Grunnleggende prinsipper i hypertensjonsbehandling RELIS Mandag 12. februar Overlege Aud Høieggen Nyremedisinsk avd Ullevål, OUS
Grunnleggende prinsipper Korrekt diagnostikk Vurdering av total kardiovaskulær risiko Behandlingsmål Livstilsendring Medikamentell behandling Et par ord om SPRINT
2013 ESH/ESC 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 (Chairperson) (Italy)*, Robert Fagard(Chairperson) (Belgium)*, Krzysztof Narkiewicz (Section co-ordinator) (Poland), Josep Redon (Section co-ordinator) (Spain), Alberto Zanchetti (Section co-ordinator) (Italy), Michael Bo hm (Germany), Thierry Christiaens (Belgium), Renata Cifkova (Czech Republic), Guy De Backer (Belgium), Anna Dominiczak (UK), Maurizio Galderisi (Italy), Diederick E. Grobbee (Netherlands), Tiny Jaarsma (Sweden), Paulus Kirchhof (Germany/UK), Sverre E. Kjeldsen (Norway), Ste phane Laurent (France), Athanasios J. Manolis (Greece), Peter M. Nilsson(Sweden), Luis Miguel Ruilope (Spain), Roland E. Schmieder (Germany), Per Anton Sirnes (Norway), Peter Sleight (UK), Margus Viigimaa (Estonia), Bernard Waeber (Switzerland), Faiez Zannad (France) J Hypertens 2013; 31: 1281-1357, Eur Heart J 2013; 34: 2159-2219, Blood Press. 2013;22(4):193 278.
Classifications of office blood pressure levels ESH/ESC 2013 Guidelines Mancia et al; ESH/ESC 2013 Guidelines. J Hypertens
Mortality due to leading risk factors Global Burden of Disease (WHO) Update Lancet 2012
The Silent killer Sorrentino MJ et al. Postgrad Med 1999; 105(5):82-93
Complications of hypertension Prehypertension Established hypertension Asymptomatic Subclinical organ damage Symptomatic Polysymptomatic or end-stage disease Proteinuria & nephrosclerosis Left ventricular hypertrophy & enlarged atria Atherosclerosis & arteriosclerosis Retinopathy & Binswanger lesions Chronic Renal Failure Atrial fibrillation Ventricular arrhythmias Systolic/ diastolic dysfunction Coronary artery disease Dementia Transient ischemic attack End-stage renal disease Ventricular tachycardia/ fibrillation Congestive heart failure Myocardial infarction Stroke Silent killer DEATH Modified from Messerli FH, et al. Lancet. 2007;370:591-603.
Blodtrykksbehandling nytter
Essensiell hypertensjon 90-95 % av alle hypertonikere Essensiell betyr at det- i motsetning til ved sekundær hypertensjon- ikke er funnet en spesifikk årsak til det høye blodtrykket
Sekundær hypertensjon? Når skal man lete spesielt etter det? Behandlingsresistens BT>140/90 mmhg med 3 medikamenter inkludert et diuretikum Plutselig debut/forverring av allerede etablert HT Manglende døgnvariasjon Svært høye blodtrykk Yngre personer Metabolsk syndrom/dia II (renovaskulær)
Årsaker til sekundær hypertensjon Nyresykdom 5% Renovaskulær sykdom ( nyrearteriestenose) 2% Primær hyperaldosteronisme 5-22% Søvnapnoesyndrom Medikamenter (P-piller, NSAIDs mm) Pheochromocytom 0.1% Cushing syndrom 0.1% Meget sjeldne årsaker Koarktasjon av aorta Thyroideasykdommer
Diagnostiske prosedyrer 1. Gjentatte BT målinger 2. Anamnese alder v/diagnose, familieanamnese, T.S., medikamenter, stimulantia, kosthold, trening, røyk, symptomer 3. Fysisk undersøkelse 4. Laboratorieundersøkelser
Korrekt måling av BT Ro i 5 min, ikke kryssede ben, ikke snakk, BT apparat i hjertehøyde Mål 3 ganger, gj sn av de 2 siste målingene Sjekk i begge armer, høyeste BT- arm gjelder Anpass mansjett etter overarm
Ambulatory Blood Pressure Monitoring Slide by prof. Jean-Michel Mallion
Definition of hypertension by office and out-of-office blood pressures Category SBP (mmhg) DBP (mmhg) Office/clinic BP 140 and/or 90 Home BP 135 and/or 85 Ambulatory BP Daytime (or awake) 135 and/or 85 Night-time (or asleep) 120 and/or 70 24-hour 130 and/or 80 J Hypertens 2013; 31: 1281-1357, Eur Heart J 2013;34:2159-2219, Blood Press. 2013;22(4):193 278.
Laboratorieprøver (a) Rutinetester (bør tas hos alle pas som får dignostisert hypertensjon) Glucose- helst fastende/ HbA1C Total kolesterol HDL-kolesterol Triglycerider, fastende Urinsyre Kreatinin Kalium Hb og Hct Urinalyse (teststrimmel og mikro) EKG (mange falske negative) Høy spesifisitet, lav sensitivitet. Et normalt EKG kan ikke utelukke VVH
Laboratorieprøver (b) Anbefalte tester Kvantifisering av proteinuri (AKR) Ekko (kapasitetsproblem) Ultralyd carotis (kapasitetsproblem) Oftalmoskopi (ved alvorlig HT) Utvidet utredning hos spesialist Komplisert hypertensjon: Hjerne, hjerte og nyrefunksjon Renin, aldosteron, cortisol, katekolaminer, MR angio nyrearterier med visualisering av binyrer, CT eller MR av hjerne Ultralyd nyre
Stratification of total CV risk *Metabolic syndrome was also included in 2007, but has been omitted from the 2013 guidelines BP, blood pressure; CKD, chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; DBP, diastolic BP; OD, organ damage; SBP, systolic BP 1 Mancia G et al. Eur Heart J 2013; 34: 2159 219; 2 Mancia G et al. Eur Heart J 2007; 28: 1462 536.
NORRISK
ESH guidelines, 2013 Indikasjoner for behandling
Røykestopp Vektreduksjon Reduksjon av overdrevent alkoholforbruk Økt fysisk aktivitet Redusert saltinntak Økt inntak av frukt og grønt og redusert inntak av mettet og totalt fett Livstilsendringer
Hence if too much salt is used for food, the pulse hardens. Huang Ti Nei Ching Su Wen, 2698-2598 BC Huang Ti Nei Ching Su Wen. The Yellow Emperor s Classic of Internal Medicine (Veith I, 1949)
Pizza-3 ganger daglig dose med salt!
2013: Possible combinations between some classes of antihypertensive drugs Thiazide diuretics β-blockers Angiotensin receptor antagonists Dual RAAS blockade out Other Calcium antagonists ACE inhibitors
Beta-blocker controversy Beta-blockers cornerstone in treatment of patients with coronary heart disease, heart failure and tachy-arrhythmias incl. A.fib. - irrespective hypertension or not Atenolol inferior in LIFE (left ventricular hypertrophy) and ASCOT (primary prevention in healthy people) Beta-blocker not first line in young people
ESH Guidelines, 2013
Årsaker til sekundær hypertensjon Nyresykdom 5% Renovaskulær sykdom ( nyrearteriestenose) 2% Primær hyperaldosteronisme 5-22%?? Søvnapnoesyndrom Medikamenter (P-piller, NSAIDs mm) Pheochromocytom 0.1% Cushing syndrom 0.1% Meget sjeldne årsaker Koarktasjon av aorta Thyroideasykdommer
Prevalens av primær hyperaldosteronisme
Treatment recommendations for specific indications Condition Antihypertensive drug class Asymptomatic organ damage Left ventricular hypertrophy ACE inhibitor, CCB, ARB Asymptomatic atherosclerosis CCB, ACE inhibitor Microalbuminuria ACE inhibitor, ARB (but not together) Renal dysfunction ACE inhibitor, ARB (but not together) A+C+D+A? Clinical cardiovascular event Previous stroke Any effective BP-lowering agent Previous myocardial infarction Beta-blocker, ACE inhibitor, ARB Angina pectoris Beta-blocker, CCB Heart failure Diuretic, beta-blocker, ACE inhibitor, ARB, mineralocorticoid receptor antagonist Aortic aneurysm Beta-blocker AF, prevention Consider ARB, ACE inhibitor, beta-blocker or mineralocorticoid receptor antagonist AF, ventricular rate control Beta-blocker, non-dihydropyridine CCB ESRD/proteinuria ACE inhibitor, ARB (but not together) Peripheral artery disease ACE inhibitor, CCB Other ISH (elderly) Diuretic, CCB Metabolic syndrome ACE inhibitor, ARB, CCB Diabetes mellitus ACE inhibitor, ARB (but not together) Pregnancy Methyldopa, beta-blocker, CCB Black ethnicity Diuretic, CCB
ESH 2013 Blodtrykksmål ved behandling
Anbefalinger BT < 140/90 Ved proteinuri: BT < 130/80 Ved DM: BT < 135/85 Redusere andre risikofaktorer for CV sykdom 2013 ESH/ESC guidelines for the management of arterial hypertension Helsedirektoratet.no: Nasjonale retningslinjer for diabetes, 2017
Landmark NIH study shows intensive blood pressure management may save lives (Press Release From NIH Sept. 11, 2015) The SPRINT Study started in 2009 N=9,361 hypertensive patients above 50 years Randomized to SBP target <120 mmhg vs. <140 mmhg (135-139 mmhg) Heart attack and heart failure, as well as stroke, reduced by almost a third and the risk of death by almost a quarter Presented at AHA, Orlando, Nov. 9 and published Online in NEJM
Implications of the SPRINT Study? Critical points are: 1) in SPRINT «the systolic BP target of 120 mmhg» corresponds to approx. 140 mmhg in other trials 2) the main finding the difference in heart failure was caused by up and down-titration of diuretics, masking and de-masking the endpoint 3) «the risk of doing harm» was higher than the «potential benefit of treatment»
Unattended Automatic Office Blood Pressure Measurement
Unattended BP Measurements in SPRINT SPRINT is the first outcome trial ever to utilize un-attended automated office BP a BP method previously not validated against cardiovascular endpoints Kjeldsen SE et al. Hypertension 2016: 67: 808-812
Unattended Automatic Office Blood Pressure Measurement 5 min alone in the room SBP/DBP fell by 15.7/8.0 mmhg (n=353) for unattended automatic office BP compared to regular office BP The limit for hypertension of 140/90 mmhg according to standard office BP corresponded to 125/82 mmhg for unattended automated office BP Filipovský J et al. Blood Press. 2016; 25: 228-234 Unattended automatic office: 131±22/78±12 mmhg Regular office: 147±21/86±12 mmhg Home: 138±18/79±8 mmhg
Ukontrollert hypertensjon <140/90 mmhg Kearney PM et al. J Hypertens. 2004