Nadciśnienie tętnicze – wspólne wytyczne ESC i ESH 2013 (cześć 1)

Nadciśnienie tętnicze – wspólne wytyczne ESC i ESH 2013 (cześć 1)

Lipiec 17, 2013  |  Udostępnij  | 
nadciśnienie tętnicze

nadciśnienie tętnicze

W ostatnich dniach podczas kongresu w Mediolanie zaprezentowano aktualizację wspólnych wytycznych Europejskiego Towarzystwa Kardiologicznego (ESC) oraz Europejskiego Towarzystwa Nadciśnienia Tętniczego (ESH). Nowy dokument[1], który zastępuje poprzedni z 2007 roku, jest rodzajem podsumowania wniosków z doniesień naukowych, jakie opublikowano w ostatnich latach. Jego zadaniem jest upowszechnienie wiedzy o znaczeniu nadciśnienia tętniczego (HA), jego właściwej diagnostyce, prewencji oraz leczeniu.

Autorzy już na pierwszych stronach podkreślają, jak ważnym problemem z punktu widzenia epidemiologicznego jest HA. W Europie na tę chorobę cierpi między 30 a 45 % dorosłych pacjentów, a odsetek ten rośnie z wiekiem analizowanej grupy. Na świecie wg WHO ogólna liczba chorych sięga 1,5 miliarda. Jednocześnie nadciśnienie tętnicze jest silnie skorelowane ze wzrostem częstości zdarzeń sercowo-naczyniowych takich jak udar mózgu, zawał serca, choroby naczyń obwodowych, niewydolność nerek oraz serca, czy nagły zgon sercowy, co sprawia, że HA jest globalnie najważniejszym czynnikiem ryzyka śmierci.

W nowych wytycznych nie uległa zmianie definicja nadciśnienia tętniczego – mówimy o nim, kiedy, w prawidłowo przeprowadzonych pomiarach gabinetowych, wartości ciśnienia (BP) wynoszą 140mmHg lub więcej dla ciśnienia skurczowego (SBP) lub co najmniej 90mmHg dla ciśnienia rozkurczowego (DBP).

W porównaniu z wytycznymi z 2007 roku skorygowano wskazania odnośnie momentu, w którym korzystne jest zastosowanie leczenia farmakologicznego. U pacjentów ze stopniem 1 nadciśnienia (140-159/90-99mmHg) i niskim lub umiarkowanym ogólnym ryzykiem sercowo-naczyniowym rozsądne jest rozpoczęcie od próby redukcji BP poprzez zmianę stylu życia, natomiast włączenie preparatów hipotensyjnych należy rozważyć, gdy takie postępowanie nie przynosi oczekiwanego efektu (poziom zalecenia IIa, klasa B). U chorych wysokiego ryzyka, z cukrzycą, chorobą układu krążenia lub uszkodzeniem nerek powinno się natomiast wdrażać równolegle terapię farmakologiczną oraz niefarmakologiczną (poziom I, klasa B). Leczenie hipotensyjne należy wprowadzić niezwłocznie również u osób z 2 i 3 stopniem nadciśnienia (SBP min. 160, DBP min. 100), niezależnie od występowania pozostałych czynników ryzyka (poziom I, klasa A). Przeprowadzone badania nie wykazały korzystności obniżania BP u osób z wysokim prawidłowym ciśnieniem tętniczym (130-139/85-89mmHg), nawet, gdy są to pacjenci schorowani, stąd takie postępowanie nie jest rekomendowane (poziom III, klasa A).

Lekkiej korekcie uległy cele terapeutyczne. U zdecydowanej większości pacjentów powinniśmy dążyć do poziomu BP  poniżej 140/90mmHg. Wyjątek stanowią osoby z cukrzycą, u których docelowa wartość ciśnienia rozkurczowego to <85mmHg. Nie ma natomiast dowodów na korzystność obniżania ciśnienia do poziomu 130/80 u osób z wysokim ryzykiem sercowo naczyniowym, co sugerowały wytyczne z 2007 roku. Autorzy nowego dokumentu pochylili się w sposób szczególny nad leczeniem hipotensyjnym osób starszych. U tych pacjentów dobrze udokumentowany jest dobroczynny wpływ obniżania SBP do wartości pomiędzy 150 a 140mmHg, kiedy wyjściowo ciśnienie skurczowe przekracza 160mmHg (klasa zalecenia I, poziom A). Postawienie sobie za cel terapeutyczny zmniejszenia ciśnienie skurczowego <140, jak u osób młodszych, można rozważyć, ale należy mieć przy tym na uwadze indywidualną tolerancję chorego (klasa zalecenia IIb, poziom C).

O zmianach w stylu życia, które powinniśmy rekomendować naszym pacjentom, o strategiach leczenia farmakologicznego oraz o roli, jaką nowe wytyczne ESC/ESH przewidziały dla technik inwazyjnych, będzie można przeczytać w następnym artykule.

1. 2013 ESH/ESC Guidelines for themanagement of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013 Jun 14



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