nuevos conceptos en hta

7/29/2019 Nuevos Conceptos en HTA

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Dr. Christian Amurrio Gonz

Nuevos conceptos en HTA


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Objetivo 1

Diagnostico correcto

Preguntas adicionales:

El paciente toma alguna sustancia que puede infsobre su presion arterial?

Hay otras enfermedades presentes que pueden

tener impacto sobre su riesgo cardiovascular?

Hay evidencia de dao a organo-blanco porhipertension sostenida?


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Table : Prescription medications that elevate blood pressure

Corticosteroids

NSAIDs

Cyclosporine

Tacrolimus

Erythropoietin

Tricyclic antidepressants

Venlafaxine (Effexor)

MAO inhibitors

Oral contraceptives ***


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Table : Classification of blood pressure1

BP Classification

Systolic BP, mm Hg Diastolic BP, mm

Normal 100

Riesgos asociados con HTA

enf. Cardiovascular [aortic aneurysm and aortic dissection

enf. Cerebrovascular

enfermedad renal-terminalinsuficiencia cardiaca congestica


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La curva J

Coronary perfusion occurs during diastole, andthere is concern that as diastolic pressure isbrought to ever lower levels, coronary perfusion willbe compromised and cardiovascular mortality willincrease. INVEST trial

"in view of the uncertainty on this issue, it wouldseem prudent to counsel that in patients with anelevated DBP and occlusive CAD with evidence ofmyocardial ischemia, the BP should be loweredslowly, and caution is advised in inducing falls ofDBP below 60mm HG if the patient has diabetes

"


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Every 5mm Hg increase in diastolic blood pressure andevery 10mm Hg increase in systolic blood pressure is

associated with a 28% increase in the risk of death from

coronary heart disease, even in individuals who are not

classified as hypertensive.

Systolic blood pressure has been shownto be a

stronger predictor
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10955386http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10955386


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Objetivo 2Table : Objectives of evaluation of the newly-diagnosed hypertensive

ObjectiveExamples

Identification of other cardiovascular risk

factors Diabetes

Hypercholesterolemia

Tobacco

Positive family historyIdentification of possible secondary

causes Renal artery stenosis

Obstructive sleep apnea

Cushing's disease

Conn's syndromeIdentification of possible target organdamage Left ventricular hypertrophy

Chronic kidney disease


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Table : Physical evidence of target organ damage

Physical finding Comments

Hypertensive retinopathy18 ExamplesArteriovenous nicking

"Copper-wiring"

Retinal hemorrhagesVascular bruits Examples:

Carotid bruits

Renal artery bruits

Femoral artery bruitsLeft ventricular hypertrophy LV heave on physical exam; EKG may sh

evidence of hypertrophy or strain

Left or right ventricular failure Examples:S3 gallop

Pulmonary rales

Elevated JVP

Peripheral edemaDiminished pedal pulses Inquire about intermittent claudication; co

obtaining ankle/brachial indices

Neurologic abnormalities (i.e. stroke) Consider evaluation of cerebrovascular c

T bl 6 C l d d i h l di d h i 1 19
http://content.nejm.org/cgi/content/short/351/22/2310http://content.nejm.org/cgi/content/short/351/22/2310


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Table 6: Commonly recommended tests in the newly diagnosed hypertensive1, 19

Test Comment

EKG May demonstrate evidence of LVH, conduction abnormalities, ischemia or in

all of which will demonstrate target organ damage and alter not only the init

of therapy, but also the time course of instituting therapyBasic metabolic panel Demonstrates pre-treatment sodium and potassium, which will affect initial c

therapy along with providing a possible clue to a secondary cause of hyperte

(e.g. hyperaldosteronism). Ca++The BUN and creatinine will demonstrate the presence or absence of targe

damage, and also guide initial choice of therapy (thiazides do not work well

creatinine is above 1.5 -2 mg/dL; a loop diuretic should be considered if a di

needed. ACE-inhibitors do not work well if the creatinine is above 3mg/dL).Guidelines for antihypertensive therapy for diabetics and those with renal d

among the most aggressive; thus the creatinine and glucose provided with t

metabolic panel will alter therapy.Urinalysis Provides evidence of target organ damage that will guide initial managemen

proteinuria).

Lipids Indicated for risk stratification for coronary artery disease. Elevated LDL cho

an independent risk for the development of coronary artery disease, and wil

be evaluated in most individuals diagnosed with hypertensionComplete blood count To exclude polycythemia as a possible cause of hypertension

T bl Lif t l difi ti d i t bl d 1


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Table : Lifestyle modification and impact on blood pressure1

Modification RecommendationsApproximate Systolic

Pressure Reduct

Weight reductionMaintain normal body weight (BMI

18.5-24.9)5-20mm Hg/10kg weig

Adopt DASH eating plan

Consume a diet rich in fruits,

vegetables, and low-fat dairy products

with a reduced content of saturated

and total fat

8-14mm Hg

Dietary sodium

reduction

Reduce dietary sodium intake to no

more that 2.4 g sodium or 6g sodium

chloride

2-8mm Hg

Physical activity

Engage in regular aerobic physical

activity such as brisk walking (30mins,

most days/week)

4-9mm Hg

Moderation of alcoholconsumption

Limit consumption to no more than 2

drinks/day (men) or 1 drink/day(women and lighter weight persons)

2-4mm Hg


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inmediato?

The individual who presents with an elevated bloo

pressure who has no target organ damage or othecardiovascular risks The level of blood pressureelevation will also impact your decision.

Salt restriction lowers blood pressure in patients w

and without hypertension.

In one study, individuals who lost as little as 2.4kghad a 77% reduction in the odds of developinghypertension seven years later.

DASH and TONE
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10679495&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10679495&dopt=Abstract


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Objetivo 4 HTA secundaria

Table : Red flags for secondary hypertension

Evaluation component Finding Potential implication


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p g p

History Onset of HTN age 50 Prevalence of secondary causes higher

population

History of well-controlled HTN, now poorly controlled Suggests secondary cause, especially

artery stenosis

Flash pulmonary edema Suggests renal artery stenosis

Episodic hypertension Suggests pheochromocytoma

Daytime somnolence; loud snoring Suggests obstructive sleep apnea

Physical exam Obesity Suggests obstructive sleep apneaThyroid goiter Suggests hyperthyroidism

Moon facies Suggests Cushing's

Dorsal fat pad Suggests Cushing'sPurple striae Suggests Cushing's

Vascular bruits Suggests renal artery stenosis

Abdominal mass Suggests polycystic kidney disease

Decreased pulses in lower extremities Suggests coarctation of the aorta

Isolated systolic hypertension Suggests anemia, hyperthyroidism, aor

insufficiency, arteriovenous fistula, Pag

disease of bone

Labs Hypokalemia Suggests Cushing's, hyperaldosteronis

artery stenosisHypercalcemia Suggests hyperparathyroidism

Metabolic alkalosis Suggests Cushing's, hyperaldosteronis

possibly obstructive sleep apnea

Elevated hematocrit Suggests polycythemia


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HTA resistente y refractaria

History: onset of HTN before 30 or after 50; h/owell controlled HTN now out of control; flashpulmonary edema; episodic HTN; daytimesomnolence, loud snoring; uncontrolled BPdespite 3 meds at or near maximal dose(including a diuretic)

Physical: Obesity; thyroid goiter; moon facies;dorsal fat pad; purple striae; vascular bruits;abdominal mass; decreased pulses lowerextremities

Labs: Hypokalemia; hypercalcemia; metabolicalkalosis; elevated hematocrit


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Figure 1: Considerations in resistant hypertension

Table: Review of causes of secondary hypertension


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Table: Review of causes of secondary hypertensionCause Clues

Renal parenchymal disease Microalbuminuria; proteinuria; nocturia; edema

Renal artery stenosis Flash pulmonary edema; multiple vascular risks

well-controlled hypertension, now poorly contro

vascular bruits; hypokalemia; renal insufficiency

Fibromuscular dysplasia Women between ages 15 and 50; beaded appe

renal angiogram

Obstructive sleep apnea Daytime somnolence; loud snoring; met. alkal

Pheochromocytoma Sustained or episodic hypertension with headac

palpitations, diaphoresis

Hyperaldosteronism ( Conn syndrome) Hypokalemia; metabolic alkalosis

Hypercortisolism (including Cushing syndrome) Dorsal fat pad; moon facies; purple striae; trunc

proximal muscle weakness; metabolic alkalosis

hypokalemia

Hyperparathyroidism Hypercalcemia; "bones, stones, abdominal groa

Hyperthyroidism Systolic hypertension, tachycardia, weight loss,

exophthalmos, goiter, thyroid bruit.

Hypothyroidism Cold intolerance; constipation; mental slowing;

hypertension; lateral thinning of eyebrows; perio

edema; delayed relaxation of reflexes

Table 10: AHA recommendations for blood pressure targets in cardiac d


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Table 10: AHA recommendations for blood pressure targets in cardiac d

Area of concern TargetBP Comments

General CAD prevention 160 of DBP > 100High CAD risk 1

Stable angina


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et vo e camentoadecuado

The single most important aspect in

treating a patient with hypertension is

the level of blood pressure control.

However, the agent(s) chosen to

achieve blood pressure control may

provide additional benefit in specificclinical conditions

ALLHAT
http://jama.ama-assn.org/cgi/content/abstract/288/23/2981http://jama.ama-assn.org/cgi/content/abstract/288/23/2981


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ALLHAT Men and women aged 55 or older with blood pressure

greater than 140/90 and at least one other cardiovascu

risk factor were randomized to receive treatment witheither a diuretic (chlorthalidone), an alpha-blocker(doxazosin), a calcium channel blocker (amlodipine) oan ACE-inhibitor (lisinopril). Beta blockers were notincluded. Goal blood pressure reduction for all groupswas set at BP


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Clinical outcomes of those patients treated withchlorthalidone were compared to those treated withamlodipine or lisinopril. Chlorthalidone proved superior

the other agents in lowering blood pressure, reducingclinical events, and was better tolerated than the otheragents. As compared to amlodipine, chlorthalidone wasassociated with 25% fewer cases of heart failure,although other clinical outcomes were not statistically

different. As compared to lisinopril, chlorthalidone wasbetter tolerated and resulted in better blood pressurecontrol. In addition, the lisinopril group had a greater risof stroke, heart failure, angina, and coronaryrevascularization as compared to chlorthalidone. Theauthors concluded that "thiazide-type diuretics should bconsidered first for pharmacologic therapy in patients

Table : Indicaciones convincentes


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Table : Indicaciones convincentes

High-risk condition

with compelling

indication

Diuretic

recommen

ded

Beta-blocker

recommende

d

ACEI

recomme

nded

ARB

recomm

ended

CCB

recomm

ended

Aldo

anta

recom

CHF

Post-MI

High CAD risk **

DM

CKD

Recurrent CVA

prevention

**ACCOMPLISH ACE-inhibitor/dihydropyridine CCBbenazepril/amlodipine


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y yp gDiuretics Drug of choice for hypertension without compel

indications for another drugThiazide diuretics may have beneficial effects o

metabolismLow dose diuretics may be of benefit in patients

diabetesThiazide diuretics may precipitate gout

Beta-blockers Drug of choice for preoperative hypertensionIncreasingly useful in cardiovascular risk reduct

cardiac surgeryDrug of choice for hypertension associated with

hyperthyroidismUseful for migraine prophylaxisAcceptable for use during pregnancy (other acc

agents: methydopa; vasodilators)

ACE-inhibitors Absolutely contraindicated in pregnancyA 35% increase in creatinine is acceptable whe

therapy with ACE-inhibitorsMay be less effective for blood pressure control

Americans, who are also more likely to dev

angioedema in response to ACE-I

Angiotensin-receptor blockers (ARBs) Not currently a first line agent; Used when ACEb t t t l t d


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but not toleratedEvidence continues to increase that they are eq

ACE-I in benefits to kidneys in diabeticsAbsolutely contraindicated in pregnancyAs with ACE-I, a 35% increase in creatinine ma

when initiating therapy

Calcium channel blockers May be of particular use when treating isolat

hypertension in the elderlyMay be more effective for blood pressure co

African AmericansMay be used for migraine prophylaxisNon-dihydropyridine CCBs (e.g. verapamil) t

choice in diabetic nephropathy if ACE otolerated55

Non-dihydropyridine CCBs may also delay p

of proteinuria in other causes of chronic

disease 56

In the absence of benefit in specific clinical s

calcium channel blockers are now consi

line agents, after therapy with diuretics, blockers, and/or ACE-inhibitors

Alpha blockers Should not be used as monotherapt t t f h t i
http://jama.ama-assn.org/cgi/content/abstract/290/21/2805http://jama.ama-assn.org/cgi/content/abstract/290/21/2805http://jama.ama-assn.org/cgi/content/abstract/290/21/2805http://jama.ama-assn.org/cgi/content/abstract/290/21/2805


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treatment of hypertension May help treat symptoms in men w

prostatic hypertrophy

Aldosterone antagonists Includes spironolactone and eplere

(brand name Inspra) Defined role in management of CH

Both cause hyperkalemia Spironolactone associated with sex

effects, seen less with eplerenone


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GRACIAS

SE PUEDE VER SOLO LO QUE SE OBSERVA Y SE OBSERVA SOLO LO Q

YA ESTA EN LA MENTE

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