What s new in the hypertension management?

Transcription

1 What s new in the hypertension management? R. Brenner, OA Kardiologie, KSSG

2 2 Case report: 55yo woman

3 55yo secretary GP consultation because upper respiratory tract infection Risk factors Diabetes type 2 (Dx 2y ago, OAD), obesity (BMI 37kg/m 2 ), current smoker (30py), pos. Family history for cv diseases and HT, hyperlipidemia

4 BP 164/79 mmhg (mean of 3 measurements). P 70/min, regular. Current Medikation Metfin 1000mg Atorvastatin 40mg Aspirin cardio

5 Management: Instruction concerning home BP measurements, reevaluation in 2 weeks 2 weeks later HBP: mean 154/72 mmhg OBP: 161/77 mmhg

6 6 Which examination do you need? No examination necessary? AMBP? Renal artery duplex? Echocardiography and/or ECG? ARR? 24h-urine? Metanephrins? Search for proteinuria / albuminuria? Routine blood examination including TSH?

7 Sensitivity and specificity of blood pressure measurement methods compared to 24h ABPM Sensitivity Specificity Clinic (140/90 mmhg) Home (135/85 mmhg) Hodgkinson et al, BMJ 2011;342:d3621

8 Major role of 24h ABPM Exclude white coat effect Confirm therapy resistance Reverse nocturnal dipping Heart rate Low HR, suggestive for therapy adherence (i.e.ß-blocker) Increased HR during nighttime Rimoldi SF et al., Eur Heart J 2013 in press

9 First Take home message How measure blood pressure to improve the diagnostic and therapeutic approach to hypertension? -> 24h ABPM

10 Hypertension and cardiovascular mortality Mancia G et al. Eur Heart J 2013

11 Hypertension and cardiovascular mortality Mancia G et al. Eur Heart J 2013

12 Hypertension and organ damage Marker Predictive value Availability Reproducibility Cost- Effectiveness ECG ECHO IMT PWV egfr Microalbuminuria Mancia G et al. Eur Heart J 2013

13 Second take home message Hypertensive patients with low to moderate risk: -> search for subclinical organ damage (ECG), Echocardiography egfr, Albumin-creatinin ratio Vascular assessment (PWV, IMT) -> reclassification of ca. 20% patients

14 ECG: no hypertrophy, Echo: incipient hypertensive heart disease, LVEF 65% Blood tests: Normal red/white blood count. K 3.9mmo/l, creatinine 71umol/l. Urine-albumin 15.5g/mol creatinine, no other abnormalities Total-cholesterol 5.7mmol/l, TG 2.2mmol/l, HDL 1.3mmol/l, LDL 2.6mmol/l

15 What do you recommend in this situation? 1. Lifestyle, AMBP after 3 months 2. Start with a HCTZ in usual dosis (ISH) 3. Start with a low dosis combination therapy 4. Start with a high dosis ACE-inhibitor

16 Reduction in systolic BP with combination 4 x 1/4 1/1 1/1 1/1 1/1 Mahmud, A. et al. Hypertension 2007;49:

17 17

18 Swiss Guidelines Frühstücks-Workshop Hypertonie, SGK 2015

19 19 Diamond

20 20

21 Drugs to be preferred in specific conditions 65 % 45 % A or C 25 % A or C Mancia et al. J Hypertens and Eur Heart J 2013

22 Guidelines or

23 NICE Guidelines A (ACE-I / ARB) Patient < 55 y C (Ca-Antagonist) Patient > 55 y A + C A + C + D(iuretics) A + C + D + R(est) BMJ 2011;343:d4891 doi: /bmj.d4891

24 24 Circulation. 2006;113:

25 25 Blocking medication-reinforced mechanisms (synergy) CCB Diuretika RAS inhibitors Natriuresis Vasodilatation Stimulation RAS & Sympathicus

26 26 Fewer side effects Arterielle Hypertonie Vasokonstriktion 7% 6% 5% 4% 3% 2% 6,0% 3,2% 2,0% CCB Monotherapie CCB + RASI CCB Arterioläre Vasodilatation, KEINE Venodilatation 1% 0,6% 0% Inzidenz periphere Ödeme Medikamentenabbruch wegen Ödemen RASI: vasodilation of the venous limb of the capillary bed reduction of the intracapillary pressure ACEI + CCB Arterioläre + venöse Vasodilatation Messerli, Kardiovaskuläre Medizin 2009;12(11): Makani, The American Journal of Medicine (2011) 124,

27 27 Effect of CCB and ACEI in randomized studies SBP difference between randomized groups Verdecchia, Hypertension. 2005;46:

28 28 Effekt von CCB und ACEI in randomisierten Studien SBP difference between randomized groups Verdecchia, Hypertension. 2005;46:

29 Patienten mit primärem Endpunkt (%) Frühstücks-Workshop Hypertonie, SGK 2015 ACCOMPLISH study >11400 hypertensive patients - Randomiszed, controlled, double-blind - mean. BP at inclusion145/80mmhg - 61% diabetics, 24% prior MI Benazepril + HCTZ 11.8% RRR: -19.6% 9.6% Benazepril + Amlodipin 6 4 Mean SBD-Difference: 0.9 mm Hg (p<0.001) Mean DBD-Difference: 1.1 mm Hg (p<0.001) B+A<B+H 2 Trial prematurely stopped Monate Prim. endpont: composite of cv death, non-fatal MI, non-fatal stroke, hosp. AP, SCD und coronary revasc. Jamerson et al, NEJM 2008

30 Nach Van Vark LC et al., Eur Heart J, 2012; 33(16): Brugts JJ et al., Int J Cardiol 2014 ;181C: doi: /j.ijcard

31 Nach Van Vark LC et al., Eur Heart J, 2012; 33(16): Brugts JJ et al., Int J Cardiol 2014 ;181C: doi: /j.ijcard

32 32 Compliance fix-combination vs free combination 1,6 Odds ratio fix vs free 1,4 1,2 1 0,8 0,6 0,4 0,2 0 Fix vs free Gupta et al, Hypertension. 2010;55:

33 Case Lifestyle + start Perindopril + Amlodipin 10/5mg HBP after 4 weeks: 132/64mmHg AMBP

34 34 Take home messages

35 35 Take home messages An early combination therapy is useful in many cases of grade II HT and superior to a high dose monotherapy or a stepped care. A combination of RASI/CCB is favorable in patients with high cardiovascular risk: Good data (ASCOT, ACCOMPLISH) Side effects reduced Synergy A RASI is recommended in patients with DM2. ACEI have somewhat more solid data (mortality) compared to sartans. However, direct comparison between ACEI/Sartans shows no major differences (ONTARGET). A fixed-dose combination is appreciated by many patients (as few tablets as possible) und supports patient compliance.