Hypertension

Dr. Lucia Mazur-Nicorici MD. PhD

Definition
High risk hypertensive patient means
hypertensive patient with evidence of
atherosclerosis (coronary, cerebral or peripheral)
Or one or more atherosclerotic risk factors
Or with target organ damage
(cardiac, renal, eye or cerebral affection)

Epidemiology
The prevalence of hypertension worldwide is
estimated approximately 1 million individuals
mortality is about 7.1 million decese/an.
According to WHO hypertension is the leading
cause of mortality consequences worldwide.
Although hypertension is more common in
developed countries (37.3%) compared with those
in developing countries (22.9%), hypertensive
largest number in absolute terms the latter is found
in.

ESC Guidelines 2007

Risk stratification
Category
optimal
normal
High normal

Stage 1
Stage 2
Stage 3
ISP

Systolic
< 120
120-129
130-140
140-159
160-179
>180
>140

and
and/or
and/or
and/or
and/or
and/or
and

Diastolic
< 80
80-84
85-89
90-99
100-109
> 110
< 90

Aetiology of Hypertension
Primary 90-95% of cases also termed essential of idiopathic
Secondary about 5% of cases
Renal or renovascular disease
Endocrine disease

Phaeochomocytoma
Cusings syndrome
Conns syndrome
Acromegaly and hypothyroidism

Coarctation of the aorta

Iatrogenic
Hormonal / oral contraceptive
NSAIDs

This left ventricle is very thickened (slightly over 2 cm in

thickness), but the rest of the heart is not greatly enlarged.
This is typical for hypertensive heart disease. The
hypertension creates a greater pressure load on the heart to
induce the hypertrophy.

The left ventricle is markedly thickened in this patient

with severe hypertension that was untreated for many
years. The myocardial fibers have undergone
hypertrophy.

ESC Guidelines 2007:

Risc stratification

Benefits of lowering BP
Average percent reduction

Stroke incidence

35-40%

Myocardial infarction

20-25%

Heart failure

50%

HOT
Hypertension
Optimal
Treatment

H O T Findings
Lowest incidence of major CV events
occurred at a mean achieved DBP of 83
mmHg. This target (compared to mean
achieved of 105 mmHg was associated with
a 30% reduction in main CV events.
In diabetes Diastolic< or = 80mmhg 51 %
lower risk compared to 90 mmHg

Global heart threat from diabetes

A global explosion in the number of cases
of diabetes is threatening to reverse the
reduction in deaths from heart disease in
many western countries, including the
United Kingdom. To coincide with World
Diabetes Day on 14 November, Diabetes
UK is calling for action to be taken to
reduce the 20,000 deaths per year from
coronary heart disease (CHD) among
people with diabetes in the UK.

Hypertension and Diabetes

Hypertension co-exists with type II in about
40% at age 45 rising to 60% at age 75.
70% of type II patients die from cardiovascular disease.
At least 60% of patients will require 2 or 3
antihypertensive agents to achieve tight
control.

Stages

Identification of hypertensive patients

Baseline investigations
Initiating therapy
Reviewing patients
Stepping up therapy
Motivation and compliance

Investigation of the New

Hypertensive

History and examination

Exclude secondary Hypertension
Urea and electrolytes
FBP and ESR
ECG
Lipid profile

Chest x-ray no longer routinely indicated

Clinical clues to renal vascular

disease
Hypertension under 50 Yrs of age.
Generalised vascular (esp peripheral)
disease.
Mild moderate renal dysfunction.
Sudden onset pulmonary oedema.

Tailored Approach

Assessment of overall cardiovascular risk

Recognition of co-morbidities
Lipid profile
Renal function
Existing contra- indications

Coronary Risk Calculator

Launch risk calculator program

Compelling and possible indications and contrindications for

the major classes of antihypertensive drugs
INDICATIONS

CONTRAINDICATIONS

CLASSSOFDRUG

COMPELLING

POSSIBLE

POSSIBLE

COMPELLING

-blockers

Prostatism

Dyslipidaemia

PosturalHypotension

Unrinaryincontinence

Angiotensinconvertingenzyme(ACE)inhibitors

Heartfailure
Leftventriculardysfunction

Chronicrenaldisease*
TypeIIdiabeticnephropathy

Renalimpairment*
Peripheralvasculardisease

Pregnancy
Renovasculardisease

AngiotensinIIreceptorantagonists

CoughinducedbyACEinhibitor

Heartfailure
Intoleranceofotherantihypertensivedrugs

Peripheralvasculardisease

Pregnancy
Renovasculardisease

blockers

Myocardialinfarction

Heartfailure

Angina

Heartfailure
Dyslipidaemia
Peripheralvasculardisease

AsthmaorCOPD
Heartblock

Calciumantagonists(dihydropyridine)

Isolatedsystolichypertension(ISH)inelderlypatients

Angina
Elderlypatients

Calciumantagonists(ratelimiting)

Angina

Myocardialinfarction

Combinationwithblockade

Heartblock
Heartfailure

Thiazides

ElderlypatientsincludingISH

Dyslipidaemia

Gout

*ACEinhibitorsmaybebeneficialinchronicrenalfailurebutshouldbeusedwithcaution.Closesupervisionandspecialistadviceareneededwhenthereisestablishedand
significantrenalimpairment
CautionwithACEinhibitorsandangiotensinIIreceptorantagonistsinperipheralvasculardiseasebecauseofassociationwithrenovasculardisease.
IfACEinhibitorindicated
-blockersmayworsenheartfailure,butinspecialisthandsmaybeusedtotreatheartfailure

British Hypertension Society Guidelines 2000

Therapeutic targets
MeasuredinclinicMeandaytimeABPM
orhomemeasurement
BloodPressureNodiabetesDiabetesNodiabetesDiabetes
Optimal<140/85<140/80 <130/80<130/75
AuditStandard<150/90<140/85<140/85<140/80

TheauditstandardreflectstheminimumrecommendedlevelsofBPcontrol.Despitebestpractice,itmaynotbe
achievableinsometreatedhypertensivepatients.
NB:Bothsystolicanddiastolictargetsshouldbereached
BritishHypertensionSocietyGuidelines

Logical Combinations

Diuretic
-blocker
CCB

Diuretic
blocker

ACEinhibitor

CCB
-

*
-

ACE
inhibitor

blocker

-blocker

* Verapamil+beta-blocker=absolutecontra-indication

ACE Inhibitor Side Effects

Cough (15% of patients. Is reversible)

Taste disturbance (reversible)
Angiodema
First-dose hypotension
Hyperkalaemia ( esp. in patients with type
II diabetes and renal dysfunction)

Follow-up
ForpatientswithBPstabilisedbymanagement,
followupshouldnormallybethreemonthly(interval
shouldnotexceed6months),atwhichthefollowing
shouldbeassessedbyatrainednurse:
*MeasurementofBPandweight
*Reinforcementofnon-pharmacologicaladvice
*Generalhealthanddrugside-effects
*Testurineforproteinuria(annually)

Drug Treatment of Essential

Hypertension in Older People
Hypertension is very common, occuring in over
50% of older people, and is a major risk factor
for stroke and ischaemic heart disease.
Drug treatment of hypertension in older people
saves lives and prevents unnecessary morbidity.
Treating isolated systolic hypertension also saves
lives.

Drug Treatment of Essential

Hypertension in Older People
There is strong evidence to support the use of diuretics as
first-line agents.
Antihypertensive treatments are most cost-effective when
targeted at older patients.
There is evidence of under detection and under treatment
of hypertension.
Factors influencing patient adherence with treatment are
not well understood and require further research.

RECOMMENDATIONS

(for the treatment of the elderly)

Through the wider use of antihypertensive therapies more older

people would be able to maintain a healthy and active lifestyle.
Through the wider use of antihypertensive therapies more older
people would be able to maintain a healthy and active lifestyle.
For first-line agents there is strong evidence to support the use of
diuretics and some evidence for the use of beta-blockers.
Systems to ensure that older people with hypertension are
diagnosed, treated and followed up need to be developed.
A system of audit should be cultivated to assure adequate treatment.
High quality research on patient adherence with antihypertensive
medications is needed.
NHS Centre for reviews and dissemination 1999

Practical Points

15 20% of adult western population.

Isolated systolic hypertension just as dangerous.
Primary cause identified in only 5%.
Investigate Urine, FBP, ESR, ECG, U&E, Lipids.
Target < 140/85.
Refer patients needing more than 3 drugs to control their
hypertension.

Este important ca efectul antihipertensiv

al preparatelor utilizate s acopere 24 de
ore. Alegerea preparatelor cu administrare
unic zilnic favorizeaz creterea
complianei la tratament.
Au fost demonstrate i efecte favorabile
ale anumitor medicamente antihipertensive
asupra riscului cardiovascular global, la
pacienii cu valoare TA relative controlate
sau pentru reduceri mici n valoare
absolut ale valorilor TA de pornire .

Antihipertensive cu efect dovedit de reducere a riscului

cardio-vascular independent de reducerea valorilor TA

Principalele clase de antihipertensive: reprezentani, doze, numr de

administrri zilnice, trialuri n care au fost evaluat eficacitatea acestora n
reducerea evenimentelor cardiovasculare.

Save your heart