Chiabrando Juan Guido · 2020-04-23 · Definicion SISTOLICA DIASTOLICA 120 130 140 160 180 80 85...
Transcript of Chiabrando Juan Guido · 2020-04-23 · Definicion SISTOLICA DIASTOLICA 120 130 140 160 180 80 85...
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Hipertension arterial
Chiabrando Juan Guido
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No tengo conflictos de interes
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Definicion
SISTOLICA
DIASTOLICA
120 130 140 160 180
80 85 90 100 110
OPTIMA NORMAL GDO 1 GDO 2 GDO 3NL/ALTA
IaIIbBryan Williams, Giuseppe Mancia, Wilko Spiering, et al. 2018 ESC/ESHGuidelines for themanagement ofarterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). European Heart Journal (2018) 39, 3021–3104 doi:10.1093/eurheartj/ehy339
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Impacto
ACV
IAM
ICC
Muerte
ERC
FA
HTA
Bryan Williams, Giuseppe Mancia, Wilko Spiering, et al. 2018 ESC/ESHGuidelines for themanagement ofarterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). European Heart Journal (2018) 39, 3021–3104 doi:10.1093/eurheartj/ehy339
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Rapsomaniki Eleni, Timmis Adam, George Julie, et al. Blood pressure and incidence of twelve cardiovascular diseases: Lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people. The Lancet 2014, 383. 1899-1911 DOI:10.1016/S0140-6736(14)60685-1
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Determinantes de Hipertension arterial
Volumen Minuto Resistencia periferica
IECA / ARAII
CA++ BLOCK
DIURETICOS
NITRATOS / NITROPRUSIATO
BETABLOCK
Contractilidad Precarga PoscargaFC
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“Buscar la indicacion y la contraindicacion”
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En general
• Tiene que tener indicacion de inicio de tratamiento• Siempre has optimizado las medidas higienico dieteticas• ‘Combinacion es mejor que una sola’ + ‘Si en una sola pastilla, mejor
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Caso #1
DM
60 a.
Antec. IAM reciente
TA: 160/80
Examen fisico normal
Na: 145 Cr: 1.1 K:3.7
ECG secuela anterior
IECA / ARA II
Eco con Fey 40%
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IECAs
•Captopril, Enalapril, Lisinopril, Ramipril, Perindopril, etc.
•VO (hay formulaciones IV de Enalaprilato). • Eliminacion renal. •Profarmacos (Enalapril, Ramipril y Perindopril)
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Messerli, Franz H. Bangalore Sripal, Bavishi Chirag, Rimoldi Stefano F. Angiotensin-Converting Enzyme Inhibitors in Hypertension: To Use or Not to Use? Journal of the American College of Cardiology, 2018; 71; 1474-1482. DOI 10.1016/j.jacc.2018.01.058
The AT2 stimulation counteracts the negative consequences of Ang II, presenting favorable effects on tissue growth and repair processes, potentially providing additional endorgan protection.
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AA AEPG AgII
IECA / ARAIIAINEsICC
HipovolemiaDiureticos
Estenosis renal
G
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• Tos (5-20%)•Angioedema (0.1-0.5%)•HiperK•HipoTA• Toxicidad fetal• IRA [en ciertas condiciones]• Examentema•Neutropenia•Hepatotox colestasica
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Indicacion: •HTA• ICC con Fey severa (<35%)•Post IAM•Nefropatia diabetica.
CI: • Estenosis renal bilateral• Estenosis renal unilateral en monorrenos•Angioedema
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ARA/II
• Losartan, Candesartan, Irbesartan, Telmisartan, etc.•VO - Metabolismo hepatico no microsomal, excepto
Losartan [CYP2C9 y 3 A4]
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Messerli, Franz H. Bangalore Sripal, Bavishi Chirag, Rimoldi Stefano F. Angiotensin-Converting Enzyme Inhibitors in Hypertension: To Use or Not to Use? Journal of the American College of Cardiology, 2018; 71; 1474-1482. DOI 10.1016/j.jacc.2018.01.058
The AT2 stimulation counteracts the negative consequences of Ang II, presenting favorable effects on tissue growth and repair processes, potentially providing additional endorgan protection.
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• Angioedema menos frecuente que IECA. No producen Tos• Toxicidad fetal• Hiper K• IRA [en ciertas condiciones]
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Caso #2
RAYNAUD
40 a Mujer
Hiponatremias sintomaticas frec.
TA: 160/80
Examen fisico normal
ECG con signos de hipertrofia VI
ETT con signos de hipertrofia ventricular
Na:135 Cr:2.2 K:4
IRC (2.1 habitual)
Ca++ Block
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Ca++ Block (Dihidropiridinas)
•Amlodipina, Lercanidipina• Inhibicion canales Ca++ tipo L•VO. Metabolismo hepatico• Edema periferico, constipacion
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Caso #3
IAM reciente
50 a
Estenosis renal bilateral
TA: 160/80
Soplo abdominal en ambos flancos. Sin ICC
ECG con ritmo sinusal. Secuela anterior.
ETT con VI severo (35% Fey)
Na:145 Cr:1 K:4
Beta Block
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BetaBlock
•Dinamica depende de receptores involucrados (B1 selectivo vs No Selectivo)•Metabolismo Hepatico o Renal•Adversos cardiacos (Fc / Ino) y extracardiacos
(Respiratorio, SNC).•Contraindicaciones absolutas y relativas.
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Caso #4
Sin Antecendentes
30 a
Cumplio medidas higienicodieteticas.
TA: 160/80
Examen fisico normal
ECG normal
ETT normal
Na:145 Cr:1 K:4
Tiazidas
2da consulta
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Tiazidas
•Natriuresis y vasodilatacion•VO•HipoNa, HipoK, HiperCa, impotencia, Lipidos glucosa y urea • Interaccion con AINEs, Digital
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Caso #5
TBQ activo
Ant. Enf. Coronaria
EVP
TA: 220/130
Confuso, con dolor precordial en curso.
Sin ICC, normoperfundido. Sin
soplos80 a
Nitroprusiato
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Nitroprusiato
• Liberacion de -> Oxido Nitrico – Estimulo GMPc – Fosforilacion cadena ligera Miosina – Vasodilatacion arterial y venosa. -> Cianuro [toxicidad a corto plazo] –> Tiocianato (via rodanasa hepatica [Acumulacion y toxicidad prolongada]. Necesidad de Tiosulfato para metabolizar. NO INFUNDIR POR >24-48 HS• IV! No genera tolerancia• HipoTA
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Caso #6
TBQ activo
Sin ant. personales
50 a
TA: 220/130 BD. 150/90 BI
Dolor precordial terebrante
Hemiplejia izquierda.
ECG con ST elevado en cara inferior
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Labetalol
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JAMA, December 18, 2002—Vol 288, No. 23DOI: 10.1001/jama.288.23.2981
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Poblacion
Intervencion
Comparacion
Outcome
Pacientes hipertensos (≥140 / 90)
IECA (Lisinopril) o BC (Amlodipina) o
Alfa Block (Doxazosina)
Diureticos (clortalidona)
Evento coronario fatal o IAM no fatal
Randomizado
Doble ciego
Multicentrico
4.9 a follow up
33357 pac.
PICO y Caracteristicas
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EXCLUSION
Ant. ICC o Fey <35%
Criterios
INCLUSION
>55 a
HTA Gdo 1 o 2
Al menos 1 FRCV
Ant. IAM o ACVHVI (Eco o ECG)DM IITBQ activoHDL bajo
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Outcomes
SECUNDARIOS
Mortalidad total
ACV
Eventos cardiovasculares mayores [ICC,
Revascularizacion, angina y enf. Vasc. Periferica]
PRIMARIO
Evento coronario fatal o IAM no fatal
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Intervencion
Amlodipina [2.5 -10 mg]N = 9048
Lisinopril [10-40 mg]N = 9054
Clortalidona [12.5-25 mg]N =15255
Doxazosin [2-8 mg]N = 9054
OBJ = <140/90
ATENOLOL , RESERPINA Y CLONIDINA
Si no cumplian
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Muestra obtenidaCaracteristicas generales
Edad 66.9 años
Blancos 47.2%
Mujeres 47%
TBQ activo 21.9%
IAM o Stroke Previo 23.5%
Revascularizacion previa 13%
DBT II 36.2%
HDL Bajo 11.3%
HVI por Eco 16.5%
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Resultados
Evento coronario fatal o IAM no fatal
Amlodipina vs Clortalidona
Lisinopril vs Clortalidona
(11.3% vs. 11.5% RR 0.98, p = 0.65)
11.4% vs. 11.5%, RR 0.99, p = 0.81
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Amlodipina vs Clortalidona
Lisinopril vs Clortalidona
10.2% vs. 7.7%, RR 1.38 IC95[1.25-1.52] , p < 0.001) 6.3% vs 5.6%, RR 1.15 IC95 [1.02-1.30] , p=0.02
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Perlitas
AmlodipinaMayor riesgo CHF hospitalizado / Fatal (RR 1.35, p < 0.001)
LisinoprilMayor riesgo de Eventos cardiovasculares combinados (RR 1.10, p < 0.001)Mayor riesgo de CHF (RR 1.19, p < 0.001), angina (RR 1.11, p = 0.01), y eventos de revascularizacion (RR 1.10, p = 0.05).
Crossover-13% de pacientes en Clortalidona tomaban diuretico con BC o IECA- 9% estaban tomando BC o IECA sin diuretico
Doxazosin fue terminado prematuramente por - Mayor riesgo de ACV (RR 1.19, p = 0.04)- Mayor riesgo de CVD (CHF, revascularizacion, angina,
EVP (riesgo a 4 25.5% vs. 21.8%, RR 1.25, p < 0.001). - El riesgo de CHF fue el doble a 4 años (8.13% vs. 4.45%,
RR 2.04, p < 0.001)