The Specialist Forum Volume 13 No 11 November 2013

HYPERTENSION • Serum total cholesterol, low-density lipoprotein cholesterol, highdensity lipoprotein cholesterol • Fasting serum triglycerides • Serum potassium and sodium. • Serum uric acid • Serum creatinine (with estimation of GFR) • Urine analysis: microscopic examination; urinary protein by dipstick test; test for microalbuminuria • 12-lead ECG. Additional tests, based on history, physical examination, and findings from routine laboratory tests • Haemoglobin A1c (if fasting plasma glucose is >5.6 mmol/L (102 mg/ dL) or previous diagnosis of diabetes) • Quantitative proteinuria (if dipstick test is positive); urinary potassium and sodium concentration and their ratio • Home and 24 hour ambulatory BP monitoring • Echocardiogram • Holter monitoring in case of arrhythmias • Carotid ultrasound • Peripheral artery/abdominal ultrasound • Pulse wave velocity • Ankle-brachial index • Fundoscopy. Extended evaluation (mostly domain of the specialist) • Further search for cerebral, cardiac, renal, and vascular damage, mandatory in resistant and complicated hypertension • Search for secondary hypertension when suggested by history, physical examination, or routine and additional tests. Therapeutic reduction of high BP Evidence favouring the administration of BP-lowering drugs to reduce the risk of major clinical CV outcomes (fatal and non-fatal stroke, myocardial infarction, heart failure and o ther CV deaths) in hypertensive individual’s results from a number of RCTs—mostly placebo-controlled— carried out between 1965 and 1995. The new recommendations are based on available evidence from randomised trials and focus on important issues for medical practice: • When drug therapy should be initiated • The target BP to be achieved by treatment in hypertensive patients at different CV risk levels • Therapeutic strategies and choice of drugs in hypertensive patients with different clinical characteristics. Initiation of antihypertensive drug treatment Recommendation Class Level Prompt initiation of drug treatment is I A recommended in individuals with grade two and three hypertension with any level of CV risk, a few weeks after or simultaneously with initiation of lifestyle changes Lowering BP with drugs is also recommended I B when total CV risk is high because of OD, diabetes, CVD or CKD, even when hypertension is in the grade one range Cardiology & Stroke Forum | November 2013 Initiation of antihypertensive drug treatment should also be considered in grade one hypertensive patients at low to moderate risk, when BP is within this range at several repeated visits or elevated by ambulatory BP criteria, and remains within this range despite a reasonable period of time with lifestyle measures In elderly hypertensive patients drug treatment is recommended when SBP is ?160 mmHg Antihypertensive drug treatment may also be considered in the elderly (at least when younger than 80 years) when SBP is in the 140–159 mmHg range, provided that antihypertensive treatment is well tolerated Unless the necessary evidence is obtained it is not recommended to initiate antihypertensive drug therapy at high normal BP Lack of evidence does also not allow recommending to initiate antihypertensive drug therapy in young individuals with isolated elevation of brachial SBP, but these individuals should be followed closely with lifestyle recommendations IIa B I A IIb C III A III A Choice of drugs Recommendation Diuretics (thiazides, chlorthalidone and indapamide), beta-blockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers are all suitable and recommended for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in some combinations with each other Some agents should be considered as the preferential choice in specific conditions because used in trials in those conditions or because of greater effectiveness in specific types of OD Initiation of antihypertensive therapy with a twodrug combination may be considered in patients with markedly high baseline BP or at high CV risk The combination of two antagonists of the RAS is not recommended and should be discouraged Other drug combinations should be considered and probably are beneficial in proportion to the extent of BP reduction. However, combinations that have been successfully used in trials may be preferable Combinations of two antihypertensive drugs at fixed doses in a single tablet may be recommended and favoured, because reducing the number of daily pills improves adherence, which is low in patients with hypertension Class Level I A IIa C IIb C III A IIb C IIb B Reference: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). 2013 ESH/ESC Guidelines for the management of arterial hypertension. The European Heart Journal, doi:10.1093/eurheartj/eht151? CF Page 13

The Specialist Forum Volume 13 No 11 November 2013 | Page 71