ΜΑΡΙΑ Ε. ΜΑΡΚΕΤΟΥ ΕΠΙΜ. Α ΠΑΓΝΗ

Transcript

1 ΥΠΕΡΤΑΣΗ ΚΑΙ ΔΥΣΛΙΠΙΔΑΙΜΙΑ ΜΑΡΙΑ Ε. ΜΑΡΚΕΤΟΥ ΕΠΙΜ. Α ΠΑΓΝΗ

2 Παράγοντες κινδύνου και θνητότητα Blood pressure Tobacco Underweight Alcohol Cholesterol Unsafe sex Overweight Unsafe water, sanitation, hygiene Low fruit and vegetable intake Indoor smoke from solid fuels Physical inactivity Developing countries Developed countries Percentage of Mortality Attributable to Risk Factors World Health Report Yach et al. JAMA. 2004;291:

3 Framingham Offspring Study No additional CV risk factors 1 additional CV risk factor 81% 19% Less than 20% of HTN occurs in the absence of other risk factors Kannel WB. Am J Hypertens. 2000;13:3S-10S.

4 REACH Registry N=67,888 patients aged 45 years or older from 44 countries 81.8% patients with atherothrombosis have HTN 90.3% hypertensive patients have 3 risk factors REACH=Reduction of Atherothrombosis for Continued Health. Risk factors : treated diabetes mellitus, diabetic nephropathy, asymptomatic carotid stenosis 70%, SBP 150 mm Hg, hypercholesterolaemia, smoking, men 55 y, women 70 y.

5 Οι περισσότεροι ασθενείς έχουν πολλαπλούς παράγοντες καρδιαγγειακού κινδύνου Οι πολλαπλές παθήσεις αυξάνουν τον κίνδυνο 400% µε 700% Από όλους τους υπερτασικούς 65% έχουν δυσλιπιδαιµία 16% έχουν Σ τύπου 2 45% είναι υπέρβαροι ή παχύσαρκοι Από όλους τους δυσλιπιδαιµικούς 48% έχουν αρτηριακή υπέρταση 14% έχουν Σ τύπου ΙΙ 35% είναι υπέρβαροι ή παχύσαρκοι υσλιπιδαιµία Αρτ. Υπέρταση Σ τύπου ΙΙ Από όλους τους διαβητικούς τύπου ΙΙ 60% έχουν υπέρταση 60% έχουν δυσλιπιδαιµία 90% είναι υπέρβαροι ή παχύσαρκοι

6 The importance of standard risk factors Globally, 62% of cerebrovasculardisease and 49% of ischaemicheart disease is attributable to sub-optimal blood pressure (systolic BP 115 mm Hg) High cholesterol (TC >3.8mmol/L) is estimated to account for 18% of cerebrovasculardisease (mostly non-fatal) and 56% of ischaemic heart disease World Health Report 2002

7 34 (11 Χ) MRFIT / πο-έτη Θάνατοι / Ανθρωπ >245) (4 Χ) < <118 n= (4 Χ) Neaton JD, Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med. 1992;152:56-64.

8 Trends in Awareness, Treatment, and Control of Hypertension in the US* Percentage of Population % 73% Ενήµεροι 68% 55% 54% 10% % 29% 27% Θεραπευµένοι *Data represent percentage of adults 18 to 74 years of age who have systolic blood pressure 140 mm Hg, diastolic blood pressure 90 mm Hg, or are taking antihypertensive medication. Systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg. Adapted from JNC VI. Arch Intern Med. 1997;157: Ρυθµισµένοι

9 EUROASPIRE II: Μόνο οι μισοί στο στόχο θεραπείας ΑΠ Percentage of Patients Who Reached Goal* at Interview Among Those Using BP-Lowering Medication Hungary Czech Republic Belgium Spain Greece Poland Ireland Finland Italy The Netherlands United Kingdom France Slovenia Sweden Germany Total % At Goal *BP <140/90 mm Hg. Weighted average of total population. EUROASPIRE II Study Group. Eur Heart J ;22:

10 Λιγότερο από 50% των ασθενών σε θεραπεία μείωσης των λιπιδίων επιτυγχάνουν τον στόχο LDL-C France a 54.9 Germany a 24 Hungary b Italy (TC) b,c Italy (LDL-C) b,c 14 Netherlands b 30.2 Norway c 32.9 Spain a 26.3 Sweden c 29.7 Switzerland d 34.2 UK c 50 TOTAL % of patients achieving goal a National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) (LDL-C <2.6 mmol/l with coronary heart disease [CHD]/CHD risk equivalent); b Total cholesterol (TC) <5.2 mmol/l; c LDL-C <3.0 mmol/l, TC <5.0 mmol/l; d Determined by treating physician or according to NCEP ATP III Adapted from Van Ganse E et al. Curr Med Res Opin. 2005;21:

11 Most Patients Diagnosed With Hypertension and Dyslipidemia Were Not at Both Goals In a managed care population, the vast majority of patients diagnosed with hypertension and dyslipidemia (n = 154,235) were not at both goals More than 90% were not at both goals Less than 10% were at both goals As the number of CV risk factors increased, the rate of goal attainment decreased Pettitt D et al. Poster presented at: 26th Annual Meeting of the Society of General Internal Medicine 2003; Vancouver, Canada.

12 Hypertension Dyslipidemia Endothelial dysfunction NO Synthesis Inflammation Endothelin Vasoconstriction Thrombosis Superoxide production Leukocyte adhesion Endothelial permeability Foam cell formation T cell activation Vasoconstriction Calcium mobilization Mason RP. Cerebrovasc Dis. 2003;16(Suppl 3):11-17.

13 In Patients With Hypertension, LDL-C Deposition Is Greatest in Areas of Disturbed Blood Flow It has been hypothesized that hypertension causes disturbed flow, altering shear stress and biomechanical strain in the arterial wall These altered biomechanical forces may lead to LDL-C accumulation in the arterial wall and promote LDL-C oxidation Disturbed flow and altered shear stress

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15 ASCOT Study Design Randomised N=19,342 Amlodipine ± Perindopril ± Doxazosin GITs Atenolol ± Bendroflumethiazide ± Doxazosin GITs Eligible for Lipid Lowering Double-Blind Randomisation n=10,305 Not Eligible for Lipid Lowering n=5168 Atorvastatin 10 mg n=5137 Placebo 1. Study design adapted from Sever et al, for the ASCOT Investigators. J Hypertens ;19: ; 2. Data from Sever et al. Lancet. 2003;361:

16 Αντιυπερτασικό και Υπολιπιδαιµικό Σκέλος Ατορβαστατίνη -42 Ατορβαστατίνη + Αµλοδιπίνη Ατορβαστατίνη + Ατενολόλη Καρδιαγγειακά συµβάντα

17 ASCOT-LLA: Primary End Point of Nonfatal MI and Fatal CHD Cumulative Incid dence (%) Atorvastatin (10 mg) Placebo Final LDL-C = 29% HR = 0.64 ( ) 0.83) Trial was stopped early because of 36% reduction in events P= Years Sever et al, for the ASCOT Investigators. Lancet. 2003;361:

18 ASCOT-LLA: Secondary End Point of Fatal and Nonfatal Stroke Cumulative Incidence (%) Atorvastatin (10 mg) Placebo 27% Reduction HR = 0.73 ( ) 0.96) P= Years Sever et al, for the ASCOT Investigators. Lancet. 2003;361:

19 Multiple CV Risk Management Results in Dramatic Reductions in CVD 10% Reduction in BP + 10% Reduction in TC = 45% Reduction in CVD

20 Pleiotropic effects of treatment Coagulation Platelet activation Endothelial progenitor cells Endothelial function NO bioactivity Reactive oxygen species Effects on collagen MMPs AT 1 receptor VSMC proliferation Endothelin Macrophages Inflammation Immunomodulation

21 Effect of various antihypertensives on lipid levels Total cholesterol HDL LDL Triglycerides Diuretics B -blockers - ACE-i CCBs a-blockers

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23 Intensity of interventions should be proportional to the total cardiovascular risk

24 Low and high CV risk countries European Heart Journal 2012;33:

25 Lipid profiling in all hypertensives(i, C)

26 2013 ESH/ESC Guidelines for the management of arterial hypertension

27 What happened to the polypill? Improved delivery of care The composition of the Ιmproved adherence ideal polypill remains uncertain Reduced cost

28 The Danish advertising campaign promoting fresh fruit & vegetable consumption, 6-a-day.. and exercise

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