Καηεσθσνηήριες οδηγίες για ηην Αρηηριακή Υπέρηαζη Γκαλιαγκούζη Δσγενία MD, PhD Β Προπαιδεσηική Παθολογική Κλινική
ESH/ESC 2013 Guidelines for the management of arterial hypertension Αλλαγή θεραπεσηικών ζηότφν ζε ειδικές καηηγορίες αζθενών Γιαζηρφμάηφζη καρδιαγγειακού κινδύνοσ-δκηίμηζη βλάβης οργάνφν ζηότφν Θεραπεία ανθεκηικής ΑΥ?
Αλλαγή θεραπεσηικών ζηότφν
ESH/ESC Guidelines 2013 Blood pressure goals in hypertensive patients Recommendations SBP goal for most Patients at low moderate CV risk Patients with diabetes Consider with previous stroke or TIA Consider with CHD Consider with diabetic or non-diabetic CKD SBP goal for elderly Ages <80 years Initial SBP 160 mmhg SBP goal for fit elderly Aged <80 years SBP goal for elderly >80 years with SBP 160 mmhg DBP goal for most DB goal for patients with diabetes <140 mmhg 140-150 mmhg <140 mmhg 140-150 mmhg <90 mmhg <85 mmhg SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease; DBP, diastolic blood pressure.
Θεραπεσηικοί ζηότοι ζηην ΑΥ Mancia G et al, Diabetes Care 2011
The Navigator study group McMyrray et al NEJM 2010
ACCORD Study group ACCORD STUDY GROUP, NEJM 2010
ACCORD Study group ACCORD STUDY GROUP, NEJM 2010
INVEST Mancia G, Hypertension 2007
ONTARGET Sleight P, J Hypertension 2009
In-treatment SBP levels in trials with DM patients Mancia G. Circulation 2010
Hypertension treatment for people with diabetes Recommendations Mandatory: initiate drug treatment in patients with SBP 160 mmhg Additonal considerations Strongly recommended: start drug treatment when SBP 140 mmhg SBP goals for patients with diabetes: <140 mmhg DBP goals for patients with diabetes: <85 mmhg All hypertension treatment agents are recommended and may be used in patients with diabetes RAS blockers may be preferred Especially in presence of preoteinuria or microalbuminuria Choice of hypertension treatment must take comorbidities into account Coadministration of RAS blockers not recommended Avoid in patients with diabetes ESH Guidelines 2013
Φρόνια Νεθρική Νόζος 2 ζηότοι Πρόληυη καρδιαγγειακών ζσμβαμάηφν Δπιβράδσνζη επιδείνφζης πρφηεινοσρίας και νεθρικής λειηοσργίας ESH Guidelines 2013
Annals of Internal Medicine Upadhyay et al, Annals of Internal Medicine, 2011
Hypertension treatment for people with nephropathy Recommendations Additonal considerations Consider lowering SBP to <140 mmhg Consider SBP <130 mmhg with overt proteinuria RAS blockers more effective to reduce albuminuria than other agents Combination therapy usually required to reach BP goals Combination of two RAS blockers Aldosterone antagonist not recommended in CKD Monitor changes in egfr Indicated in presence of microalbuminuria or overt proteinuria Combine RAS blockers with other agents Not recommended Especially in combination with a RAS blocker Risk of excessive reduction in renal function, hyperkalemia ESH Guidelines 2013
OPTIMAL IN-TREATMENT BP TARGETS MAY BE DIFFERENT FOR THE BRAIN, THE KIDNEY AND THE HEART
Γιαζηρφμάηφζη καρδιαγγειακού κινδύνοσ ESH Guidelines 2013
Treatment of risk factors associated with hypertension Recommendations Use statin therapy in hypertensive patients at moderate to high CV risk Use statin therapy when overt CHD is present Additonal considerations LDL-C target: <3.0 mmol/l (<115 mg/dl) LDL-C target: <1.8 mmol/l (<70mg/dL) Use antiplatelet therapy, in particular low-dose aspirin, for hypertensive patients with previous CV events Consider aspirin therapy in hypertensive patients with reduced renal function or High CV risk Aspirin not recommended for CV prevention in low-moderate risk hypertensive patients Providing that BP is well controlled Benefit and harm are equivalent For hypertensive patients with diabetes Treat to a HbA 1c target <7.0% Fragile elderly patients with long diabetes duration, more comorbidities and at high risk Treat to a HbA 1c target <7.5 8.0% ESH Guidelines 2013
Διαζηρωμάηωζη καρδιαγγειακού κινδύνοσ Νέοι δείκηες αγγειακής λειηοσργίας ESH Guidelines 2013
PWV and cardiovascular risk Vlachopoulos C, et al, JACC 2010
PWV ως εργαλείο επαναδιαζηρωμάηωζης ηοσ CV κινδύνοσ ζε αζθενείς με ενδιάμεζο ρίζκο -PWV improves CVD risk prediction - 12.7% reclasssification in intermediate risk patients Ben-Schlomo Y, et al, JACC 2013
Ruijter HM JAMA 2012
Lifestyle changes for hypertensive patients Recommendations to reduce BP and/or CV risk factors Salt intake Restrict 5-6 g/day Moderate alcohol intake Limit to 20-30 g/day men, 10-20 g/day women Increase vegetable, fruit, low-fat dairy intake BMI goal 25 kg/m 2 Waist circumference goal Exercise goals Men: <102 cm (40 in.)* Women: <88 cm (34 in.)* 30 min/day, 5-7 days/week (moderate, dynamic exercise) Quit smoking ESH Guidelines 2013
Δπιλογή θεραπείας ESH guidelines-τι είναι διαθορεηικό Γεν σπάρτει ηλικιακό όριο Γεν σπάρτει κριηήριο θύλοσ ή θσλής Γεν προηείνεηαι θάρμακο πρώηης γραμμής
Δπιλογή θεραπείας JNC-8 guidelines
Δπιλογή θεραπείας NICE/BHS guidelines BHS/NICE Guidelines 2011
Δπιλογή θεραπείας ESH guidelines Grade I Grade II-III ESH Guidelines 2013
Possible combinations of classes of antihypertensive drugs Thiazide diuretics β-blockers Angiotensin-receptor blockers Other antihypertensives Calcium antagonists ACE inhibitors Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well tested combinations; red continuous line: not recommended combination. Although verapamil and diltiazem are sometimes used with a beta-blocker to improve ventricular rate control in permanent atrial fibrillation, only dihydropyridine calcium antagonists should normally be combined with beta-blockers.
Ανθεκηική Υπέρηαζη (RHTN) AY ανθεκηική ζηην θεραπεία: ΑΠ>140/90mmHg Υγιεινοδιαιηηηικά μέηρα και Θεραπεσηική αγφγή (3 ζκεσάζμαηα, οπφζδήποηε ηο ένα διοσρηηικό, ζε πλήρεις δόζεις)
RHTN-Σστνόηηηα USA Spain 12% Persell SD, Hypertension 2011 A De la Sierra Hypertension 2011
Σπειρονολακηόνη φς θεραπεία ζηην RHTN Chapman N, Hypertension 2007 De Souza Hypertension 2010
Φαρμακεσηική θεραπεία ζηην RHTN Recommendations Additonal considerations Withdraw any drugs in antihypetensive treatment regimen that have absent or minimal effect Consider mineralocorticoid receptor antagonists, amiloride, and the alpha-1-blocker doxazosin should be considered (if no contraindication exists) Invasive approaches: renal denervation and baroreceptor stimulation may be considered If no contraindications exist If drug treatment ineffective No long-term efficay, safety data for renal denervation, baroreceptor stimulation only experienced clinicians should use Diagnosis and follow-up should be restricted to hypertension Centres Invasive approaches only for truly resistant hypertensive patients Clinic values: SBP 160 mmhg or DBP 110 mmhg with BP elevation confirmed by ABPM ESH Guidelines 2013
Simplicity HTN-3 Bhatt DL et al, NEJM April 2014
Simplicity HTN-2 and HTN-3 Messerli et al, NEJM April 2014
ESH position letter after Simplicity HTN-3 One, given the multifactorial contribution of renal nerves to blood pressure elevation, renal denervation has a strong pathophysiological rationale. Two, albeit in a less well controlled fashion, several studies have found renal denervation to be accompanied not only by sizeable blood pressure reduction, but also by an improvement of biomarkers that have been shown to be prognostically relevant in individuals with a blood pressure elevation. Three, there are in the Symplicity HTN-3 study data, such as the greater blood pressure effects of renal denervation in non-african Americans, that suggest that the procedure may be effective in specific subgroups. Thus, the reaction to the negative results of the Symplicity HTN-3 study should not be to abandon the renal denervation approach, but to perform further studies of high scientific calibre that could provide further evidence on its overall position in the treatment of resistant hypertension, determine whether the blood pressure effects are limited to some patients' subgroups (and clarify their characteristics), and see whether and to what extent their blood pressure reductions translate into cardiovascular and renal protection.
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