Czech Guidelines 2017 ESH Guidelines 2018 Czech Hypertension Society Hypertension uDefinition: u uRepeated increase of BP ≥ 140 and/or 90 mmHg uin 2 measurements in past 2-3 months. Current situation in Czech republic u60 -70 % hypertensive patients are treated u u45 % pts treated achieve BP target values u u55 % pts treated don´t achieve BP target values Suboptimal treatment Treatment intolerance Secondary hypertension Reduced compliance The most common causes of inadequate treatment Others True resistance 10-15 % 70 % Definitions and classification of BP levels (mmHg) (ESH + CZ) Category Optimal Normal High normal Hypertension Grade 1 (mild) Grade 2 (moderate) Grade 3 (severe) Isolated systolic hypertension (ISH) SYSTOLIC < 120 120-129 130-139 140-159 160-179 ≥ 180 ≥ 140 DIASTOLIC < 80 80-84 85-89 90-99 100-109 ≥ 110 < 90 • Heart • Brain • Kidney • Arteries Target organs •Left ventricular hypertrophy •(CV risk tripled) HLK Why we treat hypertension? uPrevalence in Czech republic 35% uPatients over 60 years > 50% u uReducing SBP by 10 mmHg and DBP by 5 mmHg u ureduces stroke risk by 45% ureduces heart attack risk by 20% ureduces CV event risk by 33% •Repeated measurement of BP •Casual BP (in office, measured by physician) –Sfygmomanometer (newly without mercury content) –Automatic or semiautomatic oscilometric devices •Home BP measurement (HBPM) •24hour ambulantory BP monitoring (ABPM) Diagnosis BP measurement Cuff size Normal cuff size 12 cm : arm circumference below 33 cm size 15 cm: arm circumference 33- 41 cm size 18 cm: arm circumference up 41 cm l BP accuracy 2 mmHg lBP is measured three times and we take a mean of 2 and 3 measurement l BP device should by calibrated – sphygmomanometer/2 years - other devices/1 year HBPM •BP at home – exclusion of hospital environment •Adequately instructed and cooperating patients •Higher number of measurements between clinical controls • Daily profil of BP –Morning surge –Noon decrease –Evening increase •Adjustment of medication according daily background •Improved aproach to treatment •Determination of white coat and masked hypertension ABPM •BP in „daily living“ •70-80 measurements in 24 hours with HR •Daily and night profile of BP •White coat hypertension •Masked hypertension Definition of hypertension and corresponding BP values (mmHg) SBP DBP Casual BP Home BP ABPM 24h mean Asleep mean Sleep mean 140 135 130 135 120 90 85 80 85 70 Screening and diagnosis of hypertension LF Masarykovy univerzity a FN u svaté Anny, Brno Optimal BP ˂ 120/80 Normal BP 120-129/80-84 High normal BP 130-139/85-89 Hypertension ≥ 140/90 Consider masked hypertension Out-of-office BP measurement ABPM or HBPM Repeat BP at least every 5 years Repeat BP at least every 3 years Repeat BP at least annually Repeated visits for office BP measurement Out-of-office BP (ABPM or HBPM (if Grade 1 hypertension) Classification of hypertension l Etiopatogenetic essential secondary o Essential (primary) hypertension (90-95%) • unknown cause • polygenic disease • high impact of external factors • salt, obesity, stress, … • direct connection to metabolic syndrome and type II DM • familiar disease •Renal parenchymal disease 5% •Renovascular hypertension 3% •Endocrine hypertension 0,5 -5% •Coarctation of aorta < 0,5% •Neurogenic, stress < 0,5% • •Drugs, chemicals, foods •Pregnancy (preeclampsia, eclampsia) 5% Secondary hypertension 5-10% Prognostics factors (CV risk stratification) l Estimate risk of fatal CV events (SCORE) l Target organ damage l Established CV disease High impact to initiation and targets of treatment !! Not only for hypertension but for DM and hyperlipidemia too. SCORE (10 years risk to developing fatal CV event in CR) •SCORE risk assessment: • •Susceptible • •Levels of SBP •Levels of cholesterol •Smoking • •Non susceptible • •Age •Gender Vaverková H. et al.: Doporučení pro diagnostiku a léčbu dyslipidémií; Vnitř Lék 2007; 53 (2):181-197. Female Male Pro stanovení KV rizika a nasazení terapie pro snížení lipidů v krvi počítáme tzv. SCORE riziko – 10leté riziko úmrtí na KV onemocnění. Pomyslná hranice, od kdy je třeba věnovat pacientovi zvýšenou péči a zahájit hypolipidemickou terapii, je 5. Existují i tabulky, kde zjišťujeme riziko Score z naměřených hodnot celkového a HDL cholesterolu. U některých pacientů je SCORE riziko vysoké vždy. V případě vysokého rizika a nadlimitních hladin cholesterolu nasazujeme hypolipidemika, nejčastěji statiny. V případě méně časté izolované hypertriglyceridemie jsou indikovány fibráty. Male - nonsmoker BP (mm Hg): 155/100 Total cholesterol: 7,0 mmol/l AGE: 53 years SCORE RISK: 8 % People over 65 years Example of SCORE stratification Praktická ukázka výpočtu rizika SCORE: pacient: muž, nekuřák, TK 155/100 mm Hg, věk 53 let, celkový choelsterol 7,0 mmol/l tento pacient má 8% riziko, že v následujících 10 letech zemře na kardiovaskulární onemocnění. Pacient má vysoké riziko KV onemocnění (hranice je 5 a více). Pokud jsou udaje mezi uvednými čísly, priklanime se k těm bližím hodnotam (věk 53 let posuzujeme jako věk 55 let). U pacientu s vysokym celkovym rizikem následnych cévních příhod, stejně jako jedincu s prokázanym KVO je nutná změna chování. Je proto u nich třeba nejvíce ovlivnit životosprávu a přiípadně zahájit farmakoterapii. Cardivascular risk stratification (SCORE) uSCORE 0 - 1 % low u uSCORE 2 – 4 % medium u uSCORE 5 - 9 % high u uSCORE ≥ 10 % very high u Podle doporučení Evropské kardiologické společnosti (ESC) – projekt SCORE Soška V et al. Stanovisko výboru ČSAT k doporučením ESC/EAS pro diagnostiku a léčbu dyslipidemií z roku 2011. Vnitř Lék 2013;59(2):120–126 High risk 5 - 9 % (extra of SCORE stratification) uFamiliar hypercholesterolaemia (LDL ≥ 6 mmol/l) u uDiabetes type 1. and 2. without organ damage or other RF u uDecreased GFR, stadium G3a or G3b (30-60 ml/min/m2) u uLeft ventricular hypertrophy (ECHO, ECG) u u u Soška V et al. Stanovisko výboru ČSAT k doporučením ESC/EAS pro diagnostiku a léčbu dyslipidemií z roku 2011. Vnitř Lék 2013;59(2):120–126 Very high risk ≥ 10 % uDiabetes type 1. or 2. with albuminuria or micro/macro vascular changes or with other RF (hypertension…) u uEstablished CV disease (IM, CMP …) u uSubclinical aterosclerosis or plaque u uDecreased GFR stadium G4 or G5 (below 30 ml/min/m2) u u Soška V et al. Stanovisko výboru ČSAT k doporučením ESC/EAS pro diagnostiku a léčbu dyslipidemií z roku 2011. Vnitř Lék 2013;59(2):120–126 (extra of SCORE stratification) Ethnicity and CV risk assessing CVD risk using SCORE among first-generation immigrants •Southern Asia: multiply the risk by 1.4 •Sub-Saharan Africa and the Caribbean: 1.3 •Western Asia: 1.2 • Northern Africa: 0.9 •Eastern Asia or South America: 0.7 Renal failure classification (CKD) Stadium CKD Level GFR (ml/min/1,73 m2) Clearens ml/s G1 Normal GFR over 90 over 1,5 G2 Mild 60 – 89 1,0 – 1,5 G3a Medium 40 – 59 0,75 – 0,99 G3b Medium 30 – 39 0,5 – 0,74 G4 Severe 15 – 29 0,25 – 0,49 G5 Uremia below 15 below 0,25 Renal failure – GFR below 60 ml/min sustained more than 3 month (formula CKD-EPI) Adapted according Doporučení CNS 2014 - http://www.nefrol.cz/odbornici/doporucene-postupy-cns GFR, albuminuria and CV risk Prediction of CKD: formula CKD-epi according eGFR (ml.min-1.1,73m-2) and albuminuria (mg/mmol creatinine) or (mg/24 hodin) Guidelines: KDIGO 2012 Class of albuminuria A1 A2 (albuminuria) A3 (proteinuria) Normal or mild increased Medium increased Severe ˂ 3 mg/mmol ˂ 30mg/24 h 3 – 30 mg/mmol 30 – 300 mg/24h ˃ 30 mg/mmol ˃ 300 mg/24h G1 over 90 Low Medium High G2 60 – 89 G3a 45 – 59 Very High G3b 30 – 44 G4 15 – 29 G5 below 15 Adapted according http://www.nefrol.cz/odbornici/doporucene-postupy-cns 2014 • Relationship between GFR and frequency of CV events in 1 120 295 adults CV event: Hospitalisation propter CHD, heart failure, iStroke or PAD Decrease of GFR and CVR Signs of renal disease •Early •Albuminuria: ≥ 30 mg/24 hour or • albumin/kreatinin ratio ≥ 3,0 mg/mmol A2 •Mild decrease of GFR: CKD G2 and G3a • •Advancet •Proteinuria ≥ 150 mg/24 hodin A3 •Oliguria and elevated creatinine in plasma •Hypalbuminaemia ˂ 35 g/l •Oedema Newly diagnosed hypertension work up l Necessary in all l Need in somebody Case history Physical examination (with palpation and auscultation of periferal arteries) Sitting and standing BP, both upper extremities, one lower extremity Urine sample and Albuminuria S-Na+, S-K+, S-creat, glycemia, uric acid HGB, HCT Calculated GFR (according formula CKD epi) Lipids panel (TCH, HDL, LDL, TG) ECG, ABPM HBPM Ankle/arm index of BP (˃ 0,90 normal ) Echocardiography USG of carotic or femoral arteries Proteinuria/24h oGTT if fasting glykaemia is between 5,6 and 6,9 mmol/l Aorto-femoral pulse-wave velocity Need to CV risk stratification and to excluding some secondary hypertension causes !! Targets of treatment Maximale decrease of long-term CV risk Treatment: - all reversible RF and TOD - all established CV diseases - increased BP Treatment goal of hypertension uAll population BP below 140/90 mmHg u uDiabetes, high risc. BP near 130/80 mmHg (CSH) u BP 120-130/70-80 mmHg (ESH) u if tolerated Treatment target of dyslipiaemia (EAS 2019) Low risk (˂ 1 % SCORE) Medium risk (≥1 a ˂ 5 % SCORE) High risk (≥ 5 a ˂ 10 % SCORE) Very high risk (≥ 10 % SCORE) LDL ˂ 3 mmol/l LDL ˂ 2,6 mmol/l LDL ˂ 1,8 mmol/l (˃ 50% decrease) LDL ˂ 1,4 (˃ 50% decrease) Apo B ˂ 1 g/l Apo B ˂ 0,8 g/l Apo B ˂ 0,65 g/l Non HDL ˂ 3,4 Non HDL ˂ 2,6 Non HDL ˂ 2,2 Non HDL ˂ 3,8 Non HDL chol is better predictor in people with hypertriglyceridaemia Diabetes targets (type 2. in 92 %) uTarget: HbA1c* < 45-53 mmol/mol u Fasting glycaemia < 6,0 mmol/l u Postprandial < 7,5 mmol/l u uHigh CVR, macro and micro vascular complications (individual): uTarget: HbA1c < 60 mmol/mol u Fasting glycaemia < 8,0 mmol/l u Postprandial < 9,0 mmol/l * Treatment adjustment if HbA1c is over 53 mmol/mol http://www.diab.cz/dokumenty/dm2_12.pdf Doporučení ČDS pro léčbu DM 2. typu 2012 Treatment of hypertension l Lifestyl changes l Pharmacological treatment Lifestyl changes l Smoking cesation l Weight reduction (BMI 20-25, waist ˂ 88 cm F, ˂ 102 cm M) Idealy: waist ˂ 80 cm F, ˂ 94 cm M l Physical aerobic exercise (30-45 min daily, important!) l Moderate alcohol consumption (20-30g/daily) l Salt restriction (5-6 g/day) l DASH diet (a diet rich in fruits, vegetables, and low-fat dairy products, with a reduced content of dietary cholesterol as well as saturated and total fat) o Pharmacological treatment First choice of antihypertensive drug: (EBM) Calcium channel blockers (CaB) Angiotensin convertase inhibitors (ACEI) AT1 – blockers (sartans) Diuretics (D) Betablockers (BB) Others drugs for combination treatment: alfa-blockers other sympatetic drugs (urapidil, moxonidin, rilmenidin) Diuretics Sulfonamide diuretic (thiazides, thiazide like diuretics) Indication: heart failure, hypertension in older people, systolic hypertension, hypertension in afroamericans, combination therapy (chlorthalidone, indapamide, thiazides) Contraindication: absolute: gout relative: pregnancy, metabolic sy, diabetes mellitus Diuretics Loop Indication: renal failure - CKD, heart failure Aldosterone antagonists Indication: HF, MI + HF, resistant hypertension, primary aldosteronism Contraindication: absolute: hyperkalemia (high level of potassium) Betablockers Indication: CAD, angina pectoris, after MI, HF, pregnancy, tachyarrhytmias, glaukom Contraindication: absolute: astma, bradycardia below 50/min, AV blok (grade 2 or 3) relative: CHOPD, PAD, metabolic sy, DM, young and fysicaly active patients Calcium channel blockers Dihydropyridines Indication: older people, systolic hypertension angina pectoris, PAD, pregnancy, LVH, combination Contraindication: relative: tachyarrhytmia, systolic HF Calcium channel blockers Verapamil, diltiazem Indication: angina pectoris, supraventricular arrhytmias, combination, older age Contraindication: absolute: A-V block (grade 2 or 3), systolic HF Angiotensin-converting enzyme inhibitors (ACEI) Indication: HF, decreased LVEF, after MI, LVH, diabetic and nondiabetic nephropathy, proteinuria/mikroalbuminuria, metabolic sy, DM Contraindication: absolute: pregnancy, hyperkalemia, bilateral renal artery stenosis AT1 blockers - sartans Indication: HF, after MI, diabetic nephropathy, proteinuria/mikroalbuminuria, LVH, atrial fibrilation, metabolic sy, DM, cough by ACEI Contraindication: absolute: pregnancy, hyperkalemia, bilateral renal artery stenosis Alfa1 – blockers Indication: benign prostate hypertrophy, combination Contraindication: absolute: ortostatic hypotension relative: HF 4539 M Sympathetic tone modified drugs: only in combination % Indication: hypertension and renal insufficiency hypertension and metabolic syndrome, DM hypertension in pregnancy – methyldopa hypertension and increased sympathetic tone Rilmenidin, moxonidin, urapidil, alfa methyldopa (did not have randomised mortality trials) Initiation of treatment hypertension High normal BP BP 130-139/80-89 mmHg Grade 1 Hypertension BP 140-159/90-99 mmHg Grade 2 Hypertension BP 160-179/100-109 mmHg Grade 3 Hypertension BP ≥ 180/110 mmHg Consider drug in very high risk patients (CAD, CVD + DM) Immediate drug treatment in high or very high risk patients with CVD, renal disease or HMOD Immediate drug treatment in all patients Immediate drug treatment in all patients Drug treatment in low moderate risk patients without CVD, renal disease or HMOD after 3-6 months of lifestyle intervetion if BP is not controlled Aim for BP control within 3 months Aim for BP control within 3 months Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle advice Core drug treatment for uncomplicated hypertension • • LF Masarykovy univerzity a FN u svaté Anny, Brno 1 Pil 1 Pil 2 Pills ACE or AT1 + CB or D ACE or AT1 + CB + D Rezistant hypertension Ad spironolactone 25-50mg 1xd, or other D, alfa bl. or BB Initial therapy Dual combination Step 2 Triple combination Step 3 + spironolactone or other drug Monotherapy if low risc grade I (BP˂ 150 mmHg) or in very old (80 years) or frailer patients Consider referall to a specialist centre to further investigation Beta-blockers Consider treatment in each step if is specific indications (AP, after MI, HF, AF, young women with childbearing potential, high aktivity of SNS) Lifestyl changes (obesity, ¯ intake of Na, physical activity) Target BP near 130/80 mmHg Target LDL 1,8 mmol/l (1,4 mmol/l secondary prevention) First class drug ACEI or AT1 Combination with CaB and/or D (indapamide) Hypertension and DM High risk of CVD Target BP ˂ 140/90 mmHg (if proteinuria ≥ 1g ˂ 130 mmHg) First class drugs ACEI or AT1 Often need combination D (furosemide) and/or CaB Often need to treat hyperlipidaemia, target LDL below 1,8 mmol/l Hypertension and CKD Target BP near 130/80 mmHg Target LDL 1,4 mmol/l First class drugs: combination BB + ACEI or AT1 Other combination: CaB Other drugs: Aspirin, statin, nitrate, molsidomin Hypertension and CAD Target BP near 130/80 mmHg – (distinguish between): Diastolic heart failure (preserved LVEF, often LVH): First class drugs: ACEI or AT1 Combination: CaB and/or D and/or BB Systolic heart failure (decreased LVEF, often after MI) First class drugs: ACEI or AT1 and BB and/or D Not recommendet: CaB, alfa 1 blockers Hypertension and heart failure Acute stroke (we do not known targets of BP) No intervention if SBP is ˂ 200 mmHg, ideal BP 110-180/70-110 mmHg After stroke (secondary prevention) Target BP near 130/80 mmHg First class drugs: CaB and/or AT1 or ACEI Combination: D Other drugs: aspirin, clopidogrel, statin, target LDL 1,4 mmol/l Hypertension and stroke Target BP ˂ 140/90 mmHg if tolerated In patients up to 80 years of age, target BP ˂ 150/90 mmHg Gradual treatment, start with low doses BP measure in both: sitting and standing positions Older people and hypertension Periodically clinical controls l Stable hypertension: 1x in 3 months 1x in 6 months (low CVR, on monotherapy) l Complicated hypertension, changes of therapy 1x in 4 - 6 weeks After 6 months of uncontroled hypertension by GP – there is indication to examination in hypertension clinic.