Hypertension Treatment A TransAtlantic view

Hypertension TreatmentHypertension TreatmentA TransAtlantic viewA TransAtlantic view

Arterial Hypertension 2014

José R. González JuanateyCardiology Department and ICCU

University Hospital Santiago de Compostela. Spain

Disclosures:Research Grants: AZ, Boehringer Ingelheim, Pfizer, Novartis, Daichii-Sankyo, Sanofi-Aventis, Bayer, MSD.Consultant/Honorarium. AZ, Boehringer-Ingelheim, Bayer, Pfizer, BMS, MSD, Daichii-Sankyo, Servier.

J.R.G. JUANATEY C.H.U.Santiago

HT- 2014. A transAtlantic view

Epidemiology

HT and Risk Stratification

New Guidelines and Therapeutic Objectives

New Guidelines and Drug Selection


HT Epidemiology

.30 – 45 % of adult population (> 1.500 million persons)


World’s biggest killers World’s biggest killers –– CVD retain top spotCVD retain top spot



Epidemiology





Office and ambulatory HT mmHgCategory SBP DBP

Office ≥ 140 y/o ≥ 90

ABPM

Day (activity) ≥ 135 y/o ≥ 85

Night (rest) ≥ 120 y/o ≥ 70

24-hours ≥ 130 y/o ≥ 80

In-home ≥ 135 y/o ≥ 85

JNC VIII / ASH ESC / ESH 2013


EVALUATING THE PATIENTEVALUATING THE PATIENTHistory. History. Important previous events include:Important previous events include:Stroke, TIA, CAD, HF or symptoms of left vemtricular dysfunction, CKD, Stroke, TIA, CAD, HF or symptoms of left vemtricular dysfunction, CKD, Pripheral artery disease, Diabetes, Sleep apnea, ask about other risk Pripheral artery disease, Diabetes, Sleep apnea, ask about other risk factors and concurrent drugs.factors and concurrent drugs.Physical Examination.Physical Examination.Measuring BP; weight, height and BMI, waist circumference, signs of HF, Measuring BP; weight, height and BMI, waist circumference, signs of HF, neuro examination, optic fundi (if possible), peri-ocular xantomas, neuro examination, optic fundi (if possible), peri-ocular xantomas, peripheral pulses.peripheral pulses.

TESTSTESTSBlood Sample: Blood Sample: electrolytes, Fasting glucose, serum creatinine and electrolytes, Fasting glucose, serum creatinine and BUN, Lipids, Hb/hematocrit, liver function tests.BUN, Lipids, Hb/hematocrit, liver function tests.Urine Sample: Urine Sample: Albuminuria, red and white cells.Albuminuria, red and white cells.

ECG. ECG. All patientsAll patientsECHOCARDIOGRAMECHOCARDIOGRAM. , if available, can be helpful . , if available, can be helpful …., although this …., although this test is not routine in hypertensive patientstest is not routine in hypertensive patients

2013


Test CV predictive value Availability Reproducibility Cost-effect

ESC/ESH 2013. ESC/ESH 2013.

Guidelines Markers of organ damageGuidelines Markers of organ damage


Factores de riesgo (FRCV)Lesión de órgano diana (LOD)

Enfermedad cardiovascular (ECV)

No otros factores de riesgo

1 – 2 factores de riesgo

≥ 3 factores de riesgo

LOD, IRC 3 o Diabetes

ECV sintomática, IRC ≥ 4 o Diabetes con LOD/FRCV

Presión arterial (mmHg)

Normal altaPAS 130 – 139o PAD 85-89

HTA grado 1PAS 140 – 159o PAD 90-99

HTA grado 2PAS 160 – 179o PAD 100-109

HTA grado 3PAS ≥ 180

o PAD ≥ 110

Bajo riesgo

Bajo riesgo

Alto riesgo

Alto riesgo

Alto riesgo

Alto riesgo

Alto riesgo

Alto riesgo

Muy alto riesgo Muy alto riesgo Muy alto riesgo Muy alto riesgo

Moderado riesgo

Moderado riesgo Moderado a alto riesgo

Moderado a alto riesgo

Alto a muyalto riesgo

Bajo a moderado riesgo

Moderado a alto riesgo




Epidemiology






JAMA 2013 / AJH 2013

Eur Heart J / J Hypertens 2013

< 140/90 mmHg

< 140/90 mmHg in diabetes and chronic renal failure

“…it may be prudent to recommend lowering SBP/DBP to values < 140/90 mmHg in all hypertensive patients…” “…<140/85 mmHg in diabetes…”


Blood Pressure Goal in Patientes with HT

Recomendaciones Clase Nivel

Presión arterial sistólica < 140 mmHg

pacientes con riesgo cardiovascular bajo-moderado I B

pacientes con diabetes I A

pacientes con ictus previo o ataque isquémico transitorio IIa B

pacientes con cardiopatía isquémica IIa B

pacientes con insuficiencia renal, diabética o no diabética IIa B

Ancianos (< 80 años) con PAS ≥ 160 mmHg, objetivo PAS entre 140 y 150 mmHg

I A

Ancianos (< 80 años) en buena forma física < 140 mmHg IIb C

Ancianos (> 80 años) con PAS ≥ 160 mmHg, objetivo PAS entre 140 y 150 mmHg, si están en buenas condiciones

I B

Presión arterial diastólica < 90 mmHg; en diabéticos < 85 mmHg. Valores PAD 80-85 mmHg son seguros y bien tolerados

I A

ESC / ESH 2013


PatientsPatients BPBP

Adults Aged > 18 yAdults Aged > 18 y > 140 / 90 mmHg OBPOBP

Age Age >> 80 y 80 y > 150 / 90 mmHg OBPOBP

High Risk (DM, CKD)High Risk (DM, CKD) > 140 / 90 mmHg OBPOBP

2013Blood Pressure >140/90 in Adults Aged >18 years

(For age >80 years, pressure >150/90 or >140/90 if high risk (DM, CKD

Start Lifestyle Changes(Lose weight, reduce dietary salt and alcohol, stop

smoking)


Recommendation 1Recommendation 1In the general population In the general population aged aged 60 years or older, 60 years or older, initiate pharmacologic treatment to lower BP initiate pharmacologic treatment to lower BP at SBP of at SBP of 150 mm Hg or higher150 mm Hg or higher or DBP of 90 mm Hg or higher or DBP of 90 mm Hg or higher and treat to goal SBP lower than 150 mm Hg and goal and treat to goal SBP lower than 150 mm Hg and goal DBP lower than 90 mm Hg.DBP lower than 90 mm Hg.Strong recommendation Strong recommendation –– Grade A Grade ARecommendation 2Recommendation 2In the general population younger than 60 years In the general population younger than 60 years initiate pharmacologic treatment to lower BP at DBP of initiate pharmacologic treatment to lower BP at DBP of 90 mm Hg or higher and treat to goal DBP of lower 90 mm Hg or higher and treat to goal DBP of lower than 90 mm Hg than 90 mm Hg For ages 30-59 years: For ages 30-59 years: Strong recommendation Strong recommendation –– Grade AGrade AFor ages 18-29 years: For ages 18-29 years: Expert opinion Expert opinion –– Grade E Grade ERecommendation 3Recommendation 3In the general population younger than 60 years In the general population younger than 60 years initiate pharmacologic treatment to lower BP at SBP of initiate pharmacologic treatment to lower BP at SBP of 140 mm Hg or higher and treat to goal SBP of lower 140 mm Hg or higher and treat to goal SBP of lower than 140 mm Hg than 140 mm Hg Expert opinion Expert opinion –– Grade E Grade E


Metaregression of Treatment-induced Systolic BP Changes with Stroke and Myocardial InfarctionMetaregression of Treatment-induced Systolic BP Changes with Stroke and Myocardial InfarctionMetaregression of Treatment-induced Systolic BP Changes with Stroke and Myocardial InfarctionMetaregression of Treatment-induced Systolic BP Changes with Stroke and Myocardial Infarction

Reboldi, Gentile, Angeli, Ambrosio, Mancia, Verdecchia, 2010Reboldi, Gentile, Angeli, Ambrosio, Mancia, Verdecchia, 2010

Stroke Myocardialinfarction

3.003.002.752.752.502.502.252.25

2.002.001.751.75

1.501.50

1.251.25

1.001.00

0.750.75

0.500.50

0.250.25

Rel

ativ

e ris

kR

elat

ive

risk

SBP difference between randomized groups (mmHg)SBP difference between randomized groups (mmHg)-6-6 -4-4 -2-2 00 22 44 66 88 1010 1212 1414 1616 1818 2020 -6-6 -4-4 -2-2 00 22 44 66 88 1010 1212 1414 1616 1818 2020

3.003.002.752.752.502.502.252.25

2.002.001.751.75

1.501.50

1.251.25

1.001.00

0.750.75

0.500.50

0.250.25

ABCD-N More vs LessABCD-N More vs Less

SYST-EUR DiabSYST-EUR Diab

ACCORD BPACCORD BPUKPDS 38UKPDS 38

FACETFACET

MOSES-DiabMOSES-Diab

JMIC-B-DiabJMIC-B-Diab

HOPE-DiabHOPE-DiabIDNT/CCB -PLBIDNT/CCB -PLB

PROGRESS-DiabPROGRESS-Diab

SHEP-DiabSHEP-Diab

EUROPA-DiabEUROPA-Diab

ABCD-HABCD-HMore vs LessMore vs Less

ACTION-DiabACTION-Diab

ABCD/NormABCD/Norm

ABCD/HTABCD/HT

IDNT/ARB-CCBIDNT/ARB-CCB

IDNT/ARB-PLBIDNT/ARB-PLB

ADVANCEADVANCE

ASCOT-DiabASCOT-Diab

HOT-DM More vs LessHOT-DM More vs Less

DETAILDETAIL

DETAILDETAIL

ALLHAT/ACE-CCB-DiabALLHAT/ACE-CCB-Diab

STOP2/CCB-BB-DiabSTOP2/CCB-BB-DiabLIFE-DiabLIFE-Diab

INVEST-DiabINVEST-DiabIINSIGHT-DiabIINSIGHT-Diab

ALLHAT/CCB-D-DiabALLHAT/CCB-D-DiabSTOP2/ACE-BB-DiabSTOP2/ACE-BB-Diab

RENAALRENAALDIABHYCARDIABHYCARCAPPP-DiabCAPPP-Diab

ALLHAT/ACE-D-DiabALLHAT/ACE-D-DiabUKPDS 39UKPDS 39

STOP2/ACE-CCB-DiabSTOP2/ACE-CCB-Diab

ABCD-N More vs LessABCD-N More vs Less

ACCORD BPACCORD BP

UKPDS 38UKPDS 38

FACETFACET

JMIC-B-DiabJMIC-B-Diab

HOPE-DiabHOPE-Diab


EUROPA-DiabEUROPA-Diab

ACTION-DiabACTION-Diab

ABCD/NormABCD/Norm

ABCD/HTABCD/HT


IDNT/ARB-PLBIDNT/ARB-PLB

ADVANCEADVANCE

ASCOT-DiabASCOT-Diab

HOT-DM More vs LessHOT-DM More vs Less

DETAILDETAILSTOP2/CCB-BB-DiabSTOP2/CCB-BB-Diab

LIFE-DiabLIFE-Diab

INVEST-DiabINVEST-Diab

STOP2/ACE-BB-DiabSTOP2/ACE-BB-DiabRENAALRENAAL

DIABHYCARDIABHYCAR

CAPPP-DiabCAPPP-Diab

UKPDS 39UKPDS 39

STOP2/ACE-CCB-DiabSTOP2/ACE-CCB-Diab

ATLANTIS/1.25ATLANTIS/1.25

ATLANTIS/5ATLANTIS/5

ABCD-H More vs LessABCD-H More vs Less


CV Event Incidence in Relation to Mean FU Systolic BP (up to 1st event) in VALUE

Mancia et al., 2010Mancia et al., 2010

MIMIMIMI StrokeStrokeStrokeStroke

0

4

8

12

16

20

0

2

4

6

8

10

2.212.21 1.761.762.642.64

4.034.03

6.816.81

9.369.36

11.7211.72

17.4217.42

4.924.92

3.933.933.273.27

4.514.51

6.976.97

8.188.188.708.70

5.435.43

<120<120 120-120-<130<130

130-130-<140<140

140-140-<150<150

150-150-<160<160

160-160-<170<170

170-170-<180<180

≥≥180180

SBP (mmHg)SBP (mmHg)

<120<120 120-120-<130<130

130-130-<140<140

140-140-<150<150

150-150-<160<160

160-160-<170<170

170-170-<180<180

≥≥180180

SBP (mmHg)SBP (mmHg)

%% %%


Incidence and Incidence and Unadjusted CV Risk of Events Unadjusted CV Risk of Events in Deciles of In-treatment SBPin Deciles of In-treatment SBP

Incidence and Incidence and Unadjusted CV Risk of Events Unadjusted CV Risk of Events in Deciles of In-treatment SBPin Deciles of In-treatment SBP

Una

djus

ted

risk

of e

vent

s (%

)U

nadj

uste

d ris

k of

eve

nts

(%)

HR

(95% C

I)H

R (95%

CI)

On-treatment SBP (mmHg)On-treatment SBP (mmHg)U

nadj

uste

d ris

k of

eve

nts

(%)

Una

djus

ted

risk

of e

vent

s (%

)

HR

(95% C

I)H

R (95%

CI)

Myocardial infarctionMyocardial infarctionMyocardial infarctionMyocardial infarction StrokeStrokeStrokeStroke

Sleight, et al., J Hypert 2009; 27: 1360-1369Sleight, et al., J Hypert 2009; 27: 1360-1369

112 121 126 130 133 136 140 144 149 160 0

5

10

0

1

2

112 121 126 130 133 136 140 144 149 160 0

5

10

0

2

4

6

On-treatment SBP (mmHg)On-treatment SBP (mmHg)

Hypertension Treatment A TransAtlantic view

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