Transcript 2007 Guidelines for the Management of Arterial Hypertension

RECENT GUIDELINES
FOR THE MANAGEMENT OF
ARTERIAL HYPERTENSION
Apostolos I. Hatzitolios
Associate Professor of Internal Medicine
1st Propedeutic Department of Internal Medicine
Department of Vascular Diseases and Hypertension
Aristotle University of Thessaloniki, AHEPA Hospital
Thessaloniki, Central Macedonia, HELLAS
Diagnosis, regulation and treatment of
hypertension in USA
Hypertensive
%
73%
51%
31%
55%
68%
54%
70%
59%
34%
29%
27%
NHANES III
(Phase 1)
1988-1991
NHANES III
(Phase 2)
1991-1994
Diagnosis
Treatment
Regulation
10%
NHANES II
1976-1980
NHANES
1999-2000
Guidelines 2007
 European Society of Hypertension
 European Society of Cardiology
Journal of Hypertension 2007;25:1105-1187
Definitions and Classification
of BP Levels (mmHg)
Category
Systolic
Diastolic
Optimal
<120
and
<80
Normal
120-129
and/or
80-84
High Normal
130-139
and/or
85-89
Grade 1
Hypertension
140-159
and/or
90-99
Grade 2
Hypertension
160-179
and/or
100-109
Grade 3
Hypertension
≥ 180
and/or
≥ 110
Isolated Systolic
Hypertension
≥ 140
and
< 90
Stratification of CV risk in four categories
Blood pressure (mmHg)
Other risk
factors, TOD
or disease
Normal
SBP 120-129
or DBP 8084
High normal
SBP 130-139
or DBP 85-89
Grade 1 HT
SBP 140-159
or DBP 90-99
Grade 2 HT
SBP 160-179
or DBP 100109
Grade 3 HT
SBP ≥180 or
DBP ≥110
No other risk
factors
Average
risk
Average
risk
Low
added risk
Moderate
added risk
High added
risk
1-2 risk
factors
Low
added risk
Low
added risk
Moderate
added risk
Moderate
added risk
Very high
added risk
3 or more risk
factors,
TOD,
DM or MS
Moderate
added risk
High added
risk
High added
risk
High added
risk
Very high
added risk
Established
CV or renal
disease
Very high
added risk
Very high
added risk
Very high
added risk
Very high
added risk
Very high
added risk
High/Very High Risk Subjects





BP ≥ 180 mmHg systolic and/or ≥ 110 mmHg diastolic
High systolic BP > 160 mmHg with low diastolic BP (< 70 mmHg)
≥ 3 cardiovascular risk factors
Diabetes mellitus or Metabolic syndrome
Hypertension Target Organ Damage or Established CV or renal
disease
High/Very High Risk Subjects
 One or more subclinical organ damages:






Electrocardiographic (particularly with strain) or echocardiographic (particularly concentric)
LVH
Ultrasound evidence of carotid artery wall thickening or plaque
Increased arterial stiffness
Slight increase in serum creatinine
Reduced estimated glomerular filtration rate or creatinine clearance
Microalbuminuria or proteinuria
 Established cardiovascular disease
•
•
•
•
•
Heart
Cerebrovascular
Renal
Peripheral artery
Ophthalmic disease
Appropriate BP measurement

Allow the patients to relax for several minutes in a quiet place

Take at least two measurements spaced by 1-2 min and additional measurements if the
first two are quite different [use phase I and V (disappearance) Korotkoff sounds to
identify SBP and DBP]

Use a standard bladder but have a larger for fat arms and a smaller one for thin arms and
children

Have the cuff at the heart level

Measure BP in both arms at first visit to detect possible differences due to peripheral
vascular disease. In this instance, take the higher value as the reference one

Measure BP 1 and 5 min after assumption of the standing position in elderly subjects,
diabetic patients and in other conditions in which postural hypotension may be frequent or
suspected (e.g. heart, renal failure, SNS dysfunction, use of vasodilative agents)

Measure heart rate (at least 30 sec) after the second measurement in the sitting position
Home BP measurements
 Self-measurement of BP at home is of clinical value,
its prognostic significance is now demonstrated and
these measurements should be encouraged in order
to:


provide more information on the BP lowering effect of treatment
at through and thus on the therapeutic coverage throughout the
dose-to-dose time interval
improve patient’s adherence to treatment regimens
 On the contrary, Self-measurement of BP should be
discouraged when:


it causes anxiety to the patient
it induces self-modification of the treatment regimen
Ambulatory BP measurements
 Although office BP should be used as reference, 24-h
ambulatory BP monitoring may improve prediction of CV
risk
 Ambulatory BP should be considered, in particular, when:






considerable variability of office BP is found over the same or
different visits
high office BP is measured in subjects otherwise at low CV risk
there is a marked discrepancy between BP values measured in the
office and at home
there is a resistance to drug treatment
hypotensive episodes are suspected, particularly in elderly and diabetic
patients
office BP is elevated in pregnant women and pre-eclampsia is suspected
BP thresholds (mmHg) for definition of
Hypertension with different types of measurement
SBP
DBP
140
90
Home
130-135
85
24-hour
125-130
80
130-135
85
120
70
Office or clinic
Day
Night
Particular conditions
Isolated office hypertension (White coat hypertension)
 Office BP persistently ≥ 140/90 mmHg
 Normal daytime ambulatory or home BP < 130-135/85
Due to stress and SNS stimulation. CV risk is less than by raised office and ambulatory or home BP
but may be slightly greater than by normotension
Isolated ambulatory hypertension (Masked hypertension)
 Office BP persistently normal (< 140/90 mmHg)
 Elevated ambulatory (≥ 125-130/80 mmHg) or home BP (≥ 130-135/85 mmHg)
CV risk is close to that of hypertension. Due to «normal» variation of circadian rhythm, autonomic
nervous system dysfunction, physical or psychological stress, night consumption of alcohol, smoking
and sleep apnea.
Guidelines for family and clinical history
1.
Duration and previous level of high BP
2.
Indications of secondary hypertension:

family history of renal disease (polycystic kidneys)

renal disease, urinary tract infection, haematuria, analgesic abuse
(parenchymal renal disease)

drug/substance intake, such as: oral contraceptives, liquorice,
carbenoxolone, nasal drops, amphetamines, steroids, non-steroidal antiinflammatory drugs, erythropoietin, cyclosporine, cocaine (drug induced
hypertension)

episodes of sweating, headache, anxiety, palpitation (phaeochromocytoma)

episodes of muscle weakness and tetany (aldosteronism)
Guidelines for family and clinical history
3. Risk factors:

family and personal history of hypertension and CV disease

family and personal history of dyslipidaemia

family and personal history of diabetes mellitus

smoking habits

dietary habits ; lack of physical exercise

obesity

snoring; sleep apnea (information also from partner)

Personality type; stress due to personal, family and
environmental factors
Guidelines for family and clinical history
4. Symptoms of organ damage:

brain and eyes: headache, vertigo, transient ischemic attacks,
sensory or motor deficit , impaired vision

heart: palpitation, chest pain, shortness of breath, swollen
ankles

kidneys: thirst, polyuria, nocturia, haematuria

peripheral arteries: cold extremities, intermittent claudication
5. Previous antihypertensive therapy:

Drug(s) used, efficacy and adverse effects
Physical examination for
secondary hypertension, organ damage and visceral obesity
Signs suggesting secondary hypertension
 Features of Cushing syndrome
 Skin stigmata of neurofibromatosis (phaeochromocytoma)
 Palpation of enlarged kidneys (polycystic kidneys)
 Auscultation of abdominal murmurs
(renovascular hypertension)
 Auscultation of precordial or chest murmurs; Diminished and delayed
femoral pulses femoral BP
(aortic coarctation or aortic disease)
Physical examination for
secondary hypertension, organ damage and visceral obesity
Signs of organ damage
 Brain: murmurs over neck arteries, motor or sensory defects
 Retina: fundoscopic adnormalities
 Heart: location and characteristics of apical impulse, abnormal
cardiac rhythms, ventricular gallop, pulmonary rates, peripheral
oedema
 Peripheral arteries: absence, reduction or asymmetry of pulses,
cold extremities, ischemic skin lesions
 Carotid arteries: systolic murmurs
Physical examination for secondary hypertension
organ damage and visceral obesity
Evidence of visceral obesity
 Body weight
 Increased body mass index
[body weight (Kg)/height (m2)]
overweight ≥ 25 Kg/m2; obesity ≥ 30 Kg/m2
 Increased waist circumference
(standing position) ♂ > 102 cm; ♀ > 88 cm
Laboratory investigations
Routine tests:





Hemoglobin and hematocrit
Fasting plasma glucose
Fasting serum triglycerides
Serum total cholesterol, LDL-cholesterol, HDL-cholesterol
Serum creatinine, potassium, uric acid

Urinalysis (complemented by microalbuminuria dipstick test and
microscopic examination)
Estimated creatinine clearance (Cockroft-Gault formula) or glomerular
filtration rate (MDRD formula)



Electrocardiogram (ECG)
Thorax X-ray
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)
Laboratory investigations
Extended evaluation (domain of the specialist)

Further search for cerebral, cardiac, renal and vascular disease,
mandatory in complicated hypertension

Search for suspected secondary hypertension suggested by history,
physical examination or routine tests:

measurement of renin, aldosterone,

corticosteroids,

catecholamines in plasma and/or urine;

renal and adrenal ultrasound;

computer-assisted tomography (CT);

magnetic resonance imaging (MRI);

arteriographies
Searching for subclinical organ damage
Importance of subclinical organ damage as an intermediate stage in the
continuum of vascular disease and as a determinant of total CV risk.
Heart
 Electrocardiography should be part of all routine assessment of
hypertensives in order to detect LVH, LV strain, ischemic condition
and arrhythmias
 Echocardiography is recommended whenever a more sensitive
detection of LVH is considered useful. Concentric remodeling and
hypertrophy carries the worst prognosis, while LV diastolic
dysfunction, consists an early ECHO sign, which can be evaluated by
Doppler measurement of transmittal velocities.
Searching for subclinical organ damage
Blood vessels

Ultrasound scanning of extracranial carotid arteries is recommended
in symptomatic carotid stenosis (previous TIA), but also in
asymptomatic atherosclerosis suspected by carotid murmurs and
reveals vascular hypertrophy, increased IMT, thickening of carotid
bifurcation and presence of plaques.

Peripheral large artery stiffening (an important vascular alteration
leading to isolated systolic hypertension in the elderly), can be
measured by pulse wave velocity. This method might be more widely
recommended if its availability were greater.
A low ankle-brachial BP index (<0,9) signals advanced peripheral artery
disease

Searching for subclinical organ damage
Kidney

Diagnosis of hypertension-related renal damage is based on a reduced renal
function or detection of hyperalbuminuria

Measurement of serum creatinine as well as estimation of glomerular
filtration rate by specific formulas, should be part of routine procedures,
allowing classification of renal dysfunction and respective stratification of
CV risk

Presence of urinary protein should be sought in all hypertensives by dipstick.
In dipstick negative patients, low grade albuminuria, namely
microalbuminuria, should also be determined in spot urine and as ratio to
creatinine excretion
Searching for subclinical organ damage
Fundoscopy

Examination of eye grounds is recommended only in hypertensive with
severe hypertension, since mild retinal changes (grade 1: arteriolar
narrowing; grade 2: arteriovenous nipping) appear to be largely nonspecific alterations except in young patients

In contrast, grade 3 (hemorrhages and exudates) and 4 (papilloedema)
retinal changes, present only in severe hypertension and are
associated with an increased CV risk
Searching for subclinical organ damage
Brain

Silent brain infarcts, lacunar infarction (small / deep vessel disease),
microbleeds and white matter lesions are not infrequent among
hypertensives, especially elderly and can be detected by MRI or CT (MRI
being generally superior to CT)

Availability and costs do not allow use of these techniques in
asymptomatic patients

In elderly hypertensives, cognitive tests (e.g. Mini-mental scale) may also
help to detect initial brain deterioration
Treatment of hypertension
1.
Non pharmacological
2. Pharmacological
Goals of treatment
 Primary goal of treatment is to achieve the maximum reduction
in the long-term total risk of CV disease
 This requires not only the treatment of raised BP per se, but
also of all associated reversible CV risk factors
 BP should be reduced at least below 140/90 mmHg and even to
lower values, if tolerated, in all hypertensive patients
Goals of treatment

Target BP should be at least < 130/80 mmHg in diabetics and in high or very
high risk patients, such as those with associated clinical conditions, mainly
stroke, myocardial infarction, renal dysfunction. Especially in proteinuria
(<125/75 mmHg when >1gr/24h)

Despite the use of combination treatment, reducing SBP to <140 mmHg may be
difficult and more so if the target is a reduction to <130 mmHg, moreover while
a DBP reduction < 70 mmHg could be not beneficial.

Additional difficulties should be expected in elderly, obese and diabetic
patients and in general, in patients with CV damage. In order to more easily
achieve goal BP, antihypertensive treatment should be initiated before
significant CV damage develops
Lifestyle changes

Lifestyle measures should be instituted whenever appropriate, in all patients,
including those who require drug treatment, in order to lower BP, to control
other risk factors and to reduce the number of doses of antihypertensive
drugs to be subsequently administered

Lifestyle measures are also advisable in subjects with high normal BP (130-139
/ 85-89) and additional risk factors to reduce the risk of developing
hypertension

Lifestyle recommendations should not be given as lip service but instituted with
adequate behavioral and expert support and reinforced periodically
Lifestyle changes
Lifestyle measures widely recognized to lower BP or CV
risk are:






smoking cessation
weight reduction (and stabilization)
physical exercise
reduction of salt intake
reduction of excessive alcohol intake
increase in fruit and vegetable intake and decrease in
saturated and total fat intake (Mediterranean diet)
Lifestyle changes
Lifestyle changes
Weight loss
Possible reduction in SBP
(mmHg; mean= 38 mmHg)
5-20 mmHg/10Kg
Adoption of DASH diet
8-14 mmHg
Reduction of salt intake
2-8 mmHg
Physical exercise
4-9 mmHg
Reduction of excessive alcohol intake
2-4 mmHg
As long-term compliance with lifestyle measures is low and the BP response highly variable,
patients under non pharmacological treatment should be followed-up closely to start drug
therapy when needed and timely
Initiation of antihypertensive treatment
Other risk
factors, Target
Organ Damage or
disease
No other risk
factors
1-2 risk
factors
>3 risk
factors, MS
or TOD
Normal
High normal
Grade 1 HT
Grade 2 HT
SBP 120-129 or
DBP 80-84
SBP 130-139 or
DBP 85-89
SBP 140-159 or
DBP 90-99
SBP 160-179 or
DBP 100-109
No BP intervention
Lifestyle changes
for several months
then drug treatment
if BP uncontrolled
Lifestyle changes
for several weeks
then drug treatment
if BP uncontrolled
Lifestyle
changes +
immediate drug
treatment
Lifestyle changes
Lifestyle changes
Lifestyle changes
for several weeks
then drug treatment
if BP uncontrolled
Lifestyle changes
for several weeks
then drug treatment
if BP uncontrolled
Lifestyle
changes +
immediate drug
treatment
Lifestyle changes
Lifestyle changes
and consider drug
treatment
Lifestyle changes +
drug treatment
Lifestyle changes +
drug treatment
Lifestyle
changes +
immediate drug
treatment
Lifestyle changes +
immediate drug
treatment
Lifestyle changes +
immediate drug
treatment
Lifestyle
changes +
immediate drug
treatment
No BP intervention
Diabetes
Lifestyle changes
Lifestyle changes +
drug treatment
Established
CV or renal
disease
Lifestyle changes +
immediate drug
treatment
Lifestyle changes +
immediate drug
treatment
Grade 3 HT
SBP ≥180 or
DBP ≥110