Download - Hta 2013
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Maneig integral del pacient amb patologia crònica
Dr. Ernest Vinyoles
HTA-Novetats en el maneig de la HTA
27 Novembre 2013 Matí: 14.00 hores Tarda: 20:30 hores
Ja us podeu inscriure a la nostra pagina web
www.camfic.cat Sol·licitada acreditació al Consell Català de la Formació Continuada de les Professions Sanitàries
Col·labora:
Organitza:
e-actualització
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Novetats en HTA, 2013
Ernest Vinyoles
CAP La Mina
Universitat de Barcelona
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Novetats rellevants en:
• Mesura de la PA
• Avaluació i seguiment
• Tractament
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Les guies més actuals
• European Society of Hypertension, 2013
• American Heart Association, 2013
• American Society of Hypertension and the International Society of Hypertension, 2013
• Les de la Societat Catalana d’HTA:
– Diagnòstic i tractament, 2014
– Urgències hipertensives, 2014
– Malaltia renal crònica i HTA, 2014
http://www.schta.cat/index.asp
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Novetats rellevants en:
• Mesura de la PA
• Avaluació i seguiment
• Tractament
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Es pot mesurar la PA sense esperar un minut entre lectures tensionals?
CAP La Mina, 2013
Mesura de la PA
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SBP-WR(mmHg)
DBP-WR(mmHg)
SBP-IR(mmHg)
DBP-IR(mmHg)
Figure 1. Concordance between blood pressure readings according to measurementmethod: waiting successive readings (WR) vs immediate successive readings (IR)
SBP: systolic blood pressure; DBP: diastolic blood pressure; ICC: intraclass correlation coeficient; CI: confidence interval.
ICC: 0.946 (CI 95%, 0.925-0.961) ICC: 0.877 (CI 95%, 0.831-0.911)
CAP La Mina, 2013, submitted
Mesura de la PA
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Hypertension. 2013;62:579-584
Mesura de la PA
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J Hypertens. 2013 Sep;31(9):1731-68
Mesura de la PA
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J Hypertens. 2013 Sep;31(9):1731-68
Mesura de la PA
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Guia HTA 2014. Societat Catalana d’HTA.
Mesura de la PA
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Mancia G et al. Hypertens 2013:62
Long-Term Prognostic Value of White Coat Hypertension
Mesura de la PA
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8,3 9,2 12,4 16,5
5,4 14
20,3
8,6
36,5 41
20,9 16
48
23,9
0
10
20
30
40
50
60
% Prevalença d’hipertensió emmascarada
en diversos estudis
Poblacional
Mesura de la PA
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Incidència d’esdeveniments CV, ajustada per edat i sexe, en pacients no tractats
No diabètics Diabètics
Franklin SS et al. Hypertens 2013;61:964-971
Mesura de la PA
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Vinyoles E et al. FMC. 2012;19(1):16-9
Mesura de la PA
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24%
Prevalença d’hipertensió emmascarada en personal sanitari normotens
(estudi ESTHEN 2)
Sobrino J et al. Blood Pres Mon 2013;18:326–331
n=501
Mesura de la PA
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NICE, 2011
Hem de generalitzar l’ús de la MAPA?
?
Mesura de la PA
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Home measurement of blood pressure and CV disease:
systematic review and meta-analysis of prospective studies
8 studies with 17 698 participants.
Follow-up was 3.2–10.9 years.
J Hypertens 2012:29 DOI:10.1097/HJH.0b013e32834e4aed
Mesura de la PA
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Home measurement of blood pressure and CV disease:
systematic review and meta-analysis of prospective studies
J Hypertens 2012:29 DOI:10.1097/HJH.0b013e32834e4aed
8 studies with 17 698 participants.
Follow-up was 3.2–10.9 years.
Mesura de la PA
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Algoritme de maneig d’AMPA i MAPA
Pickering TG et al. Hypertension. 2008;52:1-9
Mesura de la PA
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Evolution of Target Organ Damage by Different Values of Self-Blood Pressure Measurement in
Untreated Hypertensive Patients
G Coll de Tuero et al Am J Hypertens 2012.
<130/80
Mesura de la PA
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Night-time SBP is
the most potent
predictor of
outcome
De la Sierra A et al. J Hypertens 2012, 30:713–719
CARDIORISC
Event study
Mesura de la PA
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Office HR – High/very high risk
Office HR – Moderate/low risk
Nighttime HR – High/very high risk
Nighttime HR – Moderate/low risk
HR: Heart rate.
A major FC, major risc CV
32,569 untreated hypertensive patients
Vinyoles E et al. CARDIORISC, submitted 2013
Mesura de la PA
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68
85
(beats per minute)
(bea
ts p
er m
inute
)
T: 14,5%
MT: 27,1%
ICT: 9,4%
No T: 49%
Vinyoles E et al. CARDIORISC, submitted 2013
Mesura de la PA
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Novetats rellevants en:
• Mesura de la PA
• Avaluació i seguiment
• Tractament
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Lesió asimptomàtica d’òrgans diana
Guia Societat Catalana d’HTA 2014. Adaptació ESH/ESC 2013
Avaluació i seguiment
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Guia Societat Catalana d’HTA 2014. Adaptació ESH/ESC 2013
Avaluació i seguiment
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ESH 2013
• Diabètics <140 / 85 mmHg (I A)
No obstant això, cal tenir en compte que els valors de PAD de 80-85 mmHg són segurs i bien tolerats
GUIA CAMFIC
• Diabètics <135 / 80 mmHg
Avaluació i seguiment
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Guia de Malaltia Renal i risc CV, Societat Catalana d’HTA, 2014
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Alteracions “menors” segment ST-T
Avaluació i seguiment
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Auer R et al. JAMA. 2012;307(14):1497-1505
risk of CHD events
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Cohort MINACOR (n=352 hipertensos, no DM)
1992 2011 1998
ECG basal COD. DE MINNESOTA
CAP La Mina Aten Prim 1992 Aten Prim 1998 Hipertens 2001 ESH 2012
Morbimortalitat CV
Avaluació i seguiment
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Factor predictor de las alteracions ECG (Cohort MINACOR)
Mal control de la PA durant el seguiment
Odds ratio: 3,2 (IC 95%: 1,2-8,6)
Avaluació i seguiment
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CAP La Mina, 2013
P= 0,003
HVE-ECG i risc de morbimortalitat CV. Cohort MINACOR
Avaluació i seguiment
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Canvis ST-T i risc esdeveniments CV.
CAP La Mina, 2013
P= 0,31
Avaluació i seguiment
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Els criteris de voltatge d’HVE són
menys reproduïbles del que pensem
38,5
39
39,5
40
40,5
41
41,5
42
Cornell Sokolow
%
Percentatge de mala concordança dels criteris de voltatge en el segon ECG
Vinyoles E et al. Blood Pressure, 2012;21:352-359
Avaluació i seguiment
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ECG detection of left ventricular hypertrophy:
the simpler, the better?
Gosse P et al. J Hypertens 2012, 30:990–996
Avaluació i seguiment
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Voltatge R aVL (mm)
RaVL
≥ 6 mm
El voltatge RaVL és una bona opció per al
el diagnòstic d’HVE-ECG
Gosse P et al. J Hypertens 2012, 30:990–996
Avaluació i seguiment
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Avaluació i seguiment
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ESH 2013
Avaluació i seguiment
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Novetats rellevants en:
• Mesura de la PA
• Avaluació i seguiment
• Tractament
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Tractament
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N Engl J Med 2013;368:1229-37.
Tractament
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Assaig clínic PREDIMED
12.150 pacients
Grup
control
Dieta mediterrània
+
Dieta mediterrània
+
n= 4.050 n= 4.050 n= 4.050
PREDIMED. Ann Intern Med. 2006;145:1-11.
Tractament
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Inici 3 mesos Inici 3 mesos Inici 3 mesos
PAS (mmHg)
PAD (mmHg)
FC (l/min)
157±24
90±10
75±13
152±20
86±10
75±11
159±16
94±14
74±9
154±16
90±12
73±9
160±24
89±9
76±12
158±20
87±11
74±11
DTM+Oli DTM+Frut.secs Grup Control
p= 0.017 p= <0.001 p= 0.048
Efectes sobre la PA
PREDIMED. Ann Intern Med. 2006;145:1-11.
Tractament
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Primary Prevention of Cardiovascular Disease with a
Mediterranean Diet - PREDIMED
Estruch R et al N Engl J Med 2013.
Tractament
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Gazpacho consumption is associated with lower blood pressure and reduced hypertension in a high cardiovascular risk cohort. PREDIMED -
Nutrition, Metabolism & Cardiovascular Diseases (2012)
Tractament
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Oli d’oliva verge extra ▼
Fruits secs ▼
Gaspatxo ▼
Lactis desnatats ▼
Carns vermelles ▲
Fibra ▼
Proteïnes vegetals ▼
Refrescs de cola amb
cafeïna ▲
Alcohol ▲
Sal ▲
PREDIMED
PREDIMED Tractament
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Hypertension 2011;58:950-958
DINAMIC RESISTANCE TRAINING
ISOMETRIC RESISTANCE TRAINING
Tractament
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Hypertension. 2013;62:1021-1026
The association between occupational PA and hypertension was not significant.
Both high and moderate levels of recreational physical
activity were associated with reduced risk of hypertension
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Guia Societat Catalana d’HTA 2014. Adaptació ESH/ESC 2013
Tractament
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Guia Societat Catalana d’HTA 2014. Adaptació ESH/ESC 2013
Tractament
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ESH 2013 Tractament
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ESH 2013 Tractament
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Guia de la Societat Catalana d’HTA 2014
Tractament
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A Statement by theAmerican Society of Hypertension and the International Society of
Hypertension, novembre 2013 – J Hypertension.
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PAS, mmHg
Peck et al. BMC Nephrology 2013, 14:201
In black adults (USA, Europe) requiring monotherapy for uncomplicated
hypertension, drugs other than ACE-inhibitors may be preferred.
Tractament
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AHA 2013
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■ Hipertensos < 60 a: IECA (substituir per un ARA-II si apareix intolerància) o amb un BB (especialment dones en edat fèrtil).
■ Hipertensos ≥ 60 a: DIU tiazídic a dosis baixes o AC d’acció perllongada.
Tractament
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Guia de la Societat Catalana d’HTA 2014
Tractament
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Guia de la Societat Catalana d’HTA 2014
Tractament
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Guia de la Societat Catalana d’HTA 2014
Tractament
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ESH Position Paper: Renal denervation - an interventional therapy of resistant hypertension
Journal of Hypertension 2012, 30:837–841
Tractament
Ablació simpàtica
renal endovascular
per radiofreqüència
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Lancet, Published Online November 7, 2013
Percutaneous renal denervation in patients with treatment-
resistant hypertension: final 3-year report of the Symplicity
HTN-1 study
88 patients had complete
data at 36 months
Nombre d’antihipertensius:
BASAL: 5,1 (1,7)
FINAL: 5,2 (1,7)
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Conclusions
• Mesura de la PA – Guia MAPA, valor pronòstic de l’AMPA
• Avaluació i seguiment - Guies
• Tractament - Guies