2013 ESH/ESC Hypertension Guidelines

Presentación del tema: "2013 ESH/ESC Hypertension Guidelines"— Transcripción de la presentación:

1 2013 ESH/ESC Hypertension Guidelines
Guías de HTA ESH/ESC

2 Evaluación diagnóstica
Confirmación del diagnóstico de HTA Detección de causas de HTA secundaria Valoración del RCV, LOD asintomática y condiciones clínicas concomitantes

3 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

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

5 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

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

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

8 PA ambulatoria

9 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

10 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

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

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

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

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

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

16 Objetivos de PA

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

18 Estrategias de tratamiento

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

20 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

21 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

22 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 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

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

24 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 mmHg IIbC PA normal alta No se recomienda tratamiento farmacológico IIIA

25 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

26 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

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

28 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

29 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)

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

31 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

32 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

33 Tratamiento en condiciones especiales

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

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

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

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

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

39 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

40 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

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

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

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

44 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