recent guidelines for the management of arterial hypertension apostolos i. hatzitolios associate...
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RECENT GUIDELINES FOR THE MANAGEMENT OF ARTERIAL HYPERTENSION
Apostolos I. Hatzitolios Associate Professor of Internal Medicine1st Propedeutic Department of Internal MedicineDepartment of Vascular Diseases and HypertensionAristotle University of Thessaloniki, AHEPA HospitalThessaloniki, Central Macedonia, HELLAS
Diagnosis, regulation and treatment of hypertension in USA
NHANES III (Phase 2) 1991-1994
NHANES III (Phase 1) 1988-1991
51%
73%68%
31%
55% 54%
10%
29% 27%
Diagnosis
NHANES II 1976-1980
Treatment
Regulation
NHANES 1999-2000
70%
59%
34%
Hypert
en
sive
%
Guidelines 2007
European Society of Hypertension European Society of Cardiology
Journal of Hypertension 2007;25:1105-1187
Definitions and Classification of BP Levels (mmHg)
Category Systolic Diastolic
Optimal <120 and <80
Normal 120-129 and/or 80-84
High Normal 130-139 and/or 85-89
Grade 1 Hypertension
140-159 and/or 90-99
Grade 2Hypertension
160-179 and/or 100-109
Grade 3 Hypertension
≥ 180 and/or ≥ 110
Isolated Systolic Hypertension
≥ 140 and < 90
Stratification of CV risk in four categoriesBlood pressure (mmHg)
Other risk factors, TOD or disease
Normal SBP 120-129 or DBP 80-84
High normal SBP 130-139 or DBP 85-89
Grade 1 HTSBP 140-159 or DBP 90-99
Grade 2 HTSBP 160-179 or DBP 100-109
Grade 3 HT SBP ≥180 or DBP ≥110
No other risk factors
Average risk
Average risk
Low added risk
Moderate added risk
High added risk
1-2 risk factors
Low added risk
Low added risk
Moderate added risk
Moderate added risk
Very high added risk
3 or more risk factors, TOD, DM or MS
Moderate added risk
High added risk
High added risk
High added risk
Very high added risk
Established CV or renal disease
Very high added risk
Very high added risk
Very high added risk
Very high added risk
Very high added risk
High/Very High Risk Subjects
BP ≥ 180 mmHg systolic and/or ≥ 110 mmHg diastolic High systolic BP > 160 mmHg with low diastolic BP (< 70
mmHg) ≥ 3 cardiovascular risk factors Diabetes mellitus or Metabolic syndrome Hypertension Target Organ Damage or Established CV or
renal disease
High/Very High Risk Subjects
One or more subclinical organ damages: Electrocardiographic (particularly with strain) or echocardiographic (particularly
concentric) LVH Ultrasound evidence of carotid artery wall thickening or plaque Increased arterial stiffness Slight increase in serum creatinine Reduced estimated glomerular filtration rate or creatinine clearance Microalbuminuria or proteinuria
Established cardiovascular disease • Heart • Cerebrovascular • Renal • Peripheral artery • Ophthalmic disease
Appropriate BP measurement
Allow the patients to relax for several minutes in a quiet place Take at least two measurements spaced by 1-2 min and additional measurements if
the first two are quite different [use phase I and V (disappearance) Korotkoff sounds to identify SBP and DBP]
Use a standard bladder but have a larger for fat arms and a smaller one for thin arms and children
Have the cuff at the heart level
Measure BP in both arms at first visit to detect possible differences due to peripheral vascular disease. In this instance, take the higher value as the reference one
Measure BP 1 and 5 min after assumption of the standing position in elderly subjects, diabetic patients and in other conditions in which postural hypotension may be frequent or suspected (e.g. heart, renal failure, SNS dysfunction, use of vasodilative agents)
Measure heart rate (at least 30 sec) after the second measurement in the sitting position
Home BP measurements
Self-measurement of BP at home is of clinical value, its prognostic significance is now demonstrated and these measurements should be encouraged in order to: provide more information on the BP lowering effect of
treatment at through and thus on the therapeutic coverage throughout the dose-to-dose time interval
improve patient’s adherence to treatment regimens
On the contrary, Self-measurement of BP should be discouraged when: it causes anxiety to the patient it induces self-modification of the treatment regimen
Ambulatory BP measurements
Although office BP should be used as reference, 24-h ambulatory BP monitoring may improve prediction of CV risk
Ambulatory BP should be considered, in particular, when: considerable variability of office BP is found over the same or
different visits high office BP is measured in subjects otherwise at low CV risk there is a marked discrepancy between BP values measured in the
office and at home there is a resistance to drug treatment hypotensive episodes are suspected, particularly in elderly and
diabetic patients office BP is elevated in pregnant women and pre-eclampsia is
suspected
BP thresholds (mmHg) for definition of Hypertension with different types of measurement
SBP DBP
Office or clinic 140 90
Home 130-135 85
24-hour 125-130 80
Day 130-135 85
Night 120 70
Particular conditions
Isolated office hypertension (White coat hypertension)
Office BP persistently ≥ 140/90 mmHg Normal daytime ambulatory or home BP < 130-135/85 Due to stress and SNS stimulation. CV risk is less than by raised office and ambulatory or home
BP but may be slightly greater than by normotension
Isolated ambulatory hypertension (Masked hypertension)
Office BP persistently normal (< 140/90 mmHg) Elevated ambulatory (≥ 125-130/80 mmHg) or home BP (≥ 130-135/85 mmHg)
CV risk is close to that of hypertension. Due to «normal» variation of circadian rhythm, autonomic
nervous system dysfunction, physical or psychological stress, night consumption of alcohol, smoking
and sleep apnea.
Guidelines for family and clinical history
1. Duration and previous level of high BP
2. Indications of secondary hypertension: family history of renal disease (polycystic kidneys)
renal disease, urinary tract infection, haematuria, analgesic abuse (parenchymal renal disease)
drug/substance intake, such as: oral contraceptives, liquorice, carbenoxolone, nasal drops, amphetamines, steroids, non-steroidal anti-inflammatory drugs, erythropoietin, cyclosporine, cocaine (drug induced hypertension)
episodes of sweating, headache, anxiety, palpitation (phaeochromocytoma)
episodes of muscle weakness and tetany (aldosteronism)
Guidelines for family and clinical history
3. Risk factors:
family and personal history of hypertension and CV disease
family and personal history of dyslipidaemia
family and personal history of diabetes mellitus
smoking habits
dietary habits ; lack of physical exercise
obesity
snoring; sleep apnea (information also from partner)
Personality type; stress due to personal, family and environmental factors
Guidelines for family and clinical history
4. Symptoms of organ damage: brain and eyes: headache, vertigo, transient ischemic
attacks, sensory or motor deficit , impaired vision heart: palpitation, chest pain, shortness of breath, swollen
ankles kidneys: thirst, polyuria, nocturia, haematuria peripheral arteries: cold extremities, intermittent
claudication
5. Previous antihypertensive therapy: Drug(s) used, efficacy and adverse effects
Physical examination for secondary hypertension, organ damage and visceral obesity
Signs suggesting secondary hypertension
Features of Cushing syndrome
Skin stigmata of neurofibromatosis (phaeochromocytoma)
Palpation of enlarged kidneys (polycystic kidneys)
Auscultation of abdominal murmurs
(renovascular hypertension)
Auscultation of precordial or chest murmurs; Diminished and delayed femoral pulses femoral BP
(aortic coarctation or aortic disease)
Physical examination for secondary hypertension, organ damage and visceral obesity
Signs of organ damage
Brain: murmurs over neck arteries, motor or sensory defects
Retina: fundoscopic adnormalities
Heart: location and characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rates, peripheral oedema
Peripheral arteries: absence, reduction or asymmetry of pulses, cold extremities, ischemic skin lesions
Carotid arteries: systolic murmurs
Physical examination for secondary hypertension organ damage and visceral obesity
Evidence of visceral obesity
Body weight
Increased body mass index
[body weight (Kg)/height (m2)]
overweight ≥ 25 Kg/m2; obesity ≥ 30 Kg/m2
Increased waist circumference
(standing position) ♂ > 102 cm; ♀ > 88 cm
Laboratory investigations
Routine tests:
Hemoglobin and hematocrit Fasting plasma glucose Fasting serum triglycerides Serum total cholesterol, LDL-cholesterol, HDL-cholesterol Serum creatinine, potassium, uric acid
Urinalysis (complemented by microalbuminuria dipstick test and microscopic examination)
Estimated creatinine clearance (Cockroft-Gault formula) or glomerular filtration rate (MDRD formula)
Electrocardiogram (ECG) Thorax X-ray
Laboratory investigations
Recommended tests
Echocardiogram
Carotid ultrasound
Quantitative proteinuria (if dipstick test positive)
Ankle-brachial BP index
Fundoscopy
Glucose tolerance test (if fasting plasma glucose > 5,6 mmol/l (102 mg/dL)
Home and 24h ambulatory BP monitoring
Pulse wave velocity measurement (where available)
Laboratory investigations
Extended evaluation (domain of the specialist)
Further search for cerebral, cardiac, renal and vascular disease, mandatory in complicated hypertension
Search for suspected secondary hypertension suggested by history, physical examination or routine tests: measurement of renin, aldosterone,
corticosteroids,
catecholamines in plasma and/or urine;
renal and adrenal ultrasound;
computer-assisted tomography (CT);
magnetic resonance imaging (MRI);
arteriographies
Searching for subclinical organ damage Importance of subclinical organ damage as an intermediate stage
in the continuum of vascular disease and as a determinant of total CV risk.
Heart
Electrocardiography should be part of all routine assessment of hypertensives in order to detect LVH, LV strain, ischemic condition and arrhythmias
Echocardiography is recommended whenever a more sensitive detection of LVH is considered useful. Concentric remodeling and hypertrophy carries the worst prognosis, while LV diastolic dysfunction, consists an early ECHO sign, which can be evaluated by Doppler measurement of transmittal velocities.
Searching for subclinical organ damage
Blood vessels
Ultrasound scanning of extracranial carotid arteries is recommended in symptomatic carotid stenosis (previous TIA), but also in asymptomatic atherosclerosis suspected by carotid murmurs and reveals vascular hypertrophy, increased IMT, thickening of carotid bifurcation and presence of plaques.
Peripheral large artery stiffening (an important vascular alteration leading to isolated systolic hypertension in the elderly), can be measured by pulse wave velocity. This method might be more widely recommended if its availability were greater.
A low ankle-brachial BP index (<0,9) signals advanced peripheral artery disease
Searching for subclinical organ damage
Kidney
Diagnosis of hypertension-related renal damage is based on a reduced renal function or detection of hyperalbuminuria
Measurement of serum creatinine as well as estimation of glomerular filtration rate by specific formulas, should be part of routine procedures, allowing classification of renal dysfunction and respective stratification of CV risk
Presence of urinary protein should be sought in all hypertensives by dipstick. In dipstick negative patients, low grade albuminuria, namely microalbuminuria, should also be determined in spot urine and as ratio to creatinine excretion
Searching for subclinical organ damage
Fundoscopy
Examination of eye grounds is recommended only in hypertensive with severe hypertension, since mild retinal changes (grade 1: arteriolar narrowing; grade 2: arteriovenous nipping) appear to be largely non-specific alterations except in young patients
In contrast, grade 3 (hemorrhages and exudates) and 4 (papilloedema) retinal changes, present only in severe hypertension and are associated with an increased CV risk
Searching for subclinical organ damage
Brain Silent brain infarcts, lacunar infarction (small / deep vessel
disease), microbleeds and white matter lesions are not infrequent among hypertensives, especially elderly and can be detected by MRI or CT (MRI being generally superior to CT)
Availability and costs do not allow use of these techniques in asymptomatic patients
In elderly hypertensives, cognitive tests (e.g. Mini-mental scale) may also help to detect initial brain deterioration
Treatment of hypertension
1. Non pharmacological
2. Pharmacological
Goals of treatment
Primary goal of treatment is to achieve the maximum reduction in the long-term total risk of CV disease
This requires not only the treatment of raised BP per se, but also of all associated reversible CV risk factors
BP should be reduced at least below 140/90 mmHg and even to lower values, if tolerated, in all hypertensive patients
Goals of treatment
Target BP should be at least < 130/80 mmHg in diabetics and in high or very high risk patients, such as those with associated clinical conditions, mainly stroke, myocardial infarction, renal dysfunction. Especially in proteinuria (<125/75 mmHg when >1gr/24h)
Despite the use of combination treatment, reducing SBP to <140 mmHg may be difficult and more so if the target is a reduction to <130 mmHg, moreover while a DBP reduction < 70 mmHg could be not beneficial.
Additional difficulties should be expected in elderly, obese and diabetic patients and in general, in patients with CV damage. In order to more easily achieve goal BP, antihypertensive treatment should be initiated before significant CV damage develops
Lifestyle changes
Lifestyle measures should be instituted whenever appropriate, in all patients, including those who require drug treatment, in order to lower BP, to control other risk factors and to reduce the number of doses of antihypertensive drugs to be subsequently administered
Lifestyle measures are also advisable in subjects with high normal BP (130-139 / 85-89) and additional risk factors to reduce the risk of developing hypertension
Lifestyle recommendations should not be given as lip service but instituted with adequate behavioral and expert support and reinforced periodically
Lifestyle changes
Lifestyle measures widely recognized to lower BP or CVrisk are:
smoking cessation weight reduction (and stabilization) physical exercise reduction of salt intake reduction of excessive alcohol intake increase in fruit and vegetable intake and decrease in
saturated and total fat intake (Mediterranean diet)
Lifestyle changes
Lifestyle changes Possible reduction in SBP(mmHg; mean= 38 mmHg)
Weight loss 5-20 mmHg/10Kg
Adoption of DASH diet 8-14 mmHg
Reduction of salt intake 2-8 mmHg
Physical exercise 4-9 mmHg
Reduction of excessive alcohol intake
2-4 mmHg
As long-term compliance with lifestyle measures is low and the BP response highly variable, patients under non pharmacological treatment should be followed-up closely to start drug therapy when needed and timely
Initiation of antihypertensive treatmentOther risk factors, Target Organ Damage or disease
Normal SBP 120-129 or DBP 80-84
High normal SBP 130-139 or DBP 85-89
Grade 1 HTSBP 140-159 or DBP 90-99
Grade 2 HTSBP 160-179 or DBP 100-109
Grade 3 HT SBP ≥180 or DBP ≥110
No other risk factors
No BP intervention No BP intervention
Lifestyle changes for several months then drug treatment if BP uncontrolled
Lifestyle changes for several weeks then drug treatment if BP uncontrolled
Lifestyle changes + immediate drug treatment
1-2 risk factors
Lifestyle changes Lifestyle changes
Lifestyle changes for several weeks then drug treatment if BP uncontrolled
Lifestyle changes for several weeks then drug treatment if BP uncontrolled
Lifestyle changes + immediate drug treatment
>3 risk factors, MS or TOD Lifestyle changes
Lifestyle changes and consider drug treatment Lifestyle changes +
drug treatmentLifestyle changes + drug treatment
Lifestyle changes + immediate drug treatment
Diabetes Lifestyle changesLifestyle changes + drug treatment
Established CV or renal disease
Lifestyle changes + immediate drug treatment
Lifestyle changes + immediate drug treatment
Lifestyle changes + immediate drug treatment
Lifestyle changes + immediate drug treatment
Lifestyle changes + immediate drug treatment