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2007 Guidelinesfor the Management of
Arterial Hypertension
Journal of Hypertension2007;25:1105-1187
European Society of HypertensionEuropean Society of Cardiology
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New guidelines, represent the common groundbetween the major organizations involved in their
production:
ESC, represented by its European Association of Preventionand Rehabilitation and Working Group on CardiovascularNursing;
European Society of Atherosclerosis; European Society of Hypertension (ESH);
European Heart Network; Family Practice (World Organization of National Colleges,
Academies and Academic Associations of GeneralPractitioners/Family Physicians - WONCA);
International Society of Behavioral Medicine; European Association for the Study of Diabetes
(EASD)/International Diabetes Federation Europe; and European Stroke Initiative
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August 24, 2007 With an estimated 1.5 billion people
expected to be hypertensive by 2025,an argument making the case that
hypertension is "uncontrolled andconquering the world" is not hyperbole.
This staggering number, as well as the factthat the risk of becoming hypertensive is
greater than 90% for individuals indeveloped countries, highlights thegrowing problem of uncontrolledhypertension, both in developed as well asundeveloped countries, according to an
editorial appearing in the August 18, 2007
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"Many people still believe that hypertension is a disease thatcan be cured, and stop or reduce medication when blood-
pressure levels fall," "Physicians need to convey the
message that hypertension is thefirst and easily measurableirreversible sign that many organs inthe body are under attack. Perhapsthis message will also make people
think more carefully about theconsequences of an unhealthylifestyle and help to give preventive
measures a real chance of success."
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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), GuidoGrassi (Italy), Anthony M. Heagerty (UK), Sverre E. Kjeldsen(Norway), Stephane Laurent (France), Krzysztof Narkiewicz(Poland), Luis Ruilope (Spain), Andrzej Rynkiewicz (Poland),Ronald E. Schmieder (Germany), Harry A.J. Struijker Boudier(Netherlands),
Alberto Zanchetti (Italy)
ESC Committee for Practice Guidelines (CPG): Alec Vahanian, Chairperson (France),John Camm (UK), Raffaele De Caterina (Italy), Veronica Dean (France), KennethDickstein (Norway), Gerasimos Filippatos (Greece), Christian Funck-Brentano(France), Irene Hellemans (Netherlands), Steen Dalby Kristensen (Denmark), KeithMcGregor (France), Udo Sechtem (Germany), Sigmund Silber (Germany), MichalTendera (Poland), Petr Widimsky (Czech Republic), Jose Luis Zamorano (Spain)
ESH Scientific Council: Sverre E. Kjeldsen, President (Norway), Serap Erdine, Vice-President (Turkey), Krzysztof Narkiewicz, Secretary (Poland), Wolfgang Kiowski,Treasurer (Switzerland), Enrico Agapiti-Rosei (Italy), Ettore Ambrosioni (Italy), RenataCifkova (Czech Republic), Anna Dominiczak (UK), Robert Fagard (Belgium), AnthonyM. Heagerty, Stephane Laurent (France), Lars H. Lindholm (Sweden), GiuseppeMancia (Italy), Athanasios Manolis (Greece), Peter M. Nilsson (Sweden), Josep Redon(Spajn), Roland E. Schmieder (Germany), Harry A.J. Struijker-Boudier (Netherlands),Margus Viigimaa (Estonia)
Document Reviewers:Gerasimos Filippatos (CPG Review Coordinator) (Greece),Stamatis Adamopoulos (Greece), Enrico Agabiti-Rosei (Italy), Ettore Ambrosioni(Italy), Vincente Bertomeu (Spain), Denis Clement (Belgium), Serap Erdine (Turkey),Csaba Farsang (Hungary), Dan Gaita (Romania), Wolfgang Kiowski (Switzerland),
Gregory Lip (UK), Jean-Michel Mallion (France), Athanasios J. Manolis (Greece), PeterM. Nillson (Sweden), Eoin OBrien (Ireland), Piotr Ponikowski (Poland), Josep Redon
Journal of Hypertension
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Definitions and Classificationof Blood Pressure Levels
(mmHg)
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Stratification of CV risk in fourcategories
SBP: systolic blood pressure; DBP: diastolic blood pressure; CV: cardiovascular; HT:hypertension. Low, moderate, high, very high risa refer to 10year risk of a CV fatal ornon-fatal event. The term added indicates that in all categories risk is greater thanaverage. OD: subclinical organ damage; MS: metabolic syndrome.
Blood pressure (mmHg)
Very highaddedrisk
Very highadded risk
Very highadded risk
Very highadded risk
Very highadded risk
EstablishedCV or renaldisease
Very highaddedrisk
High addedrisk
High addedrisk
High addedrisk
Moderateadded risk
3 or morerisk factors,MS, OD ordiabetes
Very highaddedrisk
Moderateadded risk
Moderateadded risk
Low
added risk
Low
added risk
1-2 riskfactors
Highadded
risk
Moderateadded risk
Low
added risk
Average
risk
Average
risk
No otherrisk factors
Grade 3HT SBP180 orDBP110
Grade 2 HT
SBP 160-179 or DBP100-109
Grade 1 HT
SBP 140-159 or DBP90-99
Highnormal
SBP 130-139 or DBP85-89
Normal
SBP 120-129 orDBP 80-84
Other riskfactors, ODor disease
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Factors influencing Prognosis
Microalbuminuria 30-300 mg/24h oralbumin-creatinine ratio: 22 (M), or 31(W) mg/g creatinine
Abdominal obesity(Waist circumference >102cm (M), 88cm(W))
Family history of premature CV disease(M at age 65 years)
Echocardiographic LVH(LVMI M 125g/m, W 110 g/m)
Levels of pulse pressure (in the elderly)
Electrocardiographic LVH(Sokolow-Lyon >38 mm; Cornell >2440mm*ms) or
Systolic and diastolic BP levels
Subclinical Organ DamageRisk Factors
(Cont)
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Factors influencing PrognosisRisk Factors
Dyslipidaemia
TC>5.0 mmol/l (190 mg/dL) orLDL-C >3.0 mmol/l (115 mg/dL) orHDL-C:M 55 years;W>65 years)
SmokingFasting plasma glucose5.6-6.9 mmol/L
(102-125 mg/dL)
normal glucose tolerance test
Abdominal obesity
>102cm (M),
88cm (W)
AHC prematureCV disease(M at age
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Factors influencing PrognosisSubclinical Organ Damage
Slight increase in plasmacreatinine:M: 115-133 mol/l (1.3-1.5mg/dL);W: 107-124 mol/l (1.2-1.4
Carotid-femoral pulse
wave velocity >12 m/sec
Carotid wall thickening(IMT >0.9 mm) or plaque
Echocardiographic LVH
(LVMI M 125g/m, W110 g/m)
Electrocardiographic LVH(Sokolow-Lyon >38 mm;Cornell >2440 mm*ms) or
Microalbuminuria 30-300
mg/24horalbumin-creatinine ratio:22 (M), or 31 (W) mg/gcreatinine
Ankle/Brachial BP index
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Factors influencingPrognosis
Postload plasmaglucose >11.0 mmol/l(198 mg/dL)
Fasting plasma 7.0mmol/l
(126 mg/dL) on repeatedmeasurement, or
Diabetes Mellitus
Advanced retinopathy:
haemorrhages or exudates,
Peripheral artery disease
Renal disease: diabeticnephropathy; renal impairment
(serum creatinineM >133, W >124 mmol/l);proteinuria (>300 mg/24 h)
Heart disease: myocardialinfarction; angina; coronaryrevascularization; heart failure
Cerebrovascular disease:ischaemic stroke; cerebralhaemorrhage; transient
ischaemic attack
Established CV or
renal disease
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a) High/ Very High RiskSubjects
BP
180 mmHg systolic
and/or
110 mmHg diastolic
Systolic BP >160 mmHg with low diastolic BP
(
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b). High/ Very High RiskSubjects One or more of the following subclinical organ
damages:- Electrocardiographic (particularly with strain)or echocardiographic(particularly concentric) left
ventricular hypertrophy- Ultrasound evidence of carotid artery wallthickening or plaque
- Increased arterial stiffness
- Slight increase inserum creatinine- Reduced estimated glomerular filtration rateor creatinine clearance
- Microalbuminuria or proteinuria
Established cardiovascular or renal disease
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Availability, Prognostic Value and Costof some markers of organ damage
(scored from 0 to 4 pluses)
++++++++Microalbuminuria
++++++++Est. Glomerular FiltrationRate orCreatinine Clearance
++++++?Cerebral lacunae/ Whitematter lesions
++++++Endothelial dysfunction
+++?Circulatory collagenmarkers
+++?Cardiac/Vascular tissuecomposition
++++++Coronary calcium content
+++++Ankle-Brachial index
++++++Arterial stiffness(Pulse wave velocity)
++++++++Carotid Intima-MediaThickness
++++++++Echocardiography
+++++++ElectrocardiographyCostAvailabilityCV predictive
valueMarkers
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Blood Pressure (BP)MeasurementWhen measuring blood pressure, care should
be taken to:
Allow the patients to sit for several minutes ina quiet room before beginning blood pressuremeasurement
Take at least two measurements spaced by 1-2 minutes, and additional measurements ifthe first two are quite different
Use a standard bladder (12-13 cm long and35 cm wide) but have a larger and a smallerbladder available for fat and thin arms,respectively. Use the smaller bladder inchildren
Have the cuff at the heart level, whatever the(Cont)
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Blood Pressure (BP)Measurement Use phase I and V (disappearance) Korotkoff
sounds to identify systolic and diastolic bloodpressure, respectively
Measure blood pressure in both arms at firstvisit to detect possible differences due toperipheral vascular disease. In this instance,take the higher value as the reference one
Measure blood pressure 1 and 5 min afterassumption of the standing position inelderly subjects, diabetic patients and inother conditions in which postural hypotensionmay be frequent or suspected (Cont)
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Ambulatory BPMeasurements Although office BP should be used as reference,
ambulatory BP may improve prediction ofcardiovascular risk
Normal values are different for office and ambulatoryBP
24-h ambulatory BP monitoring should beconsidered, in particular, when:
- considerable variability of office BP isfound over the same ordifferent visits
- high office BP is measured in subjectsotherwise at low CV risk
- there is a marked discrepancy betweenBP values measured in theoffice and at home
- resistance to drug treatment is suspected-
(Cont)
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Home BP Measurements
Self-measurement of BP at home is ofclinical value
and its prognostic significance is now demonstrated.These measurements should be encouraged in orderto:- provide more information on the BP lowering effect
of treatment at trough and thus on therapeuticcoverage throughout the dose- to-dose timeinterval- improve patients adherence to treatment regimens- there are doubts on technical reliability/
environmental conditions of ambulatory BP dataL Self-measurement of BP at home should be
discouraged whenever:- it causes anxiety to the patient
- it induces self-modification of the treatment regimen (Cont)
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Blood Pressure Thresholds (mmHg)for Definition of Hypertension
with Different Types ofMeasurement
85130-135Home
70120Night
85130-135Day
80125-13024-hour90140Office orClinic
DBPSBP
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Guidelines for Family andClinical History
1. Duration and previous level of high bloodpressure
2. Indications of secondary hypertension:
- family history of renal disease (polycystickidney)
- renal disease, urinary tract infection,haematuria, analgesic abuse (parenchymalrenal disease)
- drug/substance intake: oral contraceptives,
liquorice, carbenoxolone, nasal drops,cocaine, amphetamines, steroids, non-steroidalanti-inflammatory drugs, erythropoietin,cyclosporine
- episodes of sweating, headache, anxiety,
palpitation (phaeochromocytoma)
(Cont)
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drug/substance intake:
oral contraceptives, liquorice, carbenoxolone,
nasal drops, cocaine, amphetamines, steroids,
non-steroidal anti-inflammatory drugs, erythropoietin, cyclosporine
(Cont)
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Guidelines for Family andClinical History
1. Risk factors:- family and personal history of hypertensionand cardiovascular disease
- family and personal history dyslipidaemia
- family and personal history of diabetesmellitus
- smoking habits
- dietary habits
- obesity; amount of physical exercise
- snoring; sleep apnoea ( information alsofrom partner)
- personality(Cont)
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Guidelines for Family andClinical History
1. Symptoms of organ damage:- brain and eyes: headache, vertigo, impairedvision, transient ischaemic attacks, sensoryor motor deficit
- heart: palpitation, chest pain, shortness ofbreath, swollen ankles
- kidney: thirst, polyuria, nocturia, haematuria
- peripheral arteries: cold extremities,intermittent claudication
6. Previous antihypertensive therapy:
- Drug(s) used, efficacy and adverse effects (Con
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Physical Examination for SecondaryHypertension, Organ Damage and
Visceral ObesitySigns suggesting secondary hypertension andorgan damage
Features of Cushing Syndrome Skin stigmata of neurofibromatosis(phaeochromocytoma)
Palpation of enlarged kidneys (polycystic kidney)
Auscultation of abdominal murmurs (renovascularhypertension)
Auscultation of precordial or chest murmurs (aorticcoarctation or aortic disease)
Diminished and delayed femoral pulses femoral (Cont)
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Signs of organ damage
Brain: murmurs over neck arteries, motor orsensory defects
Retina: fundoscopic abnormalities
Heart: location and characteristics of apicalimpulse, abnormal cardiac rhythms, ventriculargallop, pulmonary rates, peripheral oedema
Peripheral arteries: absence, reduction, orasymmetry of pulses, cold extremities, ischaemicskin lesions
Carotid arteries: systolic murmurs
Physical Examination for SecondaryHypertension, Organ Damage and
Visceral Obesity
(Cont)
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Evidence of visceral obesity
Body weight
Increased waist circumference (standing position)
M: >102 cm, W: >88 cm
Increased body mass index [body weight (Kg)/
height (m)] Overweight 25 Kg/m, Obesity 30
Kg/m
Physical Examination for SecondaryHypertension, Organ Damage and
Visceral Obesity
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Laboratory Investigations
Routine tests
Fasting plasma glucose Serum total cholesterol Serum LDL-cholesterol Serum HDL-cholesterol
Fasting serum triglycerides Serum potassium Serum uric acid Serum creatinine Estimated creatinine clearance (Cockroft-Gault
formula) or glomerular filtration rate (MDRDformula)
Haemoglobin and haematocrit Urinalysis (complemented by microalbuminuria
dipstick test and microscopic examination) Electrocardiogram
Laboratory Investigations
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Laboratory InvestigationsRoutine tests
Fasting plasma
glucose
Serum totalcholesterol
Serum LDL-cholesterol
Serum HDL-cholesterol
Fasting serumtriglycerides
Serum potassium
Serum uric acid
Estimated creatinine
clearance (Cockroft-Gault formula) orglomerular filtrationrate (MDRD formula)
Haemoglobin andhaematocrit
Urinalysis(complemented by
microalbuminuriadipstick test andmicroscopicexamination)
Electrocardiogram(Cont)
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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)
(Cont)
a ora ory nves ga ons
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a ora ory nves ga onsExtended evaluation (domain of the
specialist)
Further search forcerebral, cardiac,renal and vascular
disease, mandatory incomplicated
hypertension
Search for secondary
hypertension whensuggested by history,physical examination
or routine tests:
measurement of :
renin,
aldosterone,
corticosteroids,
catecholamines inplasma and/or urine;
arteriographies;
renal and adrenalultrasound;
computer-assisted
tomography;
magnetic resonance
S hi f b li i l
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Searching for subclinical organdamage
HeartElectrocardiography
Echocardiography
Doppler
hypertrophy, patterns of
strain, ischaemiccondition defects andarrhythmias
detection ofleft ventricularhypertrophy is considereduseful. Geometric patterns(concentric and eccentrichypertrophy, concentric
remodeling)
Diastolic dysfunction canalso be evaluated byDoppler measurement of
transmitral blood pressure
(Cont)
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Searching for subclinical organ damage
Blood vessels Ultrasoundscanning of theextracranial carotidarteries
Pulse wave velocity
Ankle- brachial BP
index signals
vascular hypertrophy(increased thickness ofcommon carotid intima-media)
asymptomatic
atherosclerosis (thickeningof carotid bifurcation andinternal carotid arteries,presence of plagues)
Large artery stiffening(vascular alteration leadingto isolated systolichypertension in theelderly)
peripheral artery disease(Cont)
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Searching for subclinical organ damageKidney
reduced renal function or the detection of anelevated urinary excretion ofalbumin inhypertensive patients serum creatinine
as well estimationfrom serum
creatinine values ofglomerular
filtration creatinine
clearance
The presence ofurinary protein
This allowsclassification ofrenal dysfunction
and
stratification ofcardiovascular risk
(Cont)
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Searching for subclinical organ damageFundoscopy
Examination of eye grounds is recommended in hypertensive with severe
disease, only
grade 1:
arteriolar narrowing;
grade 2:arterio venousnipping
grade 3
(haemorrhages andexudates)
grade 4
(papilloedema),
appear to belargely non-specific
alterations exceptin young patients
present in severe
hypertension, areassociated with anincreased risk ofcardiovascular
events
(Con
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Searching for subclinical organ damageBrain
MRI or
CT
(MRI being generallysuperior to CT)
Availability and costs donot allow asymptomaticuse of these techniques,however
Cognitive tests
Silent brain infarcts,
lacunar infarction,
microbleeds and
white matter lesionsare not infrequentamong hypertensives
In elderlyhypertensive, mayalso help to detectinitial braindeterioration
CT
TAC
+
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Initiation of antihypertensivetreatment
Lifestylechanges +drugtreatment
Lifestylechanges
Diabetes
Lifestylechanges+immediat
e drugtreatment
Lifestylechanges +immediatedrugtreatment
Lifestylechanges +immediatedrugtreatment
Lifestylechanges +immediatedrugtreatment
Lifestylechanges +immediatedrugtreatment
Established CV orrenal
disease
Lifestylechanges+immediate drugtreatment
Lifestylechanges +drugtreatment
Lifestylechanges +drugtreatment
Lifestylechanges andconsider
drugtreatment
Lifestylechanges
3 or moreriskfactors,
MS, OD ordiabetes
Lifestyle
changes+immediate drugtreatment
Lifestylechanges for
severalweeks thendrugtreatment ifBPuncontrolled
Lifestylechanges for
severalweeks thendrugtreatment ifBPuncontrolled
Lifestylechanges
Lifestylechanges
1-2 riskfactors
Lifestylechanges+immediate drugtreatment
Lifestylechanges forseveralweeks thendrugtreatment ifBPuncontrolled
Lifestylechanges forseveralmonths thendrugtreatment ifBPuncontrolled
No BPintervention
No BPintervention
No otherriskfactors
Grade 3HT SBP180 orDBP 110
Grade 2 HT
SBP 160-179
or DBP 100-109
Grade 1 HT
SBP 140-159
or DBP 90-99
High normal
SBP 130-139
or DBP 85-89
Normal
SBP 120-129
or DBP 80-84
Other riskfactors, OD
or disease
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Stratification of CV risk in fourcategories
SBP: systolic blood pressure; DBP: diastolic blood pressure; CV: cardiovascular; HT:hypertension. Low, moderate, high, very high risa refer to 10year risk of a CV fatal or
non-fatal event. The term added indicates that in all categories risk is greater thanaverage. OD: subclinical organ damage; MS: metabolic syndrome.
Blood pressure (mmHg)
Very highaddedrisk
Very highadded risk
Very highadded risk
Very highadded risk
Very highadded risk
EstablishedCV or renaldisease
Very highaddedrisk
High addedrisk
High addedrisk
High addedrisk
Moderateadded risk
3 or morerisk factors,MS, OD ordiabetes
Very highaddedrisk
Moderateadded risk
Moderateadded risk
Low
added risk
Low
added risk
1-2 riskfactors
Highadded
risk
Moderateadded risk
Low
added risk
Average
risk
Average
risk
No otherrisk factors
Grade 3HT SBP180 orDBP110
Grade 2 HT
SBP 160-179 or DBP100-109
Grade 1 HT
SBP 140-159 or DBP90-99
Highnormal
SBP 130-139 or DBP85-89
Normal
SBP 120-129 orDBP 80-84
Other riskfactors, ODor disease
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Goals of Treatment
In hypertensive patients, the primary goal of
treatment is to achieve maximumreduction in the long-term total risk ofcardiovascular disease
This requires treatment of the raised BP perse as well as ofall associated reversible riskfactors
BP should be reduces to at least below140/90 mmHg (systolic/diastolic) and to
lower values, if tolerated, in all hypertensive(Cont)
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Goals of Treatment
Target BP should be at least
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Lifestyle Changes
Lifestyle measures should be instituted,whenever appropriate, in all patients,including those who require drug treatment.The purpose is to lower BP, to control otherrisk factors and to reduce the number of
doses of antihypertensive drugs to besubsequently administered
Lifestyle measures are also advisable insubjects with high normal BP and additionalrisk factors to reduce the risk of developinghypertension
Lifestyle recommendations should not begiven as lip service but instituted withadequate behavioral and expert support and
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Lifestyle Changes
The lifestyle measures that are widely recognized
to lower BP or cardiovascular risk and that shouldbe considered are:
smoking cessation
weight reduction (and weight stabilization)
reduction of excessive alcohol intake physical exercise
reduction of salt intake
increase in fruit and vegetable intake anddecrease in saturated and total fat intake
Because long-term compliance with lifestylemeasures is low and the BP response highlyvariable, patients under non pharmacological
treatment should be followed-up closely to start
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Choice of AntihypertensiveDrugs
The choice of a:
specific drugor a
drugcombinationand
the avoidance
of othersshould takeinto accountthe following:
The previous favorable or
unfavourable experience ofthe individual patient
the cardiovascular risk profileof the individual patient
The presence ofsubclinicalorgan damage, clinicalcardiovascular disease, renaldisease or diabetes
The possibilities ofinteractionswith drugs used for otherconditions
The presence of other
coexisting disorders that maylimit the use of articular (Cont)
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The initiation and maintenance ofantihypertensive treatment, alone or in
combination The main benefits ofantihypertensivetherapy are due tolowering of BPper se
Five major classes ofantihypertensive agents:
thiazide diuretics, calcium antagonists,
ACE inhibitors,
angiotensin receptor
antagonists and -
-blockers,especially incombination with a
thiazide diuretic,should not be usedin patients with themetabolicsyndrome or at highrisk of incidentdiabetes
(Cont)
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Choice of AntihypertensiveDrugs
Continuing attention should be given toside effects of drugs, because they are themost important cause of non-compliance.Drugs are not equal in terms ofadverse
effects, particularly in individual patientsThe BP lowering effect should last 24
hours. This can be checked by office orhome BP measurements at trough or by
ambulatory BP monitoring Drugs which exert their antihypertensive
effect over 24 hours with a once-a-dayadministration should be preferredbecause a sim le treatment schedule
(Cont)
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Antihypertensive Treatment:Preferred Drugs
General rules: lower SBP and DBP to goal. Use any effective agent at adequate doses, ifuseful in combination. Use long acting agents to lower BP throughout 24 hours. Avoid or
minimize adverse effects.
Subclinical organ damageLeft ventricular hypertrophy ACE inhibitors, calcium antagonists,
angiotensin receptor antagonistsAsymptomatic atherosclerosis Calcium antagonists, ACE inhibitorsMicroalbuminuria ACE inhibitors, angiotensin receptor antagonistsRenal dysfunction ACE inhibitors, angiotensin receptor antagonists
Clinical eventPrevious stroke Any BP lowering agentPrevious MI -blockers, ACE inhibitors, angiotensin receptorantagonists Angina pectoris -blockers, calcium antagonistsHeart failure diuretics, -blockers, ACE inhibitors, angiotensinreceptor antagonists, antialdosteroneagentsAtrial fibrillation
Recurrent ACE inhibitors, angiotensin receptor
antagonistsContinuous -blockers, non-dihydropiridine calcium
antagonistsRenal failure/proteinuria ACE inhibitors, angiotensin receptor antagonists,loop diuretics Peripheral artery disease Calcium antagonists
ConditionIsolated systolic hypertension (elderly)Duretics, calcium antagonistsMetabolic syndrome ACE inhibitors, angiotensin receptor
antagonists, calcium antagonistsDiabetes mellitus ACE inhibitors, angiotensin receptor antagonists
(Cont)
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Antihypertensive Treatment:Preferred Drugs
General rules:
lower SBP and DBP to goal. Use any effective agent at adequatedoses, if useful in combination.
Use long acting agents to lower BPthroughout 24 hours.
Avoid or minimize adverse effects(Cont)
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Antihypertensive Treatment:Preferred Drugs 1. Subclinical
organ damageLeft ventricularhypertrophy
Asymptomatic
atherosclerosis
Microalbuminuria
Renal dysfunction
ACE inhibitors, calciumantagonists, Angiotensin receptor
antagonists
Calcium antagonists,
ACE inhibitors
ACE inhibitors, angiotensin receptor
antagonists
ACE inhibitors, angiotensin receptor
antagonists(cont)
Antihypertensive Treatment: Preferred Drugs
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yp g
2. Clinical event Previous stroke
Previous MI
Angina pectoris
Heart failure
Atrial fibrillationRecurrent
Continuous
Renalfailure/proteinuria
Peripheral arterydisease
Any BP lowering agent
-blockers, ACE inhibitors,angiotensin receptor antagonists -blockers, calcium antagonists
diuretics, -blockers, ACE inhibitors,angiotensin receptor antagonists,antialdosterone agents
ACE inhibitors, angiotensin receptorantagonists
-blockers, non-dihydropiridinecalcium antagonists
ACE inhibitors, angiotensin receptorantagonists, loop diuretics
Calcium antagonists
(cont)
ih i f d
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Antihypertensive Treatment: Preferred Drugs
3. Condition
Isolated systolichypertension (elderly)
Metabolic syndrome
Diabetes mellitus
Pregnancy
Blacks
Duretics, calciumantagonists
ACE inhibitors,
angiotensin receptorantagonists, calciumantagonists
ACE inhibitors,angiotensin receptorantagonists
Calcium antagonists,methyldopa, -
blockers (cont)
Conditions favoring use of some
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Conditions favoring use of someantihypertensive drugs versus
others
Hypertension inblacks
Pregnancy
PregnancyGlaucoma
Carotid/ CoronaryAtherosclerosis
Tachyarrhythmias
Supraventriculartachycardia
LV hypertrophyHeart failureHypertension inblacks
Carotidatherosclerosis
Angina pectorisPost-myocardialinfarction
Heart failure
Angina pectorisIsolated systolichypertension(elderly)
Anginapectoris
Isolated systolichypertension(elderly)
Calcium
antagonists(verapamil/diltiazem)
Calcium
antagonists(dihydropyridines)
Beta-
blockers
Thiaside
diuretics
(cont)
Conditions favoring use of some
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Conditions favoring use of someantihypertensive drugs versus
others
Metabolic
syndrome
Atrial fibrillation
ACEI - inducedcough
Proteinuria/Microalbuminuria
Metabolicsyndrome
Carotidatherosclerosis
Atrial fibrillationLV hypertrophy
LV hypertrophyNon-diabeticnephropathy
Proteinuria/Microalbuminuria
Diabeticnephropathy
Diabeticnephropathy
Post-myocardialinfarction
Heart failurePost-myocardialinfarction
Post-myocardialinfarction
LV dysfunction
End stage renaldisease
Heart failureHeart failureHeart failure
Loop
diuretics
Diuretics
antialdosterone
Angiotensin
receptorantagonists
ACE
Inhibitors
Compelling and possible
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Compelling and possiblecontraindications to use of
antihypertensive drugs
Renal failure
Hyperkalaemia
PregnancyHyperkalaemiaBilateral renal arterystenosis
Pregnancy
Angioneurotic oedemaHyperkalaemiaBilateral renal arterystenosis
A-V block (grade 2 or 3)Heart failure
TachyarrhythmiasHeart failure
Peripheral artery diseaseMetabolic syndromeGlucose intoleranceAthletes and physically active
patientsChronic obstructive pulmonarydisease
Asthma
A-V block (grade 2 or 3)
Metabolic syndromeGlucose intolerancePregnancy
Gout
Diuretics(antialdosterone)
AT1 blockers
ACE inhibitors
Calcium antagonists(verapamil,dilitazem)
Calcium antagonists(dihydropiridines)
Beta-blockers
Thiazide diuretics
PossibleCompelling
h
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Monotherapy versusCombination Therapy
Regardless of the drug employed, monotherapy
allows to achieve BP target in only a limitednumber of hypertensive patients
Use of more than one agent is necessary toachieve target BP in the majority of patients. A
vast array of effective and well toleratedcombinations is available
Initial treatment can make use ofmonotherapy orcombination of two drugs at low doses with asubsequent increase in drug doses or number, if
needed Monotherapy could be the initial treatment for a
mild BP elevation with a low or moderate totalcardiovascular risk. A combination of two drugs atlow doses should be preferred as first steptreatment when initial BP is in the grade 2 or 3
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Monotherapy versusCombination Therapy
Fixed combination of two drugs can simplifytreatment schedule and favour compliance
In several patients BP control is not achieved by
two drugs and a combination of three of moredrugs is required
In uncomplicated hypertensives and in the
elderly, antihypertensive therapy should normallybe initiated gradually. In high risk hypertensives,goal blood pressure should be achieved morepromptly, which favours initial combinationtherapy and quicker adjustment of doses
M th
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Monotherapy versuscombination strategies
Choose between
If goal BP not achieved
If goal BP not achieved
Previousagent at full
dose
Switch todifferent agent
at low dose
Previouscombination at
full dose
Add a thirddrug at low
dose
Two-to three-drugcombination at full
dose
Full dosemonotherap
y
Two-three drugcombination at full
doses
Mild BP elevation
Low/moderate CV riskConventional BPtarget
Marked BP elevation
High/very CV high riskLower BP target
Single agent at
low dose
Two-drug combination at
low dose
P ibl bi ti b t
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Possible combinations betweensome classes of antihypertensive
drugsThiazidediuretics
ACEinhibitors
-blocker
s
Angiotensinreceptor
antagonists
Calciumantagonists
-
blockers
The preferred combinations in the general hypertensive population arerepresented as thick lines.
A tih t i T t t i
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Antihypertensive Treatment inthe Elderly
Randomized trials in patients with systolic-
diastolic or isolated systolic hypertension aged60 years have shown that a marked reduction incardiovascular morbidity and mortality can beachieved with antihypertensive treatment
Drug treatment can be initiated with thiazidediuretics, calcium antagonists, angiotensinreceptor antagonists, ACE inhibitors and -blockers, in line with general guidelines. Trialsspecifically addressing treatment of isolated
systolic hypertension have shown the benefit ofthiazide and calcium antagonists but subanalysisof other trials also show efficacy ofangiotensinreceptor antagonists
Initial doses and subsequent dose titration should
be more gradual because of a greater chance of
A tih t i T t t i
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Antihypertensive Treatment inthe Elderly
BP goal is the same as in younger patients, i.e.
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Antihypertensive Treatment inDiabetics
Where applicable, intense non-pharmacologicalmeasures should be encouraged in all diabeticpatients, with particular attention to weight loss andreduction of salt intake in type 2 diabetes
Goal BP should be
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Antihypertensive Treatment inDiabetics
A blocker of the renin-angiotensin system shouldbe a regular component ofcombination treatmentand the one preferred when monotherapy issufficient
Microalbuminuria should prompt the use of
antihypertensive drug treatment also when initialBP is in the high normal range. Blockers of therenin-angiotensin system have a pronouncedantiproteinuric effect and their use should bepreferred
Treatment strategies should consider anintervention against all cardiovascular riskfactors, including a statin
Because of the greater change ofpostural
hypotension, BP should also be measured in the
A tih t i Th i
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Antihypertensive Therapy inpatients
with Renal Dysfunction Renal dysfunction and failure are associatedwith a very high risk of cardiovascular events
Protection against progression of renaldysfunction has two main requirements: a)strict blood pressure control(1 g/day); b)lowering proteinuria to values as near tonormal as possible
To achieve the blood pressure goal,combination therapy of severalantihypertensive agents(including loopdiuretics) is usually required
(cont)
A tih t i Th i
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Antihypertensive Therapy inpatients
with Renal Dysfunction To reduce proteinuria, an angiotensin receptorblocker, an ACE inhibitor or a combination of bothare required
There is a controversial evidence as to whether
blockage of the renin-angiotensin system has aspecific beneficial role in preventing or retardingnephrosclerosis in non-diabetic non-proteinurichypertensives, except perhaps in Afro-Americanindividuals. However, inclusion of one of these
agents in the combination therapy required bythese patients appears well founded
An integrated therapeutic intervention(antihypertensive, statin and antiplatelet therapy)has to be frequently considered in patients withrenal damage because under these
A tih t i t t t
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Antihypertensive treatmentin patients with
Cerebrovascular Disease In patients with a history of stroke or transientischemic attacks, antihypertensive treatmentmarkedly reduces the incidence of stroke recurrenceand also lowers the associated high risk of cardiacevents
Antihypertensive treatment is beneficial inhypertensive patients as well as in subjects with BPin the high normal range. BP goal should be
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Antihypertensive treatment inpatients with Cerebrovascular
Disease There is at present no evidence that BP loweringhas a beneficial effect in acute stroke but moreresearch is under way. Until more evidence isobtained antihypertensive treatment should start
when post-stroke clinical conditions are stable,usually several days after the event. Additionalresearch in this are is necessary becausecognitive dysfunction is present in about 15% and
dementia in 5% of subjects aged 65 years In observational studies, cognitive decline andincidence of dementia have a positiverelationship with BP values. There is someevidence that both can be somewhat delayed by
antihypertensive treatment
Antihypertensive treatment in
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Antihypertensive treatment inpatients with Coronary Heart
Disease and Heart Failure In patients surviving a myocardial infarction, earlyadministration of-blockers, ACE inhibitors orangiotensin receptor antagonists reduces theincidence of recurrent myocardial infraction and
death. These beneficial effects can be ascribed tothe specific protective properties of these drugsbut possibly also to the associated small BPreduction
Antihypertensive treatment is also beneficial in
hypertensive patients with chronic coronary heartdisease. The benefit can be obtained withdifferent drugs and drug combinations (includingcalcium antagonists) and appears to be related to
the degree of BP reduction. A beneficial effect has
Antihypertensive treatment in
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Antihypertensive treatment inpatients with Coronary Heart
Disease and Heart Failure A history of hypertension is also beneficial inhypertensive patients with chronic coronary heartdisease. In these patients, treatment can makeuse ofthiazide and loop diuretics, as well as
of-blockers, ACE inhibitors, angiotensinreceptor antagonists and antialdosteronedrugs on top ofdiuretics. Calciumantagonists should be avoided unless needed to
control BP or anginal symptoms Diastolic heart failure is common in patients with
a history of hypertension and has an adverseprognosis. There is at present no evidence on thesuperiority of specific antihypertensive drugs
Hypertension in women
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Hypertension in women
Treatment of Hypertension in women
Response to antihypertensive agents andbeneficial effects of BP lowering appear to besimilar in women and in men. However, ACEinhibitors and angiotensin receptor antagonists
should be avoidedin pregnant and pregnancyplanning women because ofpotential teratogeniceffects during pregnancy !
Oral Contraceptives
Even oral contraceptives with low oestrogencontent are associated with an increased risk ofhypertension, stroke and myocardial infarction.
The progestogen-only pill is a contraceptiveoption for women with high BP, but their
influence on cardiovascular outcomes has been(cont.)
Hypertension in women
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Hypertension in women (cont.)
1. Hypertension in pregnancy
Hypertensive disorders in pregnancy,
particularly pregnancy induced
hypertension with proteinuria (pre eclampsia),
may adversely affect neonatal and
maternal outcomes
(cont.)
Hypertension in pregnancy (cont)
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Hypertension in pregnancy (cont)
Non- pharmacologicalmanagement
for pregnant womenwith
SBP 140-149 mmHg or
DBP 90-95 mmHg.
Pharmacological
managementIn non-severe
hypertension,
including :
close supervision and
restriction ofactivities.
oral methyldopa, labetalol, calcium antagonists
and (lessfrequently)
-blockers(cont.)
Hypertension in pregnancy (cont)
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Hypertension in pregnancy (cont)
In the presence ofgestationalhypertension (withor withoutproteinuria)
but in the case ofpre existinghypertensionwithout organdamage
drug treatment isindicated atBP levels 140/90
mmHg,
threshold fordrug treatment may be
150/95 mmHg.
SBP levels 170 or DBP 110 mmHgshould be considered an
emergency requiring hospitalisation (cont.
Hypertension in women
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Hypertension in women
Hypertension in pregnancy (cont.)
Under emergency circumstances:- intravenous labetalol,
- oral methyldopa and
- oral nifedipine are indicated.
Intravenoushydralazine is no longer the drug ofchoice because of an excess of perinatal adverseeffects. Intravenous infusion ofsodiumnitroprusside is useful in hypertensive crises, butprolonged administration should be avoided (fetal
cyanide poisoning) Calcium supplementation, fish oil and low doseaspirin have failed to consistently preventgestational hypertension, especially pre-eclampsia, and are thus not recommended.
However, low dose aspirin may be used (cont.)
Hypertension in pregnancy
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Hypertension in pregnancy(cont.)
In pre-eclampsiawith pulmonaryoedema,
Diuretic therapy isinappropriate becauseplasma volume isreduced in pre-
eclampsia. !
in the treatment ofseizures
nitroglycerine isthe drug of choice.
Magnesiumsulphate
The Metabolic Syndrome
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The Metabolic Syndrome
The metabolic syndrome is characterized by the
variable combination ofvisceral obesity andalterations in glucose metabolism, lipidmetabolism and BP. It has a high prevalence inthe middle age and elderly population
Subjects with the metabolic syndrome also havea higher prevalence ofmicroalbuminuria, leftventricular hypertrophy and arterialstiffness than those without the metabolicsyndrome. Their cardiovascular risk is high and
the chance of developing diabetes markedlyincreased
In patients with a metabolic syndrome diagnosticprocedures should include a more in-depth
assessment ofsubclinical organ damage.
Criteriile NCEP ATP IIIde diagnostic a Sindromului X Metabolic
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de diagnostic a Sindromului X Metabolic
Obezitate abdominal Femei > 88 cm
Circumferina taliei Brbai > 102cm
Trigliceride 150 mg/dL
HDL Colsterol Femei < 40
mg/dL
Brbai
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Definiia OMS a SMet
Glicemie bazal / Toleran la glucozAlterate
Indice talie-old
Trigliceride 150 mg/dL
Tensiune arterial 140/90 mm Hg
Femei> 0.85
Brbai> 0.9
Microalbuminurie rata urinar de excreie 20g/min
HDL-colesterol < 40 mg/dL
Raport albumin/creatinin 30 mg/g
IMC > 30 kg/m2
sau
sau
sau
22dincrietr
ii
dincrietr
ii
Factori geneticiFactori de mediu
si stil de via
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SindromulSindromulmetabolicmetabolic
Inflamaie
TG
HTA HDL-C
Glicemie
Obezitatevisceral
Rspunsvascular
inadecvat
Stareprotrombotic
Evenimente
cardiovasculare Diabet
The Metabolic Syndrome
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The Metabolic Syndrome
In all individuals with metabolic syndrome
individuals intense lifestyle measures should beadopted. When there is hypertension drugtreatment should start with a drug unlikely tofacilitate onset to diabetes. Therefore, a blocker ofthe renin-angiotensin system should be usedfollowed, if needed, by the addition of a calciumantagonist or a low-dose thiazide diuretic. Itappears desirable to bring BP to the normal range
Lack of evidence from specific clinical trialsprevents firm recommendations on use ofantihypertensive drugs in all metabolic syndrome
subjects with a high normal BP. There is someevidence that blocking the renin-angiotensinsystem may also delay incident hypertension
Statins and antidiabetic drugs should be given inthe presence of dyslipidemia and diabetes,
respectively. Insulin sensitizers have been shown
Causes of Resistant
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Causes of ResistantHypertension Poor adherence to therapeutic plan
Failure to modify lifestyle including: Weight gain Heavy alcohol intake (NB: binge drinking)
Continued intake of drugs that raise blood
pressure (liquorice, cocaine, glucocorticoids, non-steroid anti-inflammatory drugs, etc.) Obstructive sleep apnea Unsuspected secondary cause Irreversible or scarcely reversible organ damage
Volume overload due to: Inadequate diuretic therapy Progressive renal insufficiency High sodium intake
Hyperaldosteronism
Causes of Resistant
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Causes of ResistantHypertension
Causes of spurious resistant hypertension:
Isolated office (white-coat) hypertension
Failure to use large cuff on large arm
Pseudohypertension
Hypertensive Emergencies
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Hypertensive Emergencies
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 cerebrovascularaccident
Crisis associated with phaeochromocytoma Use of recreational drugs such as amphetamines,
LSD, cocaine or ecstasy
Hypertension perioperatively
Severe pre-eclampsia or eclampsia
Treatment of Associated Risk
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Treatment of Associated RiskFactors
Lipid Lowering Agents
All hypertensive patients with establishedcardiovascular disease or with type 2 diabetesshould be considered for statin therapy aiming atserum total and LDL cholesterol levels of,
respectively,
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Treatment of Associated RiskFactors
Antiplatelet Therapy
Antiplatelet therapy, in particular low-doseaspirin, should be prescribed to hypertensivepatients with previous cardiovascular events,provided that there is no excessive risk of
bleeding Low-dose aspirin should also be considered in
hypertensive patients without a history ofcardiovascular disease if older that 50 years, with
a moderate increase in serum creatinine or with ahigh cardiovascular risk. In all these conditions,the benefit-to-risk ratio of this intervention(reduction in myocardial infraction greater thanthe risk of bleeding) has been proven favourable
To minimize the risk of haemorrhagic stroke,
Treatment of Associated Risk
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Treatment of Associated RiskFactors
Glycaemic Control
Effective glycaemic control is of great importancein patients with hypertension and diabetes
In these patients dietary and drug treatment of
diabetes should aim at lowering plasma fastingglucose to values6 mmol/L (108 mg/dL) and at glycatedhaemoglobin of
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Patient s Follow Up
Titration to BP control requires frequent visits in
order to timely modify the treatment regimen inrelation to BP changes and appearance of sideeffects
Once target BP has been obtained, the frequency
of visits can be considerably reduced. However,excessively wide intervals between visits are notadvisable because they interfere with a gooddoctor patient relationship, which is crucial forpatients compliance
Patients at low risk or with grade 1 hypertensionmay be seen every months and regular home BPmeasurements may further extend this interval.Visits should be more frequent in high or very high
risk patients. This is the case also in patients under
Patients Follow-Up
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Patient s Follow Up
Follow-up visits should aim at maintaining control
of all reversible risk factors as well as at checkingthe status of organ damage. Because treatment-induced changes in left ventricular mass andcarotid artery wall thickness are slow, there is no
reason to perform these examinations at lessthan 1 year intervals
Treatment of hypertension should be continuedfor life because in correctlydiagnosed patients
cessation of treatment is usually followed byreturn to the hypertensivestate. Cautiousdownward titration of the existing treatment maybe attempted in low risk patients after long-termBP control, particularly ifnon pharmacologicaltreatment can be successfull im lemented
How to improve compliance to
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How to improve compliance totreatment Inform the patient on the risk of
hypertension and the benefit of effectivetreatment
Provide clear written and oral instructionsabout treatment.
Tailor the treatment regimen to patientslifestyle and needs
Simplifytreatment by reducing, if possible,the number of disease and treatmentplans
Involve patients partner or family in
information on disease and treatment
(Cont)
How to improve compliance to
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How to improve compliance totreatment
Make use ofself measurement of BP at
home and of behavioral strategies such asreminder systems
Pay great attention to side effects (even ifsubtle) and be prepared to timely changedrug doses or types if needed
Dialogue with patient regarding adherenceand be informed of his/her problems
Provide reliable support system andaffordable prices
(Cont)
Total Cardiovascular Risk
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Total Cardiovascular Risk
Dysmetabolic risk factors and subclinicalorgan damage are common in hypertensivepatients
All patients should be classified not only inrelation to the grades of hypertension but also in
terms of the total cardiovascular risk resultingfrom the coexistence of different risk-factors, organ damage and disease
Decisions on treatment strategies (initiation
of drug treatment, BP threshold and target fortreatment, use of combination treatment, need ofa statin and other non-antihypertensive drugs) allimportantly depend on the initial level of risk
Total Cardiovascular Risk
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Total Cardiovascular Risk
There are several methods by which total
cardiovascular risk can be assessed, all withadvantages and limitations. Categorization oftotalrisk as low, moderate, high and very highaddedrisk has the merit of simplicity and can therefore berecommended. The term added risk refers to the
risk additional to the average one Total risk is usually expressed as the
absolute risk of having a cardiovascularevent within 10 years. Because of its heavy
dependence on age, in young patients absolutetotal cardiovascular risk can be low even in thepresence of high BP with additional risk factors. Ifinsufficiently treated, however, this condition maylead to a partly irreversible high risk condition
years later. In younger subjects treatment
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CONCLUZII
Prof. Univ. Dr. Maria Puchi
1 Cu toate dovezile solide
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1. Cu toate dovezile solideexistente pana in prezent:
HTA reprezint unfactor de risccardiovascularmajor
Strategiile dereducere a TA
scad substanialriscul
O mare parte apacienilorhipertensivi nusunt contieni deprezena acesteia,
Sau dac sunt
contieni nu setrateaz
iar
Concluzii 2.
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inteleterapeutice suntrar atinse
Valorile TA sistolicesunt greu decontrolat,excepionalrealizabile
Indiferent dacsunt prescrise deun medic specialistsau de un medic
generalist.
Iar intele de TAsub 130/80 sunt
greu de realizatpentru pacieniidiabetici saupacienii cu risc
nalt!
Concluzii 3
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Aceste evidene explic de cehipertensiunea arterial:
o cauz important de deces imorbiditate cardiovascular n
ntreaga lume, inclusiv n rile bine
dezvoltate
Concluzii 4
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Implementarea:
2007 Guidelinesfor the Management of
Arterial Hypertension
ar putea duce lacrestereagradului dediagnostic al HTA ,
alprocentului de pacenti tratati
al controlului terapeutic
Concluzii 5
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Ghidul trebuie adaptat pentru fiecareSocietate Nationala
Autorii ghidului 2007 ESH/ESC lrecomand ca pe un material
educational si nu unul prescriptiv,
deoarece ghidul trateaz boala ngeneral, iar situatiile pot fi diferite de
la un subiect la altul.
Concluzii 6
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Judecata clinic este ceacare trebuie s aib
prioritate n practicaclinic zilnic
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2007 Guidelinesfor the Management of
Arterial Hypertension
Journal of Hypertension2007;25:1105-1187
European Society of HypertensionEuropean Society of Cardiology
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