Arterial hypertension and
preventive cardiology
Radka Adlová
Arterial hypertension (AH)
Definition:
 Hypertension is defined as values
of systolic pressure >= 140 mmHg
and/or diastolic pressure >= 90mmHg
Arterial hypertension (AH)
How to measure?
 Patient sits for 3 - 5 minutes before beginning of measurements
 Take at least two measurements, spaced 1 - 2 mins apart
 Take repeated measurements
 Use an appropriate bladder
 When adopting the auscultatory method, use phase I and V
Korotkoff sounds to identify systolic and diastolic blood pressure
Arterial hypertension (AH)
Prevalence: 30 - 45% of the general population
Age
% people with AH
18 – 29
4
30 – 39
11
40 – 49
21
50 – 59
44
60 – 69
54
70 – 79
64
> 80
65
Arterial hypertension (AH)
Blood pressure during our lives
BP (mm Hg)
Age
Arterial hypertension (AH)
Classification of blood pressure levels (mmHg):
Category
Systolic
Diastolic
Optimal
<120
<80
Normal
120 - 129
80 - 84
High normal
130 - 139
85 - 89
Grade 1 hypertension
140 - 159
90 - 99
Grade 2 hypertension
160 - 179
100 - 109
Grade 3 hypertension
>180
>110
Isolated systolic hypertension
>140
>90
Arterial hypertension (AH)
Why is it important to talk about arterial hypertension?
 an epidemic that is affects millions of people
in developed countries
 serious consequences for the patient
(a close relationship between prevalence
of hypertension and mortality for stroke)
Consequences of AH
ARTERIAL HYPERTENSION
Endothelial damage
Platelet activation
Vascular remodeling
Atherosclerosis
Arterial thrombosis
Consequences of AH
Stroke,
dementia
Retinopathy
AH
Left ventricle hypertrophy,
Coronary artery disease
Nephropathy,
renal failure
Peripheral arterial disease
Prognosis of AH
Depends on:
 the level of blood pressure
(blood pressure achieved during treatment)
 presence of risk factors
 organ damage
Prognosis of AH
Risk factors (SCORE):
 Age
 Gender
 Smoking
 Dyslipidemia
Total cardiovascular risk
 ESH/ESC guidelines, 2013
AH and total cardiovascular risk
Total cardiovascular risk increases with the number of risk
factors
12
10
No RF
Dyslipidemia
Smoking DM
140
155
170
LV hypertrophy
8
6
4
2
0
185
SBP
Examination of patient with AH
Medical history
Personal history
Physical examination
Laboratory investigations
Searching for asymptomatic organ damage :
 Heart - ECG, echocardiography
 Blood vessels - carotid arteries, pulse wave velocity
 Kidney - serum creatine, microalbuminuria
 Eyes - fundoscopy
 Brain - cerebral MRI
Classification of AH
 Primary (essential) 90 - 95%
- polygenic, multifactorial
 Secondary
5 - 10%
- Renal - renal parenchymal disease
- renal artery stenosis
- Endocrine - primary aldosteronism, thyroid disease,
pheochromocytoma, Cushings syndrome, acromegaly, …
- Hypertension in pregnancy
- Aortic coarctation
- Others ( sleep apnea, cerebral disease, ...)
Secondary hypertension
 Renal artery stenosis
Secondary AH
Typical characteristics:
 Moderate to severe hypertension
 Sudden severe hypertension or sudden worsening of
hypertension
 Resistant hypertension (despite three drugs including
diuretics no decrease of blood pressure)
 Specific symptoms of secondary hypertension
 Nondipping
 Heavier grade of organ damage
 Diagnosis can lead to permanent cure
Treatment of AH
Our goal: normal blood pressure of patient with hypertensive
disease
 A decision when and how to start
 What type of drug to choose
 Close co-operation with patient
(smaller number of tablets and simple dosing improves adherence
to treatment)
 Even if the drug is administered once a day,
the average patient at least once a week forgets to take this
medication
Treatment of AH
Treatment of AH
Blood pressure goals in hypertensive patients:
 < 140/90 mmHg : patients at low cardiovascular risk
 < 130/80 mmHg : young patients, patients with
nephropathy
 < 125/75 mmHg : patients with diabetes
 < 150 - 140 mmHg (systolic blood pressure): elderly
patients
Treatment of AH
Lifestyle changes:
- Salt restriction
- Moderation of alcohol consumption
- Other dietary changes
- Weight reduction
- Regular physical exercise
- Smoking cessation
Treatment of AH
When to start a pharmacological therapy ?
 In elderly hypertensive patients when systolic blood pressure
>160 mmHg
 Patients with grade 2 and 3 hypertension with any level of
cardiovascular risk
 Patients with high cardiovascular risk because of organ damage,
diabetes, cardiovascular disease or chronic kidney disease
Treatment of AH
Ideal pharmacological therapy
 Reduces both systolic and diastolic blood pressure
 Does not deteriorate metabolic situation
 Does not affect the activity of the sympathetic nervous
system
 Is vasoprotective, nephroprotective and cardioprotective
 Does not affect insulin sensitivity
Treatment of AH
What type of antihypertensive drugs?
 Diuretics
 Beta-blockers
 Calcium channel blockers
 Angiotensin converting enzyme inhibitors
 Angiotensin receptor blockers
 Centrally acting agents
 Peripheral alpha receptor blockers
Indications and contraindications :
Medication
Suitable
Unsuitable
Diuretics
Heart failure
Elderly people
Isolated systolic hypert.
Gout
Pregnancy
Beta-blockers
Coronary artery disease
Pregnancy
Tachyarrhythmia
Chronic obstructive pulmonary
disease
Peripheral arterial
disease
Calcium channel blockers
Angina pectoris
Peripheral arterial disease
Pregnancy, elderly pts.
Congestive heart failure
Angiotensin converting enzyme
inhibitors
Heart failure
Left ventricle hypertrophy,
Coronary artery disease
Pregnancy
Bilateral renal artery stenosis
Angiotensin receptor blockers
Nephropathy
Left ventricle hypertrophy
Heart failure
Pregnancy
Bilateral renal artery stenosis
Treatment of AH
Monotherapy or combination treatment ?
 Monotherapy can reduce blood pressure in only a limited
number of patients
 Most patients require the combination of at least two drugs to
achieve ideal blood pressure
 Combination of two agents from any two classes of
antihypertensive drugs deceases the blood pressure much more
effectively than increasing the dose of one agent
Treatment of AH
Treatment of AH
Benefits gained from blood pressure lowering
reduction
Stroke
35 – 40%
Myocardial infarction
20 – 25%
Heart failure
50%
Renal denervation (RDN)
= Renal sympathetic denervation (RSDN)
 A therapy for treatment resistant hypertension
(in case which do not respond to conventional drugs)
 Endovascular catheter based procedure using radiofrequency
ablation to the renal arteries and the nerves in the vascular
wall
 This causes reduction of renal sympathetic afferent and
efferent activity
Renal denervation (RDN)
 The RF energy is delivered to a renal artery via standard
femoral artery access
 A series of 2-minute ablations are delivered along each renal
artery to disrupt the nerves
 This therapy is administered bilaterally
Conclusion
 Diagnosis and treatment of arterial hypertension is not
simple
 Treatment should be well-timed and consistent
 Good treatment of arterial hypertension is useful
because of reduction of cardiovascular risk
 Our goal: ‘‘healthy‘‘ patient
Thank you for your attention