Current management of hypertension according to the new ESC Guidelines

Watch part one of the webinar

Watch part two of the webinar

Per Anton Sirnes and Antonio Coca

For the best learning experience, we recomment to read the ESC Guidelines on Arterial Hypertension (Management of)

The faculty will discuss the following issues:

• To review the evidence and recommendations for silent organ damage evaluation in patients with hypertension
• To discuss the usefulness of the “Table of total cardiovascular risk stratification” of the ESH/ESC 2013 Guidelines
• To discuss and review the recommendations for the best antihypertensive therapeutic strategy in specific groups of patients at high risk

The ESC Webinars are designed to help you improve your daily practice!

The format includes a case based presentation, online assessment and live discussions with the 2 key opinion leaders who will give you some useful tips for your daily clinical practice.

Your questions answered by Professor Antonio Coca

• Would lowering high-normal BP (e.g. 138/88) to normal BP (< 130/80) by non-pharmaceutical means results in lower CV events?
  No trial has explored this issue. We only know that adherence to non-pharmacological treatment reduces the incidence of hypertension in subjects with high-normal BP, and that in patients with grade 1 HT the combination of salt reduction and weight loss reduces events.
• Is a beta-blocking agent better for a patient with hypertension AND a high resting heart rate or abnormal rate recovery ?
  yes
• Pshychotherapeutic methods how often they are used for AH prevention
  They are not often used. No well-designed clinical trials on this subject.
• Night hypersympathetic activity obtain from HRV (Holter) what is the place for this method
  We never use it in hypertension. We use 24h-ABPM
• Taking into account results of Simplisity HTN-3 are u plan to make change in Guidelines 2013?
  This will depend on results of the ongoing trials
• If a patient is already on ACE and ARB and his BP is well controlled should we alter the treatment? thank you.
  If the patient is controlled but proteinuria is not, you can stay on this combination taking care of serum K+ and eGFR
• Why an evenig dose insteed of a morning dose
  Almost never. Perhaps in patients with only nocturnal HT (sleeping hours) but is very uncommon
• Why exactly Lercanidipine is preferred here over diuretic in combination with ACE-inh?
  In obese patients at risk to develop a Metabolic Syndrome or Diabetes, Guidelines recommend the combination of ACEi or ARB plus CCB
• Should the patient be prescribed with aspirin as well because of the carotid disease? Thank you.
  The use of aspirin in primary prevention is still controversial. The only trial showing a beneficial effect in patients with HT was the HOT study, and the benefits were restricted to patients with eGFR < 45 ml/min/1.73m2. IN addition, if decided, aspirin should be given only when BP is strictly controlled.
• Because this is a high risk patient don't we need a higher dose of Statine (like Atorvastatine 40mg)?
  In patients with HT and high CV risk, when LDL cholesterol is in the normal range the ASCOT-LLA study demostrated benefit in CV mortality with 10 mg of atorvastatin.
• Is it better to give all the agents concominantly eg in the morning or to use one agent in the morning and the other in the evening?
  To improve compliance is better to reduce not only the number of pills but also the number of daily intakes
• This patient is also obese with BMI> 31. So I think it is important to associate to drug therapy proper hygienic-dietary lifestyle ie physical exercise and proper dietary regimen to lower its level of risk. What do you think about?
  Absolutely !! This is the first recommendation of the 2013 ESH/ESC Hypertension Guidelines
• If patient with AH due to nephritis with proteinuria 30 MG|DL with CrCR- 65 ml/min is taking combo Amlo+Ramipril with BP 150/93 mmHg what level of BP is recommended in this case?
  Lower than 140/90 and going close to 130/80 if well tolerated
• Why this 2 patients in your cases began their treament with ARB?
  It is your decission to start with ACEi or ARB in primary prevention of CV events in patients with hypertension. ARBs are ussually better tolerated
• Does INDAPAMIDE have any pharmacological superiority to other diuretic drugs in its class - and under what circumstances?
  From the pharmacolgic perspective all thiazide or thiazide-like diuretics are similar when equipotent doses are compared
• Diuretics will increase erectile disfnction
  Yes. Particularly associated with the old betablockers (atenolol, metoprolol, bisoprolol..), but not with the new ones (Nebivolol...)
• The dose of statine should not be higher because this is a high risk patient?
  No. Because LDL-Cholesterol is in the normal range. If LDL was elevated you shopuld increase the dose to achieve the correct target
• What is your opinion in adding aspirin in this second case?
  Guidelines stated that is an individualized decission. If the plaque is stable and no significant stenosis is present is not needed. Remember that aspirine does not modify the progression of atherosclerosis whereas statins does.
• Is the addition of aspirin in these cases recommended?
  Guidelines stated that is an individualized decission. If the plaque is stable and no significant stenosis is present is not needed. Remember that aspirine does not modify the progression of atherosclerosis whereas statins does.
• When is the aspirin a good idea?
  When atherosclerosis is advanced, even asymptomatic, in patients with multiple CV risk factors or comorbidities and silent target organ damage (ie. Diabetics with hypertension, dyslipidemia, microalbuminuria and reduced eGFR)

Your questions answered by Dr Per Anton Sirnes

• how to control the systolic hypertension with normal diastolic pressure?
  ISH: The SHEP study used tiaizid and add on atenlol vs placebo. A LIFE substudy showed better effect of losartan then atenolol in systolic HT. Other studies has shown effect of dihydropyridine CCB and diuretics, the SYST EURo trial used CCB as base and added +ACE+Diuretic . ESC 2013 GL states that " diuretics and calcium antagonists may be preferred in isolated systolic hypertension." Systolic HT inf the eldrely is often the result of stiff vessels. Betablcoker increases central BP more and should probably be avoided as first line medic in ISH unless spesially indicated for other reasons
• when systolic pressure normal and diastolic hypertensive pressure. with atrial fibrillation?
  BP measurements are often not so reliable in AF, I would use the systolic as the primary goal and not worry about slight elevation of DBP if systolic is OK. Diastolic BP is important for coronary . perfusion. If overweigh, weigh reduction has often a good effect on DBP. DIuretics and CCB are often also effective. But one should be cautions with isolated Diast HT
• why hypertension not be hypotension in left ventricle?
  Usulually Left ventr end diastolic pressure will increase with increased load
• systolic hypertension how to control ?
  see above
• Role of speckle tracking echocardiography in assessment of patients with hypertension?
  to detect minor reduction in systolic function not reasily detected by traditional EF.
• what are the risks of hypertension?
  Read the recent ESC guidelines. According to WHO hypertension is responsible for 20% of mortality and takes more lives than tobacoo
• If on the amb. bp measurement we find few readings of around 170/115 and the average is normal how we interprete the test
  Use the mean day ( not above 135/85) or mean night ( not above 120/70) as the guide to therapy, If in doubt repeat 24 ABPM
• CCB have side effects as legs' edema and tachycardia that strongly limit their use.
  They have been well tolerated in several large randomized trials. Start with small doses. Lercanidipine has less oedema than amlodipine. Combination with ARB may counteract oedema somewhat. If tachycardia add small dose of betablocker or use non-dihydropyridine CCB
• Go back to the ECG: there to me there are sign of LVH and you already knew that tyhe patient was at higher risk.
  First case did not fulfull ususlal LVH criteria. Echo gives much additional info, not only LV H
• What about the role of beta blockers in reduction of Aortic dilatation?
  yes, BB are often useful as desribed in the recent ESC GL on aortic disease. However this patiens had a metabolic problem which gould be worse by BB. Most improtan is adequate BP control. This was obtained by life style intervantion and ACE+CCB
• what would you suggest on Asian decent with uncontrolled HTN and of moderate risk?? combi meds
  Asian decents may have som more cough on ACE There are subpopulation differencens in Asian decents. In one study from california HT was more common amon Filipinos than other asian subpopulations. Generally South Asians appear to respond to antihypertensive drug treatment in a similar manner to whites, Severeal studius in hypertensives Asian population has swhown good effectsd f ACE and CCB . Park IU, Taylor AL. Race and ethnicity in trials of antihypertensive therapy to prevent cardiovascular outcomes: a systematic review. Ann. Fam. Med. 5(5), 444–452 (2007).
• Why an evenig dose insteed of a morning dose
  I prefer generally evening dosage for all long acting medications. Aspirin worsk best at night. Statins works better and has less side effect. Evening dose will in my experience ofte give less side effects as peak plasma levels are reached during sleep and dupine postition. So giving ALL medications at bed time (execept diuretic) is in my view optaimal and increases adherance see Optimal Time to Take Once-Daily Oral Medications in Clinical Practice: Drugs Acting on Cardiovascular System review http://www.medscape.org/viewarticle/584529_3 Night time dosage improve night time BT cotnrol see http://content.onlinejacc.org/article.aspx?articleid=1855620 see also http://content.onlinejacc.org/article.aspx?articleid=1914722 , further http://hyper.ahajournals.org/content/50/4/715.full and also cochraen systamtic review : http://www.ncbi.nlm.nih.gov/pubmed/21975743

This programme is supported by Bayer HealthCare Pharmaceuticals, Bristol-Myers Squibb and Pfizer Alliance, Daiichi Sankyo Europe GmbH, Novartis Pharma AG and SERVIER in the form of unrestricted educational grants.  The scientific programme has not been influenced in any way by its sponsors.