Η ΘΕΡΑΠΕΙΑ ΤΗΣ ΑΡΤΗΡΙΑΚΗΣ ΥΠΕΡΤΑΣΗΣ ΣΕ ΕΙ ΙΚΕΣ ΚΑΤΑΣΤΑΣΕΙΣ: ΥΠΕΡΛΙΠΙ ΑΙΜΙΑ

Η ΘΕΡΑΠΕΙΑ ΤΗΣ ΑΡΤΗΡΙΑΚΗΣ ΥΠΕΡΤΑΣΗΣ ΣΕ ΕΙ ΙΚΕΣ ΚΑΤΑΣΤΑΣΕΙΣ: ΥΠΕΡΛΙΠΙ ΑΙΜΙΑ ΕΛΕΝΗ ΤΡΙΑΝΤΑΦΥΛΛΙ Η ΕΠΙΜΕΛΗΤΡΙΑ Α Β ΠΑΝΕΠΙΣΤΗΜΙΑΚΗ ΚΑΡ ΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ ΝΟΣΟΚΟΜΕΙΟ ΑΤΤΙΚΟΝ

Θέµατα προς συζήτηση Επιδηµιολογικά στοιχεία συνύπαρξης αρτηριακής υπέρτασης και υπερλιπιδαιµίας Εκτίµηση καρδιαγγειακού κινδύνου στην υπέρταση Στατίνες και καρδιαγγειακός κίνδυνος Στατίνες και υπέρταση Στατίνες και φυσιολογικά άτοµα Επίδραση των στατινών στην αρτηριακή πίεση. Επίδραση των αντιυπερτασικών στα λιπίδια ορού.

Epidemiology Up to 40% of patients with essential hypertension as well as many patients with pre-hypertension already have lipid abnormalities. Elevated levels of total cholesterol, non-hdl-cholesterol, and the total cholesterol/hdl-cholesterol ratio were independently associated with an increased risk of hypertension in middle aged and older men.

Prevalence, Treatment, and Control of Combined Hypertension and Hypercholesterolemia in the United States Am J Cardiol 2006 Combined hypertension and hypercholesterolemia: prevalence (dotted bars), treatment (slashed bars), and control (black bars) by gender. Prevalence indicates percentage with hypertension and with cholesterolemia (LDL cholesterol 130 mg/dl). NHANES 2001-2002

Treatment of hypertension is associated with a reduction in stroke and, to a lesser extent, coronary events. Epidemiological data show serum cholesterol concentration to be closely associated with coronary events but not with stroke.

However, statins have been shown to be effective in preventing both coronary and cerebrovascular events, prevention of both outcomes being similar in hypertensives and normotensives.

Θέµατα προς συζήτηση Συνύπαρξη αρτηριακής υπέρτασης και υπερλιπιδαιµίας Εκτίµηση καρδιαγγειακού κινδύνου στην υπέρταση Στατίνες και καρδιαγγειακός κίνδυνος Στατίνες και υπέρταση Στατίνες και φυσιολογικά άτοµα Επίδραση των στατινών στην αρτηριακή πίεση. Επίδραση των αντιυπερτασικών στα λιπίδια ορού.

Εκτίμηση συνολικού καρδιαγγειακού κινδύνου Ορίζεται ως ο απόλυτος κίνδυνος εµφάνισης ενός καρδιαγγειακού συµβάντος εντός δεκαετίας. Very high risk---- >30% High risk---------- 20-30% Moderate risk---- 15-20% Low risk ---------- <15% ΣΥΜΒΑΛΛΕΙ ΣΤΗ ΛΗΨΗ ΑΠΟΦΑΣΗΣ I. Έναρξη φαρμακευτικής αγωγής II. Επιθυμητός στόχος αρτηριακής πίεσης III. Ανάγκη χρήσης συνδυασμών IV. Μη φαρμακευτική αγωγή V. Εκτίμηση κόστους-αποτελεσματικότητας

Administration of simvastatin to patients with established cardiovascular disease markedly reduced cardiac and cerebrovascular events compared to placebo. The effects were manifest in the hypertensive subpopulation (41%) regardless of the type of antihypertensive treatment employed.

PROSPER study: pravastatin in the elderly patients (62% of whom were hypertensives). Pravastatin given for 3 years reduced the risk of coronary disease in elderly individuals. PROSPER therefore extends to elderly individuals the treatment strategy currently used in middle aged people.

Effective prevention was also found with atorvastatin, in patients with a previous stroke. In patients with recent stroke or TIA and without known coronary heart disease, 80 mg of atorvastatin/day reduced the overall incidence of strokes and of cardiovascular events, despite a small increase in the incidence of hemorrhagic stroke

Statins and established cardiovascular disease Conclusion 1 Therefore, patients up to the age of at least 80 years who have an established cardiovascular disease such as coronary heart disease, peripheral artery disease, previous stroke or long-term (at least 10 years) diabetes should receive a statin. In all these patients the goal should be set for total cholesterol <175 mg/dl and LDL <100 mg/dl. Lower goals may also be considered at <155 and 80 mg/dl respectively.

ALLHAT and ASCOT, have evaluated the benefits associated with the use of statins specifically among patients with hypertension.

Administration of 40 mg/day of pravastatin to 10.000 hypertensive patients (about two thirds of whom had established vascular disease) reduced serum total and LDL cholesterol (by 11% and 17%, respectively) compared to usual care. However, no significant effect was noticed on coronary heart disease, stroke and all cause mortality.

Administration of 10 mg/day of atorvastatin in over 10,000 hypertensive patients with additional cardiovascular risk factors and a serum total cholesterol < 250 mg/dl reduced serum total cholesterol by 19.9% compared to placebo. Substantial benefits of total cardiovascular events (36% reduction) and stroke (27% reduction).

Statins and hypertension: ASCOT vs. ALLHAT Conclusion 2 The beneficial effect seen in the ASCOT trial as compared to the lack of benefit reported in ALLHAT may depend on the greater relative difference in total and LDL cholesterol achieved among the actively treated versus the control group.

Further analyses of ASCOT have shown the addition of a statin to the amlodipine-based antihypertensive therapy can reduce the primary cardiovascular outcome even more markedly than addition of a statin to the atenolol-based antihypertensive therapy

Statins and hypertensive patients Conclusion 3 It seems reasonable to consider statin therapy in hypertensive patients aged less than 80 years who have an estimated 10 years risk of cardiovascular disease > 20%. Target levels should be a serum total <190 mg/dl and LDL cholesterol <115 mg/dl.

17,802 apparently healthy men and women with LDL less than 130 mg/dl and C-reactive protein 2.0 mg/lt or higher were assigned to rosuvastatin, 20 mg daily, or placebo. Occurrence of the combined primary end point of myocardial infarction, stroke, arterial revascularization, hospitalization for unstable angina, or death from cardiovascular causes was estimated.

The beneficial effect of statin administration to patients without previous cardiovascular events has been strengthened by the findings of the JUPITER study, showing that lowering LDL-cholesterol by 50% in patients with baseline values less than 130 mg/dl but elevated C-reactive protein (CRP), reduced cardiovascular events by 44%.

Statins and apparently healthy middle-aged Conclusion 4 Statin benefits can be observed also in patients with elevated CRP and at moderate cardiovascular risk (about 15% cardiovascular events in 10 years).

Mean difference in SBP -1.9 mmhg and in DBP -0.9 mmhg (NS). ALLHAT: Decrease in SBP -2 mmhg leads to 15% decrease in stroke and 19% CHF.

Η µελέτη ASCOT-LLA (amlodipin vs. atenolol) έδειξε ότι η χορήγηση 10mg atorvastatin ταυτόχρονα µε τη ρύθµιση της βραχιόνιας αρτηριακής πίεσης ελάττωσε την επίπτωση των καρδιαγγειακών νοσηµάτων. Η κεντρική αρτηριακή πίεση και η κεντρική πίεση σφυγµού αποτελούν προγνωστικούς δείκτες καρδιαγγειακού κινδύνου. Η χορήγηση 10mg atorvastatin έχει τη δυνατότητα να ελαττώσει την κεντρική αρτηριακή πίεση?

Conclusions In hypertensives, target levels should be a serum total <190 mg/dl and LDL cholesterol <115 mg/dl. Statin benefits can be observed also in patients with elevated CRP and at moderate cardiovascular risk (about 15% cardiovascular events in 10 years). Statins cardiovascular action is far from reducing brachial or central blood pressure. RAAS inhibitors and Ca blockers are the antihypertensive drugs of choice in hyperlipidemia due to their neutral influence in lipids.