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Practical Approaches to Managing Hypertension: Reducing Global Cardiovascular Risk. Joshua Furman, MD Staff Cardiologist Mount Sinai Medical Center Miami Beach, Florida. ?. Key Question. Which class of agents do you presently consider first-line treatment for patients

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practical approaches to managing hypertension reducing global cardiovascular risk

Practical Approaches to Managing Hypertension: Reducing Global Cardiovascular Risk

Joshua Furman, MD

Staff Cardiologist

Mount Sinai Medical Center

Miami Beach, Florida

key question

?

Key Question

Which class of agents do you presently

consider first-line treatment for patients

with hypertension?

  • Diuretics
  • β-Blockers (BBs)
  • Calcium channel blockers (CCBs)
  • Angiotensin-converting enzyme inhibitors (ACEIs)
  • Angiotensin receptor blockers (ARBs)
  • All of the above

Use your keypad to vote now!

faculty disclosure
Faculty Disclosure
  • Dr Furman has no relevant financial relationships with any commercial interests to disclose.
learning objectives
Learning Objectives
  • State the prevalence of hypertension and its role in the cardiovascular disease continuum
  • Formulate hypertension management according to risk stratification
  • Describe the importance of targeting improvement in vascular function in patients with hypertension
progression of cardiovascular disease the cardiovascular continuum
Progression of Cardiovascular Disease: The Cardiovascular Continuum

Myocardial infarction

Myocardialischemia

Ventricular dysfunction

Sudden death

Peripheral arterial disease

Endothelialdysfunction and atherothrombosis

Ventricular dilation and hypertrophy

Stroke

Congestive heart failure and death

Hyperlipidemia,hypertension, diabetes, smoking, obesity, etc

Adapted from Dzau V, Braunwald E. Am Heart J. 1991;121:1244-1263.

development and progression of vascular disease
Development and Progression of Vascular Disease

RISK FACTORS

LDL

BP

Diabetes

Smoking

Oxidative Stress

Endothelial Dysfunction andSmooth Muscle Activation

NO •  Local Mediators •  Tissue ACE, AII

EndothelinCatecholamines

PAI-1, PlateletAggregation,

Tissue Factor

VCAM/ICAMCytokines

Proteolysis

Inflammation

Growth Factors

Cytokines

Matrix

Inflammation

PlaqueRupture

Vasoconstriction

Thrombosis

Vascular Lesionand Remodeling

CLINICAL SEQUELAE

Dzau V. Hypertension. 2001;37:1047-1052.

progression from hypertension to heart failure sudden death

Diastolic

dysfunction

LVH

Death/

Sudden

Death

HF

Systolic

dysfunction

ACS

Atherothrombosis,

left ventricular

remodeling

Subclinical

left ventricular

dysfunction

Overt heart

failure

Progression From Hypertension to Heart Failure/Sudden Death

Obesity

Diabetes

Hypertension

Smoking

Dyslipidemia

Risk Factors

Time

ACS = acute coronary syndrome; HF = heart failure; LVH = left ventricular hypertrophy.

Adapted from Vasan RS, Levy D. Arch Intern Med. 1996;156:1789-1796.

jnc 7 cardiovascular risk factors
JNC 7 Cardiovascular Risk Factors
  • Microalbuminuria or estimated GFR <60 mL/min
  • Age (men >55 yr; women >65 yr)
  • Family history of premature CVD
  • Hypertension
  • Cigarette smoking
  • Obesity (BMI ≥30 kg/m2)
  • Physical inactivity
  • Dyslipidemia
  • Diabetes mellitus

Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

in nearly 2 out of 3 adults with hypertension hypertension is still not controlled

100

90

80

70

60

50

40

30

20

10

0

In Nearly 2 Out of 3 Adults With Hypertension, Hypertension Is Still Not Controlled

NHANES (1999-2000)‡

30%

41%

66%!

70

59

US Population (%)*

34

Treated

Controlled†

Aware

*Adults aged 18 to 74 years with hypertension. †Controlled = BP 140/90 mm Hg.

‡Data were computed (M. Wolz, unpublished data, 2003) from the NHLBI.

Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

patients with bp controlled worldwide
Patients With BP Controlled Worldwide

<160/95 mm Hg

<140/90 mm Hg

Australia5

Canada2

USA1

Finland5

Spain5

22%

27%

20.5%

20%

19%

France4

Germany5

England3

Scotland5

India5

6%

17.5%

24%

22.5%

9%

>65 yr only

1. JNC VI. Arch Intern Med. 1997;157:2413-2446.

2. Joffres et al. Am J Hypertens. 1997;10:1097-1102.

3. Colhoun et al. J Hypertens. 1998;16:747-752.

4. Chamontin et al. Am J Hypertens. 1998;11(6 Pt 1):759-762.

5. Marques-Vidal et al. J Hum Hypertens. 1997;11:213-220.

Adapted from G. Mancia

10 year ncep framingham risk scores for fatal or nonfatal chd in men
10-Year NCEP/Framingham Risk Scores for Fatal or Nonfatal CHD in Men*

*A separate Framingham risk calculator exists for women.

NCEP ATP III. 2002. NIH Publication No. 02-5215. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/.

key question12

?

Key Question

What percentage of patients with hypertension

have 2 or more additional CV risk factors?

  • 20%
  • 30%
  • 40%
  • 50%
  • >50%

Use your keypad to vote now!

cv risk factor clustering with hypertension framingham offspring aged 18 to 74 years
CV Risk Factor Clustering With Hypertension: Framingham Offspring, Aged 18 to 74 Years

>50% of Hypertension Occurs in Presenceof 2 or More Risk Factors

Men

Women

1 RF

2 RFs

1 RF

2 RFs

25%

24%

26%

27%

20%

22%

19%

17%

8%

12%

No Additional RFs

No Additional RFs

3 RFs

3 RFs

4 or More RFs

4 or More RFs

RF = risk factor.

Adapted from Kannel WB. Am J Hypertens. 2000;13:3S-10S.

risk of chd in mild hypertension by intensity of associated risk factors
Risk of CHD in Mild Hypertension by Intensity of Associated Risk Factors

40

42

36

30

21

10-Year Probability of Event (%)

24

18

14

10

12

6

4

6

0

Risk Factors

SBP 150-160 mm Hg + + + + + +

TC 240-262 mg/dL − + + + + +

HDL-C 33-35 mg/dL − − + + + +

Diabetes − − − + + +

Cigarette smoking − − − − + +

ECG-LVH − − − − − +

Adapted from Kannel WB. Am J Hypertens. 2000;13:3S-10S.

jnc reclassification of bp based on risk
JNC Reclassification of BP Based on Risk

JNC 7

JNC VI

Arch Intern Med. 1997;157:2413-2446; Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

nonpharmacologic interventions and bp reduction
Nonpharmacologic Interventionsand BP Reduction

Low-SaltDiet

Weight Loss(19.4 lb)

Alcohol Reduction

Exercise

0

1

2

3

BP Decrease(mm Hg)

4

5

6

SBP

DBP

7

Adapted from: Stevens VJ et al. Ann Intern Med. 2001;134:1-11; Messerli FH et al. In: Griffin BP et al, eds. 2004. Manual of Cardiovascular Medicine. 2nd ed; Whelton SP et al. Ann Intern Med. 2002;136:493-503; Cutler JA et al. Am J Clin Nutr. 1997;65(suppl):643S-651S; Xin X et al. Hypertension. 2001;38:1112-1117; Whelton PK et al. JAMA. 1997;277:1624-1632.

study design trophy
Study Design: TROPHY

STUDY N = 809

Participants had prehypertension: SBP 130-139 mm Hg and DBP 89 mm Hg ORSBP 139 mm Hg and DBP 85-89 mm Hg

n = 409

2 years candesartan + 2 years placebo

n = 400

2 years placebo + 2 years placebo

When a participant reached the study end point of stage 1 hypertension, treatment with antihypertensive agents was initiated

  • RESULTS
  • At 2 years, hypertension had developed in 154 participants in the placebo group and 53 in the candesartan group (RRR 66%, P <.001)
  • At 4 years, hypertension had developed in 240 participants in the placebo group and 208 in the candesartan group (RRR 15.6%, P <.007)

TROPHY = Trial of Preventing Hypertension. Julius S, et al. N Engl J Med. 2006;354:1685-1697.

trophy kaplan meier curves of new onset clinical hypertension
TROPHY: Kaplan-Meier Curves of New Onset Clinical Hypertension

100

90

Candesartan

Placebo

80

70

60

Cumulative Incidence (%)

50

40

30

20

10

0

0

1

2

3

4

Years in Study

TROPHY = Trial of Preventing Hypertension.

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

slide19

Key Points for Optimal Hypertension Management

<140/90 mm Hg

<130/80 mm Hg in patients with diabetes or renal disease

JNC 7BPGoals

  • JNC 7 recommends:
  • If SBP >20 mm Hg or DBP >10 mm Hg over goal,
  • consider initiating with 2-drug combination

Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

antihypertensive medications mechanism of action
Antihypertensive Medications: Mechanism of Action

American Heart Association. December 11, 2006. Available at:http://www.americanheart.org/presenter.jhtml?identifier=3038158.

jnc 7 algorithm for hypertension
JNC 7: Algorithm for Hypertension

LIFESTYLE MODIFICATIONS

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

INITIAL DRUG CHOICES

With Compelling Indications

Without Compelling Indications

Stage 2 Hypertension

2-drug combos for most (usually thiazide-type diuretics and ACEI, or ARB, or BB, or CCB)

Compelling Indications

Other drugs (diuretic, ACEI, ARB, BB, CCB) as needed

Stage 1 Hypertension

Thiazide-type diuretics for most; may consider ACEI, ARB, BB, CCB, or combo

If not at goal BP, optimize dosages or add drugs until

goal BP achieved; consider consultation with hypertension specialist

Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

slide22

JNC 7 Highlights: Key Risk-Related Messages

  • Certain high-risk conditions are compelling indications for the initial use of specific antihypertensive drug classes

Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

jnc 7 compelling indications for antihypertensive drug classes
JNC 7: Compelling Indications for Antihypertensive Drug Classes

Recommended Drugs

AldoCompelling Indication Diuretic ACEI BB ARB CCB ANT

Heart failure • • • •   •

Post MI   • •     •

High coronary disease risk • • •   •  

Diabetes • • • • •  

Chronic kidney disease   •  •    

Recurrent stroke

prevention ••

Aldo ANT = aldosterone antagonist.Chobanian AV et al, for the NHBPEPCC. Bethesda, Md: NHLBI; 2004. NIH Publication No. 04-5230. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.

study design value
Study Design: VALUE

STUDY N = 15,245

Aged 50 years;

With treated or untreated hypertension and high risk of cardiac events

Step 1: valsartan 80 mg/dayStep 2: valsartan 160 mg/dayn = 7649

Step 1: amlodipine 5 mg/dayStep 2: amlodipine 10 mg/dayn = 7596

Both regimens included HCTZ in steps 3 and 4

Further drugs could be given to achieve BP control

Randomized, double-blind, parallel group comparison

  • RESULTS
  • BP i with both treatments
  • Primary end point (composite of cardiac mortality and morbidity) occurred in valsartan 10.6% vs amlodipine 10.4%, HR 1.04
  • Amlodipine effects were more pronounced in the early period
    • BP i4.0/2.1 mm Hg in the amlodipine group after 1 month

VALUE = Valsartan Antihypertensive Long-term Use Evaluation.

Julius S, et al. Lancet. 2004;363:2022-2031.

value hazard ratios for prespecified analyses in patients with hypertension at high cv risk

Hazard Ratio

Valsartan/Amlodipine

Primary cardiac composite end point

Cardiac mortality

Cardiac morbidity

All myocardial infarction

All congestive heart failure

All stroke

All-cause death

New-onset diabetes

0.5

1

2.0

Favors Valsartan

Favors Amlodipine

VALUE: Hazard Ratios for Prespecified Analyses in Patients With Hypertension at High CV Risk
    • Patients had hypertension and were at high CV risk.
    • VALUE = Valsartan Antihypertensive Long-term Use Evaluation.
  • Julius S et al, for the VALUE trial group. Lancet. 2004;363:2022-2031.
key question26

?

Key Question

On average, how many drugs will a patient

need to control hypertension?

  • 1
  • 2
  • 3
  • 4

Use your keypad to vote now!

number of antihypertensive agents needed to achieve systolic bp control

ALLHAT

138

IDNT

138

RENAAL

141

UKPDS

144

ABCD

132

MDRD

132

HOT

138

AASK

128

*

INVEST

131

1

2

3

4

Number of Antihypertensive Agents Needed to Achieve Systolic BP Control

SBP achieved(mm Hg)

Trial

Number of BP Medications†

*~50% patients required ≥3 medications. †Average per patient.

Bakris et al. Am J Kidney Dis. 2000;36:646-661; ALLHAT. JAMA. 2002;288:2981-2997; Berl et al. Ann Intern Med. 2003;138:542-549; Bakris et al. Arch Intern Med. 2003;163:1555-1565; Wright et al. JAMA. 2002;288:2421-2431; Pepine et al. JAMA. 2003;290:2805-2816.

diabetes approximately doubles cvd risk in patients with hypertension
Diabetes ApproximatelyDoubles CVDRisk in Patients With Hypertension

Adapted from Curb JD et al. JAMA. 1996;276:1886-1892; Hansson L et al. Lancet. 1998;351:1755-1762; Tuomilehto J et al. N Engl J Med. 1999:340:677-684.

hot study fewer major cv events in patients with diabetes randomized to lower bp goal
HOT Study: Fewer Major CV Events in Patients With Diabetes Randomized to Lower BP Goal

P = .005

25

20

15

Stroke, MI, or CV Death

(per 1000 patient-years)

10

5

0

80

90

85

Target DBP (mm Hg)

Patients with hypertension and diabetes were given baseline felodipine, plus other agents in a 5-step regimen. Study N = 18,790; diabetes n = 1501.

HOT = Hypertension Optimal Treatment; MI = myocardial infarction.

Adapted from Hansson L et al, for the HOT Study Group. Lancet. 1998;351:1755-1762.

ukpds tight glucose versus tight bp control and cv outcomes
UKPDS: Tight Glucose Versus Tight BP Control and CV Outcomes

Tight glucose control (goal <6.0 mmol/L or 108 mg/dL)

Tight BP control (average 144/82 mm Hg)

Stroke

Any Diabetic

End Point

DM

Deaths

Microvascular

Complications

0

5%

-10

10%

12%

-20

Relative Risk Reduction (%)

24%

*

-30

32%

32%

*

37%

-40

*

*P <.05 compared to tight glucose control

44%

*

-50

Patients had hypertension and Type 2 diabetes. N = 1148.

UKPDS = United Kingdom Prospective Diabetes Study.

Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.

antihypertensive medications mechanism of action32
Antihypertensive Medications: Mechanism of Action

American Heart Association. December 11, 2006. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3038158.

the renin angiotensin aldosterone system raas
The Renin-Angiotensin-Aldosterone System (RAAS)

Angiotensinogen

Kininogen

Kallikrein

Renin

Bradykinin

Angiotensin I

ACE

Angiotensin II

Inactive Peptides

  • Blood Pressure
  • Vascular Proliferation
  • Oxidative Stress
  • Vascular Inflammation
  • Thrombogenesis
  • Aldosterone

AT1

Adapted with permission from Brown NJ et al. Circulation. 1998;97:1411-1420; Endemann DH. J Am Soc Nephrol. 2004;15:1983-1992.

the renin angiotensin aldosterone system raas34
The Renin-Angiotensin-Aldosterone System (RAAS)

Angiotensinogen

Kininogen

Renin

Inhibitors

Kallikrein

Renin

Bradykinin

Angiotensin I

ACE

Angiotensin II

Inactive Peptides

ARBs

¯Blood Pressure

¯Vascular Proliferation

¯Oxidative Stress

¯Vascular Inflammation

  • Thrombogenesis
  • Aldosterone

AT1

Adapted with permission from Brown NJ et al. Circulation. 1998;97:1411-1420; Endemann DH. J Am Soc Nephrol. 2004;15:1983-1992.

the renin angiotensin aldosterone system raas35
The Renin-Angiotensin-Aldosterone System (RAAS)

Angiotensinogen

Kininogen

Kallikrein

Renin

Bradykinin

Angiotensin I

ACE

Angiotensin II

Inactive Peptides

ARBs

ARBs

AT2

AT2

¯Blood Pressure

¯Vascular Proliferation

¯Oxidative Stress

¯Vascular Inflammation

  • Thrombogenesis
  • Aldosterone

AT1

Adapted with permission from Brown NJ et al. Circulation. 1998;97:1411-1420; Endemann DH. J Am Soc Nephrol. 2004;15:1983-1992.

the renin angiotensin aldosterone system raas36

Kininogen

Kallikrein

Nitric

Oxide

Bradykinin

Kininase II

Inactive Peptides

The Renin-Angiotensin-Aldosterone System (RAAS)

Angiotensinogen

Renin

ACEIs

Angiotensin I

ACE

Angiotensin II

¯Blood Pressure

¯Vascular Proliferation

¯Oxidative Stress

¯Vascular Inflammation

  • Thrombogenesis
  • Aldosterone

AT1

Adapted with permission from Brown NJ et al. Circulation. 1998;97:1411-1420; Endemann DH. J Am Soc Nephrol. 2004;15:1983-1992.

acei trials in cad without hf primary outcomes
ACEI Trials in CAD Without HF: Primary Outcomes

EUROPA: CV Death/MI/Cardiac Arrest

HOPE: CV Death/MI/Stroke

14

20

Placebo

Placebo

12

20% Risk Reduction

HR = 0.80 (0.71–0.91)

P = .0003

22% Risk Reduction

HR = 0.78 (0.70–0.86)

P <.001

15

10

Percent

8

Ramipril 10 mg

10

6

Perindopril 8 mg

Percent

4

5

2

Time (years)

Time (years)

0

0

0

1

2

3

4

5

0

1

2

3

4

QUIET: All CV Events

PEACE: CV Death/MI/CABG/PCI

50

30

Quinapril 20 mg

Placebo

4% Risk Increase

HR = 1.04 (0.89–1.22)

P = .6

40

25

4% Risk Reduction

HR = 0.96 (0.88–1.06)

P = .43

20

30

Percent

Percent

Trandolapril

4 mg

15

Placebo

20

10

10

Time (years)

Time (years)

5

0

0

1

2

3

4

5

6

0

1

2

3

EUROPA Investigators. Lancet. 2003;362:782-788; HOPE Study Investigators. N Engl J Med. 2000;342:145-153; PEACE Trial Investigators. N Engl J Med. 2004;351:2058-2068; Pitt B, et al. Am J Cardiol. 2001;87:1058-1063.

micro hope persuade cv events in patients with diabetes
MICRO-HOPE, PERSUADE: CV Events in Patients With Diabetes

MICRO-HOPE(n = 3577)CV death/MI/stroke

PERSUADE(n = 1502)CV death/MI/cardiac arrest

25

25

Placebo

Placebo

20

20

25% RRRP = .0004

19% RRRP = .13

15

15

Primary Outcome (%)

Perindopril8 mg

10

10

Ramipril10 mg

5

5

0

0

5

0

1

2

3

4

5

0

1

2

3

4

Follow-Up (years)

Follow-Up (years)

MICRO-HOPE = Microalbuminuria, Cardiovascular, and Renal Outcomes (Heart Outcomes Prevention Evaluation); PERSUADE = Perindopril Substudy in Coronary Artery Disease and Diabetes.

HOPE Study Investigators. Lancet. 2000;355:253-259; Daly CA et al. Eur Heart J. 2005;26:1369-1378.

impact of ace inhibitors on the risk of developing new onset diabetes mellitus
Impact of ACE Inhibitors on the Risk of Developing New-Onset Diabetes Mellitus

RR = 0.66 (0.51-0.85)

P <.001

5.4

New Diagnosis of Diabetes (%)

3.6

HOPE Trial: Ramipril 10 mg QD vs placebo; 9297 patients with vascular disease or diabetes plus 1 other CV risk factor, 4355 with hypertension; BP: baseline (139/79 mm Hg); 2 years: ramipril (135/76 mm Hg), placebo (138/78 mm Hg).

Yusuf S et al. N Engl J Med. 2000;342:145-153.

hope study prevention of diabetes with ramipril
HOPE Study:Prevention of Diabetes With Ramipril

0.10

0.08

0.06

0.04

0.02

0

Placebo Ramipril

Kaplan-Meier Rates

200 400 600 800 1000 1200 1400 1600

Days of Follow-Up (no diabetes at baseline)

The occurrence of self-reported diabetes was reduced by 34% (95% CI, 15%-49%; P <.001) in the HOPE study. This effect was observed early and maintained consistently throughout the trial.

HOPE Study Investigators. Lancet. 2000;355:253-259.

micro hope albuminuria in patients with diabetes
MICRO-HOPE: Albuminuria in Patients With Diabetes

3.0

Placebo

2.5

Ramipril

2.0

P = .02

Mean Albumin/Creatinine Ratio (urine)

1.5

P = .001

1.0

0.5

0.0

1

0

4-5

2

3

Time (y)

HOPE Study Investigators. Lancet. 2000;355:253-259.

life secondary end points
LIFE: Secondary End Points

No. ofEvents

Hazard Ratio (95% CI)

End Points

Total Mortality

814

Angina Pectoris

301

CHF

314

Revascularization

545

562

New-Onset Diabetes

0.5

1

2

Favors Losartan Favors Atenolol

Dahlof B et al. Lancet. 2002;359:995-1003.

life new onset diabetes
LIFE: New-Onset Diabetes

Intention-to-Treat

10

9

Atenolol

8

7

6

Proportion of Patients With

First Event (%)

Losartan

5

4

3

Adjusted Risk Reduction 25%, P = .001

Unadjusted Risk Reduction 25%, P = .001

2

1

0

0

6

12

18

24

30

36

42

48

54

60

66

Study Month

Dahlof B et al. Lancet. 2002;359:995-1003.

cv pharmacotherapy impact on newly diagnosed diabetes
CV Pharmacotherapy: Impact on Newly Diagnosed Diabetes

CAPPP

STOP-2

HOPE

ALLHAT

ANBP2

LIFE

SCOPE

CHARM

VALUE

PEACE

INVEST

ALPINE

ASCOT

STOP-2

INSIGHT

ALLHAT

0

10

20

Reduction of New Diabetes (%)

30

ACEI or ARB

CA + ACEI or ARB

100

CA

Randomized active treatment vs control (eg, placebo, diuretic, β-blocker  diuretic)

CA = calcium antagonist.Pepine CJ, Cooper-DeHoff RM. J Am Coll Cardiol. 2004;44:509-512. Sever PS et al. Lancet. 2003;361:1149-1158.

multiple mechanisms of acei in cardiovascular disease
Multiple Mechanisms of ACEIin Cardiovascular Disease

Blood pressure lowering

Cardioprotective effects

  •  Preload and afterload
  •  LV mass
  •  Sympathetic stimulation
  •  Reperfusion injury
  • Improved myocardial remodeling

Metabolic syndrome

  • Lipid neutral
  • Improved glucose metabolism
  • Increases adiponectin
  • Decreased insulin resistance

Vasculoprotective effects

  • Direct antiatherogenic
  • Enhance endogenous fibrinolysis
  • Inhibit platelet aggregation
  • Antimigratory for mononuclear cells
  •  Matrix formation
  • Improve endothelial function
  • Antioxidant
  • Anti-inflammatory
  • Protection from plaque rupture
  • Improved arterial compliance and tone

Modified from: Lonn E et al. Eur Heart J Suppl. 2003;5:A43-A48.

summary the case for global cv risk management
Summary: The Case for Global CV Risk Management
  • CV disease remains the leading cause of death in both men and women in the United States
  • Data from the Framingham Heart Study have demonstrated clustering of risk factors—and that risk of death from CHD and stroke increases further with each added risk factor
  • Hypertension, a pivotal risk factor for CV disease, should prompt the search for the presence of additional risk factors
  • Recent clinical trials have provided evidence supporting a standard of care for the management of global CV risk
case study 55 year old man from india with hypertension and type 2 diabetes
Case Study: 55-Year-Old Man From India With Hypertension and Type 2 Diabetes
  • The patient is in for a checkup
  • History
    • Hypertension
    • Type 2 diabetes
    • Nonsmoker
    • No symptoms
  • Physical examination
    • BP: 148/96 mm Hg
    • Height: 64"
    • Weight: 178 lb
    • BMI: 30 kg/m2
    • Waist circumference: 38"
    • Cardiac dysfunction status: normal ventricular function (LVEF 68%)
  • Laboratory values
    • Glucose: 148 mg/dL (fasting)
    • A1C: 8.8%
    • Creatinine: 1.5 mg/dL
    • Urinalysis: 1+ proteinuria
    • Lipid profile (mg/dL):
      • TC: 268; LDL-C: 168; HDL-C: 42; TG: 296
  • Medications
    • HCTZ 25 mg/d
    • Glyburide 5 mg/d
10 year ncep framingham risk scores for fatal or nonfatal chd in men49
10-Year NCEP/Framingham Risk Scores for Fatal or Nonfatal CHD in Men*

*A separate Framingham risk calculator exists for women.

NCEP ATP III. 2002. NIH Publication No. 02-5215. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/.

decision point

?

Decision Point

What is the JNC 7 goal for this patient who has

hypertension, diabetes, and renal disease?

  • <120/80 mm Hg
  • <130/80 mm Hg
  • <140/80 mm Hg
  • <140/90 mm Hg

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decision point51

?

Decision Point

The patient’s BP is 148/96 mm Hg while

taking HCTZ 25 mg/d and glyburide 5 mg/d.

To further lower BP, you would add a(n):

  • BB
  • CCB
  • ARB
  • ACE

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pce takeaways54
PCE Takeaways
  • Patients with hypertension often present with multiple cardiac risk factors
  • Be vigilant in your investigation of all clinical indicators
  • Creatively address patient adherence; not everyone responds to the same interventions
  • Clinical inertia is the enemy—don't settle for "close enough"
key question55

?

Key Question

How important is using an antihypertensive

agent with proven risk reduction (reducing

morbidity and mortality) when choosing

medications for your patients with hypertension?

  • Not important
  • Slightly important
  • Somewhat important
  • Extremely important

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