancianos Recomendado si PAS ≥ 160 mmHg Puede considerarse si PAS 140-159 mmHg IIbC PA normal alta No se recomienda tratamiento farmacológico IIIA

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 Data taken from European cardiovascular disease statistics 2008

Estrategias de tratamiento en condiciones especiales 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

Treatment strategies and choice of drugs Data taken from European cardiovascular disease statistics 2008

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 Data taken from European cardiovascular disease statistics 2008

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 Data taken from European cardiovascular disease statistics 2008 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)

Treatment of risk factors associated with hypertension Data taken from European cardiovascular disease statistics 2008

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 Data taken from European cardiovascular disease statistics 2008

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 Data taken from European cardiovascular disease statistics 2008 Intentar reducciones farmacológicas tras buen control largo tiempo

Tratamiento en condiciones especiales

Treatment strategies in hypertensive patients with resistant hypertension Data taken from European cardiovascular disease statistics 2008

Treatment strategies in hypertensive patients with heart disease Data taken from European cardiovascular disease statistics 2008 COMO ANTES

Treatment strategies in hypertensive patients with cerebrovascular disease Data taken from European cardiovascular disease statistics 2008

Treatment strategies in hypertensive patients with atherosclerosis, arteriosclerosis, and peripheral artery disease Data taken from European cardiovascular disease statistics 2008 PA <140/90 mmHg

Treatment strategies in hypertensive patients with nephropathy Data taken from European cardiovascular disease statistics 2008 PAS < 130-140 mmHg Si proteinuria bloqueadores de SRAA

Treatment strategies in hypertensive patients with metabolic syndrome Data taken from European cardiovascular disease statistics 2008 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) 40

Treatment strategies in patients with diabetes Data taken from European cardiovascular disease statistics 2008 PA < 140/85 mmHg

Drugs to be preferred in specific conditions Data taken from European cardiovascular disease statistics 2008

Treatment strategies in hypertensive women Data taken from European cardiovascular disease statistics 2008

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 44