Arterielle Hypertonie – wie behandeln, wann an sekundäre

Arterielle Hypertonie – wie behandeln, wann an sekundäre

19.08.2014
Arterielle Hypertonie – wie behandeln,
wann an sekundäre Ursachen denken
PD Dr. med. Stefano Rimoldi
Leiter Hypertonie
Kardiologie Inselspital
[email protected]
Outline
1) Drug therapy
2) Work-up in patients with suspected
secondary arterial hypertension.
3) Atherosclerotic renal artery stenosis
4) Catheter-based renal artery denervation
1
19.08.2014
European Guidelines 2013
Mancia et al. J Hypertens and Eur Heart J 2013
Guidelines
or
…
2
19.08.2014
Reasons for unreached target BP
Despite Guidelines only 25% of treated hypertensives
reach target blood pressure
Patient associated factor: malcompliance
Practitioner associated factor:
- frequent switching medications
- complex treatment regimens
- failure to escalate the intensity of therapy despite
poorly controlled hypertension
Simple Step-Care-Based Algorithm
Initial therapy with a low dose
ACE/diuretic or ARB/diuretic combination
Is blood pressure controlled ?
Yes
No
Continue with
current therapy
Up-titration of combination therapy
successively to the highest dose
Yes
Continue with
current therapy
No
Add calcium channel blocker
and up-titrate
Yes
Continue with
current therapy
No
Add an α-blocker,
β-blocker or
spironolactone
Feldman RD, Hypertension 2009; 53:646-
3
19.08.2014
Blood Pressure at 6 Months
Systolic BP
Diastolic BP
BP Reduction, mmHg
0
-5
-10
n = 2104
P<0.03
-15
-20
-25
P<0.002
Simple step-care-based algorithm
Feldman RD, Hypertension 2009; 53:646-
Guideline care
Proportion of Patients Achieving Target BP
Simple step-carebased algorithm
Guidelines
care
Proportion, %
p=0.026
60
50
40
64.7%
52.7%
30
20
10
0
Feldman RD, Hypertension 2009; 53:646-
4
19.08.2014
How should we start drug therapy ?
Nice Guidelines
5
19.08.2014
NICE Guidelines
A (ACE-H / ARB) Patienten < 55 y
C (Ca-Antagonist) Patienten > 55 y
A+C
A + C + D(iuretikum)
A + C + D + R(est)
BMJ 2011;343:d4891 doi: 10.1136/bmj.d4891
Take home messages
1) Drug therapy -> A or C; A + C; A + C + D (+R)
2) Work-up in patients with suspected
secondary arterial hypertension.
3) Atherosclerotic renal artery stenosis
4) Catheter-based renal artery denervation
6
19.08.2014
Work-up in patients with suspected secondary
hypertension
Rimoldi SF et al., Eur Heart J 2014 14;35:1245-
Suggestive general clinical characteristics
 Age (i.e. < 30y) in patients without other RF
 Resistant hypertension (>140/90 mmHg)
 Severe hypertension (>180/110 mmHg)
 Sudden BP increase in a previous stable patient
 Non-dipping/reverse dipping in 24h ABPM
Rimoldi SF et al., Eur Heart J 2014 14;35:1245-
7
19.08.2014
Major role of 24h ABPM
Exclude white coat effect
Confirm therapy resistance
Reverse nocturnal dipping
Heart rate
Low HR, suggestive for
therapy adherence (i.e.ß-blocker)
Increased HR during nighttime
Rimoldi SF et al., Eur Heart J 2014 14;35:1245-
Take home messages
1) Drug therapy
-> A or C; A + C; A + C + D (+R)
2) Work-up in patients with suspected
secondary arterial hypertension
-> perform 24h ABPM
3) Atherosclerotic renal artery stenosis
4) Catheter-based renal artery denervation
8
19.08.2014
asymptomatic
< 60% RAS
without
translesional
gradient
?
Flash
pulmonary
edema with
bilateral RAS
CORAL: Stenting and medical therapy for RAS
Cooper CJ et a., NEJM 2014;370:13-
9
19.08.2014
CORAL: Stenting and medical therapy for RAS
Conclusions: “Renal-artery stenting did not
confer a significant benefit with respect to
prevention of clinical events when added to
comprehensive, multifactorial medical
therapy….”
Cooper CJ et a., NEJM 2014;370:13-
Why ?
10
19.08.2014
CORAL: Baseline characteristics
Cooper CJ et a., NEJM 2014;370:13-
Relationship between systolic BP and age in patients
with RAS after revascularization
[mmHg]
Systolic BP
200
r=0.79
P<0.001
160
120
80
50
30
70
[years]
Age
Streeten DH et al., Am J Hypertens 1990;3:360-
11
19.08.2014
Questions
Are there predictors for (blood pressure-)
effective therapy of a
renal artery stenosis ?
The “oculo-stenotic reflex” of the interventionalist
30 % 50 %
70 %
90 %
“Oculo-stenotic reflex”
12
19.08.2014
Relationship between translesional pressure gradient
and quantitative angiographic diameter stenosis
Mean PG
[mmHg]
r=0.43
P=0.12
12
8
4
Stenosis [%]
50
70
Subramanian et al, Catheter Cardiovasc Interv.2005;64:480-
Translesional Pressure Gradients to Predict
Blood Pressure Response
13
19.08.2014
Ambulatory 24h blood pressure monitoring at
baseline and at 3-month follow-up
[mmHg]
162±24
143±21
200
P=0.039
150
100
81±12
78±13
Baseline
Follow-up
p<0.001
50
Baseline
Follow-up
Systolic BP
Diastolic BP
Mangiacapra et al, Circ Cardiovasc Interv 2010;3:537-
Take home messages
1) Drug therapy
-> A or C; A + C; A + C + D (+R)
2) Work-up in patients with suspected
secondary arterial hypertension
-> perform 24h ABPM
3) Atherosclerotic renal artery stenosis
-> don’t trust the “oculostenotic reflex”
-> measure translesional gradient
4) Catheter-based renal artery denervation
14
19.08.2014
Renal denervation
Renal ischemia
or hypoxia
RAAS 
• Vasoconstriction
• Atherosclerosis
• Sympathetic
activtity
Thomas G et al. CCJM 2012:79:501-
Renal denervation
Smithwick R, JAMA 1953;152:1501-
15
19.08.2014
Renal denervation: Expert Consensus ESC 2013
 Office systolic BP ≥ 160 mmHg
 ≥ 3 antihypertensive drugs (inkl. diuretics)
 Lifestyle modification
 Exclusion of pseudo-resistance (ABPM)
 Exclusion of secondary hypertension
 Preserved renal function (GFR ≥ 45ml/min/1.73)
 Eligible renal arteries: no polar or accessory
arteries, 4 mm diameter, 20 mm length
Mahfoud F. et al, Eur Heart J 2013;34:2149-
Renal denervation: eligibility
n=1209
n=15 (1.2%)
Savard S, et al. JACC 2012;60:2422-
16
19.08.2014
Renal denervation: anatomical eligibility
Rimoldi SF et al. JACC Cardiovasc Int 2014
Renal denervation: SYMPLICITY HTN-3
Bhatt DL et al. NEJM 2014;370:1393-
17
19.08.2014
Renal denervation: SYMPLICITY HTN-3
Office systolic BP
24h systolic ABPM
P= 0.98
P= 0.26
200
RDN
Sham
200
120
120
40
40
BL FUP
BL FUP
RDN
BL FUP
Sham
BL FUP
Bhatt DL et al. NEJM 2014;370:1393-
Renal denervation: lack of effect on BP
1) Procedure failure.
2) «Pathophysiological failure»: over-activity
of renal nerves is not a significant
contributor to arterial hypertension.
3) Despite technically successful RDN, no
BP lowering because of irreversible
vascular changes (arterial stiffening).
18
19.08.2014
Case report:
Von Arx R et al, Am J Medicine 2014 in press
Case report:
Von Arx R et al, Am J Medicine 2014 in press
19
19.08.2014
Arterial stiffness: pulse wave velocity
A. carotis
A. carotis
D
A. femoralis
A. femoralis
T
PWV = Distance ( D)
/ Time delay (T) [m/sec]
Case report: arterial stiffness
Eur Heart J 2010;31:2338-2350
20
19.08.2014
Take home messages
1) Drug therapy
-> A or C; A + C; A + C + D (+R)
2) Work-up in patients with suspected
secondary arterial hypertension
-> perform 24h ABPM
3) Atherosclerotic renal artery stenosis
-> don’t trust the “oculostenotic reflex”
-> measure translesional gradient
4) Catheter-based renal artery denervation
-> promising technique but...consider
-> technical failure
-> vascular remodeling
PD Dr. med. Stefano Rimoldi
Leiter Hypertonie
Kardiologie Inselspital
[email protected]
21