.The primary objective is proposed that a doctor in the treatment of hypertensive patient is to achieve the maximum reduction in risk of cardiovascular mortality and morbidity in the long term. This goal requires the treatment of all reversible risk factors identified, including:

smoking,

control of dyslipidemia which is the basis of atherosclerosis

abdominal obesity

diabetes,

appropriate treatment of clinical conditions associated

the treatment of high blood pressure.





Main variables in risk stratification

Risk Factors

· Pressure systolic and diastolic

· Pressure Differential (elderly)

· Age (M> 55, F> 65 years)

· Smoking habits

· Dyslipidemia

• C-Tot> 5.0 mmol / l (190 mg / dl) or:

• C-LDL> 3.0 mmol / l (115 mg / dl) or:

• C-HDL: M <1.0 mmol / l (40mg/dl), F <1.2 mmol / l (46 mg / dl) or:

· Tan> 1.7 mmol / l (150 mg / dl)

· Fasting: 5.6-6.9 mmol / l (102/125 mg / dl)

· Cargo impaired glucose

· Abdominal obesity [waist circumference M> 102 cm, F> 88 cm]

Familiarity precocious CV disease (M age <55 years; F <65 years)

Diabetes mellitus

· Fasting blood glucose ≥ 7.0 mmol / l (126 mg / dl) (repeated evaluations) or:

· Postprandial glucose> 11.0 mmol / l (198 mg / dl)

Organ damage

· Electrocardiographic evidence of LVH (Sokolow-Lyon> 38 mm; Cornell> 2440 mm * ms) or:

· Echocardiographic evidence of LVH (IMVS M ≥ 125 g/m2, F ≥ 110 g/m2)

· Thickening of the carotid wall (IMI> 0.9 mm) or atherosclerotic plaque

Cable / carotid-femoral pulse wave> 12 m / sec

Pressure · Index legs / arms <0.9

· Slight increase of serum creatinine:

· M 115-133 mmol / l (1.3-1.5 mg / dl), F 107-124 mmol / l (1.2-1.4 mg / dl)

· Reduction of glomerular filtration rate (MDRD) (<60 ml/min/1.73m2) or

· The creatinine clearance (Cockroft Gault formula) (<60 ml / min)

· Microalbuminuria 30-300 mg/24 h or albumin-creatinine ratio [mg / g creatinine]: M ≥ 22, F ≥ 31

Kidney disease or overt CV

· Cerebrovascular disease: ischemic stroke, cerebral hemorrhage, transient ischemic attack (TIA)

· Heart disease: myocardial infarction, angina, coronary revascularization, heart failure

· Renal diseases: diabetic nephropathy, renal failure (serum creatinine M> 133, F> 124 mmol / l),

· Proteinuria> 300 mg/24 h

· Peripheral vascular disease

· Advanced retinopathy: haemorrhages or exudates, papilloedema

The presence of at least three of the following risk factors: abdominal obesity, impaired fasting glucose, blood pressure 130/86 mmHg above, low levels of HDL cholesterol, high triglyceride levels, makes a diagnosis of metabolic syndrome. M: Male F: Female; CV: cardiovascular; LVH: left ventricular hypertrophy, BP: blood pressure, TG: triglycerides; CTOT: total cholesterol, LDL-C: LDL cholesterol, HDL-C: HDL cholesterol; IMI thickening medium intima.
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It is recommended that in all hypertensive patients blood pressure is reduced to less than 140/90 mm Hg and lower values can be a therapeutic target to pursue, if tolerated by the patient. The antihypertensive treatment should be more aggressive in diabetic patients to reduce blood pressure to values below 130/80 mmHg.

Similar pressure goals should be pursued even in patients with a history of cerebrovascular events and at least considered in patients with coronary artery disease. While taking into account some effects of variability between subjects, the risk of hypoperfusion of vital organs is really low.

An exception is dall'ipotensione orthostatic hypotension should be avoided, especially in elderly patients and diabetics. The existence of a J-curve between events and blood pressure therapy has been postulated on the basis of retrospective analysis that showed that the incidence of

increases in the presence of very low diastolic values.

It was also suggested that the J-curve phenomenon relates to blood pressure well below those that represent a therapeutic target in patients with prior myocardial infarction or heart failure. In fact, these patients beta-blockers and ACE inhibitors have achieved a reduction in the incidence of cardiovascular events even when blood pressure was lower, the effect of therapy, however, already low pre-treatment values.

It must be recognized that, despite the use of combination therapy, most trials in systolic blood pressure remains above 140 mm Hg.

Even in trials in which this was achieved, the finding of an adequate blood pressure control not cover more than 60-70% of enrolled patients. Except for the ABCD, which recruited patients with normal blood pressure or high-normal, no trial has achieved in diabetic patients with blood pressure below 130 mm Hg. It is therefore difficult to reach the target blood pressure recommended by the Guidelines, especially when the pre-treatment blood pressure is high, or in the elderly in

such as the increase in systolic aortic distensibility depends from weathering and vascular fibrosis. Data from the trial show that even when using combination therapy is still more difficult to reach the desired target blood pressure in diabetics than non diabetics.



Therapeutic approach

related links: kidney pressure complications in patients with hypertension High blood pressure: the medication> Hypertension: treatment 2010

When necessary, changes in lifestyle should be introduced in all patients, including subjects with high-normal blood pressure and patients who require drug treatment. The aim is to reduce blood pressure and modulate other risk factors and associated clinical conditions, reducing the number and doses of antihypertensive drugs to use.

However, changes in lifestyle have not proved capable in hypertensive patients to prevent cardiovascular complications and is often difficult to maintain neltempo non-pharmacological intervention. The adoption of these measures should not delay drug treatment, particularly in subjects at high risk. The vast majority of randomized clinical trials, aimed at comparing active treatment versus placebo or active treatment of different types, confirm what has already been highlighted in the Guidelines ESH / ESC 2003, ie, whether the main benefits of antihypertensive therapy depend the reduction of high blood pressure per se and in part on the type of drug used, whether thiazide diuretics (as well as el'indapamide chlorthalidone), beta blockers, calcium channel blockers, ACE inhibitors and angiotensin receptor blockers II are all effective antihypertensive drugs with well documented and can significantly reduce the incidence of fatal cardiovascular events.

It is therefore possible to conclude that the major classes of antihypertensive drugs are all mentioned as therapeutic choice with which to begin and continue treatment, either alone or in combination. However, it was revealed that the five classes of drugs may differ in some properties and therapeutic characteristics.

Choice of antihypertensive drug. The results of two large trials and a meta-analysis showed that beta-blockers do not carry any effect in terms of cerebrovascular protection, despite the favorable effects on CHD morbidity and mortality. Therefore, therapy with beta-blockers should be reserved for patients with a history of angina pectoris, heart failure and recent myocardial infarction, and that is the main complications of hypertension. Beta-blockers, therefore, may still be considered as a therapeutic option to start and / or continue antihypertensive treatment.

Beta-blockers should not be prescribed in hypertensive patients with metabolic syndrome or in the presence of abdominal obesity, impaired fasting glucose, carbohydrate intolerance or diabetogenic high risk, because it leads to an increase in body weight, have adverse effects on glycolipid metabolism and promote more often than other classes of antihypertensive drugs, the development of diabetes. Similar conclusions apply to the thiazide diuretics. In most clinical trials, in which he highlighted a high incidence of new cases of diabetes, the therapeutic strategy included a combination therapy of a thiazide diuretic and a beta-blocker, making it difficult to discriminate which of the two drugs was the main culprit dysmetabolic effects. These considerations, however, does not necessarily relate to the new generation of beta-blockers (such as carvedilol and nebivolol), which compared to traditional beta blockers, show less diabetogenic.

Since beta-blockers, ACE inhibitors and angiotensin II receptor blockers are less effective in black patients, it is preferable in this case, use diuretics and calcium channel blockers. The trials that have investigated the effects of therapy sugliendpoint intermediate revealed other differences between the various classes of drugs for several therapeutic effects, or in some specific groups of patients. For example, ACE inhibitors and receptor antagonists dellangiotensina been shown to promote regression of left ventricular hypertrophy (fibrotic component included), to reduce microalbuminuria and proteinuria, and slow the progression of renal dysfunction. Calcium channel blockers were more effective in slowing the progression of the atherogenic process in carotid vascular hypertrophy.



Antihypertensive treatment IDEAL

(See also The hypertensive patient)



Metabolic syndrome is a very bad prognostic factor because it may increase the cardiovascular risk of patients, either directly or indirectly, by providing a significant medical diseases such as hypertension, diabetes mellitus and dyslipidemia. Treatment of hypertension in patients with metabolic syndrome is particularly challenging because some classes of drugs such as beta-blockers and diuretics, promote obesity, diabetes and dyslipidaemia, thus at risk for these diseases should be avoided or used with extreme caution. The calcium channel blockers, however, are among the major classes of antihypertensive drugs available to physicians to achieve effective blood pressure reduction and organ protection. Considering the antihypertensive efficacy organ damage and cardiovascular events, we can say that this is a class of medications underused in the treatment of hypertension. Calcium channel blockers have the same effectiveness of ACE inhibitors in achieving a low dell'IVS, and are most effective for this class of drugs in preventing the progression of atherosclerosis. On the contrary, ACE inhibitors are more effective than calcium channel blockers in slowing the progression of renal failure. We must however point out one thing: the fact that ACE inhibitors or AT-1 (ARBs) offer better nephroprotection antagonists than calcium channel blockers. ACE inhibitors and AT-1 antagonists block the vasoconstrictor effect of angiotensin sull'arteriola The outflow and therefore reduce the intraglomerular pressure, which is the main mechanism nephroprotection exercised by this class of drugs. In contrast, calcium antagonists act either sull'arteriola both afferent and efferent, and then expose the systemic pressure to the glomerulus. However, to the extent that calcium antagonists reduce blood pressure, are renoprotective in parallel, it is well documented that the reduction in blood pressure is the main mechanism that determines nephroprotection. Regarding the effectiveness of calcium channel blockers on cardiovascular events, they seem to have a specific effect in the prevention of stroke, whereas for CHD their effectiveness depends on the extent of reduction in blood pressure. The main limitation to the clinical use of calcium channel blockers is the significant incidence of side effects such as edema perimalleolare.Dal because the vast majority of patients is necessary to use two or more antihypertensive drugs in combination to achieve the goal blood pressure, not useful in practice determine which is the class of therapeutic drugs of first choice. In fact, if the long-term therapy is necessary to resort to the use of two or more drugs, is of marginal interest to choose which drug treatment is started. However, it was shown that various drugs have the same safety profile, which may vary from patient to patient. Some specific classes of drugs may differ in some therapeutic effects on risk factors, organ damage and clinical conditions, specifications, or in specific patient groups. Considering the large amount of data collected so far we can say that the choice of antihypertensive drug (monotherapy or combination therapy) will be influenced by many factors, including the experience (whether positive or negative) that the patient has acquired previously with the use of a particular class of antihypertensive drugs in terms of antihypertensive efficacy and side effects, the effects of the drug on cardiovascular risk factors in relation to the risk profile of individual patients, the presence of organ damage and cardiovascular disease, renal or clinically manifest diabetes who may benefit from treatment with certain drugs over others. Do not overlook the presence of other underlying conditions that may promote or restrict the use of specific classes of antihypertensive drugs and a potential for interactions with drugs that a patient is taking for other conditions. Finally, it should be preferred drugs or long-acting formulations that once daily to be able to provide a therapeutic effect throughout the 24 hours. The simplification of the regimen has a positive impact on patient compliance to therapy. Furthermore, in terms of prognosis, it is important to get a good blood pressure control not only blood pressure monitor, but also in the course of 24 hours. Finally, the use of long-acting drugs can reduce blood pressure variability.

The Guidelines ESH / ESC 2007 there are some innovative aspects, on the factors to consider in assessing the level of cardiovascular risk, they deserve to be reported. Is mentioned, the metabolic syndrome because the disease rather than an autonomous entity, is a clinical condition characterized by the presence of multiple risk factors in addition to hypertension, the latter element that reflects negatively on the overall cardiovascular risk profile.

- It was a special emphasis on the assessment of organ damage, whose presence also greatly increases the risk of subclinical level. A specific section was devoted to the identification of organ damage and have been proposed threshold values of reference for each variable considered.

- It has been extended the list of renal markers of organ damage, which includes the calculation of creatinine clearance by Cockroft-Gault formula or the estimated glomerular filtration rate by MDRD formula. The inclusion of these variables depends on whether they are reliable markers of cardiovascular risk that is associated with renal failure. - Microalbuminuria was considered to be an essential parameter for the assessment of organ damage because its determination is easy and relatively inexpensive. - The concentric left ventricular hypertrophy is the structural alteration that increases heart rate in a large cardiovascular risk.

- It is recommended to carry out evaluations of organ damage in several districts (heart, blood vessels, kidney and brain), since the presence of multiorgan damage is associated with a worse prognosis than the condition characterized by damage of a single organ. -

- The list of factors influencing the prognosis has been added to a variable, namely the increase of pulse wave velocity as an early indicator of impaired distensibility of large arteries, while still recognizing its limited use in the clinic. - A reduced value of the relationship between blood pressure to the upper and lower limbs (<0.9) was proposed as an index of atherosclerosis. This parameter is relatively easy to evaluate in the clinic and is associated with an increased cardiovascular risk.

- It is recommended that assessment of organ damage not only to set the first therapy (risk stratification), but also during treatment, as the regression of left ventricular hypertrophy and proteinuria are reliable indices of the effects of protection induced cardiovascular therapy.

- Elevated heart rate values were included among the risk factors because their increase is associated with a higher risk of cardiovascular morbidity and mortality and overall (there is still a threshold value). Also, a high heart rate was found to be prognostic for the development of a risk of hypertension.

Finally, tachycardia at rest is very frequently associated with metabolic abnormalities and metabolic syndrome. - Shows the major diagnostic elements for risk stratification in the categories of "high" and "very high".

They are:

Systolic BP ≥ 180mmHg and / or diastolic ≥ 110mmHg, systolic BP> 160mmHg with diastolic BP <70mmHg, diabetes mellitus, metabolic syndrome, three or more cardiovascular risk factors, one or more markers of organ damage (ventricular overload or hypertrophy concentric left ventricular hypertrophy, carotid artery wall thickening or atherosclerotic plaques, decreased arterial distensibility, cretinina moderate increase in serum, reduced glomerular filtration rate or creatinine clearance, microalbuminuria or proteinuria), cardiovascular disease or renal dysfunction. The presence of multiple risk factors, diabetes or organ damage mean that a person, even with values of high-normal blood pressure falls under the category of high risk.

In recent years, results of observational studies conducted in elderly individuals have shown that the relationship between cardiovascular risk and blood pressure are complex. This risk is directly proportional to the systolic pressure, and for each value, inversely proportional to the diastolic pressure. In this way, particular importance, as a predictor of events, the pressure differential. The predictive value of the latter may vary depending on the characteristics of individuals.

As part of the larger meta-analysis of observational studies carried out so far (61 studies, of which 70% Europe, involving more than one million patients without CHD), systolic and diastolic blood pressure were predictive of coronary mortality and cerebrovascular more prominently than the differential pressure, especially in patients younger than 55 years. In contrast, the predictive role of the differential pressure has manifested itself in hypertensive middle-aged or elderly, who had risk factors or comorbidities.



Global cardiovascular risk

For many years, hypertension guidelines have considered blood pressure as the main variable to discriminate the need and type of therapeutic intervention. However, already the first guidelines ESH / ESC had emphasized the importance of carrying out, in the diagnosis and management of the hypertensive patient, a stratification of total cardiovascular risk profile, or global. This is because only a small proportion of individuals with hypertension has increased pressure "isolated", while the vast

Most patients also highlights other cardiovascular risk factors, with a close relationship between severity and extent of the increase pressure Metabolism glycolipids.

Also, when present together, the pressor and metabolic alterations are mutually reinforcing, with an impact on overall cardiovascular risk profile of exponential type and not merely additive. Finally, several evidences have shown that in high-risk individuals, the threshold and targets of antihypertensive treatment, as well as other therapeutic strategies, are different from those of individuals with the lowest risk profile. The main variables considered in risk stratification include, as in previous guidelines, the traditional risk factors (demographic, anthropometric, family history of cardiovascular disease at a young age, blood pressure levels, smoking, lipid profile and glucose) The presence of organ damage, diabetes mellitus and cardiovascular disease or renal dysfunction.

The definition of hypertension can be flexible because it depends on the level of total CV risk.

For cardiovascular risk (low, moderate, high and very high) is the risk of incurring fatal and nonfatal CV events in 10 years. The term 'added' indicates that in several categories, the risk is above average.

Choice of antihypertensive drug

The results of two large trials and a meta-analysis showed that beta-blockers do not carry any effect in terms of cerebrovascular protection, despite the favorable effects on CHD morbidity and mortality. Therefore, therapy with beta-blockers should be reserved for patients with a history of angina pectoris, heart failure and recent myocardial infarction, and that is the main complications of hypertension. Beta-blockers, therefore, may still be considered as a therapeutic option to start and / or continue antihypertensive treatment. Beta-blockers should not be prescribed in hypertensive patients with metabolic syndrome or in the presence of abdominal obesity, impaired fasting glucose, carbohydrate intolerance or diabetogenic high risk, because it leads to an increase in body weight, have adverse effects on glycolipid metabolism and promote more often than other classes of antihypertensive drugs, the development of diabetes. Similar conclusions apply to the thiazide diuretics. In most clinical trials, in which he highlighted a high incidence of new cases of diabetes, the therapeutic strategy included a combination therapy of a thiazide diuretic and a beta-blocker, making it difficult to discriminate which of the two drugs was the main culprit dysmetabolic effects. These considerations, however, does not necessarily relate to the new generation of beta-blockers (such as carvedilol and nebivolol), which compared to traditional beta blockers, show less diabetogenic. Since beta-blockers, ACE inhibitors and angiotensin II receptor blockers are less effective in black patients, it is preferable in this case, use diuretics and calcium channel blockers.......

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