farmacoterapeutica hipertension arterial wilson briceÑo castellanos farmacologo clinico 2014
TRANSCRIPT
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FARMACOTERAPEUTICA HIPERTENSION ARTERIAL
WILSON BRICEÑO CASTELLANOSFARMACOLOGO CLINICO
2014
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caso
• Paciente de 50 años no diabético, no falla renal, sin factores de riesgo cardiovascular, con TA 170/80.
• 1. Clasifique el estadio de HTA• 2. Sugiera tratamiento antiHTA inicial con
dosis • 3. Iniciaría ASA ?
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OBJETIVOS
• 1. Describir farmacoterapeutica de la hipertensión arterial no complicada en adultos
• 2. Describir las principales guías de manejo de hipertensión arterial no complicada en adultos
• 3. Describir las principales combinaciones, contraindicaciones y antihipertensivo de elección según enfermedad concomitante
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fisiopatología
NaNa
K
K
KNa
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fisiopatología
Ca
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fisiopatología
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Órgano blanco asintomático
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ORGANO BLANCO SINTOMATICO
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Objetivo control tensión arterial
• Disminuir complicaciones de la HTA
• Diminuir morbilidad Cardiovascular
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Metas control tensión arterialJNC 7 JNC 8 NICE EUROPEAS
Pacientes <140/90 <140/90 <140/90 <140/90
Diabetes Mellitus y Falla renal
<130/80 <140/90 <140/90 <140/90*
Pacientes adulto mayor
<140/90 <150/90(>60 años)
<150/90(80 años)
<150/90(80 años)
* Pacientes diabéticos PD <85
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Medidas no farmacológicas
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JNC 8
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algoritmoPaciente
hipertenso
Diabetes o falla renal?140/90
>60 años150/90
<60 años140/90
si
no
no
si
si
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Tratamiento 1 era línea
IECAS ARA II TIAZIDAS
CALCIO ANTAGONISTAS
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ELECCION ANTIHTAIECA ARA 2 TIAZIDA CaAntago B Bloque Espirino
< 60 años x x x X
>60 años x x x X
E renal x X
Diabetes x x x x X
Falla cardiaca
x x x x x X
Post IAM x x x x
Post Stroke
x x x x x
Raza negra
x x
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algoritmoHTA estadio I
Medidas no farmacologicas
1 de los AntiHTA: IECA; ARA2, tiazidas, CAanta
2 de los AntiHTA: IECA; ARA2, tiazidas, CAanta
3 de los AntiHTA: IECA; ARA2, tiazidas, CAanta
3 antihta + bb o espirinolactona o otros
Dosis maxima
Dosis maxima
Dosis maxima
Estadio II
No farmacologicas +Farmacologicas: 2 antihta: IECA,
ARA 2, CA anTA, TIAZIDAS
3 antiHTA: IECA, ARA 2, CA anTA, TIAZIDAS
3 antiHTA: IECA, ARA 2, CA anTA, TIAZIDAS + bb bloqueador o
espirinolactona u otro
Dosis maxima
Dosis maxima
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HTA refractaria
• Prazocin• Minoxidil• Espirinolactona• Furosemida• clonidina
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Guías europeas
Estadio 1
Estadio 2
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Factores de riesgo cardiovascular
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Clasificación riesgo HTA según riesgo
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Guías europeas
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ALGORITMOGrado 3 o
Enfermedad renal o diabetes y TA >140/90 oGrado 2 y 3 factores de riesgo o
Enfermedad cardiovascular sintomática y >140/90
Cambios estilo de vida
antihipertensivo
Cambios de estilo de vida por 3 meses
antihipertensivo
si NO
NO
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Guías NICE
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Combinaciones de antiHTA
verapamilo
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Contraindicaciones antiHTAcontraindicado uso con precaución
IECA Embarazo - hiperK - estenosis arteria renal – edema angioneurotico
Mujeres lactantesFalla renal
ARA 2 Embarazo - hiperK - estenosis arteria renal – edema
Mujeres lactantesFalla renal
tiazidas Gota- embarazo-falla renal TFG <30
Hiperglicemia, hipercalcemia, hipokalemia
Calcio antagonistas no dihidropiridinicos
Bloqueo AV 2 y 3 , bradicardia falla cardiaca
Calcio antagonistas dihidropiridinicos
Falla cardiacataquiarritmias
espirinolactona Fala renal severa Hiper K
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Grupo Fármaco Presentación (mg) Rango de dosis (mg/d)
Frecuencia diaria
IECAs captopril tab 25, 50 25-100 2-3enalapril tab 5, 10, 20 5-40 1-2
ARA II losartan tab 50 25-100 1-2valsartan tab 40, 80, 160, 320 80-320 1-2
CCB amlodipino tab 5, 10 2,5-10 1nifedipino XL tab 30, 60 30-60 1verapamilo IR 40, 80, 120 80-320 2
BB carvedilol 3.25, 6.25, 12.5, 25 6.25-50 2
Metoprolol tartrato tab 50, 100, XL 200 50-200 2 (XL 1)
Diuréticos hidroclorotiazida tab 25 12,5-25 1espironolactona tab 25 25-50 1
29
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Cuando se debe usar ASA?
• Pacientes con antecedente de enfermedad cardiovascular (IAM, stroke, estenosis arterial)
• Pacientes con alto riesgo cardiovascular• Enfermedad renal TFG <45
• No se indica en paciente con bajo-moderado riesgo
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caso
• Paciente de 50 años no diabético, no falla renal, sin factores de riesgo cardiovascular, con TA 170/80.
• 1. Clasifique el estadio de HTA• Estadio 2 o grado
• 2. Sugiera tratamiento antiHTA inicial con dosis segun JNC 8?
• dos antihipertensivos: IECA*, ARA2*, calcioantagonista, tiazida
• 3. Iniciaría ASA?• No