Guías de HTA 2013 Guías de HTA 2013 ESH/ESCESH/ESC

2013 ESH/ESC Hypertension Guidelines2013 ESH/ESC Hypertension Guidelines

Evaluación diagnóstica

• Confirmación del diagnóstico de HTA• Detección de causas de HTA secundaria • Valoración del RCV, LOD asintomática y condiciones

clínicas concomitantes

Factores (además de PA clínica) que influyen en el Factores (además de PA clínica) que influyen en el pronóstico para la estratificación de RCV totalpronóstico para la estratificación de RCV total

Sin cambios

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

Valoración y estratificación del RCV totalValoración y estratificación del RCV total

Recomendaciones Clase Nivel

Asintomáticos hipertensos sin ECV, DM , mínimos requerimientos

I B

Hay evidencias de que la LOD predice el riesgo de muerte CV independientemente del SCORE por lo que se debe valorar sobre todo en individuos de riesgo moderado

IIa B

Se recomienda que las decisiones del tratamiento dependan del nivel inicial de RCV total

I B

• En la estratificación, además de la HTA:– Otros FRCV– LOD asintomática– Diabetes– Enfermedad renal o CV establecida

Definición y clasificación de los niveles de PA clínicaDefinición y clasificación de los niveles de PA clínica

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

PA ambulatoria

Evaluación diagnóstica: Variables derivadas del MAPA

• Ratio Noche-Día • Categorías según el

patrón dipper:

Categoría Ratio Noche/día

Ausencia de dipping >1.0

Dipping leve >0.9 y ≤ 1.0

Dipping >0.8 y ≤ 0.9

Dipping extremo ≤ 0.8

• 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

Recomendaciones en la evaluación diagnóstica a nivel cardíaco, arterial, renal,

retiniano y cerebral

Búsqueda de daño orgánico asintomático, Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónicaenfermedad CV y enfermedad renal crónica

Sin cambios

Búsqueda de daño orgánico asintomático, Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónicaenfermedad CV y enfermedad renal crónica

Sin cambios

Búsqueda de daño orgánico asintomático, Búsqueda de daño orgánico asintomático, enfermedad CV y enfermedad renal crónicaenfermedad CV y enfermedad renal crónica

Sin cambios

Objetivos de PA

Objetivos de presión arterialObjetivos de presión arterial

Estrategias de tratamiento

Inicio de los cambios en el estilo de vida yInicio de los cambios en el estilo de vida ytratamiento antiHTAtratamiento antiHTA

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

Objetivos de PAObjetivos de PA

A SBP < 140 mmHg recommended/considered, A SBP < 140 mmHg recommended/considered, regardless the level of riskregardless the level of risk

- Low/moderate risk (IB)Low/moderate risk (IB)

- Diabetes (IA)Diabetes (IA)

- Diabetic/nondiabetic CKD (IIaB)Diabetic/nondiabetic CKD (IIaB)

- Patients with CHD/previous stroke or TIA (IIaB)Patients with CHD/previous stroke or TIA (IIaB)

A DBP < 90 mmHg recommendedA DBP < 90 mmHg recommended

PA < 140/90 mmHg

BP goals in hypertension - BP goals in hypertension - Exception to the general ruleException to the general rule

In patients with diabetes DBP values < 85 mmHg are In patients with diabetes DBP values < 85 mmHg are recommended (IA)recommended (IA)

In elderly hypertensives (< 80 years old) there is solid In elderly hypertensives (< 80 years old) there is solid evidence to recommend reducing SBP between 150-140 evidence to recommend reducing SBP between 150-140 mmHg (IA)mmHg (IA)Consider a SBP <140 mmHg in fit elderliesConsider a SBP <140 mmHg in fit elderlies

Same SBP target in individuals older than 80 years (IB)Same SBP target in individuals older than 80 years (IB)It It Applies to octogenarians in good physical/mental Applies to octogenarians in good physical/mental conditionsconditions

Initiation of antihypertensive drug treatmentInitiation of antihypertensive drug treatment

Inicio de tratamiento farmacológicoInicio de tratamiento farmacológico

Grado 2-3 Recomendado (precoz) IA

Grado I (alto RCV) Recomendado IB

Grado I (bajo RCV) Debe considerarse IIaB

Ancianos Recomendado si PAS ≥ 160 mmHg

Puede considerarse si PAS 140-159 mmHg

IA

IIbC

PA normal alta No se recomienda tratamiento farmacológico

IIIA

Choice of antihypertensive drugs - Choice of antihypertensive drugs - Conclusions from 2013 (and 2003 and 2007) GuidelinesConclusions from 2013 (and 2003 and 2007) Guidelines

The main benefits of antihypertensive treatment are due to The main benefits of antihypertensive treatment are due to lowering BP lowering BP ““per seper se”” and are largely independent of the drug and are largely independent of the drug employedemployed

Although meta-analyses occasionally claim superiority of one Although meta-analyses occasionally claim superiority of one class for some outcomes this largely depends on selection bias class for some outcomes this largely depends on selection bias of trials. The largest meta-analyses do not show clinically of trials. The largest meta-analyses do not show clinically relevant between-class differencesrelevant between-class differences

Current Guidelines reconfirm that the following drugs classes Current Guidelines reconfirm that the following drugs classes are all suitable for initiation and maintenance of are all suitable for initiation and maintenance of antihypertensive treatment either as monotherapy or in some antihypertensive treatment either as monotherapy or in some combinations with each other (IA)combinations with each other (IA)

- Diuretics (thiazides / chlorthalidone / indapamide)Diuretics (thiazides / chlorthalidone / indapamide)- Beta-blockersBeta-blockers- Calcium antagonistsCalcium antagonists- ACE-inhibitorsACE-inhibitors- Angiotensin receptor blockersAngiotensin receptor blockers

Estrategias de tratamiento en Estrategias de tratamiento en condiciones especialescondiciones especiales

• 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

Treatment strategies and choice of drugsTreatment strategies and choice of drugs

Two drug combinations as initial treatmentTwo drug combinations as initial treatment

ConsCons

One of the two drugs One of the two drugs may be ineffectivemay be ineffective

Ascribing side effects Ascribing side effects more difficultmore difficult

ProsPros

When one agent ineffective, When one agent ineffective, finding an alternative finding an alternative monotherapy may be a monotherapy may be a painstaking process, adversely painstaking process, adversely affecting complianceaffecting compliance

Prompter response in a larger Prompter response in a larger number of patients (benefit in number of patients (benefit in high risk patients?)high risk patients?)

Lower drop-out rateLower drop-out rate

Possible combinations of antihypertensive drug classesPossible combinations of antihypertensive drug classes

Only dihydropyridines to be combined with -blockers (except for verapamil or diltiazem for rate control in AF)Thiazides + -blockers increase risk of new onset DMACEI + ARB combination discouraged (IIIA)

Only dihydropyridines to be combined with -blockers (except for verapamil or diltiazem for rate control in AF)Thiazides + -blockers increase risk of new onset DMACEI + ARB combination discouraged (IIIA)

Green/continuous: preferredGreen/dashed: useful (with some limitations)Black/dashed: possible but less well testedRed/continuous: not recommended

Green/continuous: preferredGreen/dashed: useful (with some limitations)Black/dashed: possible but less well testedRed/continuous: not recommended

No doble bloqueo del

SRAA

Treatment of risk factors associated with hypertension

Follow-up of hypertensive patientsFollow-up of hypertensive patients

After treatment initiation see patients at 2-4 week After treatment initiation see patients at 2-4 week intervalsintervals

Once the target is reached, a visit interval of a few Once the target is reached, a visit interval of a few months (3 or 6) is reasonablemonths (3 or 6) is reasonable

Depending on local organization and health resources Depending on local organization and health resources later visits may be performed by non-physician health later visits may be performed by non-physician health workersworkers

For stable patients Home BP and electronic For stable patients Home BP and electronic communication may provide an acceptable alternativecommunication may provide an acceptable alternative

It is advisable to assess risk factors and OD at least every It is advisable to assess risk factors and OD at least every 2 years 2 years

Can antihypertensive medications be stopped?Can antihypertensive medications be stopped?

In some patients in whom treatment is accompanied In some patients in whom treatment is accompanied by an effective BP control for an extended period it by an effective BP control for an extended period it may be possible to reduce the number/dosage of may be possible to reduce the number/dosage of drugsdrugs

This may be particularly the case if BP control is This may be particularly the case if BP control is accompanied by healthy lifestyle changes, removing accompanied by healthy lifestyle changes, removing the environmental pressor influencesthe environmental pressor influences

Medication reduction should be gradual and patients Medication reduction should be gradual and patients should be frequently checkedshould be frequently checked

Intentar reducciones farmacológicas tras buen control largo tiempo

Tratamiento en condiciones especiales

Treatment strategies in hypertensive patients withTreatment strategies in hypertensive patients withresistant hypertensionresistant hypertension

Treatment strategies in hypertensive patients withTreatment strategies in hypertensive patients withheart diseaseheart disease

COMO ANTES

Treatment strategies in hypertensive patients withTreatment strategies in hypertensive patients withcerebrovascular diseasecerebrovascular disease

Treatment strategies in hypertensive patients withTreatment strategies in hypertensive patients withatherosclerosis, arteriosclerosis, and peripheral artery diseaseatherosclerosis, arteriosclerosis, and peripheral artery disease

PA <140/90 mmHg

Treatment strategies in hypertensive patients withTreatment strategies in hypertensive patients withnephropathynephropathy

•PAS < 130-140 mmHg •Si proteinuria bloqueadores de SRAA

Treatment strategies in hypertensive patients withTreatment strategies in hypertensive patients withmetabolic syndromemetabolic syndrome

PA < 140/90 mmHgDe elección:

Bloqueadores SRAA Calcio-antagonistas

Diabetes Mellitus - Key IssuesDiabetes Mellitus - Key Issues

High BP is common / masked HT not infrequentHigh BP is common / masked HT not infrequent

Marked CV risk increase with HT-DM associationMarked CV risk increase with HT-DM association

Major benefit of antihypertensive therapy on Major benefit of antihypertensive therapy on macrovascular and renal complicationsmacrovascular and renal complications

No clear No clear effect effect of antihypertensive therapy on of antihypertensive therapy on retinopathy and neuropathy retinopathy and neuropathy (several studies)(several studies)

Treatment strategies in patients with diabetesTreatment strategies in patients with diabetes

PA < 140/85 mmHg

Drugs to be preferred in specific conditionsDrugs to be preferred in specific conditions

Treatment strategies in hypertensive womenTreatment strategies in hypertensive women

18516 M18516 M

Young Hypertensive AdultsYoung Hypertensive Adults

Isolated DBP elevation possibleIsolated DBP elevation possible

Long-term CV risk possibly more closely related to DBP Long-term CV risk possibly more closely related to DBP than SBPthan SBP

Drug treatment may be considered prudent with BP Drug treatment may be considered prudent with BP target < 140/90 mmHgtarget < 140/90 mmHg

Selective SBP elevation sometimes associated with Selective SBP elevation sometimes associated with normal central SBP – Because there is no evidence on normal central SBP – Because there is no evidence on drug effects, close FU / lifestyle changes advisabledrug effects, close FU / lifestyle changes advisable