Nouvelles recommandations pour le traitement de l hypertension artérielle. Yves Allemann Hôpital de l Ile, Berne Cardiologie Pré-Vert, 1630 Bulle

Transkript

1 Nouvelles recommandations pour le traitement de l hypertension artérielle Yves Allemann Hôpital de l Ile, Berne Cardiologie Pré-Vert, 1630 Bulle

2 Mesure de la pression artérielle Diagnostic / Définition de l HTA 138 / 86 mmhg

3 La valeur de PA de 138/86 mmhg correspond à: 1. Une PA normale-haute selon la définition européenne 2. Une HTA, si cette valeur représente la valeur moyenne sur 24h d une MAPA 3. Les réponses 1 et 2 sont correctes 4. Les réponses 1 et 2 sont fausses

4 HTA Classification Europäische Guidelines (ESH/ESC) Systolischer Blutdruck Diastolischer Blutdruck Optimal < 120 < 80 Normal Hoch normal Hypertonie 1.Grades (leicht) Hypertonie 2. Grades (mässig) Hypertonie 3. Grades (schwer) Isolierte systolische Hypertonie 140 < 90 Journal of Hypertension 2013, 31:

5 Blutdruckmessung: Was sind normale Werte?

6 Diagnostic de l HTA Quelle technique de mesure?

7 If the clinic blood pressure is 140/90 mm Hg or higher, use ambulatory blood pressure monitoring to confirm the diagnosis of hypertension. This strategy will improve the accuracy of the diagnosis compared with current practice and was also shown to be cost effective - indeed, cost saving - for the NHS.

8 Patiente, 74 ans Pas de traitement Indication: Suspicion d HTA

9 Guidelines européennes 2013 Stratification du risque cardio-vasculaire RF = Risk Factors OD = asymptomatic Organ Damage CVD = symptomatic cardiovascular disease conditions CKD = Chronic Kidney Disease Journal of Hypertension 2013, 31:

10 Fallbeispiel: Der junge Sportler Mann, 41 Jahre, Wettkampfsportler Gesund, keine Risikofaktoren bekannt BMI 23.1 BD: 148 / 86 mmhg BD: 150 / 86 mmhg (8 Wochen später) BD Durchschnitt: 149 / 86 mmhg

11 21535

12 Fallbeispiel: Der junge Sportler Tabletten (41 bis 80-jährig) 7300 Tabletten (60 bis 80-jährig)

13 mmhg Fallbeispiel: Der junge Sportler (40-jährig) h00 22h00 06h00 15h00

14 Fallbeispiel: Der junge Sportler (40-jährig) Zusammenfassung der Statistik Blutdruck, mmhg 24 h Wach Schlaf 134 / 84 (130 / 80) 139 / 87 (135 / 85) 105 / 67 HF, Sch/min Dipping, % 25 / 23%

15 Fallbeispiel: Der junge Sportler Andere Hilfsmittel für Therapieentscheid? Microalbuminurie LV-Hypertrophie

16 Diagnostic evaluation of arterial hypertension Establishing BP values (outside the office) Identifying secondary causes of hypertension Searching for: - other risk factors - end-organ damage - associated CV diseases Journal of Hypertension 2013, 31:

17 Traitement de l HTA

18 Evolution of Mankind B.C B.C. 2014

19 ESH/ESC Practice Guidelines: J Hyperts 2013; 31:1925- BLOOD PRESSURE TREATMENT: LIFESTYLE CHANGES salt restriction to 5 6 g/day; moderation of alcohol consumption [no more than g of ethanol per day in men and g/ day in women]; high consumption of vegetables and fruits and low-fat dairy products; reduction of weight to a BMI of 25 kg/m 2 and waist circumference to less than 102 cm in men and less than 88 cm in women; at least 30 min of moderate dynamic exercise on 5 to 7 days per week; stop smoking

20 POSSIBLE COMBINATIONS OF CLASSES OF ANTIHYPERTENSIVE DRUGS ESH/ESC Practice Guidelines: J Hyperts 2013; 31:1925-

21 DRUGS TO BE PREFERRED IN SPECIFIC CONDITIONS ESH/ESC Practice Guidelines: J Hyperts 2013; 31:1925-

22 Krause T et al. BMJ 2011;343:bmj.d UK NICE Guidelines for the Treatment of Newly Diagnosed Hypertension Step 1 <55 years ACEI or ARB 55 years or black at any age CCB [thiazide diuretic*] Step 2 ACEI or ARB + CCB [thiazide diuretic*] Step 3 ACEI or ARB + CCB + diuretic Step 4 Resistant Hypertension Add further diuretic therapy, α-blocker, or β-blocker. Consider seeking specialist advice * Consider thiazide-like diuretic in people with edema or at high risk of heart failure

23 ESH/ESC Practice Guidelines: J Hyperts 2013; 31:1925- COMPELLING AND POSSIBLE CONTRAINDICATIONS TO THE USE OF ANTIHYPERTENSIVE DRUGS

24 Medikamentöse Kombinationstherapie der gängigen Antihypertensiva

25 PHARMAKOTHERAPIE

26 Treatment goals of arterial hypertension 2014 SBP: <140mmHg DBP: <90mmHg DBP in diabetic patients: <85mmHg 70 years old - systolic BP mmhg: treat - treatment goal: mmhg ESH/ESC Practice Guidelines: J Hyperts 2013; 31:1925-

27 Behandlung der zusätzlichen kardiovaskulären Risikofaktoren

28 Behandlungskonzept der arteriellen Hypertonie 2014 A=ACE-Hemmer /Angiotensinrezeptorantagonist, (Aliskiren); B=Betablocker; C=Kalziumantagonist; D=Diuretikum; Andere=Betablocker, Alphablocker, andere; RDN=Renale Denervation; Baro=Carotis-Barorezeptor-Stimulation