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OBERSCHWABENKLINIK Arterielle Hypertonie 2015 J.Maurus OSK Klinikum Westallgäu Wangen

Arterielle Hypertonie 2015 - Oberschwabenklinik · Arterielle Hypertonie Definition Epidemiologie Diagnostik Therapie . OBERSCHWABENKLINIK Patienten Blutdruckziele Patienten 60 Jahre

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OBERSCHWABENKLINIK

Arterielle Hypertonie

2015

J.Maurus

OSK Klinikum Westallgäu Wangen

OBERSCHWABENKLINIK

OSK Klinikum Westallgäu

Wangen

OBERSCHWABENKLINIK

Arterielle Hypertonie

Definition

Epidemiologie

Diagnostik

Therapie

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK

Arterielle Hypertonie

Definition

Epidemiologie

Diagnostik

Therapie

OBERSCHWABENKLINIK

systolisch diastolisch

(mmHg) (mmHg)

normaler Blutdruck 120-129 80-84 hochnormaler Blutdruck 130-139 85-89 Grad 1: leichter Bluthochdruck 140-159 90-99 Grad 2: mittelschwerer Bluthochdruck 160-179 100-109 Grad 3: schwerer Bluthochdruck über 180 über 110 isolierter systolischer Bluthochdruck über 140 unter 90 Der Praxisblutdruck ist das Mittel aus 2 Messungen im Abstand von 2 Minuten mit einem validierten Gerät nach 3-5 Minuten Sitzen an mindestens 2 Terminen.

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK

Arterielle Hypertonie

Definition

Epidemiologie

Diagnostik

Therapie

OBERSCHWABENKLINIK

Zu wenig beachtet, zu wenig behandelt ▪ In Deutschland leiden nach Schätzungen von Experten 18*-35** Mio. an Bluthochdruck.

▪ Millionen wissen es nicht, Millionen, die es wissen, sind unzureichend behandelt.

* Hochrechnung KORA St. (Meisinger et al., Journal of Hypertension; 24: 293-299)

** Quelle: Hochdruckliga 2011

Bluthochdruck

OBERSCHWABENKLINIK

Niedriger oder normaler Blutdruck entwickelt sich häufig im Lauf des Lebens zu hohem Blutdruck:

Ab 60 Jahren hat jeder Zweite einen hohen Blutdruck.

Bei sehr Alten sind es 80-90 %.

Arterielle Hypertonie

OBERSCHWABENKLINIK

Arterielle Hypertonie

Definition

Epidemiologie

Diagnostik

Therapie

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK Titel

Folie 13

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK

• Search for sleep disorders

OBERSCHWABENKLINIK

MUCH (masked uncontrolled

hypertension)

4608 (31,3%) von 14840 Pat. mit

behandelter und kontrollierter Hypertonie

OBERSCHWABENKLINIK

Arterielle Hypertonie

Definition

Epidemiologie

Diagnostik

Therapie

OBERSCHWABENKLINIK

Patienten Blutdruckziele

Patienten 60 Jahre und älter unter 150/90 mmHg alle Patienten unter 60 Jahre unter 140/90 mmHg Patienten mit Herzkranzgefäß- unter 140/90 mmHg erkrankungen, Nierenschaden, Diabetes mellitus bei Nierenschaden mit krankhafter unter 140/90 mmHg Eiweißausscheidung im Urin 2014 Evidence-based Guideline for thr Management of High Blood Pressure in Adults

Paul A.James et al. JAMA.2014;311(5):507-520

Wie tief soll der Blutdruck gesenkt werden?

OBERSCHWABENKLINIK

Original Article Benazepril plus Amlodipine or Hydrochlorothiazide

for Hypertension in High-Risk Patients

Kenneth Jamerson, M.D., Michael A. Weber, M.D., George L. Bakris, M.D., Björn Dahlöf, M.D., Bertram Pitt, M.D., Victor Shi, M.D., Allen Hester, Ph.D., Jitendra Gupte,

M.S., Marjorie Gatlin, M.D., Eric J. Velazquez, M.D., for the ACCOMPLISH Trial

Investigators

N Engl J Med Volume 359(23):2417-2428

December 4, 2008

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Study Overview

• The optimal combination drug therapy for treatment of hypertension is not established, although current U.S. guidelines recommend inclusion of a diuretic

OBERSCHWABENKLINIK

atment on Systolic and Diastolic Blood Pressure over Time

Med 2008;359:2417-2428

OBERSCHWABENKLINIK

Kaplan-Meier Curves for Time to First Primary Composite End Point

2008;359:2417-2428

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ard Ratios for the Primary Outcome and the Individual Components

J Med 2008;359:2417-2428

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afety Analysis

08;359:2417-2428

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Conclusion

• The benazepril-amlodipine combination was superior to the benazepril-hydrochlorothiazide combination in reducing cardiovascular events in patients with hypertension who were at high risk for such events

OBERSCHWABENKLINIK

Review Article Use of Diuretics in Patients with Hypertension

Michael E. Ernst, Pharm.D., and Marvin Moser, M.D.

N Engl J Med Volume 361(22):2153-2164

November 26, 2009

OBERSCHWABENKLINIK

Sites of Diuretic Action in the Nephron

Ernst M, Moser M. N Engl J Med 2009;361:2153-2164

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Summary

• This review focuses on thiazides, the diuretics most often indicated for long-term therapy for hypertension.

• Thiazide diuretics reduce blood pressure when administered as monotherapy; thiazides also enhance the efficacy of other antihypertensive agents and can reduce hypertension-related morbidity and mortality.

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Potential Complications of Diuretics and Their Associated Mechanisms

Ernst M, Moser M. N Engl J Med 2009;361:2153-2164

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Original Article Treatment of Hypertension in Patients 80 Years of

Age or Older

Nigel S. Beckett, M.B., Ch.B., Ruth Peters, Ph.D., Astrid E. Fletcher, Ph.D., Jan A. Staessen, M.D., Ph.D., Lisheng Liu, M.D., Dan Dumitrascu, M.D., Vassil Stoyanovsky, M.D., Riitta L. Antikainen, M.D., Ph.D., Yuri Nikitin, M.D., Craig Anderson, M.D., Ph.D.,

Alli Belhani, M.D., Françoise Forette, M.D., Chakravarthi Rajkumar, M.D., Ph.D., Lutgarde Thijs, M.Sc., Winston Banya, M.Sc., Christopher J. Bulpitt, M.D., for the

HYVET Study Group

N Engl J Med Volume 358(18):1887-1898

May 1, 2008

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Study Overview

• In this study, patients 80 years of age or older with sustained systolic hypertension were randomly assigned to receive either the diuretic indapamide, with or without the angiotensin-converting-enzyme inhibitor perindopril, or matching placebos, for a target blood pressure of 150/80 mm Hg

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Mean Blood Pressure, Measured while Patients Were Seated, in the Intention-to-Treat Population, According to Study Group

Beckett NS et al. N Engl J Med 2008;358:1887-1898

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Main Fatal and Nonfatal End Points in the Intention-to-Treat Population

Beckett NS et al. N Engl J Med 2008;358:1887-1898

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Conclusion

• The results provide evidence that antihypertensive treatment with indapamide (sustained release), with or without perindopril, in persons 80 years of age or older is beneficial

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Original Article Global Sodium Consumption and Death from

Cardiovascular Causes

Dariush Mozaffarian, M.D., Dr.P.H., Saman Fahimi, M.D., Gitanjali M. Singh, Ph.D., Renata Micha, R.D., Ph.D., Shahab Khatibzadeh, M.D., M.P.H., Rebecca E.

Engell, B.A., Stephen Lim, Ph.D., Goodarz Danaei, Ph.D., Majid Ezzati, Ph.D., John

Powles, M.B., B.S., for the Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NUTRICODE)

N Engl J Med Volume 371(7):624-634

August 14, 2014

OBERSCHWABENKLINIK

Study Overview

• The authors estimate that in 2010, a total of 1.65 million deaths from cardiovascular causes occurred as a result of excess sodium consumption.

• They assess correlations between sodium consumption and blood pressure and between blood pressure and cardiovascular events.

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Effects of R

2014;371:624-634

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Absolute Cardiovascular Mortality Attributed to Sodium Consumption of More than 2.0 g per Day in 2010, According to Nation.

Mozaffarian D et al. N Engl J Med 2014;371:624-634

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Conclusions

• In this modeling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day.

OBERSCHWABENKLINIK

Original Article Projected Effect of Dietary Salt Reductions on

Future Cardiovascular Disease

Kirsten Bibbins-Domingo, Ph.D., M.D., Glenn M. Chertow, M.D., M.P.H., Pamela G. Coxson, Ph.D., Andrew Moran, M.D., James M. Lightwood, Ph.D., Mark J. Pletcher,

M.D., M.P.H., and Lee Goldman, M.D., M.P.H.

N Engl J Med Volume 362(7):590-599

February 18, 2010

OBERSCHWABENKLINIK

Study Overview

• The salt intake of the U.S. population is rising

• Using the Coronary Heart Disease Policy Model, these investigators found that a reduction in salt intake of 3 g per day would result in substantial reductions in the incidence of coronary heart disease, stroke, and death

• A more modest reduction of 1 g per day would also have public health benefits

• The reduction of salt intake is an important goal for the country

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Estimated Changes in Systolic Blood Pressure Associated with Reductions in Dietary Salt

Bibbins-Domingo K et al. N Engl J Med 2010;362:590-599

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Projected Estimates of the Cost and Effectiveness of Salt Reduction and Hypertension Treatment Annually and Cumulatively, 2010-2019

Bibbins-Domingo K et al. N Engl J Med 2010;362:590-599

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Conclusion

Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target

OBERSCHWABENKLINIK

Original Article A Controlled Trial of Renal Denervation for

Resistant Hypertension

Deepak L. Bhatt, M.D., M.P.H., David E. Kandzari, M.D., William W. O'Neill, M.D., Ralph D'Agostino, Ph.D., John M. Flack, M.D., M.P.H., Barry T. Katzen, M.D., Martin B. Leon, M.D., Minglei Liu, Ph.D., Laura Mauri, M.D., Manuela Negoita, M.D., Sidney A.

Cohen, M.D., Ph.D., Suzanne Oparil, M.D., Krishna Rocha-Singh, M.D., Raymond R. Townsend, M.D., George L. Bakris, M.D., for the SYMPLICITY HTN-3 Investigators

N Engl J Med Volume 370(15):1393-1401

April 10, 2014

OBERSCHWABENKLINIK

Study Overview

• In this large trial, denervation of the kidneys with use of a radiofrequency ablation catheter in the renal arteries had no significant effect on blood pressure in patients with resistant hypertension.

• This contradicts results of smaller trials that did not include a sham control.

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Secondary Efficacy End Point.

Bhatt DL et al. N Engl J Med 2014;370:1393-1401

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Selected Subgroup Analyses.

Bhatt DL et al. N Engl J Med 2014;370:1393-1401

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Safety End Points.

Bhatt DL et al. N Engl J Med 2014;370:1393-1401

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Conclusions

• This blinded trial did not show a significant reduction of systolic blood pressure in patients with resistant hypertension 6 months after renal-artery denervation as compared with a sham control.

OBERSCHWABENKLINIK

Arteriovenöses Coupler System

83 Pat. RR>140/85

oder>135/85 (24h-RR)

44 Pat. Coupler

Endpunkt: RR nach 6

Monaten

Ergebnis: Coupler -26,9

(-3,7) mm Hg syst. und

-13,5 (-0,5) mm Hg

diast.(24h)

P jeweils <0,0001) Central arteriovenous anastomosis for the

treatment of patients with uncontrolled

hypertension (the ROX CONTROL HTN

study): a randomised controlled trial

MD Lobo et al. The Lancet online 22 January

2015

OBERSCHWABENKLINIK

Special Article Cost-Effectiveness of Hypertension Therapy

According to 2014 Guidelines

Andrew E. Moran, M.D., M.P.H., Michelle C. Odden, Ph.D., Anusorn Thanataveerat, M.P.H., Keane Y. Tzong, M.P.H., Petra W. Rasmussen, M.P.H., David Guzman, M.S.P.H., Lawrence Williams, M.S., Kirsten Bibbins-Domingo, Ph.D., M.D.,

Pamela G. Coxson, Ph.D., and Lee Goldman, M.D., M.P.H.

N Engl J Med Volume 372(5):447-455

January 29, 2015

OBERSCHWABENKLINIK

Study Overview

• The authors estimate that implementation of the 2014 treatment guidelines for all U.S. patients with untreated hypertension would save lives and money.

• The value of treatment would be greatest in patients with severe hypertension and in those with cardiovascular disease.

OBERSCHWABENKLINIK

Projected Average Annual Incremental Results of Providing Therapy for Patients with Untreated Hypertension between the Ages of 35 and 74 Years (2014–2024).

Moran AE et al. N Engl J Med 2015;372:447-455

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Conclusions

• The implementation of the 2014 hypertension guidelines for U.S. adults between the ages of 35 and 74 years could potentially prevent about 56,000 cardiovascular events and 13,000 deaths annually, while saving costs.

• Controlling hypertension in all patients with cardiovascular disease or stage 2 hypertension could be effective and cost-saving.

OBERSCHWABENKLINIK

Zusammenfassung und

Empfehlungen

Sorgfältige und umfassende (Primär-)

Diagnostik

Behandlung auch der begleitenden

Risikofaktoren

Allgemeinmaßnahmen sinnvoll

Interventionelle Verfahren derzeit nicht

ausreichend validiert

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK

OBERSCHWABENKLINIK

Vielen Dank für Ihre

Aufmerksamkeit