• Hypertension is almost never a therapeutic emergency (true emergencies are left ventricular failure, hypertensive encephalopathy, aortic dissection, hypertensive retinopathy, eclampsia).
• Diagnosis is based on the recognition, at least 3 visits over a period of 3 to 6 months, greater than or equal to 140 numbers and / or 90 mmHg.
• In case of hypertension greater than or equal to 180/100, confirmation will be made at a second close consultation.
• Place increasing the self-measurement at home and ambulatory BP measurement to correct errors by excess ( “white coat hypertension”) or rarely default ( “masked hypertension”).
• The dietary measures are a prerequisite for any pharmacological treatment.
• The fight against other risk factors must be involved.
• Allow 4 to 6 weeks to assess the effect of antihypertensive. Combination therapy is frequently necessary.
• Search for secondary hypertension when young subject, severe hypertension outset or sudden worsening numbers, hypertension resistant to combination therapy with a diuretic.
• The benefit of antihypertensive therapy has been demonstrated in patients called “normotensive” but ++ high cardiovascular risk.
The classification of hypertension:
She often varied! Currently in France, these are the recommendations of the High Authority for Health (HAS) from 2005, in force (www.has-sante.fr). They are simpler than those of the ESH (European Society of Hypertension) from 2007.
In these recommendations, the blood pressure is ranked according to levels, but the actual point at which the individual is considered hypertensive may vary depending on the overall cardiovascular risk of the subject.
Currently, it is defined as a risk factor from a mean SBP of 140 mmHg and / or DBP an average of 90 mmHg.
The PA must be assessed outside of acute pathology. Do not confuse hypertensive consequence push of a painful condition, a stress, severe infection, … at a usual normotensive and real and chronic hypertension.
* Classification of blood pressure in adults aged 18 years and over:
We now are 3 levels of hypertension: mild, moderate, severe. The ESH also distinguishes the PA “optimal”, a BP <120/80 mmHg and isolated systolic hypertension, which is isolated, which is defined by a systolic BP> or equal to 140 mmHg, diastolic remaining <90 mmHg.
According to the BP level found, monitoring, support and time from start of treatment will be different.
blood pressure measurement taken lying down or sitting, arm at heart level, after standing at least 5 minutes away from an effort of an exciting decision … with calibrated pressure gauge, the 2 arms (asymmetry retain arm where the numbers are the highest; beyond 20 mmHg asymmetry, search a subclavian stenosis of the lower side), with a cuff adapted to the template (the inflatable bladder to make at least 2/3 the circumference and 2/3 of the height of the arm; need for an obese cuff and small). Averaging several measurements.
Always take a measurement after getting sudden (orthostatic drop?).
For diagnosis, if suspected a “white coat effect” interest of ambulatory blood pressure and self-measurement by the patient himself (with a validated automatic device, PA measured with a cuff – and not the wrist or finger because these devices are less reliable – the PA is considered high from 135/85 mmHg).
Assessment of associated risk factors: older age, male sex, coronary or vascular disease of Heredity (including brain) early, smoking, high cholesterol, low HDL-cholesterol, stress, diabetes or hyperglycemia, overweight, abdominal obesity, sedentary lifestyle, trend tachycardia syndrome of apnea / hypopnea sleep kidney failure.
Supports absolute cardiovascular risk:
You have to understand that beyond the numbers, the target values of the PA also depends on associated risk factors (FdR).
Stratification of cardiovascular risk levels:
Stratification of risk levels has been established in Europe (SCORE program – Systematic Coronary Risk Evaluation – downloadable at www.escardio.org/Prevention, heading SCORE – European Low Risk Chart), especially for countries of Southeast Europe, called “low risk”, such as France; depending on the number of risk factors associated with hypertension, a table shows the risk prediction of cardiovascular death at 10 years and prompts as appropriate for more active support.
Minimal biological assessment etiological and prognostic:
Plasma: electrolytes, creatinine, blood glucose, uric acid, cholesterol, triglycerides.
Urine: proteinuria, hematuria in the strip, and in doubt: ECBU and proteinuria over 24 hours.
We can make more accurate oriented research in a young person, in case of severe hypertension immediately, or suddenly worsened or “really” resistant to HAART well conducted (adherence problem associated énolisme, …), including necessarily a diuretic, or in case of symptoms orienting toward a particular cause.
Impact of hypertension:
Kidney: creatinine (and calculating the clearance by the Cockroft and Gault formula per strip), proteinuria.
Heart: functional signs, clinical, radiological, ECG (in search of conduction disturbances, signs of LVH) and possibly echocardiography (in case of dyspnea or chest pain, heart murmur or repolarization disorders or block left leg ECG).
Arteries: palpation, auscultation possibly directing an arterial Doppler ultrasound.
Brain research history of transient ischemic attack, stroke made; imaging requested on.
Find a cause “curable”:
taking medication (corticosteroids, vasoconstrictors, derived from ergot, estrogen), licorice, excess alcohol, palpation of the femoral pulse (coarctation of the aorta), kidneys, looking for an abdominal breath (renal artery stenosis ), signs of endocrinopathy …
Treatment of hypertension:
Chronic treatment is possible at a distance of intercurrent factor that can increase the numbers: painful episode, infectious, severe stress whose short-term regression will perhaps disappearance of hypertension.
We must correct the predisposing factors (alcohol, excess salt) and risk factors (see above); under stress, try non-pharmacological therapies (relaxation, sports activity in endurance).
Initial antihypertensive treatment:
If results are insufficient, or immediately if the cardiovascular risk (disease
cardio- or cerebrovascular proven, or renal failure), it must be treated by one of the 5 main antihypertertenseurs classes that showed a benefit on cardiovascular morbidity and mortality: beta blocker, ARBs, ACE inhibitors, thiazides and calcium channel blockers.
Only 2 classes have shown a complementary effect with the other 3 classes (see diagram) thiazide diuretics and calcium channel blockers.
So monotherapy choose from 5 classes or dual therapy with low-dose marketing authorization as first line: IEC-diuretic combination microdosée or beta blocker-diuretic microdosée.
In overweight subjects net will be avoided in the first intention beta blockers “old generation” and diuretics because they have a hyperglycemic effect ++ (most frequent onset of diabetes).
In combination therapy, in theory, combine classes according to the diagram below. In practice, we try to do, as against-indications, previous attempts failed and the patient’s intolerance!
The other classes of antihypertensive drugs (central alpha-blockers and antihypertensives), which have not demonstrated their efficacy on morbidity and cardiovascular mortality, are not recommended, but can help to achieve the target blood pressure in case of side effects or after the phase of triple therapy.
The choice may be guided by against-indications, the field or related conditions (see below).
The search for the optimal dose, bringing maximum efficiency for a minimum of side effects in an easy to administer, is a priority in this condition usually well tolerated +++, if we want a good adherence.
In case of ineffectiveness of this first treatment, ask the following questions:
– The patient taking treatment? Problem of compliance, convincing information of the patient by the doctor,
– Is the dose adjusted? We must achieve the optimal effective doses, with each bearing a long enough time to judge the full effect about a month,
– There he was a drug interaction? reduced efficiency with corticosteroids, nonsteroidal anti-inflammatory drugs, cimetidine …
– Hypertension is it secondary?
Then you have a choice:
1 / or increase the dose if it is less than the maximum recommended dose (recommended if you have a small “response” to the drug)
2 / or change of family,
3 / or prescribe a combination therapy, some dual therapy is synergistic: IEC-diuretic, calcium antagonist IEC, AAII-calcium antagonist, calcium antagonist bradycardia non-beta blocker, diuretic, beta blocker, AAII-diuretic; in combination therapy are often recommended as the presence of diuretics, except in obese patients and / or diabetic (diuretics = elevation of blood glucose).
In case of failure of combination therapy, there is a choice:
1 / change combination therapy,
2 / move to a triple combination therapy; must include a diuretic ++.
If unsuccessful, re-explore the patient (specialized service), completely change the treatment. Think more one delays the processing, unless the observance will be good and there will be side effects +++.
Interest of the self-measurement and ambulatory 24-h. to guide treatment.
In patient function:
– Nervous Subject, tachycardia, stressed: rather blocker.
– Black Subject: better efficacy of diuretics and calcium antagonists.
– Coronary Subject: Rather calcium antagonist or beta blocker bradycardia, against-indication of hydralazine (arterial vasodilator).
– Subject heart failure: diuretics and ACE inhibitors; beta blockers in normal doses and verapamil are cons-indicated.
– Subject with bradycardia or sinus node dysfunction: avoid beta blocker, calcium antagonist with nodal effect (diltiazem type Verapamil), clonidine.
– Subject with orthostatic hypotension (HTO): avoid central antihypertensives, calcium channel blockers, alpha-blockers.
– Author of more than 60 years: rather diuretics (except prostatism) or calcium antagonist.
– In elderly patients in a net HTO there is so potentially dangerous, it will not seek to obtain figures “ideals” of +++ blood pressure: to settle for a treatment that does not lower the PA standing less than 110mmHg for systolic BP.
– Diabetic topic: the objective is to bring BP to 130 / 80mmHg: rather IEC and AAII (nephroprotective recognized effect), avoid as much as possible diuretics (but can be brought).
– Renal impairment topic: the objective is to reduce BP below 130 / 80mmHg: using ACE inhibitors or ARBs, reduce dose; if diuretics, furosemide and bumetanide, avoid potassium-sparing and thiazide. Combination therapy is very common.
– Gouty topic: attention to the increase of serum uric acid by diuretics.
– Sports Subject: avoid beta blockers and diuretics.
– Asthmatic Subject: avoid non cardio¬sélectifs beta blockers, CELECTOL prefer or choose another class.
Order No. 1: diuretic
– Moduretic [amiloride chloride anhydrous, hydrochlorothiazide] or ISOBAR[methylclothiazide, triamterene] or FLUDEX LP [indapamide] 1.5 mg, 1 tablet in the morning.Diuretics non potassium sparing prescribed alone frequently require supplementation in the form of potassium salts and complicate monitoring and observance. However, regular monitoring of serum creatinine, serum sodium and potassium levels remains necessary whatever the type of diuretic +++ (hyponatremia in the elderly, hypokalemia with arrhythmogenic risk, functional renal failure from dehydration) electrolytes after 2-3 weeks treatment, then 1 every 6 months. The serum uric acid and blood sugar levels will be monitored in gouty or diabetic subjects.
Ordinance No. 2 blocker
– DETENSIEL [bisoprolol] or rash things [nebivolol] 1 tab daily in the morning (preferably start with a half dose for a few days to assess tolerance).
– A prior ECG is best to not miss a conductive asymptomatic disorder (first-degree AVB). A second ECG is recommended during the monitoring.
No.3: calcium antagonist
– LERCAN [lercanidipine] 10 mg or Zanidip [lercanidipine] 10 mg or AMLOR [amlodipine] 5 mg,or 240 Isoptine LP [verapamil], or MONOTILDIEM [diltiazem] first 200 mg and 300 mg in the morning possibly.
Ordinance No. 4: IEC
– There are different dosages depending on treatment response: Triatec [ramipril] (2.5 mg, 5 mg and 10 mg) or ODRIK 2 and 4 mg [trandolapril]: 1 tablet daily in the morning.
– A control electrolytes and creatinine are desirable after 2-3 weeks, then once every 6 months.
Ordinance No. 5: antagonists of angiotensin II
– TAREG [valsartan] 80 mg or 160 mg or APROVEL [Irbesartan] 150 mg (or 300 mg) or OLMETEC[olmesartan] 20 mg or 40 mg or Atacand [Candesartan cilexetil] 8 mg or 16 mg), 1 tablet per day morning.
– Even biomonitoring the IEC.
Order No. 6: combination therapy in monoprise, low dose, approved in first intention (combination perindopril-indapamide 2.5mg 0,625mg)
– PRETERAX [perindopril, indapamide] 1 tab in the morning.
Biological monitoring is superimposed on that of diuretics and ACE inhibitors.
– Lodoz [bisoprolol, hydrochlorothiazide] 2.5 / 6.25mg (Merck Lipha), 1 tablet in the morning. A climb to a higher dosage in case of inadequate response: Lodoz 5 / 6.25mg or Lodoz 10 / 6.25mg, 1 tab in the morning.
Ordinance No. 7: Other classes
– Physiotens [moxonidine] 0.2 or 0.4 mg, 1CP daily.
– EUPRESSYL 60 mg [Urapidil], 1-2 tab daily.
– Alpress LP [prazosin] 2.5 mg or 5 mg: 1 tablet daily.
Order 8: combination therapy in monoprise validated by secondary intention (which can be administered immediately in cases of severe hypertension)
– IEC + associated diuretics: FOZIRETIC [fosinopril, hydrochlorothiazide] BIPRETERAX[perindopril, indapamide] 1 tab daily in the morning.
– Antagonist angiotensin II + diuretic associated: COTAREG 80 mg / 12.5 mg or COTAREG 160 mg / 12.5 mg or COTAREG 160/25 mg.
– Calcium antagonist + beta-blocker associated: Logimax [felodipine, metoprolol succinate], 1 tab in the morning.
– Calcium antagonist + IEC associates: LERCAPRESS [lercanidipine, enalapril] 1 tablet daily, or TARKA LP [verapamil, trandolapril] 1 tab 2 tab daily.
– Calcium antagonist + AAII associates: EXFORGE [amlodipine, valsartan] 5 mg / 80 mg or 5 mg / 160 mg or 10 mg / 160 mg, or SEVIKAR [olmesartan, amlodipine] 20 mg / 5 mg or 40 mg / 5 mg or 40 mg / 10 mg, depending on the severity of hypertension.
Monitoring is one of the individual components alone.
Ordinance No. 9: pregnant woman
– ALDOMET [methyldopa] 250 to 500mg, or CATAPRESSAN [clonidine] 1-3 cp / day or MINIPRESS[prazosin] and Alpress LP [prazosin] or trandate [labetalol], 2 tab daily, these drugs are devoid of teratogenicity.
– Anyway, ‘pregnancy risk’ advice and monitoring by specialists (cardiologist and obstetrician).
Treatment of “hypertensive emergency” (the patient’s home):
– Do not drop too sharply figures (an excessive fall can cause neurological injury)! So learn to wait a gradual decline +++.
– Always reassure the patient and his family (if not increase stress ++). Possibility of prescribing benzodiazepines.Rest.
– If asymptomatic patient: initiation of treatment or usual doses increase or modification of the previously prescribed treatment.
– If simply interrupted treatment: resumption of treatment at usual doses.
– If left heart failure: Lasix [furosemide] intravenous (IV) and sublingual nitrates and intravenous.
– If unstable angina or acute myocardial infarction: ADALATE [Nifedipine] discouraged, nitro sublingual and intravenous.
– If AVC: the hypertensive crisis in the acute phase of an ischemic or hemorrhagic stroke should be respected +++ in the early hours on pain of neurological worsening,
an intravenous treatment not winning in case of heart or kidney complications.
– It leaves only rare cases where you can use LOXEN [nicardipine chloride] 20 mg orally or CATAPRESSAN [clonidine] 1 amp IM. (The ADALATE sublingually is discouraged and no longer has the marketing authorization for this indication ++).
– Hospitalization for IV infusion LOXEN [nicardipine] trandate, BREVIBLOC, EUPRESSYL [Urapidil] Tenormine [atenolol] …