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Hypertension Treatment A TransAtlantic view

Arterial Hypertension 2014. Hypertension Treatment A TransAtlantic view. José R. González Juanatey Cardiology Department and ICCU University Hospital Santiago de Compostela. Spain.

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Hypertension Treatment A TransAtlantic view

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  1. Arterial Hypertension 2014 Hypertension Treatment A TransAtlantic view José R. González Juanatey Cardiology Department and ICCU University Hospital Santiago de Compostela. Spain

  2. Disclosures:Research Grants: AZ, Boehringer Ingelheim, Pfizer, Novartis, Daichii-Sankyo, Sanofi-Aventis, Bayer, MSD. Consultant/Honorarium. AZ, Boehringer-Ingelheim, Bayer, Pfizer, BMS, MSD, Daichii-Sankyo, Servier.

  3. HT- 2014. A transAtlantic view Epidemiology HT and Risk Stratification New Guidelines and Therapeutic Objectives New Guidelines and Drug Selection

  4. HT Epidemiology .30 – 45 % of adult population (> 1.500 million persons)

  5. World’s biggest killers – CVD retain top spot

  6. HT- 2014. A transAtlantic view Epidemiology HT and Risk Stratification New Guidelines and Therapeutic Objectives New Guidelines and Drug Selection

  7. JNC VIII / ASH ESC / ESH 2013

  8. 2013 EVALUATING THE PATIENT History. Important previous events include: Stroke, TIA, CAD, HF or symptoms of left vemtricular dysfunction, CKD, Pripheral artery disease, Diabetes, Sleep apnea, ask about other risk factors and concurrent drugs. Physical Examination. Measuring BP; weight, height and BMI, waist circumference, signs of HF, neuro examination, optic fundi (if possible), peri-ocular xantomas, peripheral pulses. TESTS Blood Sample: electrolytes, Fasting glucose, serum creatinine and BUN, Lipids, Hb/hematocrit, liver function tests. Urine Sample: Albuminuria, red and white cells. ECG. All patients ECHOCARDIOGRAM. , if available, can be helpful …., although this test is not routine in hypertensive patients

  9. ESC/ESH 2013. Guidelines Markers of organ damage Test CV predictive value Availability Reproducibility Cost-effect

  10. Presión arterial (mmHg) Factores de riesgo (FRCV) Lesión de órgano diana (LOD) Enfermedad cardiovascular (ECV) Normal alta PAS 130 – 139 o PAD 85-89 HTA grado 1 PAS 140 – 159 o PAD 90-99 HTA grado 2 PAS 160 – 179 o PAD 100-109 HTA grado 3 PAS ≥ 180 o PAD ≥ 110 JNC VIII / ASH ESC / ESH 2013 Bajo riesgo Alto riesgo No otros factores de riesgo Moderado riesgo Moderado a alto riesgo 1 – 2 factores de riesgo Bajo riesgo Moderado riesgo Alto riesgo Bajo a moderado riesgo Moderado a alto riesgo Alto riesgo ≥ 3 factores de riesgo Alto riesgo Moderado a alto riesgo Alto a muy alto riesgo LOD, IRC 3 o Diabetes Alto riesgo Alto riesgo ECV sintomática, IRC ≥ 4 o Diabetes con LOD/FRCV Muy alto riesgo Muy alto riesgo Muy alto riesgo Muy alto riesgo

  11. HT- 2014. A transAtlantic view Epidemiology HT and Risk Stratification New Guidelines and Therapeutic Objectives New Guidelines and Drug Selection

  12. JNC VIII / ASH ESC / ESH 2013 < 140/90 mmHg “…it may be prudent to recommend lowering SBP/DBP to values < 140/90 mmHg in all hypertensive patients…” “…<140/85 mmHg in diabetes…” < 140/90 mmHg in diabetes and chronic renal failure JAMA 2013 / AJH 2013 Eur Heart J / J Hypertens 2013

  13. Blood Pressure Goal in Patientes with HT ESC / ESH 2013

  14. 2013 Blood Pressure >140/90 in Adults Aged >18 years (For age >80 years, pressure >150/90 or >140/90 if high risk (DM, CKD Start Lifestyle Changes (Lose weight, reduce dietary salt and alcohol, stop smoking)

  15. Recommendation 1 In the general population aged 60 years or older, initiate pharmacologic treatment to lower BP at SBP of 150 mm Hg or higher or DBP of 90 mm Hg or higher and treat to goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg. Strong recommendation – Grade A Recommendation 2 In the general population younger than 60 years initiate pharmacologic treatment to lower BP at DBP of 90 mm Hg or higher and treat to goal DBP of lower than 90 mm Hg For ages 30-59 years: Strong recommendation – Grade A For ages 18-29 years: Expert opinion – Grade E Recommendation 3 In the general population younger than 60 years initiate pharmacologic treatment to lower BP at SBP of 140 mm Hg or higher and treat to goal SBP of lower than 140 mm Hg Expert opinion – Grade E

  16. -6 -6 -4 -4 -2 -2 0 0 2 2 4 4 6 6 8 8 10 10 12 12 14 14 16 16 18 18 20 20 Metaregression of Treatment-induced Systolic BP Changes with Stroke and Myocardial Infarction 3.00 3.00 Stroke Myocardial infarction 2.75 2.75 ABCD/HT 2.50 2.50 2.25 2.25 ATLANTIS/1.25 2.00 2.00 ABCD/Norm IDNT/ARB-CCB 1.75 1.75 IDNT/ARB-CCB ABCD/HT 1.50 1.50 STOP2/CCB-BB-Diab DETAIL ABCD-N More vs Less DETAIL ACTION-Diab 1.25 1.25 ALLHAT/ACE-CCB-Diab ABCD-H More vs Less ABCD/Norm UKPDS 39 STOP2/ACE-CCB-Diab UKPDS 39 DETAIL IDNT/ARB-PLB ALLHAT/ACE-D-Diab ATLANTIS/5 CAPPP-Diab ADVANCE DIABHYCAR INVEST-Diab 1.00 1.00 RENAAL ABCD-H More vs Less STOP2/ACE-BB-Diab IDNT/ARB-PLB ADVANCE ALLHAT/CCB-D-Diab ASCOT-Diab Relative risk IINSIGHT-Diab ACTION-Diab JMIC-B-Diab INVEST-Diab LIFE-Diab EUROPA-Diab LIFE-Diab FACET HOPE-Diab HOT-DM More vs Less STOP2/CCB-BB-Diab SHEP-Diab DIABHYCAR 0.75 0.75 ACCORD BP ASCOT-Diab MOSES-Diab RENAAL UKPDS 38 EUROPA-Diab STOP2/ACE-BB-Diab HOPE-Diab PROGRESS-Diab HOT-DM More vs Less IDNT/CCB -PLB JMIC-B-Diab IDNT/ARB-CCB ACCORD BP UKPDS 38 0.50 0.50 STOP2/ACE-CCB-Diab FACET CAPPP-Diab ABCD-N More vs Less SYST-EUR Diab 0.25 0.25 SBP difference between randomized groups (mmHg) Reboldi, Gentile, Angeli, Ambrosio, Mancia, Verdecchia, 2010

  17. 8.70 17.42 8.18 6.97 11.72 5.43 4.92 9.36 4.51 3.93 6.81 3.27 4.03 2.64 2.21 1.76 <120 <120 120- <130 120- <130 130- <140 130- <140 140- <150 140- <150 150- <160 150- <160 160- <170 160- <170 170- <180 170- <180 ≥180 ≥180 SBP (mmHg) SBP (mmHg) CV Event Incidence in Relation to Mean FU Systolic BP (up to 1st event) in VALUE MI Stroke % % Mancia et al., 2010

  18. Incidence and Unadjusted CV Risk of Events in Deciles of In-treatment SBP Myocardial infarction Stroke Unadjusted risk of events (%) Unadjusted risk of events (%) HR (95% CI) HR (95% CI) On-treatment SBP (mmHg) On-treatment SBP (mmHg) Sleight, et al., J Hypert 2009; 27: 1360-1369

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