©2011 MFMER | slide-1 Hipertensión Arterial Sistémica: Enfoque del Cardiólogo Jorge F. Trejo,...

©2011 MFMER | slide-1

Hipertensión Arterial Sistémica: Enfoque del Cardiólogo

Jorge F. Trejo, MD, MHS

Congreso Anual de Cardiología Internacional Guadalajara, Jalisco, Febrero 23, 2012

©2011 MFMER | slide-2

145

140

135

130

125

Control diet

DASH diet

-8.0 (-4.9 to -11.1)

-1.6 (0.6 to -3.8)

-5.1 (3.0 to -7.3)

-2.1 (0.1 to -4.0)

-7.5 (-4.2 to -10.8)

Higher to lower sodiumControl: -8DASH: -7

-6.0 (4.0 to -7.9)

- 6.7 (-3.5 to 9.8)

Lower-sodium DASH vs higher-sodium control: -15

High (3.5 g) Intermediate (2.3 g) Low (1.2 g)

Dietary Sodium

0

135

130

125

120

115

0

140

145

©2011 MFMER | slide-3

Typical diet,High sodium

DASH diet,low sodium

55 - 7648 - 5442 - 4723 - 41

Age (yr)

Mean S

BP (

mm

Hg)

©2011 MFMER | slide-4

Global burden of high blood pressure in 2001• Worldwide 54 % of stroke and 47 % of

ischemic heart disease were attributable to high blood pressure

• Half of this burden occurred in people with hypertension, the remainder in those with lesser degree of high BP

• About 80 % of attributable burden occurred in low and middle-income countries, over half in people aged 45-69 years old

Lawes CMM et al, Lancet 2008;371:1513-18

.

.

Ischemic Heart Disease Mortality Has a Linear Relationship with Systolic and Diastolic Blood Pressure

Lewington S et al, Lancet 2002;360:1903-1913

.

..

. .

.

. .

..

.. .

..

.

..

.. .

..

.

Age at risk:

80-89years

70-79years

60-69years

50-59years

40-49years

B: Diastolic blood pressureAge at risk:

80-89years

70-79years

60-69years

50-59years

40-49years

A: Sistolic blood pressure

IHD

Mo

rta

lity

Flo

atin

g a

bso

lute

ris

l an

d 9

5 %

Cl

IHD

Mo

rta

lity

Flo

atin

g a

bso

lute

ris

l an

d 9

5 %

Cl

1

2

4

8

16

32

64

128

256

1

2

4

8

16

32

64

128

256

70 80 90 100 110

20 40 60 80

Usual systolic blood pressure (mm Hg)

Usual diastolic blood pressure (mm Hg)

Stroke Mortality Has a Linear Relationship with Systolic and Diastolic Blood Pressure In Each Decade

Lewington S et al, Lancet 2002;360:1903-1913

Age at risk:

80-89years

70-79years

60-69years

50-59years

A: Sistolic blood pressureIH

D M

ort

alit

yF

loa

ting

ab

solu

te r

isl a

nd

95

% C

l

1

2

4

8

16

32

64

128

256Age at risk:

80-89years

70-79years

60-69years

50-59years

IHD

Mo

rta

lity

Flo

atin

g a

bso

lute

ris

l an

d 9

5 %

Cl

1

2

4

8

16

32

64

128

256

70 80 90 100 110

120 140 160 180

Usual systolic blood pressure (mm Hg)

Usual diastolic blood pressure (mm Hg)

B: Diastolic blood pressure

©2011 MFMER | slide-7

0

20

40

60

80

100

0 2 4 6 8 10 12 14 16 18 20

Ris

k of

hypert

ensi

on (

%)

*Residual lifetime risk of developing hypertension among people with blood pressure <140/90 mmHg

Years

Men Women

Source: Vasan RS, et al. JAMA 2002; 287:1003-1010

Framingham Heart Study

High Blood Pressure: Lifetime Risk* Starting at Age 55-65 Years

©2011 MFMER | slide-8

Changes in BP Classification

Hypertension 2003;289:2560-2572.

©2011 MFMER | slide-9

Ambulatory BP Monitoring >Home BP Monitoring >Clinic BP Measurement Correlation with CV Outcomes and End Organ Damage

CV

Ou

tco

me

s a

nd

En

d

Org

an

Da

mag

e

Ambulatory BPMonitoring

Home BPMonitoring

Clinic BPMeasurement

Ohkubo T et al, J Hypertens 2000;18:847-854Staessen JA et al, JAMA 1999;282:539-542

©2011 MFMER | slide-10

Compared to Ambulatory BP≥ 135/85

Sensitivity

Mean (95% CI)

Specificity

Mean (95% CI)

Clinic BP ≥ 140/90

74.6 %

(60.7-84.8)

74.6 %

(47.9-90.4)

Home BP ≥ 135/85

85.7 % (78-91)

62.4 % (48-75)

Clinic BP and Home BP Accuracy ComparedTo Ambulatory BP: Systematic Review

Hodgkinson J et al, BMJ 2011;342:d3621

©2011 MFMER | slide-11

Probability (%) that Home or Clinic BP is Correct, Compared to Ambulatory BP

Prevalence

Positive

Home Clinic

Negative

Home Clinic

10 % 19 25 97 96

30 % 47 56 90 87

50 % 67 75 80 75

Hodgkinson J et al, BMJ 2011;342:d3621

©2011 MFMER | slide-12

Antihypertensive therapy on patients with CVD without HTN: Meta-analysis

Outcome RRR ARR (events/1000)

Stroke 23 % -8

MI 20 % -13

CHF 29 % -44

Composite 15 % -27

CVD deaths 17 % -15

Total deaths 13 % -14

Thompson A M et al, JAMA 2011;305:913

©2011 MFMER | slide-13©2011 MFMER | slide-13

The Linear Relationship and Normal Distribution of Risk Factor and Events Paradox

Georgiopoulou V V et al. Circ Heart Fail 2011;4:528-533

15%

10%

0%

5% 4.8 %6.4 %

11.6%

13.6%

<120 120-139 140-159 ≥160

10-year HF Incidence

Systolic BP has adirect relationship with HF risk

0

10

30

20

<120 120-139 140-159 ≥160

40

17

38 37

15

Heart Failure EventsApprox. half the incident cases ofHF occurred in those with systolicBP < 140 mmHg

©2011 MFMER | slide-14

11,506 high-risk hypertensive patients randomized to benazepril (40 mg) and amlodipine (10 mg) or benazepril (40 mg) and HCTZ (25 mg) for 36 months*

Jamerson K et al. NEJM 2008;359:2417-28.

Benazepril/HCTZ

Benazepril/Amlodipine

Com

posi

te o

f CV

dea

th,

MI,

stro

ke, h

ospi

taliz

atio

n fo

r an

gina

, sud

den

card

iac

arre

st, a

nd c

oron

ary

reva

scul

ariz

atio

n (%

)

Time to first cardiovascular event (days)

20% RRR, HR=0.80, P=0.0002

0.16

0.14

0.12

0.10

0.08

0.06

0.04

0.02

0.000 200 400 600 800 1000 1200 1400

*The study was prematurely stopped

Is the combination benazepril + amlodipine better than benazepril + HCTZ to prevent CVD? ACCOMPLISH Trial

©2011 MFMER | slide-15

The advantage of benazepril/amlodipine vs. benazepril/hctz was driven by non-fatal MI and coronary revascularization

HOPE Trial’s components of the composite endpointshowed uniform statistical benefit on clinically relevantoutcomes

©2011 MFMER | slide-16©2011 MFMER | slide-16

115 120 125 130 135 140 145 150 155 160

0.5 x 0.8 x 0.68 x 0.5= 0.13

La estrategia de tratar al grupo de alto riesgo concentra la Intervención y limita el beneficio

Población conhipertensión arterialbajo control (50 %)

Población en tratamientoantihipertensivo conmedicamentos (68 %)

Población conscientede tener hipertensiónarterial (80 %)

Población elegiblede tratamiento anti-hipertensivo con medicamentos

©2011 MFMER | slide-17

Source: Ford, E. S. et al. Figure 2b, Circulation 2009;120:1181-1188. Reprinted with permission.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Stage 2

Stage 1

Prehypertensionnormotensive

Bloo

d pr

essu

reag

e-ad

just

ed p

erce

ntag

e

Change in Blood Pressure Levels in the United States Over Time:NHANES

©2011 MFMER | slide-18

El efecto en eventos coronarios y ataque cerebral de la reducción de presión arterial sistólica en relación a la edad y el grado en la reducción de

la presión arterial (dependiente de la intensidad de tratamiento)

Law M R et al. BMJ 2009;338:bmj.b1665

24%

CI AC

1

No.Meds.

3 48%

33%

60%

Reducción de riesgo relativo

©2011 MFMER | slide-19

Law M R et al. BMJ 2009;338:bmj.b1665

24%

CI AC

1

No.Meds.

3

33%

45% 62%

El efecto en eventos coronarios y ataque cerebral de la reducción de presión arterial diastólica en relación a la edad y el grado en la reducción

de la presión arterial (dependiente de la intensidad de tratamiento)

Reducción de riesgo relativo

Extent of awareness, treatment and control of high blood pressure by age (NHANES: 2005–2008).

Roger V L et al. Circulation 2011;123:e18-e209

©2011 MFMER | slide-21

Title Here

• Type your first bulleted point here

• Type your second bulleted point here

• First subpoint

• Second subpoint

• Type your third bulleted point here

• Etc, etc, etc…

• Etc, etc, etc…

Type the footnote/source in this space

©2011 MFMER | slide-22

Title Here Subtitle Here

• Type your first bulleted point here

• Type your second bulleted point here

• First subpoint

• Second subpoint

• Type your third bulleted point here

• Etc, etc, etc…

• Etc, etc, etc…

Type the footnote/source in this space

©2011 MFMER | slide-23

Title for ChartSubtitle for Chart

0

20

40

60

80

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Type the footnote/source in this space

%

EastWestNorth

©2011 MFMER | slide-24

Title for ChartSubtitle for Chart

Type the footnote/source in this space

©2011 MFMER | slide-25

Title for ChartSubtitle for Chart

0

20

40

60

80

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Type the footnote/source in this space

%

EastWestNorth

©2011 MFMER | slide-26

Title for ChartSubtitle for Chart

0

20

40

60

80

100

0 1 2 3 4 5

Type the footnote/source in this space

%

EastWestNorth

Years

©2011 MFMER | slide-27

Title for TableSubtitle for Table

Type the footnote/source in this space

Column 1 Column 2 Column 3 Column 4 Column 5

Row 1 Red 12.3 47% P<0.001

Row 2 Yellow 459.2 26% P=0.05

Row 3 Green 56.7 98% NS

Row 4 Blue 1.0 2% P>0.01

Row 5 Pink 56.9 14% P<0.0001

Row 6 Violet 25.4 35% P=0.01

Row 7 Orange 1,256.2 5% P<0.001

©2011 MFMER | slide-28

Title for Organizational ChartSubtitle for Organization Chart

Box 1

Box 2 Box 4 Box 5Box 3

Box 6 Box 7 Box 8 Box 9

Type the footnote/source in this space

©2011 MFMER | slide-29

Mayo ClinicLocations

©2011 MFMER | slide-30

4,733 diabetic patients randomized to intensive BP control (target SBP <120 mm Hg) or standard BP control (target SBP <140 mm Hg) for 4.7 years

Total stroke

HR=0.8895% CI (0.73-1.06)

HR=0.5995% CI (0.39-0.89)

Nonfatal MI, nonfatal stroke, or CV death

ACCORD Study Group. NEJM 2010;362:1575-85.

Intensive vs. Standard Blood Pressure Control in Diabetics: ACCORD Trial

Intensive BP control in DM does not reduce a composite of adverse CV events, but does reduce the rate of stroke

Pati

ents

wit

h E

vents

(%

)

Pati

ents

wit

h E

vents

(%

)

20

15

10

5

0

20

15

10

5

0

432 1 0 5 6 7 8 432 1 0 5 6 7 8

Years Post-RandomizationYears Post-Randomization

©2011 MFMER | slide-31

4,733 diabetic patients randomized to intensive BP control (target SBP <120 mm Hg) or standard BP control (target SBP <140 mm Hg) for 4.7 years

Intensive BP control in DM does not reduce a composite of adverse CV events, but does reduce the rate of stroke

Pat

ien

ts w

ith

Eve

nts

(%

)

0

5

10

15

20

Years Post-Randomization0 1 2 3 4 5 6 7 8

Pat

ien

ts w

ith

Eve

nts

(%

)

0

5

10

15

20

Years Post-Randomization0 1 2 3 4 5 6 7 8

Tota

l st

roke

HR=0.8895% CI (0.73-1.06)

HR=0.5995% CI (0.39-0.89)

Nonfa

tal M

I, n

onfa

tal

stro

ke, or

CV

death

ACCORD Study Group. NEJM 2010;362:1575-85.

Intensive vs. Standard Blood Pressure Control in Diabetics: ACCORD Trial

©2011 MFMER | slide-32Sipahi, I. et al. J Am Coll Cardiol 2006;48:833-838

CAMELOT-IVUS Substudy (n=274)RCT, Comparisonof Amlodipine vs.Enalapril vs. PlaceboIn CHD patients with DBP<100 mmHg

Systolic Blood Pressure on Treatment WasRelated to Progression of Coronary Plaque

Cha

nge

in a

ther

oma

volu

me

(mm

3 )

JNC 7 Categories

30

20

15

-10

-20

10

0

Normal

-15

-5

5

25

Prehypertension Hypertension

p<0.001

p<0.001 by ANCOVA

p=0.01

P=0.039

40

30

20

-10

-20

10

0

-30

100 120 140 160 180

SBP (mm Hg)

Cha

nge

in a

ther

oma

volu

me

(mm

3 )

©2011 MFMER | slide-33Sipahi, I. et al. J Am Coll Cardiol 2006;48:833-838

CAMELOT-IVUS Substudy (n=274)RCT, Comparisonof Amlodipine vs.Enalapril vs. PlaceboIn CHD patients with DBP<100 mmHg

Systolic Blood Pressure on Treatment WasRelated to Progression of Coronary Plaque

40

30

20

-10

-20

10

0

-30

100 120 140 160 180

SBP (mm Hg)

Cha

nge

in a

ther

oma

volu

me

(mm

3 )

©2011 MFMER | slide-34Sipahi, I. et al. J Am Coll Cardiol 2006;48:833-838

CAMELOT-IVUS Substudy (n=274)RCT, Comparisonof Amlodipine vs.Enalapril vs. PlaceboIn CHD patients with DBP<100 mmHg

Systolic Blood Pressure on Treatment WasRelated to Progression of Coronary Plaque

Cha

nge

in a

ther

oma

volu

me

(mm

3 )

JNC 7 Categories30

20

15

-10

-20

10

0

Normal

-15

-5

5

25

Prehypertension Hypertension

p<0.001

p<0.001 by ANCOVA

p=0.01

P=0.039

©2011 MFMER | slide-35

©2011 MFMER | slide-36