la lumière des nouvelles recommandations - Prise en charge de l'hypertension artérielle Pr. AHMED BENNIS
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Prise en charge de l’hypertension artérielle
à la lumière des nouvelles recommandations
Pr. AHMED BENNIS
o Les complications cardiovasculaires restent, malgré d'énormes progrès, la seconde cause de décès juste après les cancers dans les populations occidentales. Prévenir plus tôt le risque de complications cardiovasculaires.
o Exit la pré-hypertension, place à l'HTA de grade 1 et de grade 2 avec, à la clé, +14% d'hypertendus. o le passage de 140/90 mm Hg à 130/80 mm Hg devrait augmenter de 14% la prévalence de l'HTA en population.
o La prévalence de l'HTA… devrait tripler chez les hommes de moins de 45… …et doubler chez les femmes de moins de 45 ans selon les estimations
o Pas de prescription systématique d’antihypertenseurs. Seuls les HTA de grade 1 ayant déjà fait une complication cardiovasculaire OU ayant un haut niveau de risque relèveront d'une prescription systématique.
PRESSIONS ARTERIELLES
NORMALES
PA inférieures à
120/80 mm HgPRESSIONS ARTERIELLES
ELEVEES
PAS : 120-129 mm Hg
PAD à 80 mm HgHTA DE
GRADE 1
• PAS : 130-139 mm Hg
• PAD : 80 - 89 mm HgHTA DE
GRADE 2
•PAS 140 mm Hg
•PAD 90 mm Hgo Principales catégories de PA
PA PAS PAD
NormalCRISE
HYPERTENSIVE
o PAS supérieure à 180 mm Hg et/ou PAD
supérieure à 120 mm Hg…
avec des patients nécessitant un changement urgent de
traitement s'il n'y a pas d'autres indications ou problèmes ou
requérant une hospitalisation immédiate en cas de signes
d'atteintes d'organes.Diagnostic, Effet blouse blanche
et HTA masquée
o La nécessité de "bien" mesurer la PA est
soulignée.
Un dépistage basé sur une moyenne de deux ou trois
mesures réalisées à au moins deux moments différents
est recommandé. Le recours à des systèmes de mesure
validés est aussi souligné.Diagnostic, Effet blouse blanche
et HTA masquée
De même que la nécessité de former les professionnels à
détecter une HTA blouse blanche, trompeuse mais aussi à
porter la plus grande attention à l'HTA masquée associée
qui semble associée – est-il rappelé – au même niveau de
risque qu'une HTA permanenteRECOMMANDATIONS DE
TRAITEMENT
Dans l'HTA de grade 1, les seuls patients relevant
d'un traitement médicamenteux sont ceux ayant :
o déjà une maladie cardiovasculaire (ie en prévention
secondaire)ou
o un haut niveau de risque d'infarctus ou d'AVC (fonction
de l'âge, d'un diabète, d'une maladie rénale ou d'une
évaluation du risque d'athérosclérose).o Facteurs de risque cardiovasculaires, les plus
fréquents, chez les patients hypertendus
Modifiable Risk Factors* Relatively Fixed Risk Factors†
Current cigarette smoking, CKD
secondhand smoking Family history
Diabetes mellitus Increased age
Dyslipidemia/hypercholesterolemia Low
Overweight/obesity socioeconomic/educational
Physical inactivity/low fitness status
Unhealthy diet Male sex
Obstructive sleep apnea
Psychosocial stress
*Factors that can be changed and, if changed, may reduce CVD risk.
†Factors that are difficult to change (CKD, low socioeconomic/educational status,
obstructive sleep apnea, cannot be changed (family history, increased age, male sex), or, if
changed through the use of current intervention techniques, may not reduce CVD risk
(psychosocial stress).
CKD indicates chronic kidney disease; and CVD, cardiovascular disease.o Critère de choix de brassard pour la mesure de
la PA chez l’adulte
Circonférence Taille
du bras du brassard
22–26 cm Small adult
27–34 cm Adult
35–44 cm Large adult
45–52 cm Adult thigho Mesure de la PA en dehors du cabinet médical
et Automesure
Recommendation for Out-of-Office and Self-
COR LOE
Monitoring of BP
Out-of-office BP measurements are
recommended to confirm the diagnosis of
I ASR hypertension and for titration of BP-lowering
medication, in conjunction with telehealth
counseling or clinical interventions.
SR indicates systematic review.o Correspondance entre les valeurs mesurées :
au cabinet médical, par la MAPA et par l’automesure
Daytime Nighttime
Clinic HBPM 24-Hour ABPM
ABPM ABPM
120/80 120/80 120/80 100/65 115/75
130/80 130/80 130/80 110/65 125/75
140/90 135/85 135/85 120/70 130/80
160/100 145/90 145/90 140/85 145/90
ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; DBP
diastolic blood pressure; HBPM, home blood pressure monitoring; and SBP,
systolic blood pressure.o Hypertension masquée et HTA blouse blanche
Recommendations for Masked and White Coat
COR LOE
Hypertension
In adults with an untreated SBP greater than 130 mm Hg
but less than 160 mm Hg or DBP greater than 80 mm Hg
but less than 100 mm Hg, it is reasonable to screen for
IIa B-NR the presence of white coat hypertension by using either
daytime ABPM or HBPM before diagnosis of
hypertension.
In adults with white coat hypertension, periodic
monitoring with either ABPM or HBPM is reasonable to
IIa C-LD detect transition to sustained hypertension.
In adults being treated for hypertension with office BP
readings not at goal and HBPM readings suggestive of a
IIa C-LD significant white coat effect, confirmation by ABPM can
be useful.o Hypertension masquée et HTA blouse blanche
Recommendations for Masked and White Coat
COR LOE
Hypertension
In adults with untreated office BPs that are consistently
between 120 mm Hg and 129 mm Hg for SBP or
IIa B-NR between 75 mm Hg and 79 mm Hg for DBP, screening
for masked hypertension with HBPM (or ABPM) is
reasonable.
In adults on multiple-drug therapies for hypertension
and office BPs within 10 mm Hg above goal, it may be
IIb C-LD reasonable to screen for white coat effect with HBPM
(or ABPM).
It may be reasonable to screen for masked
uncontrolled hypertension with HBPM in adults being
IIb C-EO treated for hypertension and office readings at goal, in
the presence of target organ damage or increased
overall CVD risk.
In adults being treated for hypertension with elevated
HBPM readings suggestive of masked uncontrolled
IIb C-EO hypertension, confirmation of the diagnosis by ABPM
might be reasonable before intensification of
antihypertensive drug treatment.o Catégories de PA définies pour les mesures en
cabinet médical ou hors cabinet médical
Office/Clinic/Healthcare Home/Nonhealthcare/A
Setting BPM Setting
Normotensive No hypertension No hypertension
Sustained
Hypertension Hypertension
hypertension
Masked
No hypertension Hypertension
hypertension
White coat
Hypertension No hypertension
hypertension
ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.o Identification de l’hypertension blouse blanche ou masquée chez des patients NON TRAITES Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring.
o Identification de l’hypertension blouse blanche
ou masquée chez des patients TRAITES
Detection of white coat effect or masked uncontrolled
hypertension in patients on drug therapy
Office BP
at goal
Yes No
Increased Office BP
CVD risk or ≥5–10 mm Hg
target organ above goal on
damage ≥3 agents
Yes No Yes No
Screen for Screen for
Screening Screening
masked uncontrolled white coat effect with
not necessary not necessary
hypertension with HBPM HBPM
(No Benefit) (No Benefit)
(Class IIb) (Class IIb)
HBPM BP HBPM BP
above goal at goal
Yes No
ABPM BP
above goal
White coat effect:
Continue titrating
Yes No Confirm with ABPM
therapy
(Class IIa)
Masked uncontrolled
Continue current
hypertension:
therapy
Intensify therapy
(Class IIa)
(Class IIb)
Colors correspond to Class of Recommendation in Table 1.
ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure
monitoring.o Suspicion d’HTA secondaire
New-onset or uncontrolled hypertension in adults
Cond iti ons
• Drug-resi sta nt/induced hypertension
• Abrupt onset of hypertens ion
• Ons et of hypertens ion ato Situations cliniques pouvant être à l’origine
d’une HTA secondaire
Common causes
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Uncommon causes
Pheochromocytoma/paraganglioma
Cushing’s syndrome
Hypothyroidism
Hyperthyroidism
Aortic coarctation (undiagnosed or repaired)
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary
aldosteronism
Acromegalyo Mesures non pharmacologiques
Recommendations for Nonpharmacological
COR LOE
Interventions
Increased physical activity with a structured exercise
I A program is recommended for adults with elevated
BP or hypertension.
Adult men and women with elevated BP or
hypertension who currently consume alcohol should
I A be advised to drink no more than 2 and 1 standard
drinks* per day, respectively.
*In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in
12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of
distilled spirits (usually about 40% alcohol).o Apnée obstructive du sommeil
COR LOE Recommendation for Obstructive Sleep Apnea
In adults with hypertension and obstructive sleep
apnea, the effectiveness of continuous positive
IIb B-R
airway pressure (CPAP) to reduce BP is not well
established.o Mesures non pharmacologiques ayant prouvé leur efficacité dans
la prévention et le traitement de l’HTA
Nonpharmacological Dose Approximate Impact on SBP
Intervention Hypertension Normotension
Weight loss Best goal is ideal body weight,
but aim for at least a 1-kg
reduction in body weight for
-2/3 mm Hg
Weight/body fat most adults who are -5 mm Hg
overweight. Expect about 1
mm Hg for every 1-kg
reduction in body weight.
Healthy diet Consume a diet rich in fruits,
vegetables, whole grains, and
DASH dietary pattern low-fat dairy products, with -11 mm Hg -3 mm Hg
reduced content of saturated
and total fat.
Reduced Optimal goal iso Mesures non pharmacologiques ayant prouvé leur efficacité dans
la prévention et le traitement de l’HTA (2)
Nonpharmacolo Approximate Impact on SBP
Dose
gical Intervention Hypertension Normotension
● 90–150 min/wk
Aerobic -5/8 mm Hg -2/4 mm Hg
● 65%–75% heart rate reserve
● 90–150 min/wk
Dynamic ● 50%–80% 1 rep maximum
Physical resistance -4 mm Hg -2 mm Hg
● 6 exercises, 3 sets/exercise, 10
activity repetitions/set
● 4 × 2 min (hand grip), 1 min rest
between exercises, 30%–40%
Isometric
maximum voluntary contraction, 3 -5 mm Hg -4 mm Hg
resistance
sessions/wk
● 8–10 wk
In individuals who drink alcohol,
Moderation
Alcohol reduce alcohol† to:
in alcohol -4 mm Hg -3 mm
consumption ● Men: ≤2 drinks daily
intake
● Women: ≤1 drink daily
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular
beer (usually about 5% alcohol), 5 oz of wine (usually about 12%
alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).o Bilan paraclinique initial et optionnel en cas
d’HTA essentielle
Basic testing Fasting blood glucose*
Complete blood count
Lipid profile
Serum creatinine with eGFR*
Serum sodium, potassium, calcium*
Thyroid-stimulating hormone
Urinalysis
Electrocardiogram
Optional Echocardiogram
testing Uric acid
Urinary albumin to creatinine ratio
*May be included in a comprehensive metabolic panel.
eGFR indicates estimated glomerular filtration rate.o Cibles tensionnelles, recommandations de
traitement et suivi… (suite sur la slide suivante)
BP thresholds and recommendations for treatment and follow-up
Normal BP Elevated BP Stage 1 hypertension
Stage 2 hypertension
(BP3–6 mo therapy
BP-lowering medication BP-lowering medication†
(Class I) (Class I)
(Class I) (Class I)
Reassess in Reassess in
3–6 mo 1 mo
(Class I) (Class I)
BP goal met
No Yes
Assess and Reassess in
optimize 3–6 mo
adherence to (Class I)
therapy
Consider
intensification of
therapy
Colors correspond to Class of Recommendation in Table 1.
*Using the ACC/AHA Pooled Cohort Equations. Note that patients with DM or CKD are automatically placed in
the high-risk category. For initiation of RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and
renal function 2 to 4 weeks after initiating therapy.
†Consider initiation of pharmacological therapy for stage 2 hypertension with 2 antihypertensive agents of
different classes. Patients with stage 2 hypertension and BP ≥160/100 mm Hg should be promptly treated,
carefully monitored, and subject to upward medication dose adjustment as necessary to control BP.
Reassessment includes BP measurement, detection of orthostatic hypotension in selected patients (e.g., older
or with postural symptoms), identification of white coat hypertension or a white coat effect, documentation of
adherence, monitoring of the response to therapy, reinforcement of the importance of adherence,
reinforcement of the importance of treatment, and assistance with treatment to achieve BP target.o Modalités de suivi après une évaluation initiale
de la PA
Recommendations for Follow-Up After Initial BP
COR LOE
Elevation
Adults with an elevated BP or stage 1 hypertension
who have an estimated 10-year ASCVD risk less than
I B-R 10% should be managed with nonpharmacological
therapy and have a repeat BP evaluation within 3 to 6
months.
Adults with stage 1 hypertension who have an
estimated 10-year ASCVD risk of 10% or higher should
I B-R be managed initially with a combination of
nonpharmacological and antihypertensive drug
therapy and have a repeat BP evaluation in 1 month.
Adults with stage 2 hypertension should be evaluated
by or referred to a primary care provider within 1
month of the initial diagnosis, have a combination of
I B-R nonpharmacological and antihypertensive drug
therapy (with 2 agents of different classes) initiated,
and have a repeat BP evaluation in 1 month.o Modalités de suivi après une évaluation initiale
de la PA
Recommendations for Follow-Up After Initial BP
COR LOE
Elevation
For adults with a very high average BP (e.g., SBP ≥180
I B-R mm Hg or DBP ≥110 mm Hg), evaluation followed by
prompt antihypertensive drug treatment is recommended.
For adults with a normal BP, repeat evaluation every year
IIa C-EO is reasonable.o Principes généraux dans le choix initial de
médicaments
Recommendation for General Principle of Drug
COR LOE
Therapy
Simultaneous use of an ACE inhibitor, ARB, and/or renin
III:
A inhibitor is potentially harmful and is not recommended
Harm to treat adults with hypertension.o Cibles tensionnels
Recommendations for BP Goal for Patients With
COR LOE
Hypertension
For adults with confirmed hypertension and
SBP:
known CVD or 10-year ASCVD event risk of 10%
I B-RSR
or higher a BP target of less than 130/80 mm Hg
DBP: is recommended.
C-EO
SBP: For adults with confirmed hypertension, without
B-NR additional markers of increased CVD risk, a BP
IIb target of less than 130/80 mm Hg may be
DBP:
reasonable.
C-EO
SR indicates systematic review.o Choix initial de traitements
Recommendation for Choice of Initial
COR LOE
Medication
For initiation of antihypertensive drug therapy,
first-line agents include thiazide diuretics, CCBs,
I ASR
and ACE inhibitors or ARBs.
SR indicates systematic review.o Choix initial d’une monothérapie vs une bithérapie
Recommendations for Choice of Initial
COR LOE Monotherapy Versus Initial Combination Drug
Therapy*
Initiation of antihypertensive drug therapy with 2 first-
line agents of different classes, either as separate
agents or in a fixed-dose combination, is
I C-EO recommended in adults with stage 2 hypertension
and an average BP more than 20/10 mm Hg above
their BP target.
Initiation of antihypertensive drug therapy with a
single antihypertensive drug is reasonable in adults
IIa C-EO with stage 1 hypertension and BP goalo Plan de suivi après initiation de traitement
Recommendation for Follow-Up After Initiating
COR LOE
Antihypertensive Drug Therapy
Adults initiating a new or adjusted drug regimen for
hypertension should have a follow-up evaluation of
I B-R adherence and response to treatment at monthly
intervals until control is achieved.o Stratégies spécifiques pour améliorer le contrôle de
la PA chez les hypertendus sévères
Recommendation for Monitoring Strategies to
COR LOE Improve Control of BP in Patients on Drug Therapy for
High BP
Follow-up and monitoring after initiation of drug
therapy for hypertension control should include
I A systematic strategies to help improve BP, including
use of HBPM, team-based care, and telehealth
strategies.Indications SPECIFIQUES
o HTU avec maladie cardiovasculaire stable
o Prise en charge de l’HTA chez des patients avec
une maladie rénale chronique
Treatment of hypertension in patients with CKD
BP goalo Prise en charge de l’HTA chez des patients en
phase aigue d’hémorragie cérébrale
Acute (220 mm Hg
SBP lowering with
SBP lowering to
continuous IV infusion ando Prise en charge de l’HTA chez des patients en
phase aigue d’AVC
Acute (o Prise en charge de l’HTA chez des patients avec antécédents
d’AVC (prévention secondaire d’AVC)
Stroke ≥72 h from symptom onset and stable
neurological status or TIA
Previous
diagnosed or treated
hypertension
Yes No
Restart
antihypertensive
Established Established
treatment
SBP ≥140 mm Hg or SBPo Crise hypertensive : diagnostic et prise en
charge
SBP >180 mm Hg and/or
DBP >120 mm Hg
Target organ damage new/
progress ive/worsening
Yes No
Hypertensive
Markedly elevated BP
emergency
Admit to ICU
(Class I) Reinstitute/intensif y oral
antihypertens ive drug therapy
and arrange fo llow-up
Cond itions:
• Aortic dissecti on
• Severe preeclampsia or eclampsia
• Pheochromocytoma crisis
Yes No
Reduce SB P too Hypertendu diabétique : recommandations de traitement Pages de 116-117 des recommandations
o Hypertendu âgé : recommandations de traitement Page 130 des recommandations
o Plan de soin pour la PEC de l’hypertension par le
clinicien
Clinician’s Sequential Flow Chart for the Management of Hypertension
Measure office BP accurately
Detect white coat hypertension or masked hypertension by using ABPM and HBPM
Evaluate for secondary hypertension
Identify target organ damage
Introduce lifestyle interventions
Identify and discuss treatment goals
Use ASCVD risk estimation to guide BP threshold for drug therapy
Align treatment options with comorbidities
Account for age, race, ethnicity, sex, and special circumstances in antihypertensive
treatment
Initiate antihypertensive pharmacological therapy
Insure appropriate follow-up
Use team-based care
Connect patient to clinician via telehealth
Detect and reverse nonadherence
Detect white coat effect or masked uncontrolled hypertension
Use health information technology for remote monitoring and self-monitoring of BP
ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD,
cardiovascular disease; and SBP, systolic blood pressure.o Résumé des objectifs tensionnels
Chalmers J, Neal B and Mac Mahon S on behalf of the PROGRESS Management Commitee Journal of Hypertension 2000, 18 (suppl1): S13-S19
Hypertensive patients (n=19 257) Ferrari R. Optimizing the treatment of hypertension and stable coronary artery disease: clinical evidence for fixed-combination perindopril/amlodipine. Curr Med Res Opin. 2008;24:3543-3557.
o Définition des différents seuils de la PA Page 22 des recommandations
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