Διαγνωστική αξιολόγηση του υπερτασικού ασθενούς

Διαγνωστική αξιολόγηση του υπερτασικού ασθενούς Ε. Τριανταφυλλίδη Επιµελήτρια Α Καρδιολογίας Β Πανεπιστηµιακή Καρδιολογική Κλινική Νοσοκοµείο ΑΤΤΙΚΟΝ

Αρτηριακή υπέρταση: επίπτωση 25% του πληθυσµού της γης είναι υπερτασικοί (30% έως το 2025). Η ε π ί π τ ω σ η π α ρ α µ έ ν ε ι σχεδόν σταθερή στις αναπτυγµένες χώρες ενώ αυξάνεται στις οικονοµικά αναπτυσσόµενες χώρες (διαφορά ποσοστών και µεγέθους πληθυσµού). Τ α υψηλά ποσοστά υπέρτασης συµβάλλουν στην παρατηρούµενη έξαρση των καρδιαγγειακών νοσηµάτων παγκοσµίως.

Διαγνωστική αξιολόγηση του υπερτασικού ασθενούς! Επιβεβαίωση της διάγνωσης της υπερτασικής νόσου! Μελέτη των βλαβών οργάνων-στόχων και των συνυπαρχουσών συν-νοσηροτήτων µε στόχο την αποτίµηση του συνολικού καρδιαγγειακού κινδύνου! Αποκλεισµός τυχόν αιτίων δευτεροπαθούς υπέρτασης

Evidence-based medicine Hypertension measurement (1)! Office based BP measurements predict risk of adverse outcomes and serve as therapeutic targets in the management of hypertension.! Guidelines for reliable blood pressure measurement emphasize correct patient position, a period of quiet rest, use of an appropriately sized cuff, and minimization of extraneous factors that influence blood pressure such as smoking and caffeine intake prior to blood pressure measurement.! However, blood pressures measured under routine conditions may be significantly higher (12.4/6.0 mmhg systolic/diastolic BP) than readings taken recommended guidelines.

Evidence-based medicine Hypertension measurement (2)! Conclusively, clinic BP alone might result in substantial overdiagnosis of hypertension.! Falsely high clinic readings can prompt inappropriate addition or escalation of antihypertensive drug therapy and increase risk for adverse drug effects.! Guidelines mandate confirmation of elevated office BP by measuring BP at home or by 24 hour ABPM to make a diagnosis of hypertension

ABPM (1)! Ambulatory blood pressure monitoring is a valuable tool in the management of the hypertensive patient, measuring daytime and nighttime blood pressure, and providing an assessment of diurnal blood pressure changes, which are important predictors of hypertension related morbidity and mortality.! Currently, evaluating for white-coat hypertension is the main indication for ABPM. Other indications include evaluation of autonomic neuropathy, syncope, hypotension, resistant hypertension, diurnal blood pressure variation, and effect of antihypertensive medications over the entire 24 hours.! Dipping status AND nighttime BP. ABPM provides additional information beyond clinic BP regarding risk for hypertension associated morbidity and mortality. Much of this added benefit stems from the ability to measure not daytime but nighttime blood pressure.

ABPM (2)! Conducting ABPM requires the proper equipment and careful training of clinic staff to ensure accuracy of the procedure.! BP is then measured in both arms and an appropriately sized cuff placed on the non-dominant arm if the difference in systolic BP is less than 10mmHg (the arm with the greater pressure is used if the difference is 10 mmhg).! Clinic staff should explain the details of the procedure including the frequency of measurement (typically every 15-30 during the day and every 30 at night) and instruct patients to ensure the monitor stays attached, to continue to conduct their normal daily activities, and to keep the monitored arm steady and level with the heart during each reading for the entire 24 hour period.! A diary of sleep and wake times is often used to define day and night

ABPM (3)

ABPM (4) Elevated ABPM is associated with increased risk for CV disease and allcause mortality in the general population, hypertensive patients, and patients with resistant hypertension. Significantly greater estimated cumulative tenyear incidence of both fatal and nonfatal events among patients with higher than predicted ABPs than among those with lower than predicted ABPs.

ABPM (5)! In summary, the findings are consistent and indicate that ambulatory blood pressure is superior to clinic blood pressure for predicting adverse events.! Additionally, nighttime blood pressure may have greater predictive ability than daytime blood pressure again reinforcing the benefits of ABPM for evaluating risk associated with hypertension.

HBPM (1) Home blood pressure monitoring is an attractive option in the management of hypertension because:! inexpensive and convenient method in a environment familiar to the patient! reproducibility of HBPM better than traditional office BP measurements! overcome some biases in office based readings such as digit preference and observer bias! helpful in the elderly, in whom the white coat effect is often prominent! lower health care costs associated with treatment of hypertension

HBPM (2)! Patients should use automated brachial BP monitors that have been validated and calibrated annually against standardized clinic measurements.! Home blood pressure should be measured twice daily for a 3-7 day period; some investigators do not use the values on the first day of monitoring to allow patients to acclimate to the process.! Every measurement should be documented along with the pulse rate, time, and date; devices with an integrated memory can help avoid selection bias.! The reliability of readings may be decreased by arrhythmias and frequent ectopic beats.! Home BP greater than 135/85 mmhg be defined as hypertensive.

HBPM (3)! Home BP may be a superior prognostic indicator of CV morbidity and mortality than office BP. Home-measured BP is prognostically superior to office BP

HBPM (4)! Data argue that measuring blood pressure at home might outperform ABPM in predicting hypertensive target organ damage.! It is also reasonable to expect that active participation of patients in their health care may improve therapeutic compliance.! Self-titration of antihypertensive drug therapy based on home blood pressure readings is also an interesting intervention.

HBPM (5)! In summary, when used by trained patients using validated monitors, home blood pressure monitoring can provide important prognostic information, and facilitate the management of hypertension.! With mobile technology and increasing capability to transmit such information over the internet, it is likely that home blood pressure monitoring will play a larger part in the clinical management of hypertensive patients.

HBPM vs. office BP/ABPM! When compared with office BP, HBPM yields multiple measurements over several days, or even longer periods, taken in the individual s usual environment.! Compared with ambulatory BP, HBPM provides measurements over extended periods and day-to-day BP variability, is cheaper, more widely available and more easily repeatable.! However, unlike ABPM, HBPM does not provide BP data during routine, day-to-day activities and during sleep or the quantification of short-term BP variability.

Categories by BP measurement! Categorizing patients by measuring BP both in the clinic and outside the clinic (HBPM or ABPM) provides important prognostic information and helps to guide the treatment of patients with hypertension.! Patients can be categorized as: - True normotension (clinic BP <140/90mmHg and daytime ABPM <135/85mmHg) - White-coat hypertension (elevated clinic BP and normal ABPM) - Masked hypertension (normal clinic BP and elevated ABPM) - Sustained hypertension (elevated clinic BP and ABPM).! Compared to true normotension, all forms of hypertension are associated with increased risk for hypertensive target organ damage and adverse clinical outcomes, although the risk is higher in patients with masked and sustained hypertension than in patients with white-coat hypertension.

Λήψη ιατρικού ιστορικού Κλινική εξέταση! Λαµβάνονται στοιχεία σχετικά µε την ηµεροµηνία πρώτης διάγνωσης της υπερτασικής νόσου, συνύπαρξης άλλων νοσηµάτων και τυχόν οικογενούς-γενετικής προδιάθεσης.! Ακρόαση καρδιάς, καρωτίδων, νεφρικών αρτηριών για την ανεύρεση φυσηµάτων.! Λήψη σωµατοµετρικών και καρδιακής συχνότητας! Επί υποψίας δευτεροπαθούς υπέρτασης ακολουθεί διερεύνηση για αντίστοιχη κλινική σηµειολογία.

Εργαστηριακές εξετάσεις

Βλάβες οργάνων-στόχων! A large body of evidence is available on the crucial role of asymptomatic organ damage (OD) in determining the CV risk of individuals with (and without) abnormal BP.! Any of the four main markers of OD (LVH, microalbuminuria, increased PWV, and carotid plaques) can predict CV mortality independently of SCORE stratification.

Ηλεκτροκαρδιογράφηµα! Χαµηλή ευαισθησία ως προς την ανίχνευση LVH.! Όταν διαπιστώνεται (µε ή χωρίς εικόνα strain) προβλέπει υψηλό καρδιαγγειακό κίνδυνο.! Διαπίστωση αρρυθµιών ή κολπικής µαρµαρυγήςπροδιάθεση για ΑΕΕ.

Triplex καρδιάς/αορτής (1) LVDD=45.1 mm IVS=14.5 mm PW=14.2 mm RWT=0.64 LVMI=112.5 gr/m2 EF=60%

Στεφανιαία εφεδρεία Hypertension lowers the specificity of exercise electrocardiography and perfusion scintigraphy. The use of dual echocardiographic imaging of regional wall motion and transthoracic, Doppler-derived coronary flow reserve on the left anterior descending artery has recently been suggested to distinguish: A.obstructive CHD (reduced coronary reserve plus inducible wall motion abnormalities) from B.isolated coronary microcirculatory damage (reduced coronary reserve without wall motion abnormalities)

Έλεγχος αρτηριακής σκληρίας Aortic stiffness has independent predictive value for fatal and non-fatal CV events in hypertensive patients. A substantial proportion of patients at intermediate risk could be reclassified into a higher or lower CV risk, when arterial stiffness is measured.

Εκτίµηση των καρωτίδων Triplex καρωτίδων Ultrasound examination of the carotid arteries with measurement of intima-media thickness (IMT) and/or the presence of plaques has been shown to predict the occurrence of both stroke and myocardial infarction, independently IMT= 0.13 of mm traditional CV risk factors. The relationship between carotid IMT and CV events is a continuous one and determining a threshold for high CV risk is rather arbitrary. Α carotid IMT >0.9 mm has been taken as a conservative estimate of existing abnormalities.

Νεφρική λειτουργία-βυθός οφθαλµού- Εγκέφαλος Triplex καρωτίδων The diagnosis of hypertension-induced renal damage is based on the finding of a reduced renal function and/or the detection of elevated urinary excretion IMT= of albumin. 0.13 mm CKD is classified according to estimated glomerular filtration rate (egfr), calculated by MDRD formula or the Cockcroft-Gault formula. Increased rate of urinary albumin or protein excretion points, in general, to a derangement in glomerular filtration barrier. The finding of an impaired renal function in a hypertensive patient, expressed as any of the abnormalities mentioned above, constitutes a very potent and frequent predictor of future CV events and death. ------------------------------------------------------------------------------------------------ Grade III (retinal haemorrhages, microaneurysms, hard exudates, cotton wool spots) and grade IV retinopathy (grade III signs and papilloedema and/or macular oedema) are indicative of severe hypertensive retinopathy, with a high predictive value for mortality. ------------------------------------------------------------------------------------------------- Hypertension, beyond its well-known effect on the occurrence of clinical stroke, is also associated with the risk of asymptomatic brain damage noticed on cerebral MRI, in particular in elderly individuals (white matter hyperintensities and silent infarcts. As cognitive disturbances in the elderly are, at least in part, hypertension related, suitable cognitive evaluation tests may be used in the clinical assessment of the elderly hypertensive patient.

Epidemiology and Total Cardiovascular Risk

Εκτίµηση συνολικού καρδιαγγειακού κινδύνου! Ορίζεται ως ο απόλυτος κίνδυνος εµφάνισης ενός θανατηφόρου καρδιαγγειακού συµβάντος εντός δεκαετίας. ΣΥΜΒΑΛΛΕΙ ΣΤΗ ΛΗΨΗ ΑΠΟΦΑΣΗΣ! Very high risk----!>30%! High risk----------!20-30%! Moderate risk----!15-20%! Low risk ----------!<15% I. Έναρξη φαρµακευτικής αγωγής II. Επιθυµητός στόχος αρτηριακής πίεσης III. Ανάγκη χρήσης συνδυασµών IV. Μη φαρµακευτική αγωγή V. Εκτίµηση κόστους-αποτελεσµατικότητας

A large proportion of patients with hypertension will not be at high absolute risk of cardiovascular death. However, some of these patients may be at high risk of non-fatal cardiovascular events, especially non-fatal stroke

Συµπεράσµατα! Η σωστή διαγνωστική αξιολόγηση του υπερτασικού ασθενούς βασιζόµενη αφενός στην επιβεβαίωση της υπερτασικής νόσου και αφετέρου στην εκτίµηση του καρδιαγγειακού κινδύνου θα θέσει τις βάσεις για την σωστή θεραπευτική αντιµετώπιση του ασθενούς και την αποφυγή µελλοντικών καρδιαγγειακών συµβαµάτων.