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HIPERTENSION ARTERIAL
U.S. Department of Health and Human
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CONCEPTO
• La Presión Arterial (PA) se define como la fuerza ejercida por la sangre contra cualquier área de la pared arterial y se expresa a través de las diferentes técnicas de medición como PA sistólica, PA diastólica y PA media.
U.S. Department of Health and Human
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Cont...
• Controlada por el Gasto cardiaco y Resistencia vascular periferica. (GC), (RVP).
• GC: Determinado por la frecuencia cardiaca y la fuerza de contracción.
• RVP: Dependerá de la actividad constrictora o dilatadora de las arteriolas, del eje renina angiotensina y de la propia magnitud del GC.
U.S. Department of Health and Human
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EPIDEMIOLOGIA.
• La hipertensión arterial afecta a 50 millones de personas en EEUU, y 1 Billón en todo el mundo.
• Es el diagnostico primario mas frecuente en América 35 millones de consultas como dx primario.
• Los objetivos de salud poblacional para el 2010 están por debajo del 50% del ideal.
• Aproximadamente el 30% de la población desconoce ser Hipertenso.
U.S. Department of Health and Human
Services
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CONOCIMIENTO DE LA PATOLOGIA
10
29 2734
2
16
0
10
20
30
40
50
60
70
80
1976-80 1988-91 1991-94 1999-2000
ConocidaTratadaControladaControl España
U.S. Department of Health and Human
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PREVALENCIA HTAU.S. Department of Health and Human
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45
64.471.7 70.8
0
20
40
60
80
* Banegas JR, et al. Hypertension 1998; 32: 998-1002 (datos de 35-64 años)
† Banegas JR, et al. Hypertension 2002; 20: 2157-64 (datos en > 60 años)
35-64 60-69 70-79 >79
16.3
32.2
82.3
0
10
20
30
40
50
60
70
80
90
Control global Control PAS Control PAD
FACTORES DE RIESGO CV.
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CLASIFICACION
• ETIOLOGIA
• SEGÚN RENINA.
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•CLINICA (TA)
ETIOLOGIA
• IDIOPATICA (PRIMARIA)
• SECUNDARIA
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SECUNDARIA
Renales• Enfermedad del Parénquima• Nefritis crónica. • Enfermedad poliquística. • Enfermedad del colágeno vascular. • Nefropatía diabética. • Hidronefrosis. • Glomerulonefritis aguda. Renovascular• Cualquier lesión que obstruya las arterias renales, tanto grandes;
como chiquitas. • Estenosis renal. • Infarto renal y otros
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Endocrinas• Suprarrenales• Feocromocitoma. • Aldosteronismo primario. • -Producción excesiva de: DOC y 18OH-DOC y otros mineralocorticoides. • Hiperplasia suprarrenal congénita • Síndrome de Cushing por tumoración suprarrenal, por tumores hipofisarios. • Tumores cromafines extrasuprarrenales.
Hiperparatiroidismo.Acromegalia.
HT por embarazo. Coartación de la aorta. Trastornos neurológicos.• HT intracraneana. • Cuadriplejía. • Envenenamiento por plomo. • Síndrome de Guillain-Barré. • 6.- Post-operatorio. Fármacos y sustancias químicas.• Ciclosporina. • Anticonceptivos orales. • Glucocorticoides. • Mineralocorticoides. • Simpaticomiméticos. • Tiramina e inhibidores de la MAO. Tóxicas • Plomo. • Talio. • Mercurio.
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SEGÚN NIVEL DE RENINA
• Renina alta: 10% de los pacientes hay
resistencias vasculares aumentadas.
• Renina Normal: 60% de los pacientes asociada a volumen dependiente + aumento de resistencias.
• Renina Baja: 30% de los pacientes se asocian con ser volumen dependientes.
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CLASIFICACION SEGÚN TA
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BENEFICIOS DEL CONTROL DE LA TA
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HIPERTENSION SISTOLICA.
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IDEAS CLAVES JNC7U.S. Department of Health and Human
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• Para pacientes >50 a es mas importante como RCV la presión sistólica que la diastolica.
• El RCV se duplica por 20/10mmHg por encima de 115/75.
• Los pacientes > 55a tienen 90% probabilidades de HTA
• Las personas con TA 120-39/80-89 se consideran prehipertensos y hay que modificar su LS.
Chobanian AV et al JAMA 2003; 289:2560-72
Cont…
• La hidroclorotiazida debería ser usado en la mayoría de pacientes con HTA no complicada.
• La mayoría de ptes requerirá 2 o mas antihipertensivos para obtener el nivel ideal <140/90, <130/80 en DM, IRC
• Si la presión arterial es 20/10 arriba del objetivo debería iniciarse con 2 antihipertensivos, y uno de ellos seria una tiazida.
• La efectividad del tratamiento depende de la motivación.
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Chobanian AV et al JAMA 2003; 289:2560-72
MODIFICACION ESTILO DE VIDA
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RECOMENDACIONES
• Utilizar método auscultatorio, aparato calibrado adecuadamente.
• Paciente debe estar sentado en silla por 5 minutos, pies en el suelo brazo a altura corazón.
• Tamaño adecuado del brazalete (>80% el brazo).
• Dar por escrito la TA, y concientizar en objetivos.
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AUTOMEDIDA PA
• Proporciona informacion del control del paciente.
• Evita la HTA bata blanca.
• Niveles > 135/85mmHg son tomados como hipertensos.
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M.A.P.A
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EXAMENES VALORACION INICIAL HTA.
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ANTIHIPERTENSIVO DE ELECCION SEGÚN
PATOLOGIA.U.S. Department of Health and Human
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COMBINACIONES DE ANTIHIPERTENSIVOS
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ANTIHTA Y HVIU.S. Department of Health and Human
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IECA Y DAÑO RENALU.S. Department of Health and Human
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CONSIDERACIONES ESPECIALES
• SX METABOLICO X: Modificar estilo de vida, antihipertensivos.
• HVI: Modificar estilo de vida, antihipertensivos excepto vasodilatadores directos (hidralacina, minoxidil)
• EAP( Enfermedad arterial periferica): usar ASA + antihipertensivos.
• HTA ancianos: iniciar con diureticos tiazidicos o la combinacion de tiazida mas BB, BCC, ARAII, IECA, ALDOMET.
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• Hipotension postural: Valorar este efecto en ancianos que usan sildenafil,diureticos, tomar TA de pie un descenso de TAS >10mmHG
• En Mujeres: Evitar ACO, en caso de embarazo: se
recomiendan alfametildopa, BB, vasodialtadores, evitar IECA Y ARAII.
U.S. Department of Health and Human
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U.S. Department of Health and Human
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National Heart, Lung, and Blood Institute
U.S. Department of Health and Human
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National Heart, Lung, and Blood Institute
U.S. Department of Health and Human
Services
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National Heart, Lung, and Blood Institute
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FARMACOS ENDOVENOSOS EN
EMERGENCIASU.S. Department of Health and Human
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EFECTOS ADVERSOSU.S. Department of Health and Human
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ELECCION DE FARMACOU.S. Department of Health and Human
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ANTIHIPERTENSIVOS ORALES EN URGENCIAS
