Traitements associés chez l hypertendu: Statines, Aspirine
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1 Traitements associés chez l hypertendu: Statines, Aspirine Pr Jean-Jacques Mourad CHU Avicenne, Université Paris 13, Bobigny DU HTA, Mars 2012 jean-jacques.mourad@avc.aphp.fr
2 Global Mortality 2000: Impact of Blood Pressure and Cholesterol Attributable Mortality (in thousands; total 55,861,000) Ezzati M, et al. Lancet. 2002;360:
3 Relative Risk of CHD Mortality What Is Normal Cholesterol? Chen Z, et al. BMJ. 1991;303: Mean Usual Cholesterol (mmol/l, mg/dl) Relative risk of death (± SD) from CHD by quartiles of baseline total cholesterol in 9021 Chinese people with 8-13 years follow-up.
4 Coronary disease by usual SBP Floating Absolute Risk & 95% CI mmHg 70 + years RRR= 13% years RRR= 22% < 60 years RRR= 43% Burden of Disease Usual SBP (mmhg)
5 Increased Number of CV Events (MI) in Patients With Hypertension Plus Other CV Risk Factors Odds Ratio (99% CI) Smoking Diabetes Blood Pressure Lipids 3 Risk Factors 4 Risk Factors >20-Fold Increase OR (1.9 to 42.3) Risk Factors 1 Smoking (1) Diabetes (2) HTN (3) Lipids (4) All 4 + Obes + PS All RFs Risk Ratio 2.9 ( ) 2.4 ( ) 1.9 ( ) 3.3 ( ) 13.0 ( ) 42.3 ( ) 68.5 ( ) ( ) ( ) HTN = hypertension; MI = myocardial infarction; PS = psychosocial. Reproduced with permission from Yusuf S, et al. Lancet. 2004;364:
6 INDIVIDUAL GLOBAL CV RISK NON (OR HARDLY) MODIFIABLE RISK FACTORS MODIFIABLE RISK FACTORS AGE GENDER SOCIO-ECONOMIC STATUS FAMILIAL HISTORY PERSONAL HISTORY DIABETES MELLITUS SMOKING OVERWEIGHT SEDENTARITY BLOOD PRESSURE LIPID PROFILE
7 STATINES
8 ASCOT Study design 19,257 hypertensive patients ASCOT-BPLA atenolol ± bendroflumethiazide PROBE design amlodipine ± perindopril 10,305 patients TC 6.5 mmol/l (250 mg/dl) ASCOT-LLA atorvastatin 10 mg Double-blind placebo Investigator-lead, multinational randomised controlled trial
9 ASCOT LLA: Patient Population Risk Factor Profile All patients in ASCOT have hypertension plus 3 risk factors for CHD Hyperte nsion Age 55 ye ars M ale M icroalbum in/proteinuria Sm oker Fam ily history of early coronary disease Type 2 diabetes Plas m a TC:HDL-C 6 Certain ECG abnorm alities LVH Previous cerebrovascular events Peripheral vascular disease Basically primary prevention and no previous known CHD Patients With Risk Factor (%) Sever PS, et al. J Hypertens. 2001;19:
10 ASCOT-LLA: Primary End Point: Nonfatal MI and Fatal CHD 4 Atorvastatin 10 mg Number of events 100 Placebo Number of events 154 Cumulative incidence (%) HR = 0.64 ( ) 0 0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 Years 36% reduction P = Sever PS, Dahlöf B, Poulter N, Wedel H, et al, for the ASCOT Investigators. Lancet. 2003;361:
11 ASCOT-LLA: Secondary End Point: Fatal and Nonfatal Stroke 3 Atorvastatin 10 mg Number of events 89 Placebo Number of events 121 Cumulative Incidence (%) ,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 Years 27% reduction HR = 0.73 ( ) P = Sever PS, Dahlöf B, Poulter N, Wedel H, et al, for the ASCOT Investigators. Lancet. 2003;361:
12 European Heart Journal (2011) 32,
13 J Hypertens 2011; 29:
14 J Hypertens 2011; 29:
15 NEJM 2008;359:2195
16 We randomly assigned 17,802 apparently healthy men and women with low-density lipoprotein (LDL) cholesterol levels of less than 130 mg per deciliter (3.4 mmol per liter) and high-sensitivity C-reactive protein levels of 2.0 mg per liter or higher to rosuvastatin, 20 mg daily, or placebo N Engl J Med 2008;359:
17 N Engl J Med 2008;359:
18 Hypertension. 2007;49:
19 Arch Intern Med. 2012;172(2):
20 Arch Intern Med. 2012;172(2):
21 Lancet 2010; 375:
22 JAMA. 2011;305(24):
23 ESH 2009 The benefit of combining a statin with antihypertensive treatment in hypertensive patients was well established by the ASCOT-LLA study, as summarized in the 2007 ESH/ESC guidelines. The negative results obtained with another statin in the ALLHAT study can be attributed to insufficient lowering of total cholesterol (11% in ALLHAT as compared with 20% in ASCOT). 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 LDLcholesterol by 50% in patients with baseline values less than 130 mg/dl (3.4 mmol/l), but elevated C-reactive protein (CRP), reduced cardiovascular events by 44%. In conclusion, the recommendation given in the 2007 guidelines to consider statin therapy in hypertensive patients who have an estimated 10-year risk of cardiovascular events more than 20% can be reconfirmed, but the JUPITER study suggests that statin benefits can be observed also in patients with elevated CRP and at moderate cardiovascular risk (about 15% cardiovascular events in 10 years).
24 ASPIRINE
25 Problème nosologique: Qu appelle-on prévention primaire??
26 Lancet 2009;373:1849
27 Lancet 2009;373:1849
28 Lancet 2009;373:1849
29 Lancet 2009;373:1849
30 Lancet 2009;373:1849
31 Lancet 2009;373:1849
32 J Hypertens 2002; 20:
33 J Hypertens 2002; 20:
34 J Hypertens 2002; 20:
35 J Am Coll Cardiol 2010;56:956 65
36 J Am Coll Cardiol 2010;56:956 65
37 BMJ 2008;337:a1840
38 BMJ 2009;339:B4531
39 39876 femmes; âge moyen 55ans; HTA 26%; Tabagisme 13%; Obésité : 18.2%; Diabète 2.6%; Risque framingham <5% à 10 ans : 85% NEJM 2005
40 NEJM 2005
41
42 ESH 2009 In conclusion, the prudent recommendations of the 2007 ESH/ESC guidelines can be reconfirmed: antiplatelet therapy, in particular low-dose aspirin, should be prescribed to hypertensive patients with previous cardiovascular events; It can also be considered in hypertensive patients without a history of cardiovascular disease with reduced renal function or with a high cardiovascular risk. In patients receiving aspirin, careful attention should always be given to the increased possibility of bleeding,particularly gastrointestinal.
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