Behandling af hypertension

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1 Behandling af hypertension
IRF Tage Lysbo Svendsen Ledende overlæge dr.med Holbæk Sygehus Formand for Dansk Hypertensionsselskab

2 Definitions and Classification of Blood Pressure Levels (mmHg)
85-89 and/or High Normal 80-84 Normal <80 and <120 Optimal Diastolic Systolic Category 90-99 and/or Grade 1 Hypertension and/or Grade 2 Hypertension Grade 3 Hypertension ≥180 and/or ≥110 <90 and ≥140 Isolated Systolic Hypertension

3 Stratification of CV risk in four categories
Blood pressure (mmHg) Other risk factors, OD or disease Normal SBP or DBP 80-84 High normal SBP or DBP 85-89 Grade 1 HT SBP or DBP 90-99 Grade 2 HT SBP or DBP Grade 3 HT SBP ≥180 or DBP ≥110 No other risk factors Average risk Low added risk Moderate added risk High added risk 1-2 risk factors Very high added risk 3 or more risk factors, MS, OD or diabetes Established CV or renal disease SBP: systolic blood pressure; DBP: diastolic blood pressure; CV: cardiovascular; HT: hypertension. Low, moderate, high, very high risa refer to 10year risk of a CV fatal or non-fatal event. The term “added” indicates that in all categories risk is greater than average. OD: subclinical organ damage; MS: metabolic syndrome.

4 Non farmakologisk behandling
Motion Saltrestriktion Afmagring ved overvægt Reduktion af alkoholindtagelse DASH diet

5 Farmakologisk behandling
Diuretika Betablokkere Calciumantagonist ACE/AII-antagonister Reninantagonister Alfa-blokkere Centralt virkende antihypertesiva Aldosteronantagonister

6 Betablokkere Beta1selektive(atenolol,metoprolol)
Non- selektive(Propranolol) Alfa-betablokkere(carvedilol, labetalol) Uspecifik vasodilaterende (nebivolol)

7 Reduction in the Risk of Stroke1
8 Fatal and nonfatal stroke 7 Atenolol 6 5 Losartan 4 Proportion of patients with first event (%) 3 2 Slide 16: Reduction in the Risk of Stroke1 This graph shows the Kaplan-Meier curves for the individual endpoint of fatal and nonfatal stroke. The losartan and atenolol curves separated early in the study. The outcome was in favor of losartan, with a 24.9% reduction in relative risk of stroke compared with atenolol. The risk reduction was significant (p = 0.001).No significant differences in CV death (11.4%, p = 0.206) and MI (-7.3%, p = 0.491) vs. atenolol were observed. Reference: 1. Dalhöf B, Devereux RB, Kjeldsen SE et al, for the LIFE study group. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): A randomised trial against atenolol. Lancet 2002;359: Adjusted risk reduction %, p = Unadjusted risk reduction 25.8%, p = 1 6 12 18 24 30 36 42 48 54 60 66 Time (months) Number at risk Losartan (n) Atenolol (n) No significant difference in CV death and MI vs. atenolol. Risk reduction = relative risk vs. atenolol. 7 1. Dahlöf B et al. Lancet 2002;359:

8 Ascot Atenolol (+diuretica) versus Amlodipin (+ace) 19. 257 pt.
Signifikant reduktion i Apopleksi,Kardiovaskulærmortalitet,AMI på 11-24%

9 Thiazider Thiazider er lige så effektive til at sænke blodtrykket og til at reducere morbiditet og mortalitet som ACE-hæmmmere, A-II-antagonister, calciumantagonister og betablokkkere. I de doser der anvendes i dag er bivirkningsfrekvensen lav.

10 Calciumantagonister Dihydropyridin derivater (amlodipin, nifedipin og mf) Non – dihyropyridin (verapamil og diltiazem)

11 ACE/AII-antagonister
ACE (Ramipril,enalpril,perindopril lisinopril og mf) AII-antag.(Losartan,irbesartan, candersartan og mf) Reninantagonister

12 Andre antihypertensiva
Alfa- blokker (Prazosin,doxazosin terazosin) Centralt virkende (methyldopa,moxonidin)

13 Den ukomplicerede hypertensions patient
Calciumantagonist f.eks amlodipin To stof behandling: 1)Ace- inhibitor f.eks enalpril, Tre stof behandling:Tiazid (eller ACE eller Beta blokker)

14 Possible combinations between some classes of antihypertensive drugs
Thiazide diuretics β-blockers Angiotensin receptor antagonists α- blockers Calcium antagonists ACE inhibitors The preferred combinations in the general hypertensive population are represented as thick lines. The frames indicate classes of agents proven to be beneficial in controlled intervention trials

15 Diabetes Mellitus AMI Hjerteinsufficiens Nyresygdom Angina Apopleksi Ace-inhib/a-II antag. Betablokker Ace- Inhib/ betablok Ace-inhib Betablok /calciumanta Ace-inh./A-II-anta

16 Antal patienter i monoterapi

17 Antal pt.i to-stof behandling

18 Antal pt. i tre-stof behandling

19 Pris fire-stof kombinationsbehandling
Thiazid Centyl c Kcl ,44 kr Betablok Atenolol mg ,71 kr Calciumanta. Amlodipin 10mg 0,63 kr Ace inhib. Enalpril mg ,71 kr Fire-stof kombin ,49 kr

20 Pris fire-stof kombinationsbehandling
Thiazid Centyl c Kcl ,44 kr Beta Bisoprolol mg kr Calciumant Myonil mg ,70 kr Coversyl mg ,40 kr A-II antag irbesartan 300mg ,41 kr Fires-tof kombinationsbeh ,10 kr

21 Mest anvendte behandling 2006
Monoterapi Diureticum To-stof beh. Ace/AII+Diur Tre.stofbeh Cal+ACE+D

22 Sundhedsstyrelsen 2001 2004 2006 Alle patienter 508 163 628 982
41,0% Pt på 2 stof behandling 407460 74,2 % Pt på 3 stof behandling 57 307 151,7%