ΠΑΡΟΤΙΑΗ ΠΕΡΙΣΑΣΙΚΟΤ Α. Κορδαλισ, Κ. Σςιοφφθσ

Μέγεθος: px

Εμφάνιση ξεκινά από τη σελίδα:

Download "ΠΑΡΟΤΙΑΗ ΠΕΡΙΣΑΣΙΚΟΤ Α. Κορδαλισ, Κ. Σςιοφφθσ"

Παναγιώτα Γιάγκος
7 χρόνια πριν
Προβολές:

1 ΕΛΛΗΝΙΚΗ ΚΑΡΔΙΟΛΟΓΙΚΗ ΕΣΑΙΡΕΙΑ ΠΑΡΟΤΙΑΗ ΠΕΡΙΣΑΣΙΚΟΤ Α. Κορδαλισ, Κ. Σςιοφφθσ Α ΠΑΝΕΠΙΣΗΜΙΑΚΗ ΚΑΡΔΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ «ΙΠΠΟΚΡΑΣΕΙΟ» Γ. Ν. ΑΘΗΝΩΝ ΟΜΑΔΑ ΕΡΓΑΙΑ ΤΠΕΡΣΑΗ ΚΑΙ ΚΑΡΔΙΑ ΕΜΙΝΑΡΙΑ ΟΜΑΔΩΝ ΕΡΓΑΙΑ ΦΕΒΡΟΤΑΡΙΟ 2012 ΘΕΑΛΟΝΙΚΗ

2 Παπούσα Νόσορ 53 ετϊν προςζρχεται ςτθ Μονάδα Τπζρταςθσ τθσ Αϋ Πανεπιςτθμιακισ Καρδιολογικισ Κλινικισ λόγω αναφερόμενθσ αρρφκμιςτθσ αρτθριακισ πίεςθσ από 2ετίασ παρά τθ λιψθ αντιυπερταςικισ αγωγισ

3 Παπούσα Νόσορ Αρτθριακι Τπζρταςθ διαγνωςκείςα προ 2ετίασ υπό: Ολμεςαρτάνθ / HTZ 40/12.5 mg Μετοπρολόλθ / Φελοδιπίνθ 47.5/5 mg Αναφερόμενθ HBP = / mmhg

4 Ατομικό Αναμνηστικό Καπνιςτισ 50 πακζτα - χρόνια Δ ΙΙ υπό μετφορμίνθ Γαςτρίτιδα υπό παντοπραηόλθ

5 Αντικειμενική Εξέταση Υ=160cm, B= 94kg, BMI= 37 kg/m2 OBP= 155/85 mmhg Σθ=70 bpm Κεθαλή/ηράτηλος: JVP(-) Θώρακας: S1S2 τωρίς πρόζθεηοσς ήτοσς, ΑΨ: κ.θ. Ράτη: κ.θ. Κοιλία: MEA, Η (-), Σ (-) Άκρα: τωρίς οιδήμαηα

6 Επγαστηπιακόρ έλεγχορ Glc=156mg/dl HbA1c=8% Ur=33 mg/dl, Cr=0.55 mg/dl K=4.4 meq/l, Na=140mEq/l TCHOL=205 LDL-CHOL=124 mg/dl HDL-CHOL=36 mg/dl Λεφκωμα οφρων: (-) TSH=1.76μIU/ml

7 Παπακλινικόρ έλεγχορ ΗΚΓ= SR, 60 bpm, Sokolow=2.7mV TTE: EF=60%, ΜΚΔ=12mm ΟΣΑΚ=12,2mm E=82 m/sec A=86 m/sec US νεφρϊν: φυςιολογικό μζγεκοσ και πάχοσ φλοιοφ Triplex νεφρικϊν αρτθριϊν: κφ

8 Επίκπιση 53 ετϊν, καπνιςτισ, παχφςαρκοσ (II), ςακχαροδιαβθτικόσ ΙΙ, δυςλιπιδαιμικόσ, με υπετροφία τθσ αριςτερισ κοιλίασ και αρρφκμιςτθ αρτθριακι πίεςθ παρά τθ λιψθ 4πλθσ αντιυπερταςικισ αγωγισ.

10 Θεπαπεία - Ππογπαμματισμόρ Εντατικοποίθςθ υγιεινοδιαιτθτικϊν μζτρων Ολμεςαρτάνθ/HTZ 40/25 mg Νεμπιβολόλθ 5 mg Νιφεδιπίνθ 60 mg Επανεξζταςθ ςε 1 μινα

11 Επανεξέταση HBP= / mmhg OBP=145/90 mmhg

12 Επώτηση Ο αςκενισ ζχει ανκεκτικι υπζρταςθ;

13 Resistant or Refractory Hypertension Office BP>140/90 or 130/80 mm Hg in patients with diabetes or chronic kidney disease and Patient prescribed 3 or more antihypertensive medications at optimal doses, including if possible a diuretic or Office BP at goal but patient requiring 4 or more antihypertensive medications RESISTANT HYPERTENSION UNCONTROLLED HYPERTENSION

14 Prevalence of Resistant Hypertension General Population 5 to 30% In Specialized Referral Centers True Resistant HTN on optimal Rx 3-5% The high prevalence of HTN reflects a significant actual pts number with Resistant HTN Prevalence is higher among patients with target organ damage: Renal Cardiac disease, PVD etc

15 The Phenotype of Resistant Hypertension Patient Characteristics Associated With Resistant Hypertension Older age High baseline BP Obesity Excessive dietary salt ingestion Chronic kidney disease Diabetes Left ventricular hypertrophy Black race Female sex

16 The Phenotype of Resistant Hypertension Patient Characteristics Associated With Resistant Hypertension Older age High baseline BP Obesity Excessive dietary salt ingestion Chronic kidney disease Diabetes Left ventricular hypertrophy Black race Female sex

17 Resistant hypertension: diagnostic and treatment recommendations 1 st step: Confirm Treatment Resistance 2 nd step: Exclude Pseudoresistance 3 rd step: Identify and Reverse Contributing Lifestyle Factors 4 th step: Discontinue or Minimize Interfering Substances 5 th step: Screen for Secondary Causes of Hypertension 6 th step: Pharmacologic Treatment 7 th step: Refer to Specialist Circulation 2008;117:

19 Resistant hypertension: diagnostic and treatment recommendations 1 st step: Confirm Treatment Resistance 2 nd step: Exclude Pseudoresistance 3 rd step: Identify and Reverse Contributing Lifestyle Factors 4 th step: Discontinue or Minimize Interfering Substances 5 th step: Screen for Secondary Causes of Hypertension 6 th step: Pharmacologic Treatment 7 th step: Refer to Specialist Circulation 2008;117:

20 Resistant hypertension: diagnostic and treatment recommendations Office BP>140/90 or 130/80 mm Hg in patients with diabetes or chronic kidney disease and Patient prescribed 3 or more antihypertensive medications at optimal doses, including if possible a diuretic or Office BP at goal but patient requiring 4 or more antihypertensive medications

21 Επώτηση Η 24ωρθ περιπατθτικι καταγραφι τθσ ΑΠ κα ιταν χριςιμθ;

22 Resistant hypertension: diagnostic and treatment recommendations 1 st step: Confirm Treatment Resistance 2 nd step: Exclude Pseudoresistance 3 rd step: Identify and Reverse Contributing Lifestyle Factors 4 th step: Discontinue or Minimize Interfering Substances 5 th step: Screen for Secondary Causes of Hypertension 6 th step: Pharmacologic Treatment 7 th step: Refer to Specialist Circulation 2008;117:

23 Resistant hypertension: diagnostic and treatment recommendations Evaluate adherence and improve it with Education Least costly effective drug regimen Once daily fixed dose combinations Involve the patient and environment Proper measurements of BP White coat HTN with reliable home or ABPM

26 ABPM characteristics of RHTN Higher percentage of nondippers in true RHTN (68.7% vs 49.6%, p<0.001) Muxfeldt et al, Blood Pressure Monitoring, 2003

27 ABPM ABPM= 142/81, dipper

28 Resistant hypertension: diagnostic and treatment recommendations 1 st step: Confirm Treatment Resistance 2 nd step: Exclude Pseudoresistance 3 rd step: Identify and Reverse Contributing Lifestyle Factors 4 th step: Discontinue or Minimize Interfering Substances 5 th step: Screen for Secondary Causes of Hypertension 6 th step: Pharmacologic Treatment 7 th step: Refer to Specialist Circulation 2008;117:

29 Resistant hypertension: diagnostic and treatment recommendations Obesity and weight reduction Physical inactivity and Regular aerobic exercise Evaluate the amount of alcohol intake Evaluate dietary salt intake

30 Resistant hypertension: diagnostic and treatment recommendations 1 st step: Confirm Treatment Resistance 2 nd step: Exclude Pseudoresistance 3 rd step: Identify and Reverse Contributing Lifestyle Factors 4 th step: Discontinue or Minimize Interfering Substances 5 th step: Screen for Secondary Causes of Hypertension 6 th step: Pharmacologic Treatment 7 th step: Refer to Specialist Circulation 2008;117:

31 Resistant hypertension: diagnostic and treatment recommendations NSAIDs Sympathomimetics (diet pills, decongestants) Licorice Ephedra Oral contraceptives

32 Resistant hypertension: diagnostic and treatment recommendations 1 st step: Confirm Treatment Resistance 2 nd step: Exclude Pseudoresistance 3 rd step: Identify and Reverse Contributing Lifestyle Factors 4 th step: Discontinue or Minimize Interfering Substances 5 th step: Screen for Secondary Causes of Hypertension 6 th step: Pharmacologic Treatment 7 th step: Refer to Specialist Circulation 2008;117:

33 Resistant hypertension: diagnostic and treatment recommendations Circulation 2008;117:

34 Resistant hypertension: diagnostic and treatment recommendations 1 st step: Confirm Treatment Resistance 2 nd step: Exclude Pseudoresistance 3 rd step: Identify and Reverse Contributing Lifestyle Factors 4 th step: Discontinue or Minimize Interfering Substances 5 th step: Screen for Secondary Causes of Hypertension 6 th step: Pharmacologic Treatment 7 th step: Refer to Specialist Circulation 2008;117:

35 Επώτηση Πωσ κα ενιςχφατε τθν αγωγι του αςκενοφσ;

36 ALDO - PA Tsioufis et al, International J Hypertension. 2011

37 Spironolactone efficacy in RHTN ( mg, n=76) Nishizaka MK, et al, Am J Hypertens. 2003

38 Spironolactone mg, n= 175, 7 months Hypertension 2010

39 Jansen et al, Int J Hypertension. 2011

40 Τποποποίηση αγωγήρ και επανεξέταση πειρονολακτόνθ (25 50 mg) ABPM: 136/75 mmhg

41 Resistant hypertension: diagnostic and treatment recommendations 1 st step: Confirm Treatment Resistance 2 nd step: Exclude Pseudoresistance 3 rd step: Identify and Reverse Contributing Lifestyle Factors 4 th step: Discontinue or Minimize Interfering Substances 5 th step: Screen for Secondary Causes of Hypertension 6 th step: Pharmacologic Treatment 7 th step: Refer to Specialist Circulation 2008;117:

42 Resistant hypertension: diagnostic and treatment recommendations Refer to specialist: Known or suspected secondary causes of HTN Uncontrolled BP after 6 months of treatment Circulation 2008;117:

43 Resistant hypertension: diagnostic and treatment recommendations 1 st step: Confirm Treatment Resistance 2 nd step: Exclude Pseudoresistance 3 rd step: Identify and Reverse Contributing Lifestyle Factors 4 th step: Discontinue or Minimize Interfering Substances 5 th step: Screen for Secondary Causes of Hypertension 6 th step: Pharmacologic Treatment 7 th step: Refer to Specialist Circulation 2008;117:

44 Resistant hypertension: diagnostic and treatment recommendations 8 th step: Interventional Approach

45 Devise-Based Approaches to Hypertension Management

46 Ευχαριςτώ για την προςοχή ςασ!

Σχετικά έγγραφα

Υπέρταση και Διατροφή

Υπέρταση και Διατροφή Αντώνης Ζαμπέλας Μονάδα Διατροφής του Ανθρώπου Τμήμα Επιστήμης και Τεχνολογίας Τροφίμων Γεωπονικό Πανεπιστήμιο Αθηνών Συχνότητα εμφάνισης της υπέρτασης στην Ελλάδα. Μελέτη Αττικής