Radka Adlová Arterial hypertension and preventive cardiology

Arterial hypertension (AH) Definition: Hypertension is defined as values of systolic pressure >= 140 mmHg and/or diastolic pressure >= 90mmHg

Arterial hypertension (AH) How to measure? Patient sits for minutes before beginning of measurements Take at least two measurements, spaced mins apart Take repeated measurements Use an appropriate bladder When adopting the auscultatory method, use phase I and V Korotkoff sounds to identify systolic and diastolic blood pressure

Arterial hypertension (AH) Prevalence: % of the general population Age% people with AH 18 – – – – – – 7964 > 8065

Arterial hypertension (AH) Blood pressure during our lives BP (mm Hg) Age

Arterial hypertension (AH) Classification of blood pressure levels (mmHg): CategorySystolicDiastolic Optimal<120<80 Normal High normal Grade 1 hypertension Grade 2 hypertension Grade 3 hypertension>180>110 Isolated systolic hypertension>140>90

Arterial hypertension (AH) Why is it important to talk about arterial hypertension? an epidemic that is affects millions of people in developed countries serious consequences for the patient (a close relationship between prevalence of hypertension and mortality for stroke)

Consequences of AH ARTERIAL HYPERTENSION Endothelial damage Platelet activation Vascular remodeling AtherosclerosisArterial thrombosis

Consequences of AH AH Nephropathy, renal failure Left ventricle hypertrophy, Coronary artery disease Stroke, dementia Retinopathy Peripheral arterial disease

Prognosis of AH Depends on: the level of blood pressure (blood pressure achieved during treatment) presence of risk factors organ damage

Prognosis of AH Risk factors (SCORE): Age Gender Smoking Dyslipidemia

Total cardiovascular risk ESH/ESC guidelines, 2013

AH and total cardiovascular risk Total cardiovascular risk increases with the number of risk factors SBP No RF Dyslipidemia Smoking DM LV hypertrophy

Examination of patient with AH Medical history Personal history Physical examination Laboratory investigations Searching for asymptomatic organ damage : Heart - ECG, echocardiography Blood vessels - carotid arteries, pulse wave velocity Kidney - serum creatine, microalbuminuria Eyes - fundoscopy Brain - cerebral MRI

Classification of AH Primary (essential) % - polygenic, multifactorial Secondary % - Renal - renal parenchymal disease - renal artery stenosis - Endocrine - primary aldosteronism, thyroid disease, pheochromocytoma, Cushings syndrome, acromegaly, … - Hypertension in pregnancy - Aortic coarctation - Others ( sleep apnea, cerebral disease,...)

Secondary hypertension Renal artery stenosis

Secondary AH Typical characteristics: Moderate to severe hypertension Sudden severe hypertension or sudden worsening of hypertension Resistant hypertension (despite three drugs including diuretics no decrease of blood pressure) Specific symptoms of secondary hypertension Nondipping Heavier grade of organ damage Diagnosis can lead to permanent cure

Treatment of AH Our goal : normal blood pressure of patient with hypertensive disease A decision when and how to start What type of drug to choose Close co-operation with patient (smaller number of tablets and simple dosing improves adherence to treatment) Even if the drug is administered once a day, the average patient at least once a week forgets to take this medication

Treatment of AH

Blood pressure goals in hypertensive patients: < 140/90 mmHg : patients at low cardiovascular risk < 130/80 mmHg : young patients, patients with nephropathy < 125/75 mmHg : patients with diabetes < mmHg (systolic blood pressure): elderly patients

Treatment of AH Lifestyle changes: - Salt restriction - Moderation of alcohol consumption - Other dietary changes - Weight reduction - Regular physical exercise - Smoking cessation

Treatment of AH When to start a pharmacological therapy ? In elderly hypertensive patients when systolic blood pressure >160 mmHg Patients with grade 2 and 3 hypertension with any level of cardiovascular risk Patients with high cardiovascular risk because of organ damage, diabetes, cardiovascular disease or chronic kidney disease

Treatment of AH Ideal pharmacological therapy Reduces both systolic and diastolic blood pressure Does not deteriorate metabolic situation Does not affect the activity of the sympathetic nervous system Is vasoprotective, nephroprotective and cardioprotective Does not affect insulin sensitivity

Treatment of AH What type of antihypertensive drugs? Diuretics Beta-blockers Calcium channel blockers Angiotensin converting enzyme inhibitors Angiotensin receptor blockers Centrally acting agents Peripheral alpha receptor blockers

Indications and contraindications : MedicationSuitableUnsuitable DiureticsHeart failure Elderly people Isolated systolic hypert. Gout Pregnancy Beta-blockersCoronary artery disease Pregnancy Tachyarrhythmia Chronic obstructive pulmonary disease Peripheral arterial disease Calcium channel blockersAngina pectoris Peripheral arterial disease Pregnancy, elderly pts. Congestive heart failure Angiotensin converting enzyme inhibitors Heart failure Left ventricle hypertrophy, Coronary artery disease Pregnancy Bilateral renal artery stenosis Angiotensin receptor blockersNephropathy Left ventricle hypertrophy Heart failure Pregnancy Bilateral renal artery stenosis

Treatment of AH Monotherapy or combination treatment ? Monotherapy can reduce blood pressure in only a limited number of patients Most patients require the combination of at least two drugs to achieve ideal blood pressure Combination of two agents from any two classes of antihypertensive drugs deceases the blood pressure much more effectively than increasing the dose of one agent

Treatment of AH

Benefits gained from blood pressure lowering reduction Stroke35 – 40% Myocardial infarction20 – 25% Heart failure 50%

Renal denervation (RDN) = Renal sympathetic denervation (RSDN) A therapy for treatment resistant hypertension (in case which do not respond to conventional drugs) Endovascular catheter based procedure using radiofrequency ablation to the renal arteries and the nerves in the vascular wall This causes reduction of renal sympathetic afferent and efferent activity

Renal denervation (RDN) The RF energy is delivered to a renal artery via standard femoral artery access A series of 2-minute ablations are delivered along each renal artery to disrupt the nerves This therapy is administered bilaterally

Conclusion Diagnosis and treatment of arterial hypertension is not simple Treatment should be well-timed and consistent Good treatment of arterial hypertension is useful because of reduction of cardiovascular risk Our goal: ‘‘healthy‘‘ patient

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