Αρχές και στόχοι της αντιϋπερτασικής θεραπείας
Η Συνύπαρξη Παραγόντων Κινδύνου Πολλαπλασιάζει τον Κίνδυνο Εµφάνισης Καρδιαγγειακών Συµβαµάτων Κάπνισµα Υπέρταση (ΣΠ 195 mmhg) x 1,6 x 4,5 x 3 x 16 x 6 x 9 x 4 Xoληστερόλη (8,5 mmol/l) Προσαρµογή από Poulter et al 1993
US and European Guidelines Define Hypertension as Blood Pressure 140/90 mmhg ESH/ESC category 1 Systolic Blood Pressure (mmhg) Diastolic Blood Pressure (mmhg) JNC 7 category 2 Optimal <120 and <80 Normal Normal 120 129 and/or 80 84 High normal 130 139 and/or 85 89 Prehypertension Grade 1 hypertension 140 159 and/or 90 99 Stage 1 hypertension Grade 2 hypertension 160 179 and/or 100 109 Grade 3 hypertension 180 and/or 110 Stage 2 hypertension Isolated Systolic Hypertension 140 and <90 Normal While European guidelines consider systolic values of 120 139 mmhg and diastolic values of 80 89 mmhg to be normal, the US guidelines define this as prehypertensive 1. Mancia G. et al. J Hypertens 2007;25:1105 1187 2. Chobanian AV et al. JAMA 2003;289:2560 2572
Risk Stratification
Initiation of Treatment
ΥΓΙΕΙΝΟ ΙΑΙΤΗΤΙΚΗ ΑΓΩΓΗ 1. ιακοπή καπνίσµατος 2. Απώλεια βάρους 3. Μείωση της κατανάλωσης οινοπνεύµατος 4. Αύξηση της φυσικής δραστηριότητας 5. Ελάττωση της κατανάλωσης αλατιού 6. ίαιτα
ΣΤΟΧΟΣ ΘΕΡΑΠΕΙΑΣ The SBP and DBP targets are at least <140/90 mmhg The primary focus should be on achieving the SBP goal In patients with hypertension and diabetes (renal disease, proteinuria, stroke, myocardial infraction) the BP goal is <130/80 mmhg SBP, systolic blood pressure; DBP, diastolic blood pressure; BP, blood pressure
Journal of Hypertension 2009; 27: 2121-2158.
Στόχος θεραπείας Τα τρέχοντα δεδομένα στηρίζουν τη μείωση της συστολικής/διαστολικής αρτηριακής πίεσης στο εύρος 130 139/80 85mmHg και κατά προτίμηση στο κατώτερο όριο αυτού του εύρους, γενικά για όλους τους υπερτασικούς ασθενείς
Treatment of hypertension in the elderly Drug treatment can be initiate when SBP > 140 mmhg as in the younger patients. The target SBP is <140 mmhg Journal of Hypertension 2009; 27: 2121-2158.
Treatment of hypertension in the elderly Hypertensives > 80 years Start antihypertesive treatment with SBP above 160 mmhg Target SBP< 150 mmhg (gradual and carefully monitored) Journal of Hypertension 2009; 27: 2121-2158.
Background DIABETIC PATIENTS: current HTN treatment guidelines SBP <130 mm Hg P O S I T I O N S T A T E M E N T there is no threshold value for BP, and risk continues to decrease well into the normal range Evidence supporting SBP <130 mm Hg is lacking, particularly in diabetic patients with CAD Diabetes Care. 2010;33 Suppl 1:S11-61, Hypertension. 2003;42(6):1206-1252, Diabetes Care. 2002;25(1):199-201
ACCORD Study Design Randomized multi-center clinical trial Conducted in 77 clinical sites in North America (U.S. and Canada) Designed to independently test three medical strategies to reduce CVD in diabetic patients BP question: does a therapeutic strategy targeting systolic blood pressure (SBP) <120 mmhg reduce CVD events compared to a strategy targeting SBP <140 mmhg in patients with type 2 diabetes at high risk for CVD events
The ACCORD BP Trial results provide no conclusive evidence that a strategy targeting normal SBP, compared with a standard SBP goal, reduces a composite of major CVD events in high-risk patients with type 2 diabetes, in the setting of good glycemic control. There was a higher risk of SAE in the intensive BP group, but also a 41% lower stroke rate. The stroke effect is consistent with other BP treatment trials. SBP goal <120 mm Hg may reduce strokes in patients with diabetes like those in ACCORD.
INVEST Trial Design International trial in 22,576 patients with CAD and hypertension Randomized to multi-drug treatment strategies verapamil SR + trandolapril + HCTZ atenolol + HCTZ + trandolapril Trandolapril recommended for all patients with diabetes Primary Outcome: First occurrence of allcause mortality, nonfatal MI or nonfatal stroke Secondary Outcomes: All-cause mortality, nonfatal MI, nonfatal stroke, total MI and total stroke Main finding: risk for CV adverse outcomes was equivalent comparing the strategies Pepine et al. JAMA. 2003:290:2805-2816
Summary As expected, diabetic patients with SBP not controlled ( 140 mm Hg) had the worst outcomes Tight Control (<130 mm Hg) of SBP was not associated with improved CV outcomes compared with Usual Control ( 130-< 140 mmhg) There was increased risk for mortality in the Tight Control group which persisted during extended follow up SBP <115 mm Hg was associated with an increase in risk for mortality
ESH-ESC guidelines update 2009 Focus on 5 areas due to newer data compared with 2007 guidelines i. Assessment of sublinical organ damage for total cardiovascular risk stratification ii. Treatment approach iii. Treatment strategies iv. Therapeutic approach in special conditions v. Treatment of associated risk factors Subclinical organ damage Assessment of total CV risk in patients with HTN is important Quantification of total CV risk must include a search for subclinical organ damage Presence of subclinical organ damage raises the CV risk to the high range Multiple measures of organ damage are usually available Assessment should be made at screening and during follow-up to assess treatment benefits Treatment approach Grade 1 HTN at low/moderate risk, lifestyle measures should be tried first, although treatment is reasonable High normal BP levels uncomplicated by diabetes or previous cardiac events does not yet warrant initiation of antihypertensive therapy. Consider if subclinical organ damage is present Early BP-lowering treatment appears a prudent recommendation SBP targets should be below 140mmHg; in patients with diabetes, <130mmHg may be wise but not supported consistently by trial data Progressive reduction of CV events down to levels around 120mmHg systolic and 75mmHg diastolic. Lower levels may be associated with increased events in those with atherosclerotic disease Prudent recommendation to lower all hypertensive patients to 130-139/80-85mmHg Major antihypertensive drug classes do not differ significantly although each class has specific favourable effects as well as contraindications and choice should made according to this evidence Source: Mancia et al. J Hypertens. 2009 Nov;27 (11):2121 5 17