Nadciśnienie tętnicze – wspólne wytyczne ESC i ESH 2013 (cześć 2)

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nadciśnienie tętnicze

nadciśnienie tętnicze

Zgodnie z zapowiedzią z poprzedniego artykułu, w poniższym tekście przedstawimy spektrum możliwości terapeutycznych u pacjentów z nadciśnieniem tętniczym (HA), które zalecają we wspólnym stanowisku[1] Europejskie Towarzystwo Kardiologiczne (ESC) oraz Europejskie Towarzystwo Nadciśnienia Tętniczego (ESH).

Jeśli chodzi o zmiany w stylu życia, autorzy nowych wytycznych przytaczają wiele ciekawych faktów, zachęcających do informowania chorych oraz dopingowania ich do wprowadzenia tych zmian w życie. Spożycie soli kuchennej, które wg badań w diecie przeciętnego Europejczyka sięga 9-12 g/dobę, powinno zostać ograniczone do poziomu 5-6g/dobę. Taki krok przynosi u osób z HA korzyść w postaci obniżenia ciśnienia tętniczego (RR) o przeciętnie 4-5mmHg. Równie ważna jest redukcja masy ciała. Autorzy określili cel, do którego powinni dążyć chorzy, za pomocą dwóch wskaźników – body-mass index (BMI) oraz obwodu tali. Pierwszy z nich powinien być utrzymywany na poziomie <25 kg/m2, a drugi w zależności od płci pacjenta – <102 cm u mężczyzn i <88 cm w przypadku kobiet. Szacuje się, że samo obniżenie masy ciała o 5 kg u osoby z nadwaga i nadciśnieniem pozwala na redukcję RR o 4mmHg. Jednocześnie regularne ćwiczenia aerobowe (pływanie, nordic walking, czy jazda na rowerze), którym wg. zaleceń ESC/ESH powinno się poświęcać nie mniej niż pół godziny dziennie przez 5 dni w tygodniu, pozwalają na dodatkowe obniżenie ciśnienia skurczowego o 7mmHg. Rekomendowana jest także walka z nikotynizmem, ponieważ palenie nie pozostaje bez wpływu na RR, a jednocześnie samo w sobie jest silnym czynnikiem ryzyka chorób serca.

W kwestii farmakologicznego leczenia nadciśnienia tętniczego nowe wytyczne pozostają stosunkowo konserwatywne. W dokumencie możemy znaleźć dobrze znany schemat w kształcie wielokąta (diamentu), obrazujący równorzędność podstawowych leków hipotensyjnych (inhibitorów konwertazy, β-blokerów, sartanów, diuretyków oraz blokerów kanału wapniowego) oraz zalecane połączenia do zastosowania w terapii wielolekowej. Spośród wszystkich możliwych kombinacji tych leków, przeciwwskazane jest jedynie stosowanie podwójnej blokady układu renina-angiotensyna-aldosteron, np.: jednoczesne włączanie inhibitorów konwertazy angiotensyny (ACEI) oraz blokerów receptora angiotensyny. Jak pokazały badania ONTARGET i ALTITUDE, stosowanie takiej kombinacji co prawda skutecznie obniża ciśnienie tętnicze, ale wiąże się z ryzykiem uszkodzenia nerek (klasa zalecenia III, poziom A). Oczywiście autorzy wytycznych określają szczególne wskazania i przeciwwskazania do leków z poszczególnych grup (np.: ACEI powinny być preferowane u chorych z HA i cukrzycą, ale w żadnym razie u kobiet ciężarnych), jednak ich szczegółowe omówienie znacznie wykraczałoby objętościowo poza ramy tego artykułu, więc zainteresowanych czytelników odsyłamy do pełnego tekstu wytycznych.

Eksperci ESC i ESH poświęcili nieco miejsca także metodom inwazyjnym stosowanym w leczeniu nadciśnienia tętniczego – denerwacji nerek oraz stymulacji baroreceptorów. Techniki te mogą być rozważone u pacjentów z nadciśnieniem opornym, jeśli leczenie farmakologiczne jest nieefektywne (klasa zalecenia IIb, poziom C). Jednocześnie autorzy wytycznych postulują by zabiegi były wykonywane jedynie u chorych z dobrze udokumentowanym HA, przy poziomie ciśnienia co najmniej 160/110mmHg, nie reagującym na poprawnie prowadzone leczenie i by procedurę przeprowadzono wyłącznie w najsilniej wyspecjalizowanych ośrodkach (klasa zalecenia I, poziom C).

Jak widać badania przeprowadzone od czasu publikacji poprzednich wytycznych ESC/ESH z 2007 roku nie zrewolucjonizowały strategii leczenia nadciśnienia, ale potwierdziły skuteczność wcześniej sugerowanego postępowania. Jednocześnie zwraca uwagę niski poziom zaleceń dotyczących metod inwazyjnych. Poziom C, oznaczający, że wytyczne powstały na bazie pojedynczych, małych badań klinicznych oraz opinii ekspertów, jednoznacznie wskazuje na konieczność przeprowadzenia szerszych badań na tym polu.

1. 2013 ESH/ESC Guidelines for the management 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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