? ?pe?tas???? as?e??? ?????? ?a?d?a??e?a??? ???d????

1
?s?e?e?? ?????? ?a?d?a??e?a??? ???d???? ???????
?e?ape?a ??????? 24/6/2006

• ? ?pe?tas???? as?e??? ?????? ?a?d?a??e?a???
  ???d????
• ?.?s???f??
• ?pe?????? ??t??pe?tas???? ?at?e???
• ?pp????te?? G.?.?
• ???ed??? ?µ?da? ???as?a? ?p??tas? ?a? ?a?d?? t??
  ???

2
S?µe?a s???t?s??

• ? ?? ?? pa?????ta? ?a?d?a??e?a??? ???d????
• ?a?µ???µ?s? ?a?d?a??e?a??? ???d????
• S???pa??? ????? pa?a???t??
• ???ße? sta ???a?a st?????
• ?e??s? ?? ?a? ?a?d?a??e?a?? ?f???

3
? ?? e??a? p???pa?a???t??? ??s??
? ?? a????e? µe t?? ?????a

• ?? 90 t?? at?µ?? p?? e??a? ???µ?tas??? st??
  ?????a t?? 55 et?? ?a ?????? ?pe?tas??? st??
  ?????a t?? 75 et??
• (JNC 7)
• ?p??e? ?a a?t?µet?p?s?e? t? fa???µe?? a?t??

4
???p?? ????
??t?stas? st?? ??s??????
????s? t?? ep?p?d?? ??s???????
????s? t?? s???????? ?a?d?a??e?a??? ???d????
5
? ?? ?? pa?????ta? ???d????

• ?e? ?p???e? ap?? d?a????st??? ??aµµ? µeta??
  f?s????????? ?a? a???µ???? ?? (G.Pickering, 50
  ?????a p???)

? s??s? ?? ?a? ??? e??a? s??e???, sta?e?? ?a?
a?e???t?t? ap? t?? pa???s?a ????? pa?a???t??
???d???? ? ????p??tas? s?µat?d?te? t?? a????? ??a
???e????d?a?t?t??? µ?t?a p?? ?a µe?????? t?? ??
?a? ?a p???aµß????? t?? a??pt??? t?? ??
N Engl J Med 2001
JNC 7
6
TROPHY STUDY???f???sse? ? a?t??pe?tas??? a????
se p???p??tas? t?? a??pt??? ???
Se 2?t?, ? s?et???? ???d???? a??pt???? ??
?ta? µe??µ???? ?at? 66.3 st?? ?µ?da t??
?a?tesa?t???? s?????t??? µe t? placebo (plt0.001)
400
409
N.Engl J Med 20063541685-97
7
.? µ?t??s? t?? ??, ?p?? ???eta? st?? ?a??µe????
??????? p???? e??a? a?a???ß?? a??? sta
ap?te??sµat? t?? p??pe? ?a st???????? ap?f?se??
µe s?ßa??? µa???p???esµe? ep?pt?se?? ??a t??
as?e??OBrien 1996
???? ?? ?a µet??µe?
James Conway 1991
8
Borderline hypertension Labile hypertension
Hypertension only on first visits Hypertension
at work Spurius Hypertension Nocturnal
hypertension White Coat Hypertension Masked
Hypertension
F?S????G??? ??
??????S?
9
WHITE COAT HYPERTENSION

• ????µ??? ?? st? ?at?e??
• ?aµ??? ?? e?t?? ?at?e???

• ?f??? t? 15-30 t?? at?µ?? µe a???µ??? ??
• ???a??e?, ??????µ????, s?st????? ?p??tas?, pa?d??

10
Masked Hypertension Thomas G. Pickering

Hypertension 200240795-6
Reverse White Coat Effect White Coat
Normotension Isolated Home Hypertension

• ? ?? ?at?e??? e??a? f?s???????? a??? ? 24??? ?? ?
  ? ?? st? sp?t? e??a? a???µ???
• ???. ? ?? e??a? ???µµ??? µ???? ?a ???e? 24???
  ?ata??af? ? ?a µet???e? st? sp?t?

?f??? t? 10-15 t?? at?µ?? µe f?s????????
?? Fa??eta? ?s?d??aµ? ? 24??? ?ata??af? µe t??
µet??se?? st? sp?t?
11
MASKED HYPERTENSION
SHEAF Study
Bobrie G, et al. JAMA 20042911342-9
2,5
1.3-3.0 P0.001
2,0
1.96
Hazard ratio
1,5
1
1,0
Normotension
Hypertension
12
?p?peda t?µ?? ?? (mmHg) ??a t?? ???sµ? t?? ??
S?? ???
?? ?at?e??? 140 90
24??? ?? 125 80
?et??se?? st? sp?t? (?e??pat?t??? ??) 135 85
ESC/ESH 2003
JNC VII
13
H S?? e??a? p?? s?µa?t???? pa?????ta?
?a?d?a??e?a??? ???d????
Ages 20-79 years (5 groups lt 40, 40-49, 50-59,
60-69, 70-79)
ß(SBP)-ß(DBP)
AGE (Years)
Adjusted for age, sex and other risk factors
Franklin SS et al. Circulation 20011031245-1249
14
??ast??µ?t?s? ?a?d?a??e?a??? ???d????st??
?pe?tas??? as?e??
?? (mmHg) ?? (mmHg) ?? (mmHg) ?? (mmHg) ?? (mmHg) ?? (mmHg)
????? ?? ?a? at?µ??? ?st????? F?s???????? S?? 120-129 ? ??? 80-84 ????? F?s???/?? S?? 130-139 ? ??? 85-89 St?d?? 1 S?? 140-159 ? ??? 90-99 St?d?? 2 S?? 160-179 ? ??? 90-99 St?d?? 3 S?? ?180 ? ??? ?110
??e? ???p?? ?? ?aµ???? ???d???? ?aµ???? ???d???? ?p??? ???d???? ??t???? ???d???? ?????? ???d????
1-2 ?? ?p??? ???d???? ?p??? ???d???? ??t???? ???d???? ??t???? ???d???? ???? ?????? ???d????
3 ? ?? ? ??S ? d?aß?t?? ??t???? ???d???? ?????? ???d???? ?????? ???d???? ?????? ???d???? ???? ?????? ???d????
S?? ?????? ???d???? ???? ?????? ???d???? ???? ?????? ???d???? ???? ?????? ???d???? ???? ?????? ???d????

• St?d?? ??
• ?a?????te? ???d????
• ???ße? ??????? st????
• S?
• S?et???µe?e? ???????? ?atast?se??

ESC/ESH 2003
15
?t?µa ?????? ???d???? ??a ?a?d?a??e?a?? p??????

• ?s?e?e?? µe ???st? S?, PVD, ???
• ?s?µpt?µat??? ?t?µa p?? ?????
• ????ap???? pa?????te? ???d???? - 10et?? ???d????
  ??a ??a µ???a?? stef. s?µßaµa ?5
• ?eµ???µ????? pa?????te? se ????? ep?peda p.?. ??
  ?180/110 mm Hg, LDL ?160 mg/dL
• S?
• S???e?e??
• ?s?e??? µe p???µ? a????s?????t??? ?a?d?a??e?a??
  ??s?
• ?s?µpt?µat???? at?µ?? se ????? ???d???

European Guidelines On Cardiovascular Disease
Prevention In Clinical Practice Eur Heart
J.2003241601-1610
16
?a?????te? ?a?d?a??e?a??? ???d????

• ?p??tas?
• ??p??sµa
• ?a??sa???a (BMI gt30 kg/m2)
• ?p??s?a f?s???? ?s??s??
• ??s??p?da?µ?a
• S?
• ?????a?ß??µ??????a ? GFR lt60 ml/min
• ?????a(gt 55 ?, gt65 G)
• ?????e?e?a?? ?st????? p?????? S?
• (?lt 55 , Glt 65)

S?stat??? t?? µetaß?????? s??d??µ??.
JNC VII
17
Yp??tas? ?a? d?aß?t?? t?p?? 2 p????sµ?? ??????
???d????
12
N??µ?tas???? d?aß?t???? ??t?e? Ype?tas???? d?aß?t
???? ??t?e? N??µ?tas???? d?aß?t????
???a??e? Ype?tas???? d?aß?t???? ???a??e?

10
8

Ep?p??asµ?? ()
6
4



2
0
?µf?a?µa µ???a?d???
AEE/pa??d??? ?s?a?µ??? epe?s?d??
Ype?t??f?a t?? a??ste?? ?????a?
The Hypertension in Diabetes Study Group. J
Hypertens 1993a11309-317.
Stat?st??? s?µa?t???, ?pe?tas???? vs
???µ?tas????. ?pe?t??f?a a??ste??? ?????a? se
??G.
18
?p??tas?, sa??a??d?? d?aß?t??, pa??sa???a,
µetaß????? s??d??µ?,

• ?? µ????a??e?a??? ep?p????? a??????? µe t??
  ??a??? t?? ?pe?????a?µ?a? e?? ?? µa???a??e?a???
  ep?p????? p??? t?? ?pe?????a?µ?a

19
???ß? ???????-st???? (??S)?? p?????st????
pa????? st?? ??

• ??? (??G Sokolow-Lyons gt38mm, Cornell gt2440
  mmms, Echo LVMI ? ?125, T ?110 g/m2)
• ?pe??????af???? e?de??e?? p????s?? t?? a?t???a???
  t????µat?? (IMT ?a??t?d?? ?0.9 mm) ? pa???s?a?
  a????s??????t???? p???a?
• ????? a???s? t?? ??eat?????? ???? (? 1.3-1.5, T
  1.2-1.4 mg/dl)
• ?????a?ß??µ??????a (30-300 mg/24h,
  a?ß??µ???/??eat????? ??22, T ?31 mg/g, ? ?2.5, T
  ?3.5 mg/mmol)

ESC/ESH 2003
20
??S ?a? a?µ?d??aµ??? f??t??

• ?s????te?? s?s??t?s? µe pa?aµ?t???? ap? t?? 24???
  ?? s?????t??? µe t?? ?? ?at?e??? (???, ???, ??)
• Ge?µet??a ?? f??t?a ??
• (Tsioufis et al, JHH
  199913677-682)
• ?e?a??te?e? ß??ße? st??? non dippers vs dippers
  (???, ???, ??)
• ?p?de???s? e?ast???t?ta? ?a??t?d??
• (Tsioufis et al, JH? 200014813-18)
• ????µ??? ap?????s? a?ß??µ????
• (Tsioufis et al,Am J Hypertens 2002 15600-604)

21
??????S?
????s? ?ng II ?e??s? ?? ??e??? ???? t??
NF-k? ?p???????? f?e?µ???d? a?t?d?as?
???
?????S ??G??O? S???O?
22
S???, ?p??tas? ?a? ?a?d?a??e?a??? ???d????
... the RAAS appears to be the root of most evil
D.G. Beevers, November 2003
Lip GYH, More evidence of blocking the
renin-angiotensin-aldosterone system in
cardiovascular disease and the long-term
treatment of hypertension data from recent
clinical trials (CHARM, EUROPA, Val-HEFT,
HOPE-TOO and EUR2) J Hum Hypertens
200317747-750
23
Renin-Angiotensin Aldosterone System
Non-ACE Pathways(e.g., chymase)

• Vasoconstriction
• Cell growth
• Na/H2O retention
• Sympathetic activation

Angiotensinogen
AT1
Angiotensin I
renin
Angiotensin II
ACE
AT2
Aldosterone

• Vasodilation
• Antiproliferation(kinins)

Cough,Angioedema Benefits?
InactiveFragments
? Bradykinin
24
??? ???a? ? ?s????te??? p?????st???? pa?????
µet? t?? ?????aG?a ???e 39 gr a???s? t?? µ??a?
t?? ??, ? ??? a????eta? ?at? 37 (MAVI Study,
JACC 2001381829-35)
?a?d?a??e?a?? ???t?t?ta ?a? ?e?µet??a ( as?e???)

• ???a??sµ??
• ??ata?a?? t?? p????s?? t?? ??
• ?e??s? t?? stefa??a?a? efed?e?a?
• ????µ??? ?????a?? ??e?t???? d?ast????t?ta
• ?e??s? s?st?????? ?e?t?????a?

25
?eta????s? t??a??p???µ???? µe?et?? ?p?st??f?? ???
st?? ??
Ca- antagonist
ACE- inhibitors
Diuretics
?-blockers
ARBs
0
-2
-4
?e??s? µ??a? ?? ()
-6
-8
-10
-12
80 ???a??p???µ??e? µe??te? 4,113 as?e?e??
-14
-16
Schmieder RE et al. Am J Med 2003 11541-6.
26
??p??? µ??a??sµ?? a?ast???? t?? ep??sa?t????

• ??ast??? t?? S???
• ?atast??? t?? s?µpa??t???? t????
• ??ast??? t?? ?e?????µ?????? ??e???p???s??
• ?e??s? t?? ?a?d?a??e?a??? ep?p?????

27
??????? PAF se ?pe?tas????? as?e?e??

• LIFE STUDY Se as?e?e?? µe ??Gf??? ??? ?
  ??sa?t??? s?????t??? µe t?? ate?????? µe??se ?at?
  33 t?? pe??pt?se?? ?e?-eµfa????µ???? ??
• Wachtell et al J Am Coll Cardiol
  200545712719.
• CHARM STUDY Se as?e?e?? µe ?a?d?a?? a?ep???e?a
  ? ?a?tesa?t??? s?????t??? µe t? placebo µe??se
  ?at? 30 t?? pe??pt?se?? ?e?-eµfa????µ???? ??

28
????µ??? IMT ?a? ?a?d?a??e?a??? ß??ße?

• ????fa??? (???, pa??d??? ???)
• ?a?d?? (???)
• Stefa??a?a ??s??
• ?sß?st?s? stefa??a???
• ?e??fe???? a????s?????s?
• ?ef?? (p??te??????a, µ????a?ß??µ??????a)
• S????? ?p?st??f? st? ??? µe ta a?t??pe?tas???
  (?????? a?ta????st?? asßest???) a??? ??? ße?t??s?
  sta ???, ??, ?p?ß??s?

29
??s?e?t?????a t?? e?d??????? - S?????t?ta
a?t????? ?a? ??

• ???t??e??? ? de?te???e??? fa???µe???

• ??t?? ? ap?t??esµa?

• ??? p????? ? ap??t?s?

30
?? ?ef??? ?? ???a?a st???? t?? ??
31
??e???t??? p??e?a ?a?d?a??e?a??? ?a? ?ef?????
??s??
End-Stage
?a?d?a?? a?ep???e?a
?e???t?? ?ef???
??, ???
??? (? GFR)
Progression
???te??????a
S?, ???
Initiation
??????µ????,S?, ? ??
??????µ????,S?, ? ??
At Risk
?a?d?a??e?a?? ??s??
?????a ?ef???? ??s??
Adapted from Sarnak and Levey, Am J Kidney Dis
200035S11731.
32
??????s? ?ef????? ß??ß?? st?? ?pe?tas??? as?e??

• ?e? a????? ta ep?peda ??eat?????? ????
• ??e?????ta? GFR
• ?p?ßa???µ??? a?ß??µ???

33
??????s? ?ef????? ß??ß?? st?? ?pe?tas??? as?e??

• Formula Cockcroft-Gault
• 140-age (yrs) ? Weight (Kg)
• 72 ? 85 ? S-Cr (mg)

• 22 et?? ??d?a?
• Kg
• S-Cr 1.6 mg/dL
• GFR 123 ml/min

85 et?? ???a??a 46 kg S-Cr 1.6 mg/dL
GFR18.6 ml/min
34
Progression of nephropathy in type 2 diabetes
ADA. Diabetes Care 2004 27(Suppl. 1) S79-S83.
35
G?at? e??a? ??????? ???s?µ? ? ?????a?ß??µ??????a?
?CV Risk and Presence of Renal Dysfunction and
Vascular Dysfunction
mg/day
?CV Risk and Vascular Dysfunction
Microalbuminuria
Albuminuria (Proteinuria)
Normal
36
?????a?ß??µ??????a ??t??pa?????e?a

• ????µ??? a?µ?d??aµ??? f??t?? p?? ?d??e? se
  a???µ??? e?d?spe??aµat??? p?es?
• Ge???e?µ??? a??e??p??e?a - ??s?e?t?????a
  e?d??????? (a???µ??? d?ape?at?t?ta a?ß??µ????
  st?? ?ef???? ?a? s?st?µat??? a??e??p??e?a)
• Grippa G, J Hum Hypertens 200216S74-S77
• The interrelationships of microalbuminuria with
  the other surrogates of the atherosclerotic
  cardiovascular disease in hypertensive subjects
  (Review)
• Tsioufis C, et al. Am J Hypertens
  200417470-476

37
T??????????? S?????

• S? ??-S? ??lt130/85mmHg
• S? ??-??F???? ??????????
• ??lt130/85 mmHg
• S? ??O????????? gt1g/d ??120/75mmHg

38
????/AT1 a?ast??e?? ?a? ?ef???? ?e?t?????a

• ?p? ??a ta a?t??pe?tas??? f??µa?a, µ??? ?? ??1
  a?ast??e?? ?a? ?? a -??? ????? ap?dede??µ???
  ?ef??p??stas?a se d?aß?t??? ? ?pe?tas???
  ?ef??p??e?a
• ??a??? a????? µe a-??? ? ??1 a?ast??e?? µp??e? ?a
  p???a??se? µ?a pa??d??? a???s? t?? t?µ?? t?? Cr
  ???? p?? µet? p???d? ????? eßd?µ?d?? ?? t?µ??
  epa??????ta? sta p??????µe?a ep?peda ? ?a?
  ?aµ???te?a
• Se pe??pt?s? a???s?? t?? t?µ?? t?? Cr ???? se
  ep?peda gt20-30 t?? a?????? t?µ?? ? a???? p??pe?
  ?a d?a??pteta?.
• ?a??te??? de??t?? fa??eta? ?a e??a? ta ep?peda K
  pa?? ? Cr.
• ?p????µe ?a a???s??µe a???? µe a-??? ? ??1 µ????
  ep?peda Cr ????3mg/dl ? K5mEq/l.

39
M? Fa?µa?e?t??? µ?sa
Fa?µa?e?t??? µ?sa

• ??????t???
• S?µpa????t???

• ?p??e?a ß?????
• ??a??p? ?ap??sµat??
• ?e?????sµ?? p??s????? ?at????
• ?e?????sµ?? ????p?e?µat?d??
• S?µat??? d?ast????t?ta
• ???s???? ?a????

• ß-ap???e?st??
• a- ap???e?st??
• ?e?t????? d???ta

• ??ta????st?? asßest???
• a- ???
• ??ta?.Ang ?? (At1)
• ?µ?s?? d???ta a??e??d?asta?t???

40
?pa?t?se?? ??t??pe?tas???? Te?ape?a?

• ?p?te?esµat??? µe??s? ??
• 24-??? d??s?
• ?????ste? pa?e????e?e?
• ??d?te?? µetaß?????
• ???a??p??stas?a
• ?e??s? ???t?t?ta?

?pe?t??f?a
Stefa??a?a ??s??
?a?d??
?a?d?a?? a?ep???e?a
???te??????a
?ef???
Spe??aµat?s??????s?
??ast???t?ta, ??d?t???t?ta
??d??????, ?????µ?t?s?
???e?a
?a??? ?s?-µ?s?? ??t??a
???
????fa???
41
Antihypertensive Treatments and Incidence of New
Onset Diabetes
Study Higher Incidence in Patients Using Diuretics, b-Blockers Higher Incidence in Patients Using Diuretics, b-Blockers Higher Incidence in Patients Using Diuretics, b-Blockers Higher Incidence in Patients Using Diuretics, b-Blockers
CAPPP diuretics, b-blockers 13 vs. captopril
CHARM placebo SOC 16 vs. candesartan SOC
INVEST atenolol HCTZ or trandolapril 17 vs. verapamil HCTZ or trandolapril
INSIGHT co-amiloride b-blocker 30 vs. nifedipine GITS
LIFE atenolol 33 vs. losartan
ALLHAT chlorthalidone 18 43 vs. amlodipine vs. lisinopril
HOPE placebo SOC 50 vs. ramipril SOC
ALPINE HCTZ atenolol 720 vs. candesartan felodipine
Lancet 1999353611-16. Lancet 2003362759-66.
JAMA 20032902805-2816. Lancet 2000356366-72.
Lancet 2002359995-1003. JAMA 20022882981-97.
N Engl J Med 2000342145-53. J Hypertension
2003211563-1574.
42
???a??? µ??a??sµ?? a?t?d?aß?t?????? d??s?? ap?
t?? a?ast??? t?? s?st?µata? RAS

• ????s? t?? a?µat???? ???? st??? µ?e?
• ?ata???t?s? ?a????
• ???stas?a t?? ß-??tt???? t?? pa????at?? ap? t?
  e?e???p???s? t?? t?p???? S??? µe µe??s? t??
  ???s?? ?a? t?? ap?pt?s??
• ?e??s? t?? ??e?d?t???? stress p?? p???a?e? Ang II
• ?????st??? d??s? st??? PP??-?
• ?p??at?stas?/d?af???p???s? t?? ??p???tt????
  (Adiponectin ?)
• ????µ??? ?e?t?????a GLUT 4

43
CV Events in Treated Hypertensives without DM,
with New-Onset DM Previously Known DM
100
No Diabetes
90
A
80
plt0.0001
70
Previously Known Diabetes
Probability of Event-Free Survival ()
60
C
50
New-Onset Diabetes
B
40
30
0
3
6
9
12
15
Time to Event (years)
Verdeccia et al 2004
44
SHEP Long term mortality rates
S? e? a????
At?µa p?? a??pt??a? S? st?? ?µ?da t??
??????a??d???? de? e??a? a???s?
t?? ?a?d?a??e?a??? epe?s?d??? ?a? e??a? ?a??te??
p?????s? ap? t??? ????te? S? e? a????
???pt??? S?
45
?µf?sß?te?ta? ? p??te???sa ??s? t?? ß a?ast?????
st?? fa?µa?e?t??? a?t?µet?p?s? ??

• 1. ?p?t???a t?? ate??????? st?? ASCOT
• 2. ?p? µeta-a????s? d?ap?st????e ?t? ? ate??????
  ?ta? ????te?? ep?fe??? se ?a?d??p??stas?a ??a?t?
  ????? fa?µ???? ?a? e?af??? ?a??te?? ap? t?
  placebo se p??stas?a ap? ???
• 3. ????µ??? p??a??t?ta a??pt???? S? a?
  s??d?????ta? µe d?????t??? s?????t??? µe ACE-I,
  ARBs, CCBs
• 4. G??st?? pa?e????e?e? (libido, a???s? ß?????,
  ??p?da?µ??? p??f??)

46
ß-Blockers To use or not to use?
CAD
DM
Lone Hypertension
Hypertension
Sympathetic activity
Congestive heart failure
BB Use
100
0
Messerli FH, et al. In Griffin BP, Topol EJ,
eds. Manual of Cardiovascular Medicine 2nd Ed.
Cleveland. Ohio Cleveland Clinic Foundation,
2004.
47
?p??e??eta? ? ?a??µe???? p?a?t??? µa? ap? ta ??a
a?t? st???e?a?

• Ta a??????? ?? ?ate????t???e? ?d???e? ??a t??
  p??t? ep????? t?? a?t??pe?tas???? fa?µ???? ?
• ????? ? ????? t?? t?? d?????t???? ?

??????t??? ?p?te???sa? ?a? ap?te???? t??
?eµ???? ???? t?? a?t??pe?tas???? a????? ?e?
fa??eta? ?a t??p?p?????ta? ?? ?s????se? s?st?se??
a??? se as?e?e?? µe µetaß????? s??d??µ? ?
p??d???es? ??a S? ?a ap?fe????ta? ?a? ?a µ?
????????ta? se s??d?asµ? µe ß-a?ast??e??
48
???te???µe??? a?????? s??d?asµ?? a?t??pe?tas????
fa?µ???? (se ap??s?a e?d???? e?de??e??)
??????t???
ACE ?/ ARBs
??ta????st?? asßest???
49
??a?efa?a??s? ???????/a?t?µet?p?s? ß?aß?? ???????
st???? st?? ??

• ?? e??a? sp??da??te??
• ?e??s? t?? ??
• ?
• ?p???e?sµ?? t?? S???
• ?
• ?a? ta d??

• S?????
• ? ep????? t?? s?st?? d?s?????a? e??a? t?? ?d?a?
  s?µas?a? µe t?? ?e?ape?t??? ep?????

50
BP Reductions as Little as 2 mm Hg Reduce the
Risk of CV Events by Up to 10

• Meta-analysis of 61 prospective, observational
  studies
• 1 million adults
• 12.7 million person-years

7 reduction in risk of ischemic heart disease
mortality
2 mm Hg decrease in mean SBP
10 reduction in risk of stroke mortality
Lewington S et al. Lancet 20023601903-1913.
51
VALUE ?µf?a?µa µ???a?d??? ?a? d?af???? st? S??,
se s???e???µ??e? ???????? pe???d???
??F??G?? ??????????
D
S??
???e?
(mmHg)
S??????? st? µe??t?
2.2
3.8
03
2.3
36
2.0
612
1.8
1224
1.6
2436
1.4
3648
????? µe??t??
1.7
4.0
1.0
2.0
0.5
0.25
Favours amlodipine
Favours valsartan
Julius S et al. Lancet. June 2004363.
52
New Guidelines on Hypertension Possible
Changes (?) and Reinforcements ()

• No CCB in CAD patients
• No CCB for CHD/CHF function
• ARB and CHD
• ARB and stroke prevention
• Metabolic variables and choice of T

Metabolic Syndrome
New Onset Diabetes/Prediabetes
Lipid variables

• BP control (lt140/90 mmHg)
• ? BP threshold/target (high risk)
• Combination T also as 1st choice
• Consistency of BP control
• Control of out-of-office BP

• D as min 1st choice
• BB as 1st choice
• D/BB combination as
• priorital
• ACEI/ARB combination as
• last priorital

??

Guidelines
??

• Total CV risk in screening/FU
• TOD assessment in screening/FU
• Emerging risk factors/TODs?

53
St?? ?e???s? t?? ?pe?tas???? as?e???? ??????
???d????

• ?a?? e?t?µ?s? t?? a?µ?d??aµ???? f??t??? t??
  as?e????
• ??t?µ?s? t?? pa?a???t?? ???d????
• ??t?µ?s? t?? ß?aß?? t?? ??????? st????
• ?pa?a?t?t? ? ???e???d?a?t?t??? a????
• ?e??se ta ep?peda t?? ?? st?? t?µ?? st????? se
  s??t?µ? ??????? d??st?µa (µe??t? VALUE)
• St?? pe??ss?te?e? t?? pe??pt?se?? ?a apa?t??e?
  s??d?asµ?? a?t??pe?tas???? fa?µ????
• ???s?µ?p???se f??µa?a µe ??d?te?? µetaß?????
  d??s? ?a? µe e?e??et???? d??se?? p??a? t??
  µe??s?? t?? ??

54
?-a?ast??e??/d?????t????pe?????? µ??a??sµ??
d?aß?t?????? d??s??

• ?p??a??a?µ?a
• ?e??s? ?????s?? ??s???????
• ??e???p???s? RAS µe d??s? st? e?d??????
• ?pe?pa?a???? ???????? ap? t? ?pa?
• ?pe???s?????a?µ?a
• ??d?????a?? d?s?e?t?????a
• ??e?d?t??? stress