M. Kozák, IKK, FN Brno HYPERTENSION title_prac_med_dv [USEMAP] HT THERAPY - HISTORY G:\hypertenze\hyp02.tif G:\hypertenze\hyp03.tif • life regime • gymnastics • eating moderation • salt reducing • nonsmoking • analgetics • physical th. • liquor drenaige • iodids • rhodanid • Ca • NTG [USEMAP] ETIOLOGY CHF - Framingham st. 1950 -70 G:\hypertenze\HLK02.jpg [USEMAP] ETIOLOGY CHF - European data 1990 - 2000 G:\hypertenze\aslumen.jpg [USEMAP] BP MEASUREMENT - HOLTER G:\hypertenze\bpholter01.jpg G:\hypertenze\bpholter02.jpg • diagnostic - hypertension • epizodic HT • white-coat syndrome • autonomic dysfunction • therapeutical effect • hypotension ? INDICATIONS Dipping versus non-dipping Ambulatory blood pressure monitoring 24 hours [USEMAP] HT IMPACTS hypepi [USEMAP] BP VALUES ACC/AHA 2018 [USEMAP] X RAY CORRELATION C:\Prezentace\hypertenze\rtghyp.bmp [USEMAP] ECG CORRELATION G:\hypertenze\hyp01.tif • McPhie - SVmax + RVmax over 40 mm • Sokolov/Lyon - SV1 + RV5,6 over 35 mm [USEMAP] ETIOLOGY • essential HT(primary, idiopathic) • secondary HT (10%) • renal (acute, chronic dissease) • renovascular • endocrine (hyperA, hyperK, feochromocytom, acromegaly, hyperparathyreozis) • neurogenic (Tu, injuries) • coarctation ao • sleeping apnoe • iatrogenic (contraceptives, steroids, cocain, liquorice) G:\hypertenze\1.JPG G:\hypertenze\2.JPG [USEMAP] MORBUS CUSHING C:\Prezentace\hypertenze\cushing01.bmp C:\Prezentace\hypertenze\cushing02.bmp C:\Prezentace\hypertenze\cushing03.bmp C:\Prezentace\hypertenze\conscinti.bmp C:\Prezentace\hypertenze\conct.bmp [USEMAP] FUNDUSCOPIC CORRELATION C:\Prezentace\hypertenze\opvse.bmp Arteriosclerotic and hypertensive retinopathy [USEMAP] HT IMPACTS G:\hypertenze\hlk03.jpg G:\hypertenze\aneurao.gif G:\hypertenze\karotidartg.jpg [USEMAP] HYPERTENSION + METABOLIC SYNDROM •Reaven´s sy (1996) : hypertension in pt with obesity, hyperglycemia (insulin resistance) ATP III (Adult Treatment Panel) 2001 - 3 or more from: • obezity • TG • HDL • hypertension • hyperglycemia rozcestnik [USEMAP] l Estimation of risk of fatal CV events (SCORE) l Subclinical organ damage l Clinical organ damage PROGNOSTIC FACTORS HT [USEMAP] lRisk prediction of fatal CV events l lBased on 12 overall population studies 205 178 pts; 2,7 mil. person/years follow-up lCholesterol level /HDL cholesterol l lProjected risk multiplied 2x for male DM pts, multiplied 4x for female DM pts lHigh risk ≥ 5% l lSCORECARD SCORE [USEMAP] l LV hypertrophy EKG: Sokolow-Lyons > 38 mm Cornell > 2 440 mm x ms ECHO: LVMI ³ 125, F ³ 110 g/m2 l USG thickening of the arteriol wall (thickening of the carotid wall ³ 0,9 mm or plaque) l Moderate elevation serum creatinine level M 115-133, F 107-124 mmol/l l Lowering GF bellow 60ml/min l Microalbuminuria 30 – 300 mg/24h ratio albumin/creatinine M ³ 2,5 F ³ 3,5 mg/mmol SOP – SUBCLINICAL ORGAN DAMAGE HLK02 ledvina02 [USEMAP] l CVD: ischemic stroke, cerebral bleeding; TIA l l Structural heart disease: CAD post MI, AP, revascularization, CHF l l Renal disease: diabetic nefropathy renal function decrease S creatinine: M > 133, F > 124 mmol/l proteinuria: > 300 mg/24 h l PAD, CLTI, CLI l l Advanced retinopathy: hemorrhage or exsudate, papilledema POP – CLINICAL ORGAN DAMAGE karotida aphercna ledvina retnopat retnopat02 IV [USEMAP] [USEMAP] ANTIHYPERTENSIVE DRUGS antihypertensive-drugs-classification-amp-mechanism-1-1024.jpg [USEMAP] [USEMAP] • 2-3x higher prevalence of HT in DM population • comparable total risk of HT + DM and HT +MI populations • CV risk estimation male 2x, female 4x higher with DM • treated HT - positive effect to macroangiopathy HYPERTENSION + DM [USEMAP] Nonpharmacological therapy ¯ intake Na, weight Target BP < 130/80 mmHg RAS blockade – ACEI, ARB prefered Almoust combined therapy MAU is indication for RAS blockator Intervention of all risk factors HYPERTENSION + DM [USEMAP] ANTIHYPERTENSIVE DRUGS /STROKE karotidartg • benefit for pts with normal BP and hypertension • profit without consideration to type of stroke • sex and age • time interval from stroke • we prefer monotherapy ACEI/ARB • CAB better in older pts (PATS, PROGRESS, EUROPA, Syst-Eur, EWPHE, MRC, SHEP…) tmp+n tmp+n [USEMAP] 0.12 0.10 0.08 0.06 0.04 0.02 0 0 Time (years) Placebo Ramipril The HOPE and HOPE-TOO Investigators. Circulation 2005; 112:1339-46. Main HOPE Trial Ends In-trial Period RR: 0.69 (95% CI, 0.56-0.85) p=0.0006 1 2 3 4 5 6 7 zzz_HOPE_white DEVELOPMENT OF DM [USEMAP] 1 2 3 4 5 6 0 500 1,000 1,500 0 Days of follow-up Placebo Ramipril Bosch J, et al. BMJ 2002; 324(7339):699-702. RR: 0.68 (95% CI, 0.56-0.84) p<0.0002 zzz_HOPE_white INCIDENCE OF STROKE [USEMAP] KM_bkg.png KM_lines.png HR (95% CI): 0.80 (0.72, 0.90) 20% Risk Reduction Time to 1st CV morbidity/mortality (days) p = 0 ACEI / HCTZ CCB / ACEI 650 526 .0 0 0 2 ACCOMPLISH - Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension 11.000 hypertonics with CV risk or CKD. - amlodipin 10, benazepril 40 mg Jamerson K et al. A Engl J Med 2008;359:2417-28 [USEMAP] ASCOT Anglo-Scandinavian Cardiac Outcomes Trial - 19.257 pts. hypertension + 3 risk factors - 5year follow-up [USEMAP] CKD [USEMAP] CKD [USEMAP] HT - TREATMENT [USEMAP] SIDE EFFECTS ACEI + CAB • cough • peripheral edema, palpitations • flush ACEI + diuretic •cough • obstipation, dryness in mouth nauzea, pain in epigastrium, anorexie • K depletion • Na depletion, hypovolemia • hyperglycemia, hyeruricemia [USEMAP] [USEMAP]