Guías de HTA 2013 ESH/ESC

1. 2013 ESH/ESC Hypertension Guidelines Guías de HTA 2013 ESH/ESC

2. Evaluación diagnóstica • Confirmación del diagnóstico de HTA • Detección de causas de HTA secundaria • Valoración del RCV, LOD asintomática y condiciones clínicas concomitantes

3. Factores (además de PA clínica) queinfluyen en el pronósticopara la estratificación de RCV total Sin cambios

4. Estratificación del RCV en categorías: bajo, moderado, alto y muy alto riesgo

5. Valoración y estratificación del RCV total • En la estratificación, además de la HTA: • Otros FRCV • LOD asintomática • Diabetes • Enfermedad renal o CV establecida

6. Definición y clasificación de los niveles de PA clínica

7. Definición de HTA a través de los niveles de PA clínica y no clínica

8. PA ambulatoria

9. Evaluación diagnóstica: Variables derivadas del MAPA • Ratio Noche-Día • Categorías según el patrón dipper: • La mayoría de marcadores de LOD se correlacionan de forma más estrecha con la PA ambulatoria • PA ambulatoria es un predictor más sensible de los eventos clínicos CV coronarios e ictus tanto fatales como no fatales que la PA clínica • La PA nocturna es un predictor más robusto de la morbi-mortalidad que la PA diurna • La incidencia de eventos CV es mayor en pacientes con menor o ausencia de descenso de la presión arterial nocturna

10. Recomendaciones en la evaluación diagnóstica a nivel cardíaco, arterial, renal, retiniano y cerebral

11. Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónica Sin cambios

12. Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónica Sin cambios

13. Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónica Sin cambios

14. Objetivos de PA

15. Objetivos de presión arterial

16. Estrategias de tratamiento

17. Inicio de los cambios en el estilo de vida y tratamientoantiHTA

18. Modificación del estilo de vida • Restricción de sal • Moderación del consumo de alcohol • Reducción y mantenimiento del peso • Ejercicio físico regular • Cese del tabaquismo Sin cambios

19. Objetivos de PA • A SBP < 140 mmHg recommended/considered, regardless the level of risk • Low/moderate risk (IB) • Diabetes (IA) • Diabetic/nondiabetic CKD (IIaB) • Patients with CHD/previous stroke or TIA (IIaB) • A DBP < 90 mmHg recommended PA < 140/90 mmHg

20. BP goals in hypertension - Exception to the general rule • In patients with diabetes DBP values < 85 mmHg are recommended (IA) • In elderly hypertensives (< 80 years old) there is solid evidence to recommend reducing SBP between 150-140 mmHg (IA)Consider a SBP <140 mmHg in fit elderlies • Same SBP target in individuals older than 80 years (IB)It Applies to octogenarians in good physical/mental conditions

21. Initiation of antihypertensive drug treatment

22. Inicio de tratamientofarmacológico

23. Choice of antihypertensive drugs - Conclusions from 2013 (and 2003 and 2007) Guidelines • The main benefits of antihypertensive treatment are due to lowering BP “per se” and are largely independent of the drug employed • Although meta-analyses occasionally claim superiority of one class for some outcomes this largely depends on selection bias of trials. The largest meta-analyses do not show clinically relevant between-class differences • Current Guidelines reconfirm that the following drugs classes are all suitable for initiation and maintenance of antihypertensive treatment either as monotherapy or in some combinations with each other (IA) • Diuretics (thiazides / chlorthalidone / indapamide) • Beta-blockers • Calcium antagonists • ACE-inhibitors • Angiotensin receptor blockers

24. Estrategias de tratamiento en condicionesespeciales • HTA de bata blanca • HTA enmascarada • Ancianos • Adultos jóvenes • Mujeres • Diabetes mellitus • Síndrome metabólico • SAHS • Cardiopatía • Aterosclerosis /Arteriosclerosis / Enfermedad arterial periférica • Disfunción eréctil • HTA resistente • HTA maligna • Emergencias / urgencias hipertensivas • Manejo de la HTA en el perioperatorio • HTA renovascular • Aldosteronismo primario

25. Treatment strategies and choice of drugs

26. Two drug combinations as initial treatment • Cons • One of the two drugs may be ineffective • Ascribing side effects more difficult • Pros • When one agent ineffective, finding an alternative monotherapy may be a painstaking process, adversely affecting compliance • Prompter response in a larger number of patients (benefit in high risk patients?) • Lower drop-out rate

27. Possible combinations of antihypertensive drug classes Green/continuous: preferred Green/dashed: useful (with some limitations) Black/dashed: possible but less well tested Red/continuous: not recommended No doble bloqueo del SRAA Only dihydropyridines to be combined with -blockers (except for verapamil or diltiazem for rate control in AF) Thiazides + -blockers increase risk of new onset DM ACEI + ARB combination discouraged (IIIA)

28. Treatment of risk factors associated with hypertension

29. Follow-up of hypertensive patients • After treatment initiation see patients at 2-4 week intervals • Once the target is reached, a visit interval of a few months (3 or 6) is reasonable • Depending on local organization and health resources later visits may be performed by non-physician health workers • For stable patients Home BP and electronic communication may provide an acceptable alternative • It is advisable to assess risk factors and OD at least every 2 years

30. Can antihypertensive medications be stopped? • In some patients in whom treatment is accompanied by an effective BP control for an extended period it may be possible to reduce the number/dosage of drugs • This may be particularly the case if BP control is accompanied by healthy lifestyle changes, removing the environmental pressor influences • Medication reduction should be gradual and patients should be frequently checked Intentar reducciones farmacológicas tras buen control largo tiempo

31. Tratamiento en condiciones especiales

32. Treatment strategies in hypertensive patients with resistant hypertension

33. Treatment strategies in hypertensive patients with heart disease COMO ANTES

34. Treatment strategies in hypertensive patients with cerebrovascular disease

35. Treatment strategies in hypertensive patients with atherosclerosis, arteriosclerosis, and peripheral artery disease PA <140/90 mmHg

36. Treatment strategies in hypertensive patients with nephropathy • PAS < 130-140 mmHg • Si proteinuria bloqueadores de SRAA

37. Treatment strategies in hypertensive patients with metabolic syndrome PA < 140/90 mmHg De elección: Bloqueadores SRAA Calcio-antagonistas

38. Diabetes Mellitus - Key Issues • High BP is common / masked HT not infrequent • Marked CV risk increase with HT-DM association • Major benefit of antihypertensive therapy on macrovascular and renal complications • No clear effect of antihypertensive therapy on retinopathy and neuropathy (several studies)

39. Treatment strategies in patients with diabetes PA < 140/85 mmHg

40. Drugs to be preferred in specific conditions

41. Treatment strategies in hypertensive women

42. Young Hypertensive Adults • Isolated DBP elevation possible • Long-term CV risk possibly more closely related to DBP than SBP • Drug treatment may be considered prudent with BP target < 140/90 mmHg • Selective SBP elevation sometimes associated with normal central SBP – Because there is no evidence on drug effects, close FU / lifestyle changes advisable 18516 M