Upload
others
View
5
Download
0
Embed Size (px)
Citation preview
ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ
Ι.Ε.ΚΑΝΟΝΙΔΗΣ
CAD: Statistics
• CAD is the largest killer of American males and females
• 13 million Americans have CAD
• 1.1 million MI’s per year
• Every 26 seconds an American will suffer from a coronaryevent
• Every 60 seconds an American will die because of acoronary event
• 42% of those having a coronary event will die from it
• 350000 people die per year because of a coronary event in theEmergency Department before even being admitted to thehospital
• Death Rate in 2001:
– 177 in 100,000
CAD: Demographics and Statistics
• 84% of those who die from CAD are 65 or older
• Within 1 year of initial MI:
– 25% of men and 38% of women will die
• Within 8 years of initial MI:
• 50% of men and women under 65 will die
• An average of 11.5 years of life are lost due to an MI
• IMPORTANT:
– 50% of men and 64% of women who have died suddenlyvia CAD DID NOT HAVE ANY PREVIOUS SYMPTOMS
• Sudden Death:
– Those with a previous history of MI have a 5-6 timesSudden Death rate compared to the general population
Hypertension
• Hypertension( HTN) is the most common primary diagnosis in America.
• 35 million office visits are as the primary diagnosis of HTN.
• 50 million or more Americans have high BP.
• Worldwide prevalence estimates for HTN may be as much as 1 billion.
• 7.1 million deaths per year may be attributable to hypertension.
Ηypertension
The estimated prevalence of hypertension in theUnited States in 2005 was :
• 35.3 million for men
• 38.3 million for women.
Hypertension is more prevalent in black personsthan in Hispanic and non-Hispanic whitepersons.
This prevalence is increasing.
Data from 1988-1994 and 1999-2002 demonstratedan increased prevalence of hypertension inblack individuals from 35.8% to 41.4%.
6
Peripheral
vascular disease
Morbidity
Disability
Renal
disease
CADCHF
LVHStroke
Hypertension
National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:186-208.
Hypertension: A Significant CV and Renal Disease Risk Factor
7
8
Hypertension and CHD : (MRFIT)
Adapted from Neaton JD et al. Arch Intern Med. 1992;152:56-64.
SBP versus DBP in Risk of CHD Mortality
Diastolic BP
(mm Hg)
Systolic BP
(mm Hg)
CHD Death Rate
100+90–99
80–8975–79
70–74<70 <120
120–139
140–159
160+
9
Risk of Cardiovascular Events by Hypertensive Status
36-Year Follow-up in Patients Aged 35-64 Years
9.5
3.3 2.45.0
2.03.5
2.1
45.4
21.3
12.4
6.2
9.97.3
13.9
6.3
22.7
0
10
20
30
40
50
Men Women Men Women Men Women Men Women
Normotensive
Hypertensive
Coronary Disease Stroke Peripheral Arterial
DiseaseCardiac Failure
Bie
nn
ial A
ge
-Ad
jus
ted
Ra
te
pe
r 1
,00
0
Reprinted with permission from Kannel WB. JAMA. 1996;275:1571-1576.
10
Disease Relative Risk
Kidney failure (ESRD) 2.8
Stroke 2.7
Heart failure 1.5
Peripheral vascular disease 1.8
Myocardial infarction* =1.6
Coronary artery disease 1.5
ESRD = end-stage renal disease; SBP 165 mm Hg.
*Men only.
Adapted from Kannel WB. Am J Hypertens. 2000;13:3S-10S; Perry HM Jr et al. Hypertension. 1995;25(part 1):587-594;
Klag MJ et al. N Engl J Med. 1996;334:13-18; Nielsen WB et al. Ugeskr Laeger. 1996;158:3779-3783; Neaton JD et al.
Arch Intern Med. 1992;152:56-64.
Elevated SBP Alone Is Associated With Increased Risk of Cardiovascular and Renal Disease
12
Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
TROPHY Study ACC 2006:
Even lowering BP in those with pre-HTN appears to reduce incidence of new HTN by up to 60%
INTERHEART study
About 25% of the
population-attributable risk of a myocardial
infarction can be accounted
for by hypertension
Pathophysiological Association of hypertension
with IHD
• Endothelial dysfunction, which leads to the
developement of atherosclerosis,
• Increased afterload leading to myocardial
hypertrophy.
• Atherogenesis
• Hypertrophy
LVH
The rate of LVH based on ECG findings
2.9% for men
1.5% for women.
based on echocardiographic findings
15-20%
33% of patients without LVH have evidence
of asymptomatic LV diastolicdysfunction.
ECG -Hypertension
Electrocardiogram from a 46-year-old man with long-standinghypertension showing left atrial abnormality and leftventricular hypertrophy with strain.
17
Blood Pressure Classification
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 HTN 140–159 or 90–99
Stage 2 HTN >160 or >100
BP Classification SBP mmHg DBP mmHg
BHS classification of blood pressure levels
Category Systolic blood
pressure (mmHg)
Diastolic blood
pressure
(mmHg) Optimal blood pressure <120 <80
Normal blood pressure <130 <85
High-normal blood pressure 130-139 85-89
Grade 1 Hypertension (mild) 140-159 90-99
Grade 2 Hypertension (moderate) 160-179 100-109
Grade 3 Hypertension (severe) >180 >110
Isolated Systolic Hypertension (Grade 1) 140-159 <90
Isolated Systolic Hypertension (Grade 2) >160 <90
Total Cardiovascular risk in Hypertensive Patients
Treatment modalities in Hypertensive Patients
Non pharmacological Treatment
of hypertension and lifestyle changes
• Lose weight, if overweight
• Increase physical activity
• Reduce salt intake
• Stop smoking
• Limit intake of foods rich in fats and cholesterol
• Increase consumption of fruits and vegetables
• Limit alcohol intake
Lifestyle Modification
Modification Approximate SBP reduction(range)
Weight reduction 5–20 mmHg / 10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg
Drug therapy for hypertension
Class of drug Example dose Initiating dose Usualmaintenance
Diuretics Hydrochlorothiazide 12.5 mg o.d. 12.5-25 mg o.d.
-blockers Atenolol 25-50 mg o.d. 50-100 mg o.d.
Calcium Amlodipine 2.5-5 mg o.d. 5-10 mg o.d.
channel
blockers
-blockers prazosin 2.5 mg o.d 2.5-10mg o.d.
ACE- inhibitors ramipril 1.25-5 mg o.d. 5-20 mg o.d.
Angiotensin-II Losartan 25-50 mg o.d. 50-100 mg o.d.
receptor blockers
Pharmacological Treatment in
Hypertension
INVEST
TNT
SMART
• In favor
Stewart Lancet 1979
Cruickshank et al Lancet 1987
Miller Hypertension 2000
• Against
Farnett et al JAMA 1991
McMahon et al Lancet 1990
J-Curve in HTN plus CAD
J-Curve
HOT Study: Significant Benefit From
Intensive Treatment in the Diabetic Subgroup
Hansson L et al. Lancet. 1998;351:1755-1762.
0
5
10
15
20
25
90 85 80
Major
cardiovascular
events/1,000
patient-years
p=0.005 for trend
mm Hg
Target Diastolic Blood Pressure
. In patients with an elevated DBP and CAD with evidence
of myocardial ischemia, the BP should be lowered slowly,
and caution is advised in inducing decreases in DBP to
<60 mm Hg in any patient with diabetes mellitus or who is
>60 years of age.
In older hypertensive individuals with wide pulse
pressures, lowering SBP may cause very low DBP values
(<60 mm Hg). This should alert the clinician to assess
carefully any untoward signs or symptoms, especially
those resulting from myocardial ischemia (Class Iia;Level
of Evidence: C).
Recommendations
Best BP
CAMELOT
ACCORD
SPRINT
Recommendations
1. The <140/90-mm Hg BP target is reasonable for
the secondary prevention of cardiovascular
events in patients with hypertension and CAD
(Class IIa; Level of Evidence: B).
2. A lower target BP (<130/80 mm Hg) may be
appropriate in some individuals with CAD,
previous MI, stroke or transient ischemic attack,
or CAD risk equivalents (carotid artery disease,
PAD, abdominal aortic aneurysm) (Class IIb;
Level of Evidence: B).
Treatment of BP in pts with IHD
• Treatment of BP in primary prevention of IHD
• Treatment of BP in secondary prevention of
IHD
• Treatment of BP in established IHD
• Treatment of BP in ACS
• Δεν υπάρχει διαφορά μεταξύ των διαφόρων
κατηγοριών αντιυπερτασικών φαρμάκων στην
πρωτογενή πρόληψη, όσον αφορά την
επίπτωση της στεφανιαίας νόσου και των
καρδιαγγειακών επιπλοκών γενικώτερα.
ΕΠΙΛΟΓΗ ΑΝΤΙΥΠΕΡΤΑΣΙΚΩΝ ΦΑΡΜΑΚΩΝ ΣΤΗΝ
ΠΡΩΤΟΓΕΝΝΗ ΠΡΟΛΗΨΗ ΣΤΕΦΑΝΙΑΙΑΣ ΝΟΣΟΥ
B-blockers
ACE Inhibitors
ARBBs
Diuretics
CCB
ΕΠΙΛΟΓΗ ΑΝΤΙΥΠΕΡΤΑΣΙΚΩΝ ΦΑΡΜΑΚΩΝ ΣΤΗΝ
ΔΕΥΤΕΡΟΓΕΝΝΗ ΠΡΟΛΗΨΗ ΣΤΕΦΑΝΙΑΙΑΣ ΝΟΣΟΥ
THIAZIDES
• Veterans Administration
• MRC
• SHEP
• HYVET
Chlorothalidone
• ALLHAT
Diuretics in secondary prevention
ARBs
• VALUE
• OPTIMAAL
• VALIANT
• TRANSCEND
ACE Inhibitors in secondary prevention
• HOPE
• EUROPA
• PEACE
• ONTARGET
CCB
• ALLHAT amlodipine VS diuretic or ACE
• ASCOT amlodipine VS b-blockers
• CONNICLE verapamil VS b-blockers or
diuretic
• INVEST verapamil VS
• NORDIL diltiazem VS b-blockers or diuretic
1. Patients with hypertension and chronic stable angina should be
treated with a regimen that includes:
a) b-blocker in patients with a history of prior MI
b) An ACE inhibitor or ARB if there is prior MI, LV
systolic dysfunction, diabetes mellitus, or CKD; and
c) A thiazide or thiazide-like diuretic (Class I; Level of Evidence: A).
2. The combination of a b-blocker, an ACE inhibitor or
ARB, and a thiazide or thiazide-like diuretic should
also be considered in the absence of a prior MI, LV
systolic dysfunction, diabetes mellitus, or proteinuric
CKD (Class IIa; Level of Evidence: B).
3. If b-blockers are contraindicated or produce intolerable
side effects, a nondihydropyridine CCB (such as
diltiazem or verapamil) may be substituted, but not if
there is LV dysfunction (Class IIa; Level of Evidence: B).
Recommendations I
4. If either the angina or the hypertension remains uncontrolled, a
long-acting dihydropyridine CCB can be added to
the basic regimen of b-blocker, ACE inhibitor, and thiazide or
thiazide-like diuretic.
The combination of a b-blocker and either of the nondihydropyridine
CCBs (diltiazem or verapamil) should be used with caution in
patients with symptomatic CAD and hypertension because of
the increased risk of significant bradyarrhythmias and HF
(Class IIa; Level of Evidence: B).
5. For patients with stable angina, the BP target is <140/
90 mm Hg. (Class I; Level of Evidence: A)
A lower target BP (<130/80 mm Hg) may be considered in
some individuals with CAD, with previous stroke or
transient ischemic attack, or with CAD risk equivalents
(carotid artery disease, PAD, abdominal aortic
aneurysm) (Class IIb; Level of Evidence: B). .
Recommendations II
6. There are no special contraindications in hypertensive
patients for the use of antiplatelet or anticoagulant
drugs, except that in patients with uncontrolled severe
hypertension who are taking antiplatelet or
anticoagulant
drugs, the BP should be lowered without delay to
reduce the risk of hemorrhagic stroke (Class IIa; Level
of Evidence: C).
Antiplatelet or Anticoagulant drugs
B-blockers
ACE Inhibitors
ARBBs
Diuretics
Nitates
ΕΠΙΛΟΓΗ ΑΝΤΙΥΠΕΡΤΑΣΙΚΩΝ ΦΑΡΜΑΚΩΝ
ΣΤΑ ΟΞΕΑ ΙΣΧΑΙΜΙΚΑ ΣΥΝΔΡΟΜΑ
ACE inhibitors in ACS
• GISSI – 3
• ISSIS – 4
• CCS – 1
• ACE inh post ACS
. Recommendations
1. If there is no contraindication to the use of b-blockers, in
patients with ACS, the initial therapy of hypertension should
include a short-acting b1-selective b-blocker without intrinsic
sympathomimetic activity (metoprolol tartrate or bisoprolol).
b-Blocker therapy should typically be initiated orally within 24
hours of presentation (Class I; Level of Evidence: A). For
patients with severe hypertension or ongoing ischemia,
an intravenous b-blocker (esmolol) can be considered
(Class IIa; Level of Evidence: B).
For hemodynamically unstable patients or when
decompensated HF exists, the initiation of b-blocker therapy
should be delayed until stabilization has been achieved (Class
I; Level of Evidence: A).
2. In patients with ACS and hypertension,
nitratesshould be considered to lower BP or to
relieve ongoing ischemia or pulmonary
congestion (Class I; Level of Evidence: C).
Nitrates should be avoided in patients with
suspected right ventricular infarction and inthose
with hemodynamic instability. Sublingual or
intravenous nitroglycerin is preferred for initial
therapy and can be transitioned later to a longer-
acting preparation if indicated.
3. If there is a contraindication to the use of a b-blocker or intolerable
side effects, then a nondihydropyridine CCB such as verapamil or
diltiazem may be substituted
for patients with ongoing ischemia, provided that LV dysfunction or
HF is not present. If the angina or hypertension is not controlled on a
b-blocker alone,
a longer-acting dihydropyridine CCB may be added
after optimal use of an ACE inhibitor (Class IIa; Level
of Evidence: B).
4. An ACE inhibitor (Class I; Level of Evidence: A) or an ARB (Class I;
Level of Evidence: B) should be added if the patient has an anterior
MI, if hypertension persists, if the patient has evidence of LV
dysfunction or
HF, or if the patient has diabetes mellitus. For lowerrisk
ACS patients with preserved LV ejection fraction
and no diabetes mellitus, ACE inhibitors can be
considered a first-line agent for BP control (Class IIa;
Level of Evidence: A).
5. Aldosterone antagonists are indicated for patients who are already receiving b-
blockers and ACE inhibitors after MI and have LV dysfunction and either HF or
diabetes mellitus. Serum potassium levels must be monitored. These agents should be
avoided in patients with elevated serum creatinine levels (‡2.5 mg/dL in
men, ‡2.0 mg/dL in women) or elevated potassium levels (‡5.0 mEq/L) (Class I; Level of
Evidence: A).
6. Loop diuretics are preferred over thiazide and thiazide-type diuretics for patients with
ACS who have HF (NYHA class III or IV) or for patients with CKD and
an estimated glomerular filtration rate <30 mL/min.
For patients with persistent hypertension not controlled with a b-blocker, an ACE
inhibitor, and an aldosterone antagonist, a thiazide or thiazide-type
diuretic may be added in selected patients for BP
control (Class I; Level of Evidence: B).
7. The target BP is <140/90 mm Hg in patients with ACS who are hemodynamically
stable (Class IIa; Level ofEvidence: C)
. A BP target of <130/80 mm Hg at the time of hospital discharge is a reasonable option
(Class IIb;Level of Evidence: C).
The BP should be lowered slowly, and caution is advised to avoid decreases in
DBP to <60 mm Hg because this may reduce coronary perfusion and worsen ischemia.
ΕΥΧΑΡΙΣΤΩ