Guidelines 2007 Guidelines for the Management of Arterial Hypertension

1. Guidelines 2007 Guidelines for the Management of Arterial Hypertension The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) Authors/Task Force Members: Giuseppe Mancia, Co-Chairperson (Italy), Guy De Backer, Co-Chairperson (Belgium), Anna Dominiczak (UK), Renata Cifkova (Czech Republic), Robert Fagard (Belgium), Giuseppe Germano (Italy), Guido Grassi (Italy), Anthony M. Heagerty (UK), Sverre E. Kjeldsen (Norway), Stephane Laurent (France), Krzysztof Narkiewicz (Poland), Luis Ruilope (Spain), Andrzej Rynkiewicz (Poland), Roland E. Schmieder (Germany), Harry A.J. Struijker Boudier (Netherlands), Alberto Zanchetti (Italy) Journal of Hypertension 2007, 25, 1105-1187

2. ESH/ESC Guidelines: Definition and classification (mmHg) Cathegory Optimal Normal High normal Hypertension grade 1 (mild) grade 2 (moderate) grade 3 (severe) Izolated systolic hypertension BPs < 120 120-129 130-139 140-159 160-179 ≥ 180 ≥ 140 BPd < 80 80-84 85-89 90-99 100-109 ≥ 110 < 90 6254 M

3. 2007 ESH/ESC Guidelines: NORMAL VALUES Office 140/90 mmHg Self monitoring 135/85 mmHg 24 hod monitoring 125/80 mmHg Daily 135/85 mmHg Night 120/70 mmHg 6271 M

4. Classification according BP JNC 7 vs. ESC

5. Healthy “Prediseased” Hypertension Hypertension with complications 6421 M

6. Cardiovascular events in patients with „normal“ blood pressure Female Male High normal High normal Normal Optimal Normal Optimal No. at risk Optimal Normal High- normal 1875 1126 891 1867 1115 874 1851 1097 859 1839 1084 840 1821 1061 812 1734 974 722 887 649 520 No. at risk Optimal Normal High- normal 1005 1059 903 995 1039 879 973 1012 857 962 982 819 934 952 795 892 892 726 454 520 441 Vasan et al., N Engl J Med 2001; 345: 1291-7 2843

7. ESH/ESC Guidelines – Risc factors BPs / BPd Age: male > 55 years, female > 65 years Smoking Dyslipidemia - total chol. > 6,5mmol/l - LDL-chol. > 4,0mmol/l - HDL-chol. < 1,0 (male) or <1,2 (female) mmol/l Family history CVD (male < 55 years; female < 65 years) Abdominal obesity (waist> 102 cm male, > 88cm female) C-reactiv protein > 1 mg/l 6366 M

8. ESH/ESC Guidelines –organ demage LVH - ECG (Sokolow-Lyon > 38 mm / Cornell > 2440 mmxms) - Echo: LVMI>125 g/m2(male) >110 g/m2 (female) Intima/media carotid thickness (IMT > 9 mm) Or plake Increased S-cr (115 - 133 µmol/l male, 107 – 124 µmol/l u žen) Mikroalbuminuria - 30-300 mg/24 hour - albumin / creatinin - male: > 22 mg/g - female: > 31 mg/g 6376 M

9. 2007 ESH/ESC Guidelines: Greades for treated HT I = without changes II = with changes III = with end organ damage

10. 2007 ESH/ESC Guidelines: Organ damage Heart - IHD Brain - Stroke Kidney - Nefropathy, MIA Periphery - ID of LE Eyesi - hemorhagy

11. 2007 ESH/ESC Guidelines: Examinations ALL Pers. and fam. hist Fysical exam BP on both upper ex Urine + MIA Kreat, U, Na, K, gly, UA Lipids ECG SELECTED USD carotid USD heart MIA (DM) Creat clear, proteinuria Retinopathy

12. Countries with high risk

13. 2007 ESH-ESC Guidelines Expected risk 10-year risk IHD 10-year risk death onemocnění do 10 let Low < 15% < 4% Moderate 15-20% 4-5% High 20-30% 5-8% Very high > 30% > 8%

14. Case report Male, 55 years 6,2 mmol/l 1,3 mmol/l 160/95 mm Hg 4,2 mmol/l 3,4 mmol/l YES • Demography • Total cholesterol • HDL • BP • LDL • TG • Smoking, LVH, DM • 10year risk IHD

15. Male, 55 smoker BPs 160 Chol 6,2

16. Case report Male, 55 years 6,2 mmol/l 1,3 mmol/l 160/95 mm Hg 4,2 mmol/l 3,4 mmol/l YES 11% • Demography • Total cholesterol • HDL • BP • LDL • TG • Smoking, LVH, DM • 10year risk IHD

17. Case report • Demography • Total cholesterol • HDL • BP • LDL • TG • Smoking, LVH, DM • 10year risk IHD Male, 55 years 6,2 mmol/l 1,3 mmol/l 160/95 mm Hg 4,2 mmol/l 3,4 mmol/l YES 11% Male, 55 years 4,1 mmol/l 1,4 mmol/l 140/83 mm Hg 2,7 mmol/l 3,0 mmol/l YES

18. Male, 55 smoker BPs 140 Chol 4,1

19. Case report • Demography • Total cholesterol • HDL • BP • LDL • TG • Smoking, LVH, DM • 10year risk IHD Muž, 55 let 6,2 mmol/l 1,3 mmol/l 160/95 mm Hg 4,2 mmol/l 3,4 mmol/l YES 11% Muž, 55 let 4,1 mmol/l 1,4 mmol/l 140/83 mm Hg 2,7 mmol/l 3,0 mmol/l YES 5%

20. Case report • Demography • Total cholesterol • HDL • BP • LDL • TG • Smoking, LVH, DM • 10year risk IHD MALE, 55 4,1 mmol/l 1,4 mmol/l 140/83 mm Hg 2,7 mmol/l 3,0 mmol/l NO !!! MALE, 55 6,2 mmol/l 1,3 mmol/l 160/95 mm Hg 4,2 mmol/l 3,4 mmol/l YES 11% MALE, 55 4,1 mmol/l 1,4 mmol/l 140/83 mm Hg 2,7 mmol/l 3,0 mmol/l YES 5%

21. Muž, 55 nonsmoker BPs 140 Chol 4,1

22. Case report • Demography • Total cholesterol • HDL • BP • LDL • TG • Smoking, LVH, DM • 10year risk IHD Male, 55 4,1 mmol/l 1,4 mmol/l 140/83 mm Hg 2,7 mmol/l 3,0 mmol/l NO !!! 2% Male, 55 6,2 mmol/l 1,3 mmol/l 160/95 mm Hg 4,2 mmol/l 3,4 mmol/l YES 11% Male, 55 4,1 mmol/l 1,4 mmol/l 140/83 mm Hg 2,7 mmol/l 3,0 mmol/l YES 5%

23. Case report Male, 56 6,8 mmol/l 1,4 mmol/l 175/90 mm Hg 2,7 mmol/l 3,0 mmol/l NO !!! • Demography • Total cholesterol • HDL • BP • LDL • TG • Smoking, LVH, DM • 10year risk IHD Male, 55 4,1 mmol/l 1,4 mmol/l 140/83 mm Hg 2,7 mmol/l 3,0 mmol/l NO !!! 2% Because he did not smoke, he overweight 15 kg

24. Male, 56 nonsmoker TKs 175 Chol 6,8

25. Case report Male, 56 let 6,8 mmol/l 1,4 mmol/l 175/90 mm Hg 3,9 mmol/l 4,2 mmol/l NE !!! 10% Male, 55 let 4,1 mmol/l 1,4 mmol/l 140/83 mm Hg 2,7 mmol/l 3,0 mmol/l NE !!! 2% • Demography • Total cholesterol • HDL • BP • LDL • TG • Smoking, LVH, DM • 10year risk IHD Because he did not smoke, he overweight 15 kg

26. Case report Muž, 56 let 6,8 mmol/l 1,4 mmol/l 175/90 mm Hg 3,9 mmol/l 4,2 mmol/l NE !!! 20% Muž, 55 let 4,1 mmol/l 1,4 mmol/l 140/83 mm Hg 2,7 mmol/l 3,0 mmol/l NE !!! 2% • Demography • Total cholesterol • HDL • BP • LDL • TG • Smoking, LVH, DM • 10year risk IHD Because he did not smoke, he overweight 15 kg and got DM

27. Basic antihypertensives are: Diuretics ACE inhibitors Betablockers Ca antagonists AII antagonists These groups are equal. If BP > 20/10 mmHg above normal value We can start the treatment with combinations !!! JNC - ESC/ESH (2007)

28. Diuretics (thiazid)

29. Diuretics (thiazid and K sparing)

30. Diuretics (loop)

31. Diuretics (loop)

32. Diuretics (aldosteron antagonists)

33. Diuretics (aldosteron antagonists)

34. Betablockers

35. Betablockers

36. ACE inhibitors

37. ACE inhibitors

38. AIIA - ARB

39. AIIA - ARB

40. Ca blockers (dihydropyridin)

41. Ca blockers (dihydropyridin)

42. Ca blocker (diltiazem, verapamil)

43. Ca blocker (diltiazem, verapamil)

44. - blocker

45. - blokcker

46. Central agonist of presynaptic alfa 2 receptors metyldopa 2-3 x 250 mg gravidity guanfacin 1 x 1-2 mg clonidin HT krize 0,1-0,3 mg Central agonist of imidazolin receptors moxonidin 1 x 0,2 až 2 x 0,3 mg rilmenidin 1 x 1 mg Peripheral alfa 1 blockers and a central serotonin receptor agonists urapidil HT crises 10-20 mg i.v. Other   

47. ESH/ESC Guidelines – Indications Thiazids Loop diuretics Aldosteron antagonists B Ca antagonists (DHP) Ca antagonists (non-DHP) ACEI ARB Heart failure / Older / ISH / Afroamericanns Renal insuficienci / Heart failure Heart failure /post MI AP / post MI / Heart failure / Pregnancy / Tachyarytmias Older personc / ISH /AP / Aterosklerosis / Pregnancy AP / Aterosklerosis / Suprav. Tachykardias Heart failure / LV dysfunction / postMI / DM / Proteinurie DM / microalbuminuria / proteinuria / LVH / ACEI-caugh 6372 M

48. Combination treatment Thiazid diuretics Ca blockers ACE inhibitors or AT1 blockers β-blockers Non DHP Ca blocker + betablocker = clear contraindication ACE-I/AT1 blocker + betablocker = combination - CHF, ICD ACE-I + AT1 blocker = combination - proteinuria