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Clinical Management of Hypertensive Heart Disease: Preventing Heart Failure. Clyde W. Yancy, MD, FACC, FAHA, FACP Medical Director, Baylor Heart and Vascular Institute Chief, Cardiothoracic Transplantation Baylor University Medical Center Dallas, Texas.

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clinical management of hypertensive heart disease preventing heart failure

Clinical Management of Hypertensive Heart Disease:Preventing Heart Failure

Clyde W. Yancy, MD, FACC, FAHA, FACP

Medical Director, Baylor Heart and Vascular Institute

Chief, Cardiothoracic Transplantation

Baylor University Medical Center

Dallas, Texas

prevalence of heart failure increases with age
Prevalence of Heart Failure Increases With Age*

10

Male

8

Female

6

Population (%)

4

2

0

20–24

25–34

35–44

45–54

55–64

65–74

75+

Age (yr)

*NHANES, 1999-2002.

NHANES=National Health and Nutrition Examination Survey.

Adapted from American Heart Association. Heart Disease and Stroke Statistics—2005 Update. Dallas, TX: American Heart Association; 2005.

slide3

From Risk Factors to Heart Failure: The Cardiovascular Continuum

Myocardial

infarction

Arrhythmia

Coronary

thrombosis

Loss of

muscle

Myocardial ischemia

Sudden

death

B

CAD

Remodeling

A

Atherosclerosis

LVH

Ventricular

dilatation

  • Risk factors
  • Hyperlipidemia
  • Hypertension
  • Diabetes
  • Insulin resistance

Heart failure

c

Death

D

Adapted from Dzau V, et al. Am Heart J. 1991;2(4 pt 1):1244-1263.

risk factors for chf among hypertensive subjects
Risk Factors for CHF Among Hypertensive Subjects*

1 2 4 6 8 10

CHF=congestive heart failure; CI=confidence interval.

* Based on 165 CHF events in 1707 men and 192 events in 2118 women with hypertension prior to CHF. Based on dynamic model with reclassification of hypertension and risk factors at each follow-up examination. †Adjusted for myocardial infarction,angina pectoris, diabetes, left ventricular hypertrophy, and valvular heart disease.

Adapted from Levy D, et al. JAMA. 1996;275:1557–1562.

hf algorithm
HF Algorithm

HF

At Risk for HF

STAGE D

Refractory HF requiring specialized interventions.

STAGE C

Structural heart disease with prior or current symptoms of HF.

STAGE B

Structural heart disease but without signs or symptoms of HF.

STAGE A

At high risk for HF but without structural heart disease or symptoms of HF.

  • eg, Patients with:
  • Hypertension
  • Atherosclerotic disease
  • Diabetes
  • Obesity
  • Metabolic syndrome or
  • Patients
  • Using cardiotoxins
  • With family history of cardiomyopathy
  • Therapy Goals
  • Treat hypertension
  • Encourage smoking cessation
  • Treat lipid disorders
  • Encourage regular exercise
  • Discourage alcohol intake, illicit drug use
  • Control metabolic syndrome
  • Drugs
  • ACEI or ARB in appropriate patients for vascular disease or diabetes

ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker.

slide7

New Features and Key Messages

  • For persons over age 50, SBP is more important than DBP as CVD risk factor
  • Starting at 115/75 mm Hg, CVD risk doubles with each increment of 20/10 mm Hg throughout the BP range
  • Persons who are normotensive at age 55 have a 90% lifetime risk for developing hypertension
  • Those with SBP 120-139 mm Hg or DBP 80-89 mm Hg require health-promoting lifestyle modifications to prevent CVD andshould be considered prehypertensive

SBP=systolic blood pressure; DBP=diastolic blood pressure; CVD=cardiovascular disease.

new features and key messages cont d
New Features and Key Messages (cont’d)
  • Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes
  • Certain high-risk conditions are compelling indications for other drug classes
  • Most patients will require ≥2 antihypertensive drugs to achieve goal BP
  • If BP is >20/10 mm Hg above goal, initiate therapy with 2 agents, 1 usually should be a thiazide-type diuretic
algorithm for treatment of hypertension

Without Compelling Indications

With Compelling Indications

Drug(s) for the Compelling Indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed

Stage 1 Hypertension(SBP 140-159 or DBP 90-99 mm Hg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination

Stage 2 Hypertension(SBP >160 or DBP >100 mm Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB)

Not at Goal BP

Optimize dosages or add additional drugs until goal BP is achieved.Consider consultation with hypertension specialist

Algorithm for Treatment of Hypertension

Lifestyle Modifications

Not at Goal BP (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial Drug Choices

BB=β-blocker; CCB=calcium channel blocker.

compelling indications for individual drug classes
Compelling Indications for Individual Drug Classes

THIAZ=thiazide; NKF-ADA=National Kidney Foundation-American Diabetes Association; UKPDS=UK Prospective Diabetes Study; ALLHAT=Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; RENAAL=Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan; IDNT=Irbesartan in Diabetic Nephropathy Trial; AASK=African American Study of Kidney Disease and Hypertension; PROGRESS=Perindopril Protection Against Recurrent Stroke Study.

treatment of hypertension
Optimal BP control:

Optimal BP control in patients with prior MI:

Treatment of Hypertension

Decreases

risk of

new HF

by 50%

Decreases

risk of

new HF

by 80%

MI=myocardial infarction.

Dahlöf B, et al. Lancet. 1991;338:1281-1285.

Kostis JB,et al. JAMA. 1997;278:212-216.

slide13
The Pyramid of HF and Potential Impact of a Range of Preventive and Treatment Strategies in Lowering Age-Specific Mortality

Percent Type of Intervention Impact

Class IV HF + <0.2 Transplantation; Tiny

low ejection fraction left ventricular assist device,

implantable cardiac defibrillator

Any CHF <2 ACEIs, ß-blockers, Modest

spironolactone

High-risk individuals <20 Antihypertensive therapy; Moderate

(eg, those with hypertension drugs to lower cholesterol,

or who have had an ACEIs, smoking

MI) cessation

Obese or overweight >40 Weight loss, plus above Large

individual (eg, body mass measures

index >25), plus those in

above category

Affected (40+ y)

Adapted from Yusuf S, et al. Circulation. 2002;106:2997-2998.

ukpds hypertension study benefits of 144 82 vs 154 87
UKPDSHypertension Study:Benefits of 144/82 vs 154/87
  • Tight BP control, with either a β-blocker or an ACEI, in type 2 diabetes decreases1:
    • Death related to diabetes by - 32%
    • Stroke by - 44%
    • Microvascular disease by - 37%
    • HF by - 56%
    • Progression of retinopathy by - 34%
    • Deterioration of visual acuity by - 47%
  • BP target <130/80 for patients with diabetes and in chronic renal disease, JNC 72

1. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713. 2. National Institutes of Health, National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, MD: National Institutes of Health; December 2003. NIH Publication No. 03-5233.

minority populations
Minority Populations
  • In general, treatment similar for all demographic groups
  • Socioeconomic factors and lifestyle important barriers to BP control
  • Prevalence, severity of hypertension increased in African Americans
  • African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs
  • These differences usually eliminated by adding adequate doses of a diuretic
hypertension in african americans
Hypertension in African Americans
  • 3-7 times more prevalent in African American vs nonAfrican American1
  • Higher incidence of ESRD due to hypertension1
  • Higher risk of stroke2
  • Increased mortality due to stroke1
  • Higher incidence of LVH, 31% vs 10%1
  • The above likely represents a more malignant vascular response to hypertension1
  • Optimal adherence to hypertension guidelines is imperative in this high-risk group1

ESRD=end-stage renal disease; LVH=left ventricular hypertrophy.

1. Yancy CW. J Card Fail. 2000;6:183-186. 2. American Heart Association. Heart Disease and Stroke Statistics—2006 Update. Dallas, TX: American Heart Association; 2006.

hf in african americans overview
HF in African Americans: Overview
  • Affects 3% of the African American population1
  • Atypical natural history2
  • Unique epidemiology3,4
    • Lower prevalence of ischemic heart disease4
    • More likely associated with history of hypertension4
  • Worrisome prognosis2,5
    • Higher rate of hospitalization5
  • ? Question of altered responses to medical therapy2

1. American Heart Association. Heart Disease and Stroke Statistics—2006 Update. Dallas, TX: American Heart Association; 2006. 2. Yancy CW. J Card Fail. 2000;6:183-186. 3. Philbin EF, et al. Am J Cardiol. 1998;82:76-81. 4. Mathew J, et al. Am J Cardiol. 1996;78: 1447-1450. 5.Dries DL, et al. N Engl J Med. 1999;340:609-616.

trophy results trends in sbp
TROPHY Results: Trends in SBP

placebo

candesartan

difference placebo - candesartan

Difference in BP (mm Hg)

-2.0

-10.4

SBP (mm Hg)

Month

Adapted from Julius S, et al. N Engl J Med. 2006;354:1685-1697.

trophy conclusions
TROPHY Conclusions
  • Over 4 years, nearly two-thirds of the placebo group developed stage 1 treatment-requiring hypertension
  • In patients with prehypertension, 2 years of treatment with the ARB candesartan 16 mg/d:
    • Delayed onset of stage 1 hypertension for up to 2 years after discontinuation of treatment
    • Substantially suppressed development of stage 1 hypertension during the 2 years of active treatment
    • Substantially prolonged the hypertension-free period throughout the trial
    • Was well tolerated

Julius S, et al. N Engl J Med. 2006;354:1685-1697.

aliskiren bp reduction
AliskirenBP Reduction
  • Placebo
  • Aliskiren 150 mg
  • Aliskiren 300 mg
  • Aliskiren 600 mg

sys

sys

sys

sys

dias

dias

dias

dias

*

*

*

*

*

n=165

n=172

n=169

n=166

*P<.0001 for all doses vs placebo.

†P<.05 for 600 mg compared to 150 mg.

Oh BH, et al. J Am Coll Cardiol. 2007;49:1157-1163.

slide22

From Risk Factors to Heart Failure:

The Cardiovascular Continuum

Myocardial

infarction

Arrhythmia

Coronary

thrombosis

Loss of

muscle

Sudden

death

Myocardial ischemia

B

CAD

Remodeling

A

Atherosclerosis

LVH

Ventricular

dilatation

  • Risk factors
  • Hyperlipidemia
  • Hypertension
  • Diabetes
  • Insulin resistance

Heart failure

c

Death

D

Adapted from Dzau V, et al. Am Heart J. 1991;2(4 pt 1):1244-1263.