Jackson T. Wright, Jr. MD, PhD

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Jackson T. Wright, Jr. MD, PhD"

Transcription

1 DIFFERENTIAL EFFECTS OF BLOOD PRESSURE MEDICATIONS IN BLACK PATIENTS Jackson T. Wright, Jr. MD, PhD Professor of Medicine Program Director, WT Dahms MD Clinical Research Unit Clinical and Translational Science Collaborative Director, Clinical Hypertension Program University Hospitals Case Medical Center

2 Presenter Disclosure Information Jackson T. Wright, Jr, MD, PhD FINANCIAL DISCLOSURE: Research support: NIH Consulting: Novartis, Takada, Sanofi-Aventis, CVRx, NIH UNLABELED / UNAPPROVED USES DISCLOSURE: None

3 RACE IN MEDICINE Definition not standardized Usually defined by self-identification in research studies Unless participant questionnaire utilized or telephone survey, often have little assurance that all participants are actually asked the question Especially a problem for retrospective studies where method of ascertainment often not defined Racial differences usually confounded by SES which usually cannot be adequately adjusted for statistically However, racial differences are often sufficiently large that ambiguity in the definition of race is unlikely to account for these differences

4 RACE IN MEDICINE Some have suggested that race is a social construct, BUT it does have biological consequences Blacks have a higher rate of complications all of the major causes of death and hospitalization, including CVD, many cancers, infectious diseases, etc. A Black child born today has the life-expectancy of a White child born yrs ago and is twice as likely to die in the first year of life Racial differences often confused with genetic differences; however genetics is only one (and probably least important explanation)

5 RACE IN MEDICINE Clinically significant differences in disease presentation, pathophysiologic characteristics and response to treatment are evident by race and ethnicity Evaluation of disease differences in subsegments of the population is essential to understand the variation in pathophysiological mechanisms The study of population differences may provide valuable information on the disease in the affected population but is also likely to benefit the overall population

6 Increased Complications in Black Hypertensive Patients Cause of death in 30% African American males and 20% Black females Nonfatal strokes 30% than in whites Fatal strokes 80% than in whites Heart disease deaths 50% than in whites and occurs at younger age Kidney failure 400% than in whites (HTNrelated up to 2000% greater)

7 Prevalence of Hypertension, % Prevalence of HTN in African- and European- Origin Populations* *Age-adjusted. Cooper RS et al. BMC Medicine. 2005;3:2.

8 Percentage of Population Prevalence of HTN Among the African Diaspora St. Lucia Jamaica Maywood, IL Barbados Cameroon (rural) Nigeria Cameroon (urban) Average BMI Adapted from Cooper R, et al. Am J Public Health. 1997;87:166.

9 Development of Antihypertensive Therapies Effectiveness Tolerability 1940 s s 1970 s 1980 s 1990 s 2002 Peripheral sympatholytics Ganglion blockers Veratrum alkaloids Direct vasodilators Thiazide diuretics Central 2 agonists Calcium antagonistsnon DHPs -blockers -blockers Calcium antagonists- DHPs ACE inhibitors ARBs DRIs

10 % of Treated Patients on Medication Hypertension Treatment by Drug Class Diuretics ß-Blocker ACE Inhibitors CCBs ARBs Year IMS Health NDTI,

11 The reason to prescribe a treatment is that there is good evidence that it provides benefit NOT that there is insufficient evidence that it does not THIS IS PARTICULARLY TRUE IN POPULATIONS (LIKE BLACKS) AT HIGHEST RISK

12 RENIN ANGIOTENSIN SYSTEM (RAS) INHIBITORS Angiotensin converting enzyme (ACE)- Inhibitors Angiotensin Receptor Blockers (ARBs) Direct Renin Inhibitors (DRIs) (Beta Blockers)

13

14 HISTORY OF RAS INHIBITOR USE IN US RAS inhibitors leading class of CV medications since the early 80 s (> $7 billion/yr market) During much of their history on the market, industry avoided studies containing significant numbers of Blacks It more commonly generously supported programs and speakers aimed at promoting their use Lessened efficacy of β-blockers and ACEIs lowering BP in Black hypertensives not appreciated for 10 yrs after introduction Efficacy of ACEI on renal disease not available in Blacks for 8 yrs after proven effective in non-blks A-level evidence still missing for both β-blockers and ACEIs in Blacks for CHF

15 Patients with Response (%) Patients with Response (%) BP Response Rates in VA Trial by Race Older Blacks Older Whites DILT HCTZ CLON PRAZ ATEN PLAC CAPT ATEN DILT CAPT CLON HCTZ PRAZ PLAC Materson, B. J. et. al. N Engl J Med 1993;328:

16 Frequency Distribution SBP in Response to Quinapril in Black and White Participants (E. Mokwe et. al., HTN 2004;43:1) White s n = 2046 Black s n = 533

17 Decrement in Blood Pressure Mean Black-White Difference in mmhg (CI) 4.6 ( )/3.0 ( ) Ashwini R. Sehgal, Hypertension 2004; 43;

18 HOPE Trial Heart Outcomes Prevention Evaluation Ramipril Vs Placebo in 9,541 High CV Risk Participants Event(s) Risk Reduction CV deaths + MI + stroke 22% CV death 25% Nonfatal MI 20% Nonfatal stroke 32% Revascularization 15% CHF hospitalizations (#) 16% New-onset diabetes 30% HOPE Investigators. NEJM 2000; 342:145

19 Representation of Blacks in Major CVD/DM/Renal Clinical Trials Trial Year # Blacks (%) Trial Year # Blacks (%) ALLHAT ,133 (35.6%) SOLVD/Rx (15.3%) AASK ,094 (100%) TONE (24.0%) A-HeFT ,050 (100%) IDNT (14%) HDFP ,846 (44.3%) RENAAL (15%) SHEP (13.9%) HOPE 2000 ~175 (1.8%) VA Coop (53.8%) UKPDS (7.6%) VA Coop (41.3%) MDRD (7.9%) ACCOMPL ,416 (12%) ABCD (13.8%) HOT (3.1%) MRFIT (7.2%) LIFE (5.8%) ELITE (4.7%) VALUE (2.7%) CAPT-DM (7.3%) ASCOT 2005 ~960 (5%)* DREAM 2006 <5%

20 AASK Clinical Endpoint Analysis ACEI vs. CCB ACEI vs. BB Outcome % Risk 95 % Reduction 1 Confidence Interval % Risk Reduction 95 % Confidence Interval GFR event, 38% (+ 14 to + 55) ESRD or Death 2 p< % (+ 1 to + 38) p< GFR event or ESRD 3 40% (+ 13 to + 59) p<0.007 ESRD or Death 4 48% (+ 26 to + 65) p< % (- 1 to + 41) p< % (- 5 to + 40) p< 0.11 ESRD alone 5 59% (+ 34 to + 74) p< % (- 10 to + 45) p< ) Adjusted for baseline proteinuria, MAP,gender, Hx CHF and age; 2) 179 declining GFR, 84 ESRD, 77 death; 3) 170 declining GFR, 84 ESRD; 4) 171 ESRD, 79 deaths; events, deaths censored. Wright et al 2002; JAMA, 288:2421

21 Blood Pressure During Follow-up Ramipril Amlodipine Metoprolol Low MAP Goal Usual MAP Goal SBP (mm Hg) DBP (mm Hg) MAP (mm Hg) * * * 104 *Significantly different between two blood pressure goals P<0.01 Wright et al. JAMA. 2002;288:2421.

22 Cumulative Incidence (%) AASK Grp. Arch Intern Med 2008;168:832 Cumulative Incidence of Events (Doubling SCr, ESRD, or Death) Only Trial Mixed Trial and Post-Trial Composite Follow-up Time (Years) Only Post-Trial ESRD or Doubling SCr Death Number at Risk:

23 Cumulative Incidence (%) 60 Cumulative Incidence of Events in (1) ACEI with Low BP Group and (2) Non-ACEI with Usual BP Groups Only Trial Mixed Trial and Post-Trial Only Post-Trial Non-ACEI with Usual BP ACEI with Low BP 0 Number At Risk Usual BP & non-acei: Low BP and ACEI: Follow-Up Time (Years)

24 ALLHAT Hypertension Trial 42,418 high-risk hypertensive patients 90% previously treated 10% untreated STEP 1 AGENTS Chlorthalidone mg Amlodipine mg Lisinopril mg Doxazosin 1-8 mg Non-Blacks: 9,886 Blacks: 5,369 Non-Blacks: 5,844 Blacks: 3,210 Atenolol 28.0% STEP 2 AND 3 AGENTS (5 years) Clonidine 10.6% Reserpine 4.3% Hydralazine 10.9%

25 ALLHAT Blood Pressure at 5 Years by Race Chlorthalidone Amlodipine Lisinopril SBP mean (sd) DBP mean (sd) BP compared with chlorthalidone Black (15.8) (15.3) (19.7) (14.8) (14.6) (16.7) Black 77.4 (10.0) 76.3 (10.1) 78.0 (11.4) 74.4 (9.5) 73.6 (9.6) 74.1 (10.1) Black / -1.1* +4.1* / +0.6 Nonblack Nonblack Nonblack / -0.8* +0.9 / -0.3 Wright JT et al. JAMA 2005; 293:1593 *P<0.005

26 ALLHAT Black vs. Non-Black Lisinopril/Chlorthalidone Relative Risk and 95% Confidence Intervals Nonfatal MI + CHD Death All-Cause Mortality Combined CHD Combined CVD Stroke End Stage Renal Disease Heart Failure Black 1.10 ( ) 1.06 ( ) 1.15 ( ) 1.19 ( ) 1.40 ( ) 1.30 ( ) 1.30 ( ) Non-Black 0.94 ( ) 0.97 ( ) 1.01 ( ) 1.06 ( ) 1.00 ( ) 0.93 ( ) 1.13 ( ) right JT et al JAMA 2005; Favors Lisinopril Favors Chlorthalidone Favors Lisinopril Favors Chlorthalidone

27 ALLHAT Summary Lisinopril vs. Amlodipine Non-Blacks Blacks SBP Control <+0.5 mmhg mmhg # antihypertensive drugs similar Combined CHD, Mortality, ESRD, cancer Stroke Combined CVD HF hospitalized angina PAD similar similar but men -11%, women +46% similar - 15% similar + 18% similar + 45% + 13% - 11% + 26% + 22% GI Bleed + 16% + 28% Angioedema > >> +favors amlodipine - favors lisinopril Leenen F,et.al. Hypertens 2006;48:1

28 ALLHAT ANGIOEDEMA Total Chlorthalidone 8 / 15, % Lisinopril 38 / 9, % Blacks 2 / 5,369 <0.1% 23 / 3, % Nonblacks 6 / 9, % 15 / 5, % P<0.001 P<0.001 P=0.002 There were 3 cases (<0.1%) of angioedema in the amlodipine group (comparison to chlorthalidone not significant).

29 Endpoint Rate LIFE: Primary Composite Endpoint Intention-to-Treat Atenolol Losartan Adjusted Risk Reduction 13 0%, p=0 021 Unadjusted Risk Reduction 14 6%, p= Study Day Study Month Losartan (n) Atenolol (n) B Dahlof et al. Lancet 2002;359:

30 Results of Primary Composite Endpoint in LIFE by Ethnic Group Results of primary composite end point by ethnic group. The dots represent the hazard ratio; dot size is proportional to the number of patients for each ethnic group, as shown to the left. The line through each dot corresponds to the 95% confidence interval. Results of primary composite end point by ethnic group in the U.s.: blacks versus nonblacks. Julius et al. J Am Coll Cardiol. 2004;43:

31 Figure 2 J Hypertens 2006;24:2163

32 ALLHAT Biochemical Results Fasting Glucose mg/dl Chlorthalidone Amlodipine Lisinopril Total mean (SD) Baseline (58.3) (57.0) (56.1) 4 Years (55.6) (52.0) (51.3)* Among baseline nondiabetics with baseline <126 mg/dl mean (SD) Baseline 93.1 (11.7) 93.0 (11.4) 93.3 (11.8) 4 Years (28.5) (27.7) (19.5)* Diabetes incidence (follow-up fasting glucose 126 mg/dl) 4 Years 11.6% 9.8%* 8.1%* *P<0.05 compared to chlorthalidone

33 DREAM RAS Blockade & New Diabetes (Diabetes - Not Primary Outcome) Study N (no DM) Active Control RRR ACE Inhibitors HOPE 5720 Ramipril 10 OD Placebo 34% PEACE 6174 Trandolapril Placebo 17% Overall Effect (HOPE, EUROPA, PEACE): 0.86 ( ) EUROPA 10716Dagenais Perindopril et al. Lancet 8 mg 2006;368:581 Placebo 3% D-SOLVD 291 Enalapril Placebo 74% Angiotensin Receptor Blockers SCOPE 4368 Candesartan 16/d Placebo 20% CHARM 5436 Candesartan 4-32/d Placebo 24%

34 Cardiovascular Mortality Rate per 10,000 Patient-Years Elevated SBP in Type 2 Diabetes Increases Cardiovascular Risk Elevated SBP increases risk of CV death almost twofold in diabetic vs nondiabetic patients Nondiabetic patients Diabetic patients < Stamler J et al. Diabetes Care. 1993;16: SBP (mm Hg) MRFIT 20

35 DREAM Metabolic Changes Baseline 4 Years A B A B Serum cholesterol, mg/dl Serum potassium, mmol/l Fasting serum glucose, mg/dl Serum creatinine, mg/dl

36 DREAM Summary of Chlorthalidone / Doxazosin Comparisons from ALLHAT Outcome RR (95% CI) p value CVD 1.20 ( ) <0.001 Heart failure 1.80 ( ) <0.001 Stroke 1.26 ( ) CHD 1.03 ( ) 0.62 All-cause mortality 1.03 ( ) 0.50 ALLHAT Collab Res Grp. Hypertens 2003; 42:239

37 ALLHAT Effect of Incident Diabetes on ALLHAT Endpoints* (Cox Regressions Beginning at 2 Years) Incident Diabetes / No Diabetes HR (95% CI) CHD 1.64 ( ) Stroke 1.61 ( ) CCVD 1.04 ( ) Heart failure 1.37 ( ) ESRD 2.86 ( ) Total mortality 1.31 ( ) * In patients without diabetes at baseline. Adjusted for age, treatment group, race, gender, smoking, baseline FG, baseline BMI, 2-year BP, 2- year serum potassium, 2-year atenolol & statin treatment. Barzilay J et al: Arch Intern Med. 2006;166:2191

38 ALLHAT Effect of Change in Fasting Glucose on ALLHAT Endpoints* (Cox Regressions Beginning at 2 Years) ΔFG to 2 Yr (per 10 mg/dl) HR (95% CI) CHD 1.02 ( ) Stroke 1.00 ( ) CCVD 1.00 ( ) Heart failure 1.02 ( ) ESRD 1.06 ( ) Total mortality 1.01 ( ) * In patients without diabetes at baseline. Adjusted for age, treatment group, race, gender, smoking, baseline FG, baseline BMI, 2-year serum potassium, 2-year atenolol atenolol & statin treatment. Barzilay J et al: Arch Intern Med. 2006;166:2191

39 ALLHAT Effect of Change in Fasting Glucose on ALLHAT Endpoints* (Cox Regressions Beginning at 2 Years) ΔFG to 2 Yr (per 10 mg/dl) HR (95% CI) P compared with chlorthalidone CHD Total 1.02 ( ) 0.44 Chlorthalidone 1.00 ( ) 0.94 Amlodipine 0.99 ( ) 0.87 Lisinopril 1.09 ( ) 0.03 CCVD Total 1.00 ( ) 0.84 Chlorthalidone 0.99 ( ) 0.56 Amlodipine 1.00 ( ) 0.95 Lisinopril 1.06 ( ) 0.04 * In patients without diabetes at baseline. Adjusted for age, treatment group, race, gender, smoking, baseline FG, baseline BMI, 2-year serum potassium, 2-year atenolol atenolol & statin treatment.

40 ALLHAT CHD Black With Metabolic Syndrome Lisinopril/Chlorthalidone Relative Risk and 95% Confidence Intervals 6-year Rate per 100 Black 1.17 ( ) Without Metabolic Syndrome 1.07 ( ) All-cause Mortality 1.14 ( ) 1.02 ( ) Stroke 1.37 ( ) 1.31 ( ) Heart Failure 1.49 ( ) 1.09 ( ) Combined CVD 1.23 ( ) 1.09 ( ) ESRD 1.70 ( ) 0.75 ( ) Wright et al. Arch Int Med 2008; 168: Favors Lisinopril Favors Chlorthalidone Favors Lisinopril Favors Chlorthalidone

41 2010 Consensus Recommendations from the International Society of Hypertension in Blacks (ISHIB) A major recommendation of this consensus panel was the preference of the combination of a RAS-inhibitor with a calcium channel blocker over a RASinhibitor + a diuretic in Black hypertensives Flack J et al. Hypertens 2010; online

42 ACCOMPLISH Preliminary Results: Primary* and Secondary End Points End point Hazard ratio (95% CI) *Cardiovascular morbidity/mortality 0.80 ( ) Cardiovascular morbidity/mortality (excluding coronary revascularization) 0.79 ( ) Cardiovascular mortality 0.81 ( ) Nonfatal MI 0.81 ( ) Nonfatal stroke 0.87 ( ) Hospitalization for unstable angina 0.74 ( ) Coronary revascularization 0.85 ( ) Resuscitation for sudden death 1.75 ( ) Jamerson KA, et al. NEJM 2008;359:2117

43 Randomization ACCOMPLISH: Design Amlodipine 10 + benazepril 40 mg Free add-on antihypertensive agents* Amlodipine 5 mg + benazepril 40 mg Screening Amlodipine 5 mg + benazepril 20 mg Benazepril 20 mg + HCTZ 12.5 mg Benazepril 40 mg + HCTZ 12.5 mg Titrated to achieve BP<140/90 mmhg; <130/80 mmhg in patients with diabetes or renal insufficiency Benazepril 40 mg + HCTZ 25 mg Free add-on antihypertensive agents* 14 Days Day 1 Month 1 Month 2 Month 3 Year 5 *Beta blockers; alpha blockers; clonidine; (loop diuretics). Jamerson KA et al. Am J Hypertens. 2003;16(part2)193A

44 Thiazide-type Diuretic Doses in Hypertension Morbidity Trials Trial Drug Dose of Thiazide (mg/d) VA CSP M&M HCTZ 100 HDFP chlorthalidone MRC I bendroflumethiazide 10 HAPPHY bendroflumethiazide 5-10 HCTZ EWPHE HCTZ/triamterine MRC Elderly HCTZ/amiloride SHEP chlorthalidone ALLHAT chlorthalidone PATS indapamide 2.5 PROGRESS indapamide (+ACEI) 2.5 HYVET indapamide 1.5 ADVANCE BP indapamide (+ACEI) 1.25

45 Reduction in SBP (mmhg) Chlorthalidone vs HCTZ Estimated Dosing Equivalence based on Estimated Equivalent BP Reduction Current dosing of mg can be viewed as compromise between antihypertensive efficacy and kaliuresis HCTZ Chlor. 50 mg HCTZ ~ 25 to 37.5 mg chlorthalidone Carter BL, Ernst ME, Cohen JD. Hypertension 2004;43:4-9.

46 Pharmacokinetics HCTZ Chlorthalidone Vd 3-4 L/kg 40% protein bound 3-13 L/kg 75% protein bound 98% distribution into RBC Relative Potency* Oral Bioavail Onset (h) Peak (h) Half-life (h) 1 ~70% (single dose) 8-15 (longterm dosing) 1 ~65% (single dose) (longterm dosing) Duration (h) 12 (single dose) (longterm dosing) (single dose) (longterm dosing) Indapamide 20 ~93% 1-2 <2 14 Up to 36 * per most pharmacology texts; research suggests otherwise Carter BL, Ernst ME, Cohen JD. Hypertension 2004;43:4-9.

47 Perspective May be promoted by some to encourage use of CCBs over thiazide-type diuretics (each with RAS inhibitors). Calls for guidelines changes are premature. Dose of thiazide-type diuretic Doses of thiazide-type diuretics equivalent to <25-50 mg/day HCTZ have not been evaluated in clinical outcome trials demonstrating the benefits of HCTZ on CVD outcomes In ALLHAT, adequate dosage of diuretic was superior to both the CCB and ACE-inhibitor in preventing HF and unsurpassed for other CVDrenal outcomes, esp in Black patients 8/20/2008

48 Combination Therapy Needed to Achieve Target SBP Goals Trial/SBP Achieved UKPDS (144 mm Hg) RENAAL (141 mm Hg) ALLHAT (135 mm Hg) IDNT HOT (138 mm Hg) (138 mm Hg) INVEST (133 mm Hg) ABCD MDRD AASK (132 mm Hg) (132 mm Hg) (128 mm Hg) Updated from Bakris GL et al. Am J Kidney Dis. 2000;36: Number of BP meds

49 If most hypertensives (especially Black hypertensives) need 2-3 meds, which medications would these include CCB, DIURETICS, RAASI

50 RAS INHIBITOR USE IN HYPERTENSIVE BLACKS ACEIs/ARBs should be considered first in patients (including Blacks) with nephropathy (esp with proteinuria) and/or heart failure Available data suggest that RAS inhibitors are less effective in lowering BP in Black hypertensives in the absence of adequate doses of a diuretic or CCB (and in preventing clinical outcomes) ACEI also carry increased of angioedema, esp in Blacks In the absence of HF or CKD, particularly in Black hypertensives, beta blockers, ACEIs, and ARBs (and presently renin inhibitors) should be prescribed only in combination with thiazide-type diuretics or calcium channel blockers

51 The End

52 2010 Consensus Recommendations from the International Society of Hypertension in Blacks (ISHIB) Flack J et al. Hypertens 2010; online

53 POTENTIAL COSTS/RISKS OF LOWER THAN INDICATED BP TARGETS Increased cost of potentially unnecessary medications Increased risk of medication side effects Increased clinic visits if BP not at lower goal Increased monitoring required More complicated regimen that may jeopardize adherence to evidence-based treatment of other risk factors Potential increased risk of lower BP goals

54 Cumulative Incidence (%) TRIAL AND COHORT ALL PATIENTS Only Trial Mixed Trial and Cohort Only Cohort Low BP Usual BP Low BP vs. Usual BP Goal HR (95%CI) = 0.90 (0.77,1.07) p = Follow-Up Time (Months) AASK. NEJM 2010;363:10

55 Cumulative Incidence (%) TRIAL AND COHORT SUBGROUP WITH UP/Cr > Only Trial Mixed Trial and Cohort Only Cohort Low BP Usual BP Low BP vs. Usual BP Goal HR (95%CI) = 0.72 (0.57,0.92) p = Follow-Up Time (Months) AASK. NEJM 2010;363:10

56 Mean # Meds Intensive: Standard: Average after 1 st year: Standard vs Intensive, Delta = 14.2

57 ACCORD BP-Lowering: Reduction of SBP to <120 mmhg significantly Reduces the Rate of STROKE Outcome Intensive Therapy (n = 2363) Number of Events %/Year Standard Therapy (n = 2371) Number of Events %/Year Hazard Ratio (95% CI) Primary outcome* ( ) 0.20 Prespecified secondary outcomes Nonfatal MI ( ) 0.25 Any stroke ( ) 0.01 Nonfatal stroke ( ) 0.03 Death from any cause ( ) 0.55 Death from CV cause ( ) 0.74 Primary outcome plus revascularization or nonfatal heart disease ( ) 0.40 Major coronary disease event ( ) 0.50 Fatal or nonfatal heart failure ( ) 0.67 *Primary outcome: composite of nonfatal MI, nonfatal stroke, or death from CV causes Major coronary disease events included fatal coronary events, nonfatal MI, and unstable angina ACCORD: Action to Control Cardiovascular Risk in Diabetes Study P Value The ACCORD Study Group. N Engl J. Med. 2010;doi: /NEJMoa

58 Primary Outcome by Pre-defined Subgroups Also examined DBP tertiles (p=0.70) and number of screening meds (p=0.44) The ACCORD Study Group. N Engl J Med 2010;10

59 SUMMARY AND CONCLUSIONS 1/2-2/3 rd of Black hypertensives are above BP goal of 140/90 mmhg The evidence, including that in Black hypertensive patients, does not support BP goals substantially lower than 140/90 mmhg The increased cost in medications, clinic visits, monitoring, and potentially increased risk to achieve lower BP goals remains to be justified More definitive information should be forthcoming from the SPRINT trial In the meantime, efforts to control HTN in Blacks should focus on increasing the number of hypertensives controlled to <140/90 than on getting those already < 140/90 to lower goals

60 DIFFERENTIATION BETWEEN MARKETING AND EVIDENCE Who are you going to believe - me or the lying data?? Dr. Richard Pryor

61 Reduction in SBP (mmhg) Chlorthalidone vs HCTZ Estimated Dosing Equivalence based on Estimated Equivalent BP Reduction Current dosing of mg can be viewed as compromise between antihypertensive efficacy and kaliuresis HCTZ Chlor. 50 mg HCTZ ~ 25 to 37.5 mg chlorthalidone Carter BL, Ernst ME, Cohen JD. Hypertension 2004;43:4-9.

62 Direct and Indirect Comparisons of Chlorthalidone and Nonchlorthalidone Treatments for 6 Outcomes Based on Placebo-Controlled Trials RR (95% CI) Indirect Outcome Chlorthalidone Nonchlorthalidone Comparison, SI (95% Cl)* Coronary disease 0.74 ( ) 0.72 ( ) 1.03 ( ) Stroke 0.64 ( ) 0.71 ( ) 0.90 ( ) Heart failure 0.53 ( ) NA NA CVD events 0.70 ( ) 0.76 ( ) 0.92 ( ) CVD mortality 0.80 ( ) 0.79 ( ) 1.01 ( ) Total mortality 0.89 ( ) 0.91 ( ) 0.98 ( ) Psaty BM, JAMA 2004; 292:42

Hypertension Guidelines: Are We Pressured to Change? Oregon Cardiovascular Symposium Portland, Oregon June 6, Financial Disclosures

Hypertension Guidelines: Are We Pressured to Change? Oregon Cardiovascular Symposium Portland, Oregon June 6, Financial Disclosures Hypertension Guidelines: Are We Pressured to Change? Oregon Cardiovascular Symposium Portland, Oregon June 6, 2015 William C. Cushman, MD Professor, Preventive Medicine, Medicine, and Physiology University

More information

Treating Hypertension in Individuals with Diabetes

Treating Hypertension in Individuals with Diabetes Treating Hypertension in Individuals with Diabetes Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any

More information

Randomized Design of ALLHAT BP Trial

Randomized Design of ALLHAT BP Trial Outcomes in Hypertensive Black and Nonblack Patients Treated with Chlorthalidone, Amlodipine, and Lisinopril* *Wright JT, Dunn JK, Cutler JA et al. JAMA 2005:293:1595-1608. 42,418 High-risk hypertensive

More information

Hypertension Update Clinical Controversies Regarding Age and Race

Hypertension Update Clinical Controversies Regarding Age and Race Hypertension Update Clinical Controversies Regarding Age and Race Allison Helmer, PharmD, BCACP Assistant Clinical Professor Auburn University Harrison School of Pharmacy July 22, 2017 DISCLOSURE/CONFLICT

More information

Cedars Sinai Diabetes. Michael A. Weber

Cedars Sinai Diabetes. Michael A. Weber Cedars Sinai Diabetes Michael A. Weber Speaker Disclosures I disclose that I am a Consultant for: Ablative Solutions, Boston Scientific, Boehringer Ingelheim, Eli Lilly, Forest, Medtronics, Novartis, ReCor

More information

Objectives. Describe results and implications of recent landmark hypertension trials

Objectives. Describe results and implications of recent landmark hypertension trials Hypertension Update Daniel Schwartz, MD Assistant Professor of Medicine Associate Medical Director of Heart Transplantation Temple University School of Medicine Disclosures I currently have no relationships

More information

Pre-ALLHAT Drug Use. Diuretics. ß-Blockers. ACE Inhibitors. CCBs. Year. % of Treated Patients on Medication. CCBs. Beta Blockers.

Pre-ALLHAT Drug Use. Diuretics. ß-Blockers. ACE Inhibitors. CCBs. Year. % of Treated Patients on Medication. CCBs. Beta Blockers. Pre- Drug Use % of Treated Patients on Medication 60 50 40 30 20 10 0 1978 Diuretics ß-Blockers ACE Inhibitors Year CCBs CCBs Beta Blockers Diuretics ACE Inhibitors 1980 1982 1984 1986 1988 1990 1992 IMS

More information

Causes of Poor BP control Rates

Causes of Poor BP control Rates Goals Of Hypertension Management in Clinical Practice World Hypertension League (WHL) Meeting Adel E. Berbari, MD, FAHA, FACP Professor of Medicine and Physiology Head, Division of Hypertension and Vascular

More information

The Road to Renin System Optimization: Renin Inhibitor

The Road to Renin System Optimization: Renin Inhibitor The Road to Renin System Optimization: Renin Inhibitor A New Perspective on the Renin-Angiotensin System (RAS) Yong-Jin Kim, MD Seoul National University Hospital Human and Economic Costs of Hypertension

More information

State of the art treatment of hypertension: established and new drugs. Prof. M. Burnier Service of Nephrology and Hypertension Lausanne, Switzerland

State of the art treatment of hypertension: established and new drugs. Prof. M. Burnier Service of Nephrology and Hypertension Lausanne, Switzerland State of the art treatment of hypertension: established and new drugs Prof. M. Burnier Service of Nephrology and Hypertension Lausanne, Switzerland First line therapies in hypertension ACE inhibitors AT

More information

2/10/2014. Hypertension: Highlights of Hypertension Guidelines: Making the Most of Limited Evidence. Issues with contemporary guidelines

2/10/2014. Hypertension: Highlights of Hypertension Guidelines: Making the Most of Limited Evidence. Issues with contemporary guidelines Hypertension: 214 Highlights of Hypertension Guidelines: Making the Most of Limited Evidence Michael A, Weber, MD Editor-in-Chief, The Journal of Clinical Hypertension, Professor of Medicine, Division

More information

Explore the Rationale for the Dual Mechanism CCB/ARB Approach in Hypertension Management

Explore the Rationale for the Dual Mechanism CCB/ARB Approach in Hypertension Management Explore the Rationale for the Dual Mechanism CCB/ARB Approach in Hypertension Management Jeong Bae Park, MD,PhD Dept of Med/Cardiology, Cheil General Hospital, Kwandong University College of Medicine Apr

More information

Hypertension and Diabetes Should we be SPRINTING or Reaching an ACCORD?

Hypertension and Diabetes Should we be SPRINTING or Reaching an ACCORD? Hypertension and Diabetes Should we be SPRINTING or Reaching an ACCORD? Suzanne Oparil, MD Distinguished Professor of Medicine, Professor of Cell, Developmental and Integrative Biology Director, Vascular

More information

In the Literature 1001 BP of 1.1 mm Hg). The trial was stopped early based on prespecified stopping rules because of a significant difference in cardi

In the Literature 1001 BP of 1.1 mm Hg). The trial was stopped early based on prespecified stopping rules because of a significant difference in cardi Is Choice of Antihypertensive Agent Important in Improving Cardiovascular Outcomes in High-Risk Hypertensive Patients? Commentary on Jamerson K, Weber MA, Bakris GL, et al; ACCOMPLISH Trial Investigators.

More information

Talking about blood pressure

Talking about blood pressure Talking about blood pressure Mrs Khan 56 BP 158/99 BMI 32 Total cholesterol 5.4 (HDL 0.8) HbA1c 43 She has been promising to do more exercise and eat more healthily for the last 2 years but her weight

More information

Hypertension Pharmacotherapy: A Practical Approach

Hypertension Pharmacotherapy: A Practical Approach Hypertension Pharmacotherapy: A Practical Approach Ronald Victor, MD Burns & Allen Chair in Cardiology Director, The Hypertension Center Associate Director, The Heart Institute Hypertension Center 1. 2.

More information

Jared Moore, MD, FACP

Jared Moore, MD, FACP Hypertension 101 Jared Moore, MD, FACP Assistant Program Director, Internal Medicine Residency Clinical Assistant Professor of Internal Medicine Division of General Medicine The Ohio State University Wexner

More information

Metabolic Consequences of Anti Hypertensives: Is It Clinically Important?

Metabolic Consequences of Anti Hypertensives: Is It Clinically Important? Metabolic Consequences of Anti Hypertensives: Is It Clinically Important?,FACA,FICA,MASH,FVBWG,MISCP CONSULTANT OF CARDIOLOGY DIRECTOR OF PORT-FOUAD HOSPITAL CCU Consideration of antihypertensive agents

More information

Hypertension and the SPRINT Trial: Is Lower Better

Hypertension and the SPRINT Trial: Is Lower Better Hypertension and the SPRINT Trial: Is Lower Better 8th Annual Orange County Symposium on Cardiovascular Disease Prevention Saturday, October 8, 2016 Keith C. Norris, MD, PhD, FASN Professor of Medicine,

More information

STANDARD treatment algorithm mmHg

STANDARD treatment algorithm mmHg STANDARD treatment algorithm 130-140mmHg (i) At BASELINE, If AVERAGE SBP 1 > 140mmHg If on no antihypertensive drugs: Start 1 drug: If >55 years old / Afro-Caribbean: Calcium channel blocker (CCB) 2 If

More information

Hypertension Management Focus on new RAAS blocker. Disclosure

Hypertension Management Focus on new RAAS blocker. Disclosure Hypertension Management Focus on new RAAS blocker Rameshkumar Raman M.D Endocrine Associates of The Quad Cities Disclosure Speaker bureau Abbott, Eli Lilly, Novo Nordisk, Novartis, Takeda, Merck, Solvay

More information

Disclosures. Hypertension: Nationwide Dilemma. Learning Objectives. What s Currently Recommended? Specific Concerns 3/9/2012

Disclosures. Hypertension: Nationwide Dilemma. Learning Objectives. What s Currently Recommended? Specific Concerns 3/9/2012 How Should We ACCOMPLISH Good Blood Pressure Control In Our VETS? Disclosures No conflicts of interest to disclose Updates in the Management of HypertensionIn the Elderly Antoine T. Jenkins, Pharm.D.,

More information

VALUE OF ACEI IN THE MANAGEMENT OF HYPERTENSION

VALUE OF ACEI IN THE MANAGEMENT OF HYPERTENSION VALUE OF ACEI IN THE MANAGEMENT OF HYPERTENSION Dr Catherine BESEME Paris 6 th December 2005 6 th International Congress of Bangladesh Society of Medicine Hypertension is a risk factor at the source, with

More information

JNC-8. (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure- 8) An Update on Hypertension Guidelines

JNC-8. (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure- 8) An Update on Hypertension Guidelines JNC-8 (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure- 8) An Update on Hypertension Guidelines Derrick Sorweide, DO Assistant Professor of Family Medicine,

More information

Hypertension Controversies: SPRINTing to New Goals

Hypertension Controversies: SPRINTing to New Goals Hypertension Controversies: SPRINTing to New Goals Diana Isaacs, PharmD, BCPS, BC-ADM, CDE Clinical Pharmacy Specialist Cleveland Clinic Lauren Wolfe, PharmD Primary Care Clinical Specialist Cleveland

More information

Int. J. Pharm. Sci. Rev. Res., 36(1), January February 2016; Article No. 06, Pages: JNC 8 versus JNC 7 Understanding the Evidences

Int. J. Pharm. Sci. Rev. Res., 36(1), January February 2016; Article No. 06, Pages: JNC 8 versus JNC 7 Understanding the Evidences Research Article JNC 8 versus JNC 7 Understanding the Evidences Anns Clara Joseph, Karthik MS, Sivasakthi R, Venkatanarayanan R, Sam Johnson Udaya Chander J* RVS College of Pharmaceutical Sciences, Coimbatore,

More information

Hypertension: What s new since JNC 7. Harold M. Szerlip, MD, FACP, FCCP, FASN, FNKF

Hypertension: What s new since JNC 7. Harold M. Szerlip, MD, FACP, FCCP, FASN, FNKF Hypertension: What s new since JNC 7 Harold M. Szerlip, MD, FACP, FCCP, FASN, FNKF Disclosures Spectral Diagnostics Site investigator Eli Lilly Site investigator ACP IM ITE writing committee NBME Step

More information

TREATMENT AND COMPLICAtions

TREATMENT AND COMPLICAtions ORIGINAL CONTRIBUTION JAMA-EXPRESS Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic The Antihypertensive and

More information

RENAAL, IRMA-2 and IDNT. Three featured trials linking a disease spectrum IDNT RENAAL. Death IRMA 2

RENAAL, IRMA-2 and IDNT. Three featured trials linking a disease spectrum IDNT RENAAL. Death IRMA 2 Treatment of Diabetic Nephropathy and Proteinuria Background End stage renal disease is a major cause of death and disability among diabetics BP reduction is important to slow the progression of diabetic

More information

Objectives. JNC 7 Is Nice But What s Up With JNC 8? Why Do We Care? Hypertension Background: Prevalence

Objectives. JNC 7 Is Nice But What s Up With JNC 8? Why Do We Care? Hypertension Background: Prevalence JNC 7 Is Nice But What s Up With JNC 8? 37 th Annual CAPA Conference October 4 th 2013 Ignacio de Artola, Jr. M.D. Assistant Professor of Clinical Family Medicine Medical Director, Primary Care Physician

More information

Clinical cases with Coversyl 10 mg

Clinical cases with Coversyl 10 mg Clinical cases Coversyl 10 mg For upgraded benefits in hypertension A Editorial This brochure, Clinical cases Coversyl 10 mg for upgraded benefits in hypertension, illustrates a variety of hypertensive

More information

Kidney Disease, Hypertension and Cardiovascular Risk

Kidney Disease, Hypertension and Cardiovascular Risk 1 Kidney Disease, Hypertension and Cardiovascular Risk George Bakris, MD, FAHA, FASN Professor of Medicine Director, Hypertensive Diseases Unit The University of Chicago-Pritzker School of Medicine Chicago,

More information

Hypertension Management Controversies in the Elderly Patient

Hypertension Management Controversies in the Elderly Patient Hypertension Management Controversies in the Elderly Patient Juan Bowen, MD Geriatric Update for the Primary Care Provider November 17, 2016 2016 MFMER slide-1 Disclosure No financial relationships No

More information

Hypertension Update. Mayo Clinic 90 th Annual Clinical Reviews November 2 nd and 16 th, 2016

Hypertension Update. Mayo Clinic 90 th Annual Clinical Reviews November 2 nd and 16 th, 2016 Mayo Clinic 90 th Annual Clinical Reviews November 2 nd and 16 th, 2016 Hypertension Update Vincent J. Canzanello, M.D. Consultant, Division of Nephrology and Hypertension Professor or Medicine College

More information

The CARI Guidelines Caring for Australians with Renal Impairment. Specific effects of calcium channel blockers in diabetic nephropathy GUIDELINES

The CARI Guidelines Caring for Australians with Renal Impairment. Specific effects of calcium channel blockers in diabetic nephropathy GUIDELINES Specific effects of calcium channel blockers in diabetic nephropathy Date written: September 2004 Final submission: September 2005 Author: Kathy Nicholls GUIDELINES a. Non-dihydropyridine calcium channel

More information

Hypertension Guidelines Michael A. Weber, MD Division of Cardiovascular Medicine State University of New York Downstate Medical Center

Hypertension Guidelines Michael A. Weber, MD Division of Cardiovascular Medicine State University of New York Downstate Medical Center Hypertension Guidelines 2016 Michael A. Weber, MD Division of Cardiovascular Medicine State University of New York Downstate Medical Center Speaker Disclosures I disclose that I am a Consultant for: Ablative

More information

By Prof. Khaled El-Rabat

By Prof. Khaled El-Rabat What is The Optimum? By Prof. Khaled El-Rabat Professor of Cardiology - Benha Faculty of Medicine HT. Introduction Despite major worldwide efforts over recent decades directed at diagnosing and treating

More information

Prevention of Heart Failure: What s New with Hypertension

Prevention of Heart Failure: What s New with Hypertension Prevention of Heart Failure: What s New with Hypertension Ali AlMasood Prince Sultan Cardiac Center Riyadh 3ed Saudi Heart Failure conference, Jeddah, 13 December 2014 Background 20-30% of Saudi adults

More information

Sponsored by the National Heart, Lung, and Blood Institute (NHLBI)

Sponsored by the National Heart, Lung, and Blood Institute (NHLBI) 1 U.S. Department of Health and Human Services The Hypertension, Detection, and Follow-up Program (HDFP) The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) National

More information

ABSTRACT. Special Communication February 5, 2014

ABSTRACT. Special Communication February 5, 2014 Page 1 of 20 Special Communication February 5, 2014 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National

More information

Supplementary Online Content

Supplementary Online Content Supplementary Online Content James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report by the panel appointed to the Eighth Joint National

More information

Management of Hypertension. M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine

Management of Hypertension. M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine Management of Hypertension M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine Disturbing Trends in Hypertension HTN awareness, treatment and control rates are decreasing

More information

Hypertension Management in Diabetic Patients

Hypertension Management in Diabetic Patients Hypertension Management in Diabetic Patients Park, Chang G, MD, PhD Cardiovascular Center, Guro Hospital, Korea University Medical School Contents (Treatment of 2 Cases) Type 2 Diabetes Mellitus Hypertension

More information

HYPERTENSION IN THE ELDERLY A BALANCED APPROACH. Barry Goldlist October 31, 2014

HYPERTENSION IN THE ELDERLY A BALANCED APPROACH. Barry Goldlist October 31, 2014 HYPERTENSION IN THE ELDERLY A BALANCED APPROACH Barry Goldlist October 31, 2014 DISCLOSURE I have not accepted any money for myself from any pharmaceutical company in the 21 st century I have accepted

More information

Choice of therapy in esse... http://www.uptodate.co... Page 1 of 28 Official reprint from UpToDate www.uptodate.com Print Back Choice of therapy in essential hypertension: Recommendations Authors Norman

More information

Objective & Outline. How the JNC Process Has Evolved. Expertise Represented on JNC 8 Panel

Objective & Outline. How the JNC Process Has Evolved. Expertise Represented on JNC 8 Panel Implementation: Joint National Committee on High Blood Pressure JNC 8 Joel Handler, MD Kaiser Permanente Care Management Institute Hypertension Lead Southern California Permanente Group Objective & Outline

More information

Management of Hypertension in special groups. DR-Mohammed Salah Assistant Lecturer of Cardiology Mansoura University

Management of Hypertension in special groups. DR-Mohammed Salah Assistant Lecturer of Cardiology Mansoura University Management of Hypertension in special groups BY DR-Mohammed Salah Assistant Lecturer of Cardiology Mansoura University AGENDA SPECIAL GROUPS SPECIFIC DRUDS FOR SPECIAL GROUPS TARGET BP FOR SPECIAL GROUPS:

More information

Conflict of Interest Disclosure

Conflict of Interest Disclosure HYPERTENSION UPDATE: NEW JNC 8 Guideline vs OLD Federal Motor Carrier Safety Regulations PLEASE STAND BY WEBINAR WILL BEGIN AT 12:00 PM PST FOR AUDIO: CALL 866-740-1260 / ACCESS CODE: 764-4915# Conflict

More information

New Clinical Trends in Geriatric Medicine. April 8, 2016 Amanda Lathia, MD, MPhil Staff, Center for Geriatric Medicine

New Clinical Trends in Geriatric Medicine. April 8, 2016 Amanda Lathia, MD, MPhil Staff, Center for Geriatric Medicine New Clinical Trends in Geriatric Medicine April 8, 2016 Amanda Lathia, MD, MPhil Staff, Center for Geriatric Medicine Objectives Review current guidelines for blood pressure (BP) control in older adults

More information

New Hypertension Guidelines: Why the change? Neil Brummond, M.D. Avera Medical Group Internal Medicine Sioux Falls, SD

New Hypertension Guidelines: Why the change? Neil Brummond, M.D. Avera Medical Group Internal Medicine Sioux Falls, SD New Hypertension Guidelines: Why the change? Neil Brummond, M.D. Avera Medical Group Internal Medicine Sioux Falls, SD None Disclosures Objectives Understand trend in blood pressure clinical practice guidelines

More information

Blood Pressure Monitoring in Chronic Kidney Disease

Blood Pressure Monitoring in Chronic Kidney Disease Blood Pressure Monitoring in Chronic Kidney Disease Aldo J. Peixoto, MD FASN FASH Associate Professor of Medicine (Nephrology), YSM Associate Chief of Medicine, VACT Director of Hypertension, VACT American

More information

Seung Hyeok Han, MD, PhD Department of Internal Medicine Yonsei University College of Medicine

Seung Hyeok Han, MD, PhD Department of Internal Medicine Yonsei University College of Medicine Seung Hyeok Han, MD, PhD Department of Internal Medicine Yonsei University College of Medicine The Scope of Optimal BP BP Reduction CV outcomes & mortality CKD progression - Albuminuria - egfr decline

More information

Amlodipine/Valsartan (Exforge ) Changing the Landscape of BP Management

Amlodipine/Valsartan (Exforge ) Changing the Landscape of BP Management Amlodipine/Valsartan (Exforge ) Changing the Landscape of BP Management Bum-Kee Hong Yongdong Severance Hospital Yonsei University College of Medicine Rationale for Multiple-Mechanism Therapy Inadequacy

More information

Managing HTN in the Elderly: How Low to Go

Managing HTN in the Elderly: How Low to Go Managing HTN in the Elderly: How Low to Go Laxmi S. Mehta, MD, FACC The Ohio State University Medical Center Assistant Professor of Clinical Internal Medicine Clinical Director of the Women s Cardiovascular

More information

Combination therapy in the treatment of arterial hypertension. Franco Veglio SIIIA. UNIVERSITA degli STUDI di TORINO

Combination therapy in the treatment of arterial hypertension. Franco Veglio SIIIA. UNIVERSITA degli STUDI di TORINO SIIIA UNIVERSITA degli STUDI di TORINO FACOLTA DI MEDICINA E CHIRURGIA DIPARTIMENTO DI MEDICINA ED ONCOLOGIA SPERIMENTALE SCU MEDICINA INTERNA CENTRO IPERTENSIONE ARTERIOSA AOU S.GIOVANNI BATTISTA TORINO

More information

The New Hypertension Guidelines

The New Hypertension Guidelines The New Hypertension Guidelines Joseph Saseen, PharmD Professor and Vice Chair, Department of Clinical Pharmacy University of Colorado Anschutz Medical Campus Disclosure Joseph Saseen reports no conflicts

More information

Predicting and changing the future for people with CKD

Predicting and changing the future for people with CKD Predicting and changing the future for people with CKD I. David Weiner, M.D. Co-holder, C. Craig and Audrae Tisher Chair in Nephrology Professor of Medicine and Physiology and Functional Genomics University

More information

Role of Clopidogrel in Acute Coronary Syndromes. Hossam Kandil,, MD. Professor of Cardiology Cairo University

Role of Clopidogrel in Acute Coronary Syndromes. Hossam Kandil,, MD. Professor of Cardiology Cairo University Role of Clopidogrel in Acute Coronary Syndromes Hossam Kandil,, MD Professor of Cardiology Cairo University ACS Treatment Strategies Reperfusion/Revascularization Therapy Thrombolysis PCI (with/ without

More information

Combination of renin-angiotensinaldosterone. how to choose?

Combination of renin-angiotensinaldosterone. how to choose? Combination of renin-angiotensinaldosterone system inhibitors how to choose? Karl Swedberg Professor of Medicine Sahlgrenska Academy University of Gothenburg karl.swedberg@gu.se Disclosures Research grants

More information

Can Anti-hypertension Therapy Reverse Vascular Aging and Dementia?

Can Anti-hypertension Therapy Reverse Vascular Aging and Dementia? 2012. 4. 20-21 춘계심장학회 _ 부산 Can Anti-hypertension Therapy Reverse Vascular Aging and Dementia? Jeong Bae Park, MD, PhD Cardiology, Cheil General Hospital, Kwandong University, Seoul, Korea The Pulse : revived

More information

ALLHAT and its implications in the diabetic population

ALLHAT and its implications in the diabetic population SPECIAL REPORT ALLHAT and its implications in the diabetic population Samy I McFarlane, MD, MPH, FACP Associate Professor of Medicine, Fellowship Program Director, Division of Endocrinology, Diabetes and

More information

Traitements associés chez l hypertendu: Statines, Aspirine

Traitements associés chez l hypertendu: Statines, Aspirine 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 Global Mortality 2000: Impact

More information

Blood Pressure Lowering in Type 2 Diabetes A Systematic Review and Meta-analysis

Blood Pressure Lowering in Type 2 Diabetes A Systematic Review and Meta-analysis Research Original Investigation A Systematic Review and Meta-analysis Connor A. Emdin, HBSc; Kazem Rahimi, DM, MSc; Bruce Neal, PhD; Thomas Callender, MBChB; Vlado Perkovic, PhD; Anushka Patel, PhD IMPORTANCE

More information

Metoprolol Succinate SelokenZOC

Metoprolol Succinate SelokenZOC Metoprolol Succinate SelokenZOC Blood Pressure Control and Far Beyond Mohamed Abdel Ghany World Health Organization - Noncommunicable Diseases (NCD) Country Profiles, 2014. 1 Death Rates From Ischemic

More information

ACCORD, ADVANCE & VADT. Now what do I do in my practice?

ACCORD, ADVANCE & VADT. Now what do I do in my practice? ACCORD, ADVANCE & VADT Now what do I do in my practice? Richard M. Bergenstal, MD International Diabetes Center Park Nicollet Health Services University of Minnesota Minneapolis, MN richard.bergenstal@parknicollet.com

More information

Outline. Outline CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW 7/23/2013. Question 1: Which of these patients has CKD?

Outline. Outline CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW 7/23/2013. Question 1: Which of these patients has CKD? CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW MICHAEL G. SHLIPAK, MD, MPH CHIEF-GENERAL INTERNAL MEDICINE, SAN FRANCISCO VA MEDICAL CENTER PROFESSOR OF MEDICINE, EPIDEMIOLOGY AND BIOSTATISTICS,

More information

Update on pharmacological treatment of heart failure. Aldo Pietro Maggioni, MD, FESC ANMCO Research Center Firenze, Italy

Update on pharmacological treatment of heart failure. Aldo Pietro Maggioni, MD, FESC ANMCO Research Center Firenze, Italy Update on pharmacological treatment of heart failure Aldo Pietro Maggioni, MD, FESC ANMCO Research Center Firenze, Italy Presenter Disclosures Dr. Maggioni : Serving in Committees of studies sponsored

More information

Management of Hypertension in Diabetic Nephropathy: How Low Should We Go?

Management of Hypertension in Diabetic Nephropathy: How Low Should We Go? Review Advances in CKD 216 Published online: January 15, 216 Management of Hypertension in Diabetic Nephropathy: How Low Should We Go? Hillel Sternlicht George L. Bakris Department of Medicine, Section

More information

Update in Outpatient Medicine JNC 8, Hypertension and More

Update in Outpatient Medicine JNC 8, Hypertension and More Update in Outpatient Medicine JNC 8, Hypertension and More March 6 th 2015 Robert Gluckman, MD, FACP CMO Providence Health Plans Disclosures Stock Holdings Abbott Labs Abbvie Bristol Myers Squibb GE Proctor

More information

Valsartan Amlodipine HCT Combination: Control To Goal. Dr. Sameh Shaheen M.B.B.Ch, MSc, MD, FESC, FSCAI. Prof of cardiology Ain Shams University

Valsartan Amlodipine HCT Combination: Control To Goal. Dr. Sameh Shaheen M.B.B.Ch, MSc, MD, FESC, FSCAI. Prof of cardiology Ain Shams University Valsartan Amlodipine HCT Combination: Control To Goal Dr. Sameh Shaheen M.B.B.Ch, MSc, MD, FESC, FSCAI Prof of cardiology Ain Shams University Sonesta Hotel Cairo Egypt December 4 th 5 th ; 213 Hypertension

More information

Lowering blood pressure in 2003

Lowering blood pressure in 2003 UPDATE CLINICAL UPDATE Lowering blood pressure in 2003 John P Chalmers and Leonard F Arnolda Institute for International Health, University of Sydney, Sydney, NSW. John P Chalmers, MD, FRACP, Professor

More information

h i g h b l o o d p r e s s u r e

h i g h b l o o d p r e s s u r e h i g h b l o o d p r e s s u r e where are we at? The recent literature has raised doubts about the role of ßblockers for lowering blood pressure and the New Zealand Guidelines Group is updating the Assessment

More information

Challenges in Hypertension: Incorporating Evolving Clinical Data Into Practice

Challenges in Hypertension: Incorporating Evolving Clinical Data Into Practice Challenges in Hypertension: Incorporating Evolving Clinical Data Into Practice Faculty Jan Basile, MD Professor of Medicine Seinsheimer Cardiovascular Health Program Division of General Internal Medicine

More information

Drugs acting on the reninangiotensin-aldosterone

Drugs acting on the reninangiotensin-aldosterone Drugs acting on the reninangiotensin-aldosterone system John McMurray Eugene Braunwald Scholar in Cardiovascular Diseases, Brigham and Women s Hospital, Boston & Visiting Professor, Harvard Medical School

More information

Metformin should be considered in all patients with type 2 diabetes unless contra-indicated

Metformin should be considered in all patients with type 2 diabetes unless contra-indicated November 2001 N P S National Prescribing Service Limited PPR fifteen Prescribing Practice Review PPR Managing type 2 diabetes For General Practice Key messages Metformin should be considered in all patients

More information

KDIGO conference on high CV risk associated with CKD. The role of BP in CKD stage 1-4

KDIGO conference on high CV risk associated with CKD. The role of BP in CKD stage 1-4 KDIGO conference on high CV risk associated with CKD The role of BP in CKD stage 1-4 Johannes Mann, MD & Catherine Clase, MB BChir Friedrich Alexander University, Erlangen-Nuremberg Munich General Hospitals,

More information

9/29/2015. Primary Prevention of Heart Disease: Objectives. Objectives. What works? What doesn t?

9/29/2015. Primary Prevention of Heart Disease: Objectives. Objectives. What works? What doesn t? Primary Prevention of Heart Disease: What works? What doesn t? Samia Mora, MD, MHS Associate Professor, Harvard Medical School Associate Physician, Brigham and Women s Hospital October 2, 2015 Financial

More information

Are Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Especially Useful for Cardiovascular Protection?

Are Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Especially Useful for Cardiovascular Protection? EVIDENCE-BASED CLINICAL MEDICINE Are Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Especially Useful for Cardiovascular Protection? Hean Teik Ong, FRCP, FACC, FESC Purpose:

More information

Hypertension Update 2016 AREEF ISHANI, MD MS CHIEF OF MEDICINE MINNEAPOLIS VA MEDICAL CENTER PROFESSOR OF MEDICINE UNIVERSITY OF MINNESOTA

Hypertension Update 2016 AREEF ISHANI, MD MS CHIEF OF MEDICINE MINNEAPOLIS VA MEDICAL CENTER PROFESSOR OF MEDICINE UNIVERSITY OF MINNESOTA Hypertension Update 2016 AREEF ISHANI, MD MS CHIEF OF MEDICINE MINNEAPOLIS VA MEDICAL CENTER PROFESSOR OF MEDICINE UNIVERSITY OF MINNESOTA Case 1 What should be your BP goal for an elderly (> 75 yrs of

More information

ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ Ι.Ε.ΚΑΝΟΝΙΔΗΣ

ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ Ι.Ε.ΚΑΝΟΝΙΔΗΣ 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

More information

Supplementary Appendix

Supplementary Appendix Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Wanner C, Inzucchi SE, Lachin JM, et al. Empagliflozin and

More information

ANGIOTENSIN RECEPTOR BLOCKERS ARE FIRST LINE TREATMENT : PRO

ANGIOTENSIN RECEPTOR BLOCKERS ARE FIRST LINE TREATMENT : PRO ANGIOTENSIN RECEPTOR BLOCKERS ARE FIRST LINE TREATMENT : PRO Prof Xavier Girerd M.D., Ph.D., F.E.S.C. Endocrinology Department Cardiovascular Prevention Unit Groupe Hospitalier Pitié-Salpêtrière Faculté

More information

LXIV: DRUGS: 4. RAS BLOCKADE

LXIV: DRUGS: 4. RAS BLOCKADE LXIV: DRUGS: 4. RAS BLOCKADE ACE Inhibitors Components of RAS Actions of Angiotensin i II Indications for ACEIs Contraindications RAS blockade in hypertension RAS blockade in CAD RAS blockade in HF Limitations

More information

RAS Blockade Across the CV Continuum

RAS Blockade Across the CV Continuum A Summary of Recent International Meetings RAS Blockade Across the CV Continuum Copyright New Evidence Presented at the 2009 Congress of the European Society of Cardiology (August 29-September 2, Barcelona)

More information

Does renin angiotensin system blockade deserve preferred status over other anti-hypertensive medications for the treatment of people with diabetes?

Does renin angiotensin system blockade deserve preferred status over other anti-hypertensive medications for the treatment of people with diabetes? Editorial Page 1 of 6 Does renin angiotensin system blockade deserve preferred status over other anti-hypertensive medications for the treatment of people with diabetes? Joshua I. Barzilay 1, Paul K. Whelton

More information

ADVANCE post trial ObservatioNal Study

ADVANCE post trial ObservatioNal Study Hot Topics in Diabetes 50 th EASD, Vienna 2014 ADVANCE post trial ObservatioNal Study Sophia Zoungas The George Institute The University of Sydney Rationale and Study Design Sophia Zoungas The George Institute

More information

CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW MICHAEL G. SHLIPAK, MD, MPH

CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW MICHAEL G. SHLIPAK, MD, MPH CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW MICHAEL G. SHLIPAK, MD, MPH SCIENTIFIC DIRECTOR KIDNEY HEALTH RESEARCH COLLABORATIVE - UCSF CHIEF - GENERAL INTERNAL MEDICINE, SAN FRANCISCO

More information

CANADIAN STROKE BEST PRACTICE RECOMMENDATIONS. Prevention of Stroke Evidence Tables Blood Pressure Management

CANADIAN STROKE BEST PRACTICE RECOMMENDATIONS. Prevention of Stroke Evidence Tables Blood Pressure Management CANADIAN STROKE BEST PRACTICE RECOMMENDATIONS Blood Pressure Management Wein T, Gladstone D (Writing Group Chairs) on Behalf of the PREVENTION of STROKE Writing Group 2017 Heart and Stroke Foundation September

More information

Preventing the cardiovascular complications of hypertension

Preventing the cardiovascular complications of hypertension European Heart Journal Supplements (2004) 6 (Supplement H), H37 H42 Preventing the cardiovascular complications of hypertension Peter Trenkwalder* Department of Internal Medicine, Starnberg Hospital, Ludwig

More information

Drug Class Review on Calcium Channel Blockers FINAL REPORT

Drug Class Review on Calcium Channel Blockers FINAL REPORT Drug Class Review on Calcium Channel Blockers FINAL REPORT September 2003 TABLE OF CONTENTS Introduction 5 Scope and Key Questions 6 Methods 6 Literature Search 6 Study Selection 6 Data Abstraction 7 Validity

More information

This clinical study synopsis is provided in line with Boehringer Ingelheim s Policy on Transparency and Publication of Clinical Study Data.

This clinical study synopsis is provided in line with Boehringer Ingelheim s Policy on Transparency and Publication of Clinical Study Data. abcd Clinical Study Synopsis for Public Disclosure This clinical study synopsis is provided in line with s Policy on Transparency and Publication of Clinical Study Data. The synopsis which is part of the

More information

Emerging Challenges in Primary Care: Hypertension 2017: The Times and Guidelines Are Changing

Emerging Challenges in Primary Care: Hypertension 2017: The Times and Guidelines Are Changing Emerging Challenges in Primary Care: 2017 Hypertension 2017: The Times and Guidelines Are Changing 1 Faculty Jan Basile, MD Professor of Medicine Seinsheimer Cardiovascular Health Program Division of General

More information

Isolated Systolic Hypertension in the elderly. Daniel Hayoz Clinique de Médecine Interne HFR-Hôpital Cantonal Fribourg

Isolated Systolic Hypertension in the elderly. Daniel Hayoz Clinique de Médecine Interne HFR-Hôpital Cantonal Fribourg Isolated Systolic Hypertension in the elderly Daniel Hayoz Clinique de Médecine Interne HFR-Hôpital Cantonal Fribourg Case no 1 Man aged 75, from Kosovo, in CH since 1.5 years Former smoker (45 PY) BP:

More information

Impact of Hypertension Threshold and Goals on Special Populations

Impact of Hypertension Threshold and Goals on Special Populations Impact of Hypertension Threshold and Goals on Special Populations National Lipid Association 2015 Annual Scientific Sessions June 13,2015 Keith C. Ferdinand, MD, FACC,FAHA,FASH,FNLA Professor of Clinical

More information

2/9/2017. Financial Disclosures/Unapproved Use. Achieving Harmony in Blood Pressure Guidelines Around the Globe. Roger S. Blumenthal, MD.

2/9/2017. Financial Disclosures/Unapproved Use. Achieving Harmony in Blood Pressure Guidelines Around the Globe. Roger S. Blumenthal, MD. Achieving Harmony in Blood Pressure Guidelines Around the Globe Roger S. Blumenthal, MD The Kenneth Jay Pollin Professor of Cardiology Director, The Johns Hopkins Ciccarone Center for the Prevention Of

More information

Blood Pressure Control in the Elderly How High Should You Go?

Blood Pressure Control in the Elderly How High Should You Go? Blood Pressure Control in the Elderly How High Should You Go? Sara Linedecker, PharmD PGY-2 Ambulatory Care Resident University of Texas at Austin College of Pharmacy Blackstock Family Practice/CommUnityCare

More information

Executive Summary. Different antihypertensive drugs as first line therapy in patients with essential hypertension 1

Executive Summary. Different antihypertensive drugs as first line therapy in patients with essential hypertension 1 IQWiG Reports Commission No. A05-09 Different antihypertensive drugs as first line therapy in patients with essential hypertension 1 Executive Summary 1 Translation of the executive summary of the final

More information

Blood Pressure Goal in Elderly Hypertensive Patients with Diabetes Mellitus: A Subanalysis of the CASE-J Trial

Blood Pressure Goal in Elderly Hypertensive Patients with Diabetes Mellitus: A Subanalysis of the CASE-J Trial Blood Pressure Goal in Elderly Hypertensive Patients with Diabetes Mellitus: A Subanalysis of the CASE-J Trial Kenji Ueshima 1, Shinji Yasuno 1, Sachiko Tanaka 1, Akira Fujimoto 1, Toshio Ogihara 2, Takao

More information