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
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
Παπούσα Νόσορ Αρτθριακι Τπζρταςθ διαγνωςκείςα προ 2ετίασ υπό: Ολμεςαρτάνθ / HTZ 40/12.5 mg Μετοπρολόλθ / Φελοδιπίνθ 47.5/5 mg Αναφερόμενθ HBP = 150-170 / 80 100 mmhg
Ατομικό Αναμνηστικό Καπνιςτισ 50 πακζτα - χρόνια Δ ΙΙ υπό μετφορμίνθ Γαςτρίτιδα υπό παντοπραηόλθ
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
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
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
Επίκπιση 53 ετϊν, καπνιςτισ, παχφςαρκοσ (II), ςακχαροδιαβθτικόσ ΙΙ, δυςλιπιδαιμικόσ, με υπετροφία τθσ αριςτερισ κοιλίασ και αρρφκμιςτθ αρτθριακι πίεςθ παρά τθ λιψθ 4πλθσ αντιυπερταςικισ αγωγισ.
Θεπαπεία - Ππογπαμματισμόρ Εντατικοποίθςθ υγιεινοδιαιτθτικϊν μζτρων Ολμεςαρτάνθ/HTZ 40/25 mg Νεμπιβολόλθ 5 mg Νιφεδιπίνθ 60 mg Επανεξζταςθ ςε 1 μινα
Επανεξέταση HBP=150 165/ 85 95 mmhg OBP=145/90 mmhg
Επώτηση Ο αςκενισ ζχει ανκεκτικι υπζρταςθ;
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
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
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
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
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;117:510-526
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;117:510-526
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
Επώτηση Η 24ωρθ περιπατθτικι καταγραφι τθσ ΑΠ κα ιταν χριςιμθ;
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;117:510-526
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
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
ABPM ABPM= 142/81, dipper
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;117:510-526
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
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;117:510-526
Resistant hypertension: diagnostic and treatment recommendations NSAIDs Sympathomimetics (diet pills, decongestants) Licorice Ephedra Oral contraceptives
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;117:510-526
Resistant hypertension: diagnostic and treatment recommendations Circulation 2008;117:510-526
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;117:510-526
Επώτηση Πωσ κα ενιςχφατε τθν αγωγι του αςκενοφσ;
ALDO - PA Tsioufis et al, International J Hypertension. 2011
Spironolactone efficacy in RHTN (12.5-25 mg, n=76) Nishizaka MK, et al, Am J Hypertens. 2003
Spironolactone 25-100 mg, n= 175, 7 months Hypertension 2010
Jansen et al, Int J Hypertension. 2011
Τποποποίηση αγωγήρ και επανεξέταση πειρονολακτόνθ (25 50 mg) ABPM: 136/75 mmhg
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;117:510-526
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;117:510-526
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;117:510-526
Resistant hypertension: diagnostic and treatment recommendations 8 th step: Interventional Approach
Devise-Based Approaches to Hypertension Management
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