Hypertension - general overview
(guidelines)
Andrzej Tomaszewski Ass. Prof. M.D. Ph. D.
Dept. of Cardiology, Medical University Lublin, Poland
CARDIONALE, 26. 11. 2010, Prague
History of BP measurement
• In 1896 Riva-Rocci described an inflatable
cuff that allowed measurement of brachial
systolic pressure.
• In 1904 Korotkov reported the
auscultatory method that allowed
measurement of systolic and diastolic
pressure.
Basis for the lecture:
2007 Guidelines for the management of arterial
hypertension
• The Task Force for the Management of Arterial Hypertension
of the
European Society of Hypertension (ESH) and of the European
Society of Cardiology (ESC)
• Authors/Task Force Members: Giuseppe Mancia, Co-
Chairperson (Italy), Guy De Backer, Co-Chairperson (Belgium),
Anna Dominiczak (UK), Renata Cifkova (Czech Republic),
Robert Fagard (Belgium), Giuseppe Germano (Italy), Guido
Grassi (Italy), Anthony M. Heagerty (UK), Sverre E. Kjeldsen
(Norway), Stephane Laurent (France), Krzysztof Narkiewicz
(Poland), Luis Ruilope (Spain), Andrzej Rynkiewicz (Poland),
Roland E. Schmieder (Germany), Harry A.J. Struijker Boudier
(Netherlands), Alberto Zanchetti (Italy)
• European Heart Journal 2007;28:1462-1536
Basis for the lecture:
Reappraisal of European guidelines on
hypertension management: a European Society of
Hypertension Task Force document 2009
• Giuseppe Mancia, Stephane Laurent, Enrico Agabiti-Rosei,
Ettore Ambrosioni, Michel Burnier, Mark J. Caulfield, Renata
Cifkova,Denis Cle´ment, Antonio Coca, Anna Dominiczak,
Serap Erdine,Robert Fagard, Csaba Farsang, Guido Grassi,
Hermann Haller,Antony Heagerty, Sverre E. Kjeldsen,
Wolfgang Kiowski, Jean Michel Mallion,Athanasios Manolis,
Krzysztof Narkiewicz, Peter Nilsson, Michael H. Olsen,Karl
Heinz Rahn, Josep Redony Jose´ Rodicio, Luis Ruilopea,Roland
E. Schmiedera, Harry A.J. Struijker-Boudiera, Pieter A. van
Zwietena,Margus Viigimaaa and Alberto Zanchettia
• Journal of Hypertension 2009, Vol 27,2121-58
Epidemiology of arterial hypertension
• Arterial hypertension is one of the most
prevalent cardiovascular diseases.
• Arterial hypertension affects 20-50 % of adults
in developed countries.
• Frequency of arterial hypertension suddenly
increases after 50 years of life (>50% of this
population).
• Worldwide, hypertension affects over 970 milion
persons.
Definition and classification of blood
pressure 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 2 hypertension 160–179 and/or
100–109
Grade 3 hypertension ≥180
and/or ≥110
Isolated syst.
≥140
and
<90
hypertension
Cumulative Incidence (%)
of Major CV Events
Impact of High-Normal BP on Risk of
Major CV Events* in Men
1
6
1
4
1
2
1
0
8
High-normal BP
(130-139/85-89 mm
Hg)
Normal BP
(120-129/80-84 mm
Hg)
6
Optimal BP
(<120/80 mm Hg)
4
2
0
0
2
4
6
Time (y)
8
10
12
* Defined as death due to CV disease; recognized myocardial infarction (MI), stroke, or congestive heart
failure (CHF).
Adapted from Vasan RS. N Engl J Med. 2001;345:1291-1297.
Arterial Hypertension as a risk factor
• Hypertension is a highly prevalent risk factor for
cardiovascular disease
• Hypertension plays a major etiologic role in the
development of cerebrovascular disease,
ischemic heart disease, cardiac and renal failure
Assessment of global cardiovascular risk in
arterial hypertension
• grades of hypertension
• total cardiovascular risk (coexistence different
risk factors, organ damage, concomitant
diseases)
Stratification of total CV risk
• Four categories :
•
•
•
•
- Low
- Moderate
- High
- Very high
refer to 10 year risk of fatal or non-fatal CV
event
Diagnostic evaluation in arterial
hypertension
•
•
•
•
•
•
•
Establishing BP values
Identyfying secondary causes of AH
Searching for :
-other risk factors
-subclinical organ damage
-concomitant diseases
-accompanying CV and renal complications
Diagnostic procedures in arterial
hypertension
• repeated BP measurements
• family and clinical history
• physical examination
• laboratory and instrumental investigation
Laboratory and instrumental investigationroutine tests
•
•
•
•
•
•
•
•
•
•
Fasting plasma glucose
Serum total cholesterol, LDL-cholesterol, HDL-cholesterol
Fasting serum triglycerides
Serum potassium
Serum uric acid
Serum creatinine
Estimated creatinine clearance
Haemoglobin and haematocrit
Urinalysis
Electrocardiogram
Laboratory and instrumental investigation
• Echocardiogram
• Carotid ultrasound
• Quantitative proteinuria
• Fundoscopy
• Glucose tolerance test (if fasting plasma glucose
>5.6 mmol/L (100 mg/dL)
• Home and 24 h ambulatory BP monitoring
Left ventricular hypertrophy,
parasternal long axis view
Left ventricular hypertrophy,
parasternal short axis view
Left ventricular hypertrophy,
four-chamber view
Left ventricular hypertrophy,
subcostal view
Extended laboratory and instrumental
investigation
• Search for cerebral, cardiac, renal, vascular
damage, for secondary hypertension:
• measurement of renin,
aldosteron,corticosteroids,catecholamines in
plasma and/or urine
• arteriographies, CT, MRI
Secondary causes of AH :
• Renal parenchymal disease (most common
•
•
•
•
•
•
•
cause)
Renovascular hypertension (2nd most common
cause)
Pheochromocytoma
Primary hyperaldosteronism
Cushing’s syndrome
Obstructive sleep apnea
Coarctation of aorta
Drug-induced hypertension
Evidence on the benefit of antihypertensive
treatment
• Placebo controlled trials provided evidence that
•
•
BP lowering reduces fatal and non-fatal CV
events
Trials comparing different antihypertensive drugs
emphasise role of BP lowering of all CV events
(stroke, myocardial infarction, heart failure)
BP-independent effects (protection against
subclinical organ damage, prevention of high
risk condition such as diabetes, renal failure,
atrial fibrillation)
Benefits of Lowering BP
Average reduction
Stroke incidence
35–40%
Myocardial infarction
20–25%
Heart failure
50%
Aim of antihypertensive therapy
• The primary goal of treatment is to achieve
•
•
maximum reduction in the long-term total risk of
CV disease
For this reason lowering BP therapy (at least
< 140/90 mm Hg) and treatment of all
reversible risk factors are indicated
In diabetes and in high and very high risk
patients BP target should be at least < 130/80
mmHg
Treatment guidelines (ESH/ESC 2007)
Average risk
Low added risk
Moderate added risk
High added risk
ESH – ESC Guidelines Committee. J Hypertens 2007; 25: 1105–1187
Very high added risk
Lifestyle changes
•
•
•
•
•
•
•
smoking cessation
weight reduction
reduction of excessive alkohol intake
physical exercise
reduction of salt intake
increase in fruit and vegetables intake
decrease in saturated and total fat intake
Choice of the antihypertensive drugs
• Five major classes of these drugs are suitable for initiation and
maintenance of treatment, alone or in combination :
• thiazide diuretics
• calcium antagonists (CA)
• ACE-inhibitors (ACEI)
• angiotensin receptor blockers (ARB)
• beta-blockers (BB)
Conditions favouring the use of some
antihypertensive drugs versus other
• Subclinical organ damage:
LVH
ACEI, CA, ARB
Asymptomatic Atherosclerosis
CA, ACEI
Microalbuminuria
ACEI, ARB
Renal dysfunction
ACEI, ARB
Conditions favouring the use of some
antihypertensive drugs versus other
• Clinical event:
Previous stroke
Previous MI
Heart failure
any BP lowering agent
BB, ACEI, ARB
diuretics, BB, ACEI,
ARB, anti-aldosterone agents
Tachyarrhythmias BB
Periph.art.disease CA
LV dysfunction
ACEI
Conditions favouring the use of some
antihypertensive drugs versus other
• Condition :
ISH (elderly)
diuretics,CA
Metabolic syndrome ACEI,ARB,CA
Diabetes mellitus
ACEI, ARB
Pregnancy
CA,methyldopa,BB
Glaucoma
BB
Monotherapy versus combination therapy
• Monotherapy allows to achieve BP target only in
a limited number of patients
• Use of more than one agent is necessary to
achieve target BP
• Initial therapy: monotherapy or combination of
two drugs in low doses with subsequent increase
in drug doses or number
Monotherapy versus combination therapy
• Monotherapy in mild BP elevation with low or
•
•
•
moderate total CV risk
Two drugs at low doses should be preferred as
the first step when BP is in grade 2 or 3 or total
CV risk is high or very high with mild
hypertension
Fixed combination of two drugs simplify the
treatment
If BP control is not achieved by two drugs,
combination of three or more drugs is required
Possible combinations of different
classes of antihypertensive agents
Diuretics
AT1-receptor
β-blockers
blockers
α-blockers
ACE, angiotensin-converting enzyme
AT, angiotensin
CCB, calcium-channel blocker
CCBs
ACE inhibitors
The preferred combinations in general hypertensive population are represented
as thick lines. The frames indicate classes of agents proven to be beneficial
in controlled interventional trials
ESH – ESC Guidelines Committee. J Hypertens 2007; 25: 1105–1187
Antihypertensive therapy in special groups
• Elderly patients
• Diabetic patients
• Patients with renal dysfunction
• Patients with cerebrovascular disease
• Patients with coronary heart disease and
heart failure
• Patients with atrial fibrillation
Hypertension in women
• Response to antihypertensive drugs,
beneficial effect of BP lowering is similar in
men and women
• Oral contraceptives
• Hormone replacement therapy
• Hypertension in pregnancy
Resistant hypertension
• Poor adherence to therapeutic plan
• Failure to modify lifestyle including: weight gain,
•
•
•
•
•
heavy alcohol intake
Intake of drugs that raise blood pressure
Obstructive sleep apnoea
Unsuspected secondary cause
Irreversible or scarcely reversible organ damage
Volume overload due to:inadequate diuretic
therapy, progressive renal insufficiency, high
sodium intake, hyperaldosteronism
Unsuspected secondary cause
Unsuspected secondary cause
Unsuspected secondary cause
Coarctation of aorta
Unsuspected secondary cause
Coarctation of aorta
Malignant hypertension
• Clear overlap between resistant and
malignant hypertension
• Severe BP elevation (DBP usually >140
mmHG) with vascular damage (retinal
haemorrhage, papilloedema, hypertensive
encephalopathy,deterioration in renal
function, DIC)
Hypertensive emergiences
•
•
•
•
•
•
•
•
•
•
Hypertensive encephalopathy
Hypertensive left ventricular failure
Hypertension with myocardial infarction
Hypertension with unstable angina
Hypertension and dissection of the aorta
Severe hypertension associated with subarachnoid
haemorrhage or cerebrovascular accident
Crisis associated with phaeochromocytoma
Use of recreational drugs such as amphetamines, LSD,
cocaine or ecstasy
Hypertension perioperatively
Severe pre-eclampsia or eclampsia
Echocardiography
• Examples of two hypertensive
emergencies:
- aortic dissection
- fatal myocardial infarction
Aortic dissection
Aortic dissection
Chronic aortic dissection
Chronic aortic dissection
Fatal myocardial infarction
Fatal myocardial infarction
Fatal myocardial infarction
Fatal myocardial infarction
Fatal myocardial infarction,cardiac
tamponade
Hypertension – treatment of associated risk
factors
• Lipid lowering agents:
- all hypertensive pts with CV disease or
diabetes should be considered for statin therapy
aiming total cholesterol < 175 mg/dl and LDL <
100mg/dl
- pts with high CV risk should be considered for
statin therapy, even if total and LDL cholesterol
are not elevated
Hypertension – treatment of associated risk
factors
• Antiplatelet therapy (low dose aspirin):
-for pts with previous CV events
-for pts without history of CV disease if older
than 50 y., with moderate increase in serum
creatinine or with high CV risk
• Glycemic control :
- lowering fasting plasma glucose to 108 mg/dl,
glycated hemoglobin of <6,5%
Reappraisal of European guidelines on
hypertension management: a ESH Task Force
document, 2009
What is new today after reappraisal 2009 ?
1/Some of new studies have reinforced the evidence on
which the recommendations of the 2007 ESH/ESC
guidelines were based
2/Other studies have widened the information available in
2007
3/Modifying some of the previous concepts
4/New evidence-based recommendations could be
appropriate.
Reappraisal of European guidelines on
hypertension management: a ESH Task Force
document, 2009
New evicence-based recommendations:
- blood pressure goals of treatment
- indications for starting antihypertensive
pharmacotherapy
Reappraisal of European guidelines on
hypertension management: a ESH Task Force
document, 2009
• Blood pressure goals of treatment:
there is sufficient evidence to recommend that SBP be
lowered below 140mmHg (and DBP below 90mmHg) in
all hypertensive patients, both those at low moderate
risk and those at high risk.
The recommendation of previous guidelines to aim at a
lower goal SBP (<130mmHg) in diabetic patients and in
patients at very high cardiovascular risk (previous
cardiovascular events) may be wise, but it is not
consistently supported by trial evidence.
Reappraisal of European guidelines on
hypertension management: a ESH Task Force
document, 2009
• Blood pressure goals of treatment:
on the basis of current data, it may be prudent
to recommend lowering SBP/DBP to values
within the range 130–139/80–85mmHg, and
possibly close to lower values in this range, in
all hypertensive patients.
Reappraisal of European guidelines on
hypertension management: a ESH Task Force
document, 2009
• Indications for starting antihypertensive
pharmacotherapy
In the vast majority of hypertensive patients,
effective BP control can only be achieved by
combination of at least two antihypertensive
drugs.
Reappraisal of European guidelines on
hypertension management: a ESH Task Force
document, 2009
• Recommended combinations for
priority use:
• Diuretic + ACEI
• Diuretic + ARB
• Diuretic + CA
• ACEI + CA
• ARB
+CA
Reappraisal of European guidelines on
hypertension management: a ESH Task Force
document, 2009
• Not recommended combinations:
• Beta-blocker + diuretic combination favors the
•
development of diabetes
ACE inhibitor + angiotensin receptor antagonist
combination presents dubious potentiation of
benefits with a serious side efects
Reappraisal of European guidelines on
hypertension management: a ESH Task Force
document, 2009
• In no less than 15–20% of patients, BP control cannot
be achieved by a two-drug combination.
• The most rational combination of three drugs appears
to be a blocker of the renin–angiotensin system, a
calcium antagonist, and a diuretic at effective
doses.
• β-blocker or an α-blocker, may be included in a multiple
approach, depending on the clinical circumstances.
Thank you for your attention