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©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
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• First subpoint
• Second subpoint
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• Etc, etc, etc…
• Etc, etc, etc…
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©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…
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©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
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%
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