Quoi de neuf en cardio-gériatrie? Pr Olivier Hanon Hôpital Broca, Paris

Transcription

1 Quoi de neuf en cardio-gériatrie? Pr Olivier Hanon Hôpital Broca, Paris

2 Déclaration de relations professionnelles et liens d intérêt Novartis, Daiichi-Sankyo, Boehringer-Ingelheim, Bayer, BMS, Pfizer, Astra-Zeneca, Servier, Vifor

3 Hypertension artérielle

4 JAMA. Published online May 19, 2016.

5 N = (PAS mmhg) PAS < 120 mmhg PAS < 140 mmhg This article was published on November 9, 2015

6 Arrêt prématuré de l étude à 3.26 ans (au lieu de 5 ans) Critère principal (IDM, SCA, AVC, Ins cardiaque, mortalité CV) - 25% NEJM, november 9, 2015

7 N=2636 participants 75 ans JAMA. Published online May 19, 2016.

8 - 34% - 38% - 33%

9 Bénéfice : aussi chez les sujets fragiles

10

11 Oui mais Critères de non inclusion : Diabète, AVC, I cardiaque ou FEVG < 35%, Cl < 20 ml/min/1,73 m2, déclin cognitif, perte d autonomie, vie en institution hypertendus ambulatoires sans perte d autonomie

12 Diuretic antihypertensive drugs and incident dementia risk: a systematic review, meta-analysis and meta-regression of prospective studies. Tully PJ, Hanon O, Cosh S, Tzourio C. 15 articles, persons, median age 76.1 years, median follow-up was 6.1 years - 20% J Hypertens Feb 17

13 - 22% Neurosci Feb 26;615:1-8

14 Maladie coronaire

15 Lancet 2016; 387:

16 Lancet 2016; 387:

17 TAVI

18 TAVI was validated for patients with severe aortic stenosis who are not candidates for surgery or who are at high risk for complications due to surgery, We evaluated the two procedures in a randomized trial involving intermediate-risk patients. N Engl J Med Apr 28;374(17):

19 N Engl J Med Apr 28;374(17):

20 N Engl J Med Apr 28;374(17):

21 Insuffisance cardiaque

22 gain d espérance de vie sous TT IEC ou LCZ après 65 ans : Gain d espérance de vie avec Entresto : 1,3 ans N Engl J Med Dec 3;373(23):

23 Fibrillation atriale

24 Gibson et al. AHA 2016

25 Patients With Atrial Fibrillation Undergoing Coronary Stent Placement: PIONEER AF-PCI End of treatment 12 months 2100 patients with NVAF Coronary stenting No prior stroke/tia, GI bleeding, Hb<10, CrCl<30 72 hours After Sheath removal R A N D O M I Z E 1,6, or 12 months Rivaroxaban 15 mg qd* Clopidogrel 75 mg qd Pre randomization MD Choice Rivaroxaban 2.5 mg bid Clopidogrel 75 mg qd Aspirin mg qd 1,6, or 12 months Pre randomization MD Choice VKA (target INR ) Clopidogrel 75 mg qd Aspirin mg qd Rivaroxaban 15mg QD Aspirin mg qd VKA (target INR ) Aspirin mg qd WOEST Like ATLAS Like Triple Therapy Primary endpoint: TIMI major + minor + bleeding requiring medical attention Secondary endpoint: CV death, MI, and stroke (Ischemic, Hemorrhagic, or Uncertain Origin) *Rivaroxaban dosed at 10 mg once daily in patients with CrCl of 30 to <50 ml/min. Alternative P2Y 12 inhibitors: 10 mg once-daily prasugrel or 90 mg twice-daily ticagrelor. Low-dose aspirin ( mg/d). Open label VKA Gibson et al. AHA 2016

26 TIMI Major, TIMI Minor, or Bleeding Requiring Medical Attention (%) Kaplan-Meier Estimates of First Occurrence of Clinically Significant Bleeding Events 26.7% VKA VKA + DAPT + DAPT Riva + DAPT p< p< % 16.8% Riva + P2Y 12 Riva + P2Y 12 v. VKA + DAPT HR=0.59 (95% CI: ) p < ARR=9.9 NNT=11 HR = 0.63 (95% CI ) HR ARR = 0.59 = (95% 8.7 Riva + CI DAPT ) v. VKA + DAPT ARR NNT = 9.9 = 12 HR=0.63 (95% CI: ) NNT = 11 p < ARR=8.7 NNT=12 No. at risk VKA Riva + DAPT P2Y 12 VKA Riva + DAPT VKA + DAPT Days Treatment-emergent period: period starting after the first study drug administration following randomization and ending 2 days after stop of study drug. Clinically significant bleeding is the composite of TIMI major, TIMI minor, and BRMA. Hazard ratios as compared to the VKA group are based on the (stratified, only for Overall, 2.5 mg BID/15 mg QD comparing VKA) Cox proportional hazards model. Log-Rank P-values as compared to VKA group are based on the (stratified, only for Overall, 2.5 mg BID/15 mg QD comparing VKA) two-sided log rank test. Gibson et al. AHA 2016

27 Cardiovascular Death, Myocardial Infarction, or Stroke (%) Kaplan-Meier Estimates of First Occurrence of CV Death, MI or Stroke Riva + P2Y % 6.0% 5.6% Riva + DAPT VKA + DAPT Riva + P2Y 12 v. VKA + DAPT HR=1.08 (95% CI: ) p=0.750 Riva + DAPT v. VKA + DAPT HR=0.93 (95% CI: ) p=0.765 No. at risk Riva + P2Y 12 Riva + DAPT VKA + DAPT Days Treatment-emergent period: period starting after the first study drug administration following randomization and ending 2 days after stop of study drug. Composite of adverse CV events is composite of CV death, MI, and stroke. Hazard ratios as compared to VKA group are based on the (stratified, only for the Overall, 2.5 mg BID/15 mg QD comparing VKA) Cox proportional hazards model. Log-Rank P-values as compared to the VKA group are based on the (stratified, only for Overall, 2.5 mg BID/115 mg QD comparing VKA) two-sided log rank test. 6 Subjects were excluded from all efficacy analyses because of violations in Good Clinical Practice guidelines Gibson et al. AHA 2016

28 Rehospitalization (%) Hospitalization Related to Cardiovascular or Bleeding Event Cardiovascular Riva + P2Y 12 v. VKA + DAPT HR=0.68 (95% CI: ) P<0.001 ARR=8.1 NNT=13 Bleeding Riva + P2Y 12 v. VKA + DAPT HR=0.61 (95% CI: ) p=0.012 ARR=4.0 NNT=25 Riva + DAPT v. VKA + DAPT HR=0.73 (95% CI: ) p=0.005 ARR=8.1 NNT =13 Riva + DAPT v. VKA + DAPT HR=0.51 (95% CI: ) p=0.001 ARR=5.1 NNT=20 Adverse events leading to hospitalization were classified by consensus panel blinded to treatment group as potentially related to either bleeding, CV or other causes VKA + DAPT Riva + DAPT Riva + P2Y % 20.3% 20.3% Cardiovascular 10.5% 6.5% 5.4% Bleeding No. at risk cardiovascular Days No. at risk bleeding Treatment-emergent period: period starting after the first study drug administration following randomization and ending 2 days after stop of study drug. Rehospitalizations do not include the index event and include the first rehospitalization after the index event. Hazard ratios as compared to the VKA group are based on the Cox proportional hazards model. Log-Rank P-values as compared to VKA group are based on the two-sided log rank test. Gibson et al. AHA 2016

29 Bhatt DL, Circulation. 2016;134: DOI: /CIRCULATIONAHA Gibson et al. AHA 2016

30 > 75 ans OptumLabs Data Warehouse US insurance database, n= October 1, 2010, and June 30, (Mayo clinic) J Am Heart Assoc Jun 13;5(6)

31 711,298 patients Thromb Haemost July 2016

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34 Méthodes A total of Japanese men and women aged years participated in the Ohsaki study Defecation frequency was evaluated at the baseline using a self-administered questionnaire. Follow up 13 years

35 Résultats La mortalité cardio-vasculaire augmente de 39% chez les constipés

36 Résultats +20% +90% +97% Tous les événements cardio-vasculaires ischémiques augmentent chez les constipés

37 Hypothèses Defecation might be a risk factor for mortality due to intracranial hemorrhagic disease. (rupture of intracranial aneurysms) Abnormalities of Intestinal microbiota

38 Conclusions Manger des pruneaux