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Transcript of ©2011 MFMER | slide-1 Hipertensión Arterial Sistémica: Enfoque del Cardiólogo Jorge F. Trejo,...
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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
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©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
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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)
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©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
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.
.
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)
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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
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©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
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©2011 MFMER | slide-8
Changes in BP Classification
Hypertension 2003;289:2560-2572.
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©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
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©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
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©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
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©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
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©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
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©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
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©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
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©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
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©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
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©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
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©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
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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
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©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
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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…
Type the footnote/source in this space
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©2011 MFMER | slide-23
Title for ChartSubtitle for Chart
0
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1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Type the footnote/source in this space
%
EastWestNorth
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©2011 MFMER | slide-24
Title for ChartSubtitle for Chart
Type the footnote/source in this space
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©2011 MFMER | slide-25
Title for ChartSubtitle for Chart
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1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Type the footnote/source in this space
%
EastWestNorth
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©2011 MFMER | slide-26
Title for ChartSubtitle for Chart
0
20
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0 1 2 3 4 5
Type the footnote/source in this space
%
EastWestNorth
Years
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©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
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©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
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©2011 MFMER | slide-29
Mayo ClinicLocations
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©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
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©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
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©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 )
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©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 )
![Page 34: ©2011 MFMER | slide-1 Hipertensión Arterial Sistémica: Enfoque del Cardiólogo Jorge F. Trejo, MD, MHS Congreso Anual de Cardiología Internacional Guadalajara,](https://reader033.fdocument.pub/reader033/viewer/2022061304/5513d67c5503463a298b53ad/html5/thumbnails/34.jpg)
©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
![Page 35: ©2011 MFMER | slide-1 Hipertensión Arterial Sistémica: Enfoque del Cardiólogo Jorge F. Trejo, MD, MHS Congreso Anual de Cardiología Internacional Guadalajara,](https://reader033.fdocument.pub/reader033/viewer/2022061304/5513d67c5503463a298b53ad/html5/thumbnails/35.jpg)
©2011 MFMER | slide-35
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©2011 MFMER | slide-36