updates in Hypertension according to ESC guidelines 2013
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Hypertension in special conditions , updates 2013 ESC

Hypertension in special conditions , updates 2013 ESC

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  • 1. ESC 2013 updates of hypertension Ahmed Taha Hussein M.Sc.cardiology Assistant lecturer cardiology Zagazig university
  • 2. Special conditions • Heart diseases • Atherescelerosis • Sexual dysfunction • Restistamt hypertension • Malignant hypertension • Renovascular hypertension • Primary hyperaldosteronism
  • 3. CAD • Has steeper association above an SBP ofHas steeper association above an SBP of about 140 mmHg.about 140 mmHg. • HTN account for 25% of risk factors.HTN account for 25% of risk factors. • SBP & DBP are related mainly to BMI.SBP & DBP are related mainly to BMI. • J-curve phenomenon .J-curve phenomenon .
  • 4. Heart failure Preventing heart failure is the largest benefit associated withPreventing heart failure is the largest benefit associated with BP-lowering drugs, including in the very elderly.BP-lowering drugs, including in the very elderly. Whilst a history of hypertension is common in patients withWhilst a history of hypertension is common in patients with heart failure, a raised BP can disappear when heart failureheart failure, a raised BP can disappear when heart failure with LV systolic dysfunction develops.with LV systolic dysfunction develops. a higher SBP was found to be associated with bettera higher SBP was found to be associated with better outcomes.outcomes. Hypertension is more common in heart failure patients withHypertension is more common in heart failure patients with preserved LV ejection fraction.preserved LV ejection fraction.
  • 5. Atrial fibrillation • Hypertension is the most prevalentHypertension is the most prevalent concomitant condition in patients with atrialconcomitant condition in patients with atrial fibrillationfibrillation • assessed for the risk of thromboembolismassessed for the risk of thromboembolism is very important according to CHADS2is very important according to CHADS2 Vasc score .Vasc score . • good control of BP has the added advantagegood control of BP has the added advantage of reducing bleeding eventsof reducing bleeding events
  • 6. LVH • LVH, especially of the concentric type,LVH, especially of the concentric type, is associated with a CVD risk higheris associated with a CVD risk higher than 20% in 10 yearsthan 20% in 10 years the therapeutically induced reduction ofthe therapeutically induced reduction of LV mass was significantly associatedLV mass was significantly associated with CV event reduction.with CV event reduction.
  • 7. Carotid atherosclerosis • carotid atherosclerosis can be delayed bycarotid atherosclerosis can be delayed by lowering BP but calcium antagonists have alowering BP but calcium antagonists have a greater efficacy than diuretics and beta-greater efficacy than diuretics and beta- blockers, and ACE inhibitors more thanblockers, and ACE inhibitors more than diureticsdiuretics
  • 8. Increased arterial stiffness • Reduction of BP passively lead topassively lead to decrease of PWV(decrease of PWV(pulse wave velocity)pulse wave velocity).. • relationship between a reduction of arterialrelationship between a reduction of arterial stiffness and reduced incidence of CVstiffness and reduced incidence of CV events has been reported in only one studyevents has been reported in only one study • VD antihypertensive show more superiorityVD antihypertensive show more superiority in decresing the Stiffness .in decresing the Stiffness .
  • 9. Peripheral artery disease • incidence of PAD-related amputation and death inincidence of PAD-related amputation and death in patients with diabetes is strongly and inverselypatients with diabetes is strongly and inversely associated with the SBP achieved by treatmentassociated with the SBP achieved by treatment • choice of the antihypertensive agent is lesschoice of the antihypertensive agent is less important than actual BP control in patients withimportant than actual BP control in patients with PADPAD • mild-to-moderate limb ischemia did not confirm the intake of beta-blockers to be associated with exacerbation of PAD symptoms
  • 10. Sexual dysfunction • Erectile dysfunction is considered to be anErectile dysfunction is considered to be an independent CV risk factor and an earlyindependent CV risk factor and an early diagnostic indicator for asymptomatic ordiagnostic indicator for asymptomatic or clinical OD.clinical OD. • Phospho-diesterase-5 inhibitors may bePhospho-diesterase-5 inhibitors may be safely administered to hypertensives, evensafely administered to hypertensives, even those on multiple drug regimens (with thethose on multiple drug regimens (with the possible exception of alpha-blockers and inpossible exception of alpha-blockers and in absence of nitrate administration) and mayabsence of nitrate administration) and may improve adherence to antihypertensive.improve adherence to antihypertensive.
  • 11. Resistant HTN • a therapeutic strategy that includes appropriate lifestyle measures plus a diuretic and two other antihypertensive drugs belonging to different classes at adequate doses (but not necessarily including a mineralocorticoid receptor antagonist) fails to lower SBP and DBP values to ,140 and 90 mmHg,
  • 12. Resistant HTN • Resistant hypertension can be real or only apparent or spurious. • A good response has been reported to the use of mineralocorticoid receptor antagonists,.
  • 13. Carotid baroreceptor stimulation • Chronic field electrical stimulation of carotid sinus nerves via implanted devices • reduction was quite marked when initial BP values were very high and the effect included ambulatory BP and persisted for up to 53 months.
  • 14. Renal denervation • bilateral destruction of the renal nerves travelling along the renal artery, by radiofrequency ablation catheters • marked reduction in office BP which has been found to be sustained after one year and in a small number of patients two and three years following the denervation procedure.
  • 15. Reno-vascular hypertension • secondary to atherosclerosis is relatively frequent, especially in the elderly population • female) patients with uncontrolled hypertension in fibromuscular hyperplasia (82–100% success, re-stenosis in 10–11%) • Intervention is at present not recommended in atherosclerotic renal artery stenosis if renal function has remained stable over the past 6– 12 months and if hypertension can be controlled by an acceptable medical regimen (Class III, Level B
  • 16. Primary aldosteronism • unilateral laparoscopic adrenalectomy : treatment of choice in documented unilateral primary aldosteronism. • mineralocorticoid receptor antagonists is indicated in patients with bilateral adrenal disease • Glucocorticoid-remediable aldosteronism is treated with a low dose of a long-acting glucocorticoid,
  • 17. Perioperative management of hypertension • Stratifying the overall CVrisk of the surgery candidate may be more important than BP alone. • Diuretics should be avoided on the day of surgery because of potential adverse interaction with surgery-dependent fluid depletion • ACE inhibitors and ARBs may also be potentiated by surgery-dependent fluid depletion • Post-surgery BP elevation, when it occurs, is frequently caused by anxiety and pain after awakening.
  • 18. Treatment of associated risk factors Lipid-lowering agentsLipid-lowering agents  Patients with hypertension, and especially those with type 2Patients with hypertension, and especially those with type 2 diabetes or metabolic syndrome, often have atherogenicdiabetes or metabolic syndrome, often have atherogenic dyslipidemia, characterized by elevated triglycerides and LDL-dyslipidemia, characterized by elevated triglycerides and LDL- cholesterol with a low HDL-cholesterol.cholesterol with a low HDL-cholesterol.  The benefit of adding a statin to antihypertensive treatment wasThe benefit of adding a statin to antihypertensive treatment was well established by the Anglo-Scandinavian Cardiac Outcomeswell established by the Anglo-Scandinavian Cardiac Outcomes Trial Lipid Lowering Arm (ASCOT-LLA) study, as summarizedTrial Lipid Lowering Arm (ASCOT-LLA) study, as summarized in the 2007 ESH/ESC Guidelines. The lack of statisticallyin the 2007 ESH/ESC Guidelines. The lack of statistically significant benefit in the ALLHAT study can be attributed tosignificant benefit in the ALLHAT study can be attributed to insufficient lowering of total cholesterol (11% in ALLHAT,insufficient lowering of total cholesterol (11% in ALLHAT, compared with 20% in ASCOT).compared with 20% in ASCOT).
  • 19.  Further analyses of the ASCOT data have shown that theFurther analyses of the ASCOT data have shown that the addition of a statin to the amlodipine-based antihypertensiveaddition of a statin to the amlodipine-based antihypertensive therapy can reduce the incidence of the primary CV outcometherapy can reduce the incidence of the primary CV outcome even more markedly than the addition of a statin to the atenolol-even more markedly than the addition of a statin to the atenolol- based therapy.based therapy.  The beneficial effect of statin administration to patients withoutThe beneficial effect of statin administration to patients without previous CV events [targeting a low-density lipoproteinprevious CV events [targeting a low-density lipoprotein cholesterol value ,3.0 mmol/L; (115 mg/dL)] has beencholesterol value ,3.0 mmol/L; (115 mg/dL)] has been strengthened by the findings of the Justification for the Use ofstrengthened by the findings of the Justification for the Use of Statins in Primary Prevention: an Intervention Trial EvaluatingStatins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) study, showing that lowering low-Rosuvastatin (JUPITER) study, showing that lowering low- density lipoprotein cholesterol by 50% in patients with baselinedensity lipoprotein cholesterol by 50% in patients with baseline values ,3.4 mmol/L (130 mg/dL) but with elevated C-reactivevalues ,3.4 mmol/L (130 mg/dL) but with elevated C-reactive protein reduced CV events by 44%. This justifies use of statins inprotein reduced CV events by 44%. This justifies use of statins in hypertensive patients who have a high CV risk.hypertensive patients who have a high CV risk.
  • 20.  As detailed in the recent ESC/EAS Guidelines, when overt CHDAs detailed in the recent ESC/EAS Guidelines, when overt CHD is present, there is clear evidence that statins should beis present, there is clear evidence that statins should be administered to achieve low-density lipoprotein cholesteroladministered to achieve low-density lipoprotein cholesterol levels ,1.8 mmol/L (70 mg/dL).654 Beneficial effects of statinlevels ,1.8 mmol/L (70 mg/dL).654 Beneficial effects of statin therapy have also been shown in patients with a previous stroke,therapy have also been shown in patients with a previous stroke, with low-density lipoprotein cholesterol targets definitely lowerwith low-density lipoprotein cholesterol targets definitely lower than 3.5 mmol/L (135 mg/ dL).than 3.5 mmol/L (135 mg/ dL).  Whether they also benefit from a target ,1.8 mmol/L (70 mg/dL)Whether they also benefit from a target ,1.8 mmol/L (70 mg/dL) is open to future research. This is the case also for hypertensiveis open to future research. This is the case also for hypertensive patients with a low-moderate CV risk, in whom evidence of thepatients with a low-moderate CV risk, in whom evidence of the beneficial effects of statin administration is not clear.beneficial effects of statin administration is not clear.
  • 21. Antiplatelet therapyAntiplatelet therapy  In secondary CV prevention, a large meta-analysis publishedIn secondary CV prevention, a large meta-analysis published in 2009 showed that aspirin administration yielded anin 2009 showed that aspirin administration yielded an absolute reduction in CV outcomes much larger than theabsolute reduction in CV outcomes much larger than the absolute excess of major bleedings.absolute excess of major bleedings.  In primary prevention, however, the relationship betweenIn primary prevention, however, the relationship between benefit and harm is different, as the absolute CV eventbenefit and harm is different, as the absolute CV event reduction is small and only slightly greater than the absolutereduction is small and only slightly greater than the absolute excess in major bleedings. A more favorable balance betweenexcess in major bleedings. A more favorable balance between benefit and harm of aspirin administration has beenbenefit and harm of aspirin administration has been investigated in special groups of primary prevention patients.investigated in special groups of primary prevention patients.
  • 22.  Studies on diabetes have so far failed to establish a favorableStudies on diabetes have so far failed to establish a favorable benefit–harm ratio, whereas a sub-study of the HOT trial, inbenefit–harm ratio, whereas a sub-study of the HOT trial, in which hypertensive patients were classified on the basis ofwhich hypertensive patients were classified on the basis of eGFR at randomization showed aspirin administration to beeGFR at randomization showed aspirin administration to be associated with a significant trend for a progressive reductionassociated with a significant trend for a progressive reduction in major CV events and death, the lower the baseline eGFRin major CV events and death, the lower the baseline eGFR values.values.  This reduction was particularly marked in hypertensiveThis reduction was particularly marked in hypertensive patients with eGFR ,45 mL/min/1.73 m2. In this group ofpatients with eGFR ,45 mL/min/1.73 m2. In this group of patients the risk of bleeding was modest compared with thepatients the risk of bleeding was modest compared with the CV benefit.CV benefit.  Aspirin therapy should be given only when BP is wellAspirin therapy should be given only when BP is well controlled.controlled.
  • 23.  In conclusion, the prudent recommendations of the 2007In conclusion, the prudent recommendations of the 2007 ESH/ ESC Guidelines can be reconfirmed: AntiplateletESH/ ESC Guidelines can be reconfirmed: Antiplatelet therapy, particularly low-dose aspirin, should be prescribed totherapy, particularly low-dose aspirin, should be prescribed to controlled hypertensive patients with previous CV events andcontrolled hypertensive patients with previous CV events and considered in hypertensive patients with reduced renalconsidered in hypertensive patients with reduced renal function or a high CV risk. Aspirin is not recommended infunction or a high CV risk. Aspirin is not recommended in low-to-moderate risk hypertensive patients in whom absolutelow-to-moderate risk hypertensive patients in whom absolute benefit and harm are equivalent.benefit and harm are equivalent.  It is note worthy that a recent meta-analysis has shown lowerIt is note worthy that a recent meta-analysis has shown lower incidences of cancer and mortality in the aspirin (but not theincidences of cancer and mortality in the aspirin (but not the warfarin) arm of primary prevention trials.warfarin) arm of primary prevention trials.  If confirmed, this additional action of aspirin may lead to aIf confirmed, this additional action of aspirin may lead to a more liberal reconsideration of its use.more liberal reconsideration of its use.
  • 24. Treatment of hyperglycemiaTreatment of hyperglycemia The treatment of hyperglycemia for prevention of CVThe treatment of hyperglycemia for prevention of CV complications in patients with diabetes has been evaluatedcomplications in patients with diabetes has been evaluated in a number of studies.in a number of studies. For patients with type 1 diabetes, the Diabetes Control andFor patients with type 1 diabetes, the Diabetes Control and Complications (DCCT) study convincingly showed thatComplications (DCCT) study convincingly showed that intensive insulin therapy was superior for vascularintensive insulin therapy was superior for vascular protection and reduction of events, compared with standardprotection and reduction of events, compared with standard treatment.treatment. In type 2 diabetes, several large-scale studies have aimed atIn type 2 diabetes, several large-scale studies have aimed at investigating whether a tight glycemic control, based oninvestigating whether a tight glycemic control, based on oral drugs and/or insulin, is superior to less-tight controloral drugs and/or insulin, is superior to less-tight control for CV prevention.for CV prevention.
  • 25. In UKPDS, tighter glycemic control could prevent microIn UKPDS, tighter glycemic control could prevent micro vascular but not macro vascular complications, except invascular but not macro vascular complications, except in a subgroup with obesity, treated with metformin. Thea subgroup with obesity, treated with metformin. The appropriate target for a glycemic control has beenappropriate target for a glycemic control has been explored recently in the ADVANCE, ACCORD, andexplored recently in the ADVANCE, ACCORD, and Veterans’ Affairs Diabetes Trial (VADT) studies, whichVeterans’ Affairs Diabetes Trial (VADT) studies, which randomized one study arm to very low HbA1c targetsrandomized one study arm to very low HbA1c targets (6.5 or 6.0%).(6.5 or 6.0%).
  • 26. None of these individual studies showed a significantNone of these individual studies showed a significant reduction of the composite endpoint of combined CVDreduction of the composite endpoint of combined CVD events but a number of later meta-analyses haveevents but a number of later meta-analyses have documented that more intensive glycemic control is likelydocumented that more intensive glycemic control is likely to reduce non-fatal coronary events and infarction, as wellto reduce non-fatal coronary events and infarction, as well as nephropathy, but not stroke or all-cause or CV mortality.as nephropathy, but not stroke or all-cause or CV mortality. However, especially in ACCORD, the lower HbA1c targetHowever, especially in ACCORD, the lower HbA1c target arm was associated with an excess of hypoglycemicarm was associated with an excess of hypoglycemic episodes and all-cause mortality.episodes and all-cause mortality.
  • 27.  Based on these data, the American Diabetology AssociationBased on these data, the American Diabetology Association and the European Association for the Study of Diabetesand the European Association for the Study of Diabetes (EASD) have jointly taken a similar, prudent attitude,(EASD) have jointly taken a similar, prudent attitude, recommending that physicians individualize treatment targetsrecommending that physicians individualize treatment targets and avoid overtreatment of fragile, higher-risk patients byand avoid overtreatment of fragile, higher-risk patients by restricting more stringent control of hyperglycemia torestricting more stringent control of hyperglycemia to younger patients with recent diabetes, absent or minoryounger patients with recent diabetes, absent or minor vascular complications and long life expectancy (HbA1cvascular complications and long life expectancy (HbA1c target ,7.0%), while considering a less-stringent HbA1c oftarget ,7.0%), while considering a less-stringent HbA1c of 7.5–8.0%, or even higher in more complicated and fragile7.5–8.0%, or even higher in more complicated and fragile patients, particularly in elderly patients with cognitivepatients, particularly in elderly patients with cognitive problems and a limited capacity for self care.problems and a limited capacity for self care.
  • 28. Thank you