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BENEFICIOS DEL TRATAMIENTO DE LA HIPERTENSIÓN ARTERIAL. PROF. DR. JORGE RESK HOSPITAL NACIONAL DE CLINICAS UNIVERSIDAD NACIONAL DE CORDOBA. BLOOD PRESSURE, STROKE, AND CORONARY HEART DISEASE. The Lancet 1990; 335: 827-838. 1000. ALL AVAILABLE EVIDENCE FROM RANDOMISED . T = TREATMENT.

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beneficios del tratamiento de la hipertensi n arterial

BENEFICIOS DEL TRATAMIENTODE LA HIPERTENSIÓN ARTERIAL

PROF. DR. JORGE RESK

HOSPITAL NACIONAL DE CLINICAS

UNIVERSIDAD NACIONAL DE CORDOBA

blood pressure stroke and coronary heart disease
BLOOD PRESSURE, STROKE, AND CORONARY HEART DISEASE

The Lancet 1990; 335: 827-838.

1000

ALL AVAILABLE EVIDENCE FROM RANDOMISED

T = TREATMENT

ANTIHYPERTENSIVE DRUG TRIALS

C = CONTROL

(mean DBP difference 5-6 mmHg for 5 years)

= FATAL EVENTS

= NON FATAL EVENTS

771

800

671

613

600

489

484

Total numbers of individuals affected

401

396

400

356

289

316

200

97

160

86

87

0

T

C

T

C

T

C

T

C

T

C

REMAINING

ALL

ALL

STROKE

CHD

VASCULAR

VASCULAR

OTHER

% reduction

DEATHS*

DEATHS*

DEATHS

in odds

42% SD 6

14% SD 5

2P-value

<0.0001

<0.01

<0.0002

beneficios del tratamiento antihipertensivo
BENEFICIOS DEL TRATAMIENTO ANTIHIPERTENSIVO
  • Reducción significativa de la morbilidad y mortalidad cardiovascular.
  • Reducción menos significativa sobre todas las causas de muerte.
  • Los beneficios se observan en individuos de edad avanzada, incluso en pacientes con hipertensión arterial sistólica aislada.
  • Reducción del riesgo cardiovascular en hombres y mujeres.
  • Hay mayor reducción del riesgo de ACV (30 a 40%) que de ECo (20%).
  • Probablemente produce una reducción significativa en la incidencia de insuficiencia cardíaca.
slide4

ADVERSE OUTCOMES IN PLACEBO-CONTROLLED TRIALS WITH FIRST-LINE THIAZIDE OR b-BLOCKERS

TREATMENT, Nº OF

PATIENTS

RR

OUTCOME

THIAZIDE

PLACEBO

(95% CI)

0.59 *

STROKE

284

584

(0.51-0.68)

0.84 *

CAD

433

703

(0.75-0.95)

0.70 *

ANY CV EVENT

838

1512

(0.64-0.75)

0.90 *

DEATH

742

1097

(0.82-0.98)

TOTAL OF

12118

17233

PATIENTS

* P <0.05

WRIGHT JM ET AL. CMAJ 1999; 161: 25-32

slide5

RANDOMIZED CONTROLLED TRIALS IN HYPERTENSION: FIRST DRUG THERAPY

RELATIVE RISK VS PLACEBO

CV

STROKE

CHD

CHF

MORTALITY

HIGH DOSE DIURETIC

0,49

0,99

0,17

0,78

(50-100 mg)

LOW DOSE DIURETIC

0,66

0,72

0,58

0,76

(12.5-25 mg)

BETA-BLOCKER

0,71

0,93

0,58

0,89

CHD: CORONARY HEART DISEASE

CHF: CONGESTIVE HEART FAILURE

PSATY BM, SMITH NL, SISCOVICK DE, ET AL. JAMA 1997; 277: 739-745.

the blood pressure lowering treatment trialists collaboration
THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION

CALCIUM CHANNEL BLOCKERS vs PLACEBO

* BORDERLINE STATISTICAL SIGNIFICANCE.

LANCET 2003; 362: 1527-35.

slide7

THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION

CALCIUM CHANNEL BLOCKERS vs DIURETICS / b-BLOCKERS

* HIGHLY STATISTICAL SIGNIFICANCE.

LANCET 2003; 362: 1527-35.

the blood pressure lowering treatment trialists collaboration8
THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION

ANGIOTENSIN CONVERTING ENZIME INHIBITORS vs PLACEBO

* HIGHLY STATISTICAL SIGNIFICANCE.

LANCET 2003; 362: 1527-35.

slide9

THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION

ACE-INHIBITORS vs DIURETICS / b-BLOCKERS

LANCET 2003; 362: 1527-35.

slide10

THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION

ACE-INHIBITORS vs CALCIUM CHANNEL BLOCKERS

* HIGHLY STATISTICAL SIGNIFICANCE.

LANCET 2003; 362: 1527-35.

slide11

EFECTOS DEL TRATAMIENTO ANTIHIPERTENSIVO

ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA VS OTROS TRATAMIENTOS

ARCH INTERN MED 2005; 165: 1410-1419.

slide12

ADVERSE OUTCOMES IN PLACEBO-CONTROLLED TRIALS WITH FIRST-LINE THIAZIDE OR b-BLOCKERS

TREATMENT, Nº OF

PATIENTS

RR

b

-BLOCKER

OUTCOME

PLACEBO

(95% CI)

0.80

STROKE

98

243

(0.64-1.01)

0.92

CAD

183

393

(0.78-1.10)

0.89

ANY CV EVENT

297

661

(0.78-1.02)

1.01

DEATH

287

568

(0.88-1.15)

TOTAL OF

5505

10867

PATIENTS

WRIGHT JM ET AL. CMAJ 1999; 161: 25-32

slide13

LIFE STUDY

LANCET 2002; 359:995-1003.

PRIMARY AND SECONDARY OUTCOMES

Adjusted*

LosartanAtenolol RR p(n=4605) (n=4588) (%)

Primary composite** 508 588 -13 0.021

CV mortality 204 234 -11 0.206

Stroke 232 309 -25 0.001

MI 198 188 +7 0.491

Total mortality 383 431 -10 0.128

* For degree of LVH and Framingham risk score at randomization

** CV mortality, stroke and MI; patients with a first primary event

slide14

Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA)

STROKE

TOTAL CV EVENTS

LANCET 2005; 366:895-906.

slide15

Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA)

CV MORTALITY

TOTAL MORTALITY

LANCET 2005; 366:895-906.

slide16

Should b-Blockers Remain First Choice in the Treatment

of Primary Hypertension? A Meta-Analysis

  • FINDINGS:
    • When the effect of b-blockers was compared with that placebo or no treatment, the relative risk of stroke was reduced by 19% (7-29%), about half that expected from previous hypertension trials.
    • There was no difference for myocardial infarction or mortality.

LANCET 2005; 366:1545-1553.

slide17

Should b-Blockers Remain First Choice in the Treatment

of Primary Hypertension? A Meta-Analysis

  • CONCLUSIONS:
    • Hence, we believe that b-blockers should not remain first choice in the treatment of primary hypertension.

LANCET 2005; 366:1545-1553.

slide18

HOW STRONG IS THE EVIDENCE FOR USE OF b-BLOCKERS AS FIRST LINE THERAPY FOR HYPERTENSION?

SYSTEMATIC REVIEW AND META-ANALYSIS

J HYPERTENS 2006; 24: 2131-2141.

slide19

HOW STRONG IS THE EVIDENCE FOR USE OF b-BLOCKERS AS FIRST LINE THERAPY FOR HYPERTENSION?

SYSTEMATIC REVIEW AND META-ANALYSIS

J HYPERTENS 2006; 24: 2131-2141.

slide20

HOW STRONG IS THE EVIDENCE FOR USE OF b-BLOCKERS AS FIRST LINE THERAPY FOR HYPERTENSION?

SYSTEMATIC REVIEW AND META-ANALYSIS

  • CONCLUSIONS:
    • b-blockers are inferior to CCBs and to RAS inhibitors for reducing several important hard end points.
    • Compared with diuretics, they had similar outcomes, but were less will tolerated.
    • Hence, b-blockers are generally suboptimal first-line antihypertensive drugs.

J HYPERTENS 2006; 24: 2131-2141.

slide21

ALLHATJAMA Dec 2002; 288: 2981-2997

INTERVENTIONS

GOAL BLOOD PRESSURE WAS LESS THAN 140/90 mm Hg

DOSE (mg/d)

n

STEP 1 DRUGS

12.5 TO 25

15255

CHLORTHALIDONE

2.5 TO 10

9048

AMLODIPINE

10 TO 40

9054

LISINOPRIL

STEP 2 DRUGS

25 TO 100

ATENOLOL

0.05 TO 0.2

RESERPINE

0.1 TO 0.3

CLONIDINE

STEP 3 DRUG

25 TO 100

HYDRALAZINE

slide22

ALLHATJAMA Dec 2002; 288: 2981-2997

PRIMARY OUTCOME

FATAL CHD OR NON-FATAL MYOCARDIAL INFARCTION

RR

95% CI

0,98

0,90-1,07

AMLODIPINE

vs CHLORTHALIDONE

0,99

0,91-1,08

LISINOPRIL

vs CHLORTHALIDONE

slide23

ALLHATJAMA Dec 2002; 288: 2981-2997

SECONDARY OUTCOME

RR

95% CI

AMLODIPINE

vs CHLORTHALIDONE

1,38

1,25-1,52

HEART FAILURE

LISINOPRIL

vs CHLORTHALIDONE

1,10

1,05-1,16

COMBINED CV DISEASE

1,15

1,02-1,30

STROKE

1,19

1,07-1,31

HEART FAILURE

2007 guidelines for the management of arterial hypertension esh esc
2007 GUIDELINES FOR THE MANAGEMENT OF ARTERIAL HYPERTENSION (ESH/ESC)
  • IN ANY CASE, THE ABOVE QUOTED META-ANALYSIS OF BETA BLOCKERS INITIATED TRIALS WELL ILLUSTRATE THE DIFFICULTIES INHERENT IN MANY RECENT TRIALS IN WHICH COMBINATION THERAPY HINDERS THE ATTRIBUTION OF EITHER BENEFITS OR HARMS TO INDIVIDUAL COMPOUNDS.
slide25

EFECTOS DEL TRATAMIENTO ANTIHIPERTENSIVO

MAS INTENSO VS MENOS INTENSO

ARCH INTERN MED 2005; 165: 1410-1419.

2007 guidelines for management of arterial hypertension j hypertens 2007 25 1105 87
2007 Guidelines for Management of Arterial Hypertension(J Hypertens 2007; 25: 1105-87)
  • CONCLUSIONES:
    • Hay un efecto beneficioso sobre la morbilidad y mortalidad cardiovascular cuando el tratamiento es iniciado con un diurético, bloqueante beta, calcio antagonista o inhibidor de la enzima de conversión.
    • La disminución de la presión arterial parece ser el determinante más importante para reducir la incidencia del accidente cerebrovascular y eventos coronarios.
2007 guidelines for management of arterial hypertension j hypertens 2007 25 1105 8727
2007 Guidelines for Management of Arterial Hypertension(J Hypertens 2007; 25: 1105-87)
  • CONCLUSIONES:
    • Algunos agentes antihipertensivos pueden ejercer un efecto beneficioso sobre determinados eventos en forma independiente al descenso de la presión arterial (calcio antagonistas sobre ACV e inhibidores ECA sobre eventos coronarios), aunque este efecto es definitivamente más pequeño que el efecto protector dominante ejercido por el descenso de la presión arterial.
2007 guidelines for management of arterial hypertension j hypertens 2007 25 1105 8728
2007 Guidelines for Management of Arterial Hypertension(J Hypertens 2007; 25: 1105-87)
  • CONCLUSIONES:
    • En general se ha reportado una menor protección de los calcio antagonistas en la prevención de nuevo comienzo de insuficiencia cardíaca independiente de las diferencias en la presión arterial.
    • Una disminución más intensa de la presión arterial produce una reducción mayor del ACV y de todos los eventos cardiovasculares, particularmente en pacientes diabéticos.
    • Los bloqueantes de los receptores de angiotensina también son efectivos para reducir los eventos cardiovasculares.