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Guas ESH/ESC 2013 para el manejo de la HTA

RESUMEN GENERAL

2013 ESH/ESC Hypertension Guidelines

Journal of Hypertension 2013 European Heart Journal 2013 Blood Pressure 2013

2013 ESH/ESC Hypertension Guidelines

Definitions and classification of office blood pressure levels (mmHg)

2013 ESH/ESC Hypertension Guidelines

Definitions of hypertension by office and out-of-office blood pressure levels (mmHg)

2013 ESH/ESC Hypertension Guidelines

Factors - other than office BP - influencing prognosis; used for stratification of total CV risk

2013 ESH/ESC Hypertension Guidelines

Stratification of total CV risk in categories of low, moderate, high and very high risk

2013 ESH/ESC Hypertension Guidelines

Predictive value, availability, reproducibility and costeffectiveness of some markers of organ damage

2013 ESH/ESC Hypertension Guidelines

Initiation of drug treatment in hypertension


Grade 2-3 Grade 1 / High CV risk Grade 1 / Low CV risk Elderly Recommended (Promptly) Recommended Should be considered IA IB IIaB

Recommended if SBP 160 mmHg IA (also > 80 80 ys of age) May be considered if SBP 140-159 mmHg IIbC IIIA

High normal BP

No drug treatment recommended

2013 ESH/ESC Hypertension Guidelines

Initiation of lifestyle changes and antihypertensive drug treatment

2013 ESH/ESC Hypertension Guidelines

Initiation of antihypertensive drug treatment

2013 ESH/ESC Hypertension Guidelines

Adoption of lifestyle changes

2013 ESH/ESC Hypertension Guidelines

Monotherapy vs. drug combination strategies to achieve target BP


Mild BP elevation Low/moderate CV risk

Choose between

Marked BP elevation High/very high CV risk

(IIbC)

Single agent

Two-drug combination

Switch to different agent

Previous agent at full dose

Previous combination at full dose

Add a third drug

Full dose monotherapy

Two drug combination at full doses

Switch to different two-drug combination

Three drug combination at full doses

Moving from a less intensive to a more intensive therapeutic strategy should be done whenever BP target is not achieved.

2013 ESH/ESC Hypertension Guidelines

Fixed-dose combinations

Reducing the number of pills improves adherence (which is low in hypertension) and increases rate of BP control Approach facilitated by availability of different fixeddose combinations of the same two drugs (titration inconvenience minimized) This holds also for fixed-dose combinations of three drugs (usually RAS blocker / CA / D)

2013 ESH/ESC Hypertension Guidelines

Possible combinations of antihypertensive drug classes


Green/continuous: preferred Green/dashed: useful (with some limitations) Black/dashed: possible but less well tested Red/continuous: not recommended

Only dihydropyridines to be combined with -blockers (except for verapamil or diltiazem for rate control in AF) Thiazides + -blockers increase risk of new onset DM ACEI + ARB combination discouraged (IIIA)

2013 ESH/ESC Hypertension Guidelines

Major drug combinations used in trials of antihypertensive treatment in a step-up approach or as a randomized combination - 1

2013 ESH/ESC Hypertension Guidelines

Major drug combinations used in trials of antihypertensive treatment in a step-up approach or as a randomized combination - 2

2013 ESH/ESC Hypertension Guidelines

Methods to improve adherence to physicians recommendations