Blood Pressure Control. A SPRINT towards the goal

Transcription

1 Blood Pressure Control. A SPRINT towards the goal Ragab A, Mahfouz, MD Professor of cardiology Zagazig University Introduction.. The defi itio of HTN re ates a attributab e risk to a BP eve. 1

2 Introduction.. Blood pressure is frequently measured and elevated blood pressure ( 140/90 mm Hg) is extremely common. Is it all the story? NO. This reading directs the to search for other risk factors and consider them as part of a comprehensive strategy Triple paradox 1) Easy to diagnose often remains undetected 2) Simple to treat often remains untreated. 3) Despite availability of potent drugs, treatment all often is ineffective. 2

3 Introduction.. It is so c ear y proved that co tro of BP resu ts i savi g ives a d reduci g cardiovascu ar death a d eve ts. The debate becomes do to hich eve BP shou d be dropped? Current Blood Pressure Guidelines in the US JNC-8 Guidelines Subgroup Age 60 years Age < 60 years Diabetes me itus CKD BP Target < 150 / 90 mmhg < 140 / 90 mmhg < 140 / 90 mmhg < 140 / 90 mmhg James PA, et al. JAMA 2014; 311:

4 Observational Data Hazard Ratio* for Mortality by SBP Level in 398,419 Kaiser Southern California Patients The nadir of (SBP) associated with the lowest risk was estimated at 137 mm Hg. Sim JJ, J Am Coll. Cardiol., 2014; 65: Research Question. Examine effect of more intensive high blood pressure treatment than is currently recommended Randomized Controlled Trial Target Systolic BP SPRINT trial Intensive Treatment Goal SBP < 120 mm Hg Standard Treatment Goal SBP < 140 mm Hg 4

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6 Systolic BP During Follow-up Year 1 Mean SBP mm Hg Standard Mean SBP mm Hg Intensive 6

7 Readings of the SPRINT SPRINT achieved a 25% RRR i the primary composite outcome, correspo di g to a decrease i eve t rate from 6.8% to 5.2% over 3.2 years, or a abso ute risk reductio of 1.6%. 7

8 For the same period serious adverse drug eve ts i creased i the aggressive y treated group from 2.5% to 4.7%, a abso ute i crease of 2.2% or a re ative i crease of 88%. Interpretations for patients. Lo eri g SBP to 120 mm Hg by taki g at east 3 drugs every day for more tha 3 years i reduce CV eve ts from 7 out of 100 to 5 out of 100, or by a mere 0.54% per year, ith o be efit at preve ti g stroke or heart attack At the mea time risk of hypote sio, sy cope, e ectro yte ab orma ities, a d acute kid ey i jury or acute re a fai ure i creased by as much as 88%. 8

9 Comparison to ACCORD ACCORD eve t rate as 2.09 %/yr i sta dard BP a d 1.87 %/yr i i te sive BP Sprint: Exc uded peop e ith CKD due to co cer s about metformi for g ycemia questio Did ot recruit age >80 years i the mai tria Lipid tria e ro ed a most a peop e ith o HDL, exc udi g these high risk peop e from the BP tria Did ot i c ude o -fata heart fai ure or o -MI acute coro ary sy drome Thus, e be ieve SPRINT i have a higher eve t rate tha ACCORD 9

10 Clinical outcomes with a SBP < 120 mmhg in older patients with high disease burden A systo ic b ood pressure be o 120 mmhg i o der patie ts ith high disease burde as associated ith adverse outcomes. I dividua izatio of b ood pressure therapy to each specific patie t is arra ted Carlos R. Franco Palacios, September

11 Pre-specified Subgroups: By Thirds of SBP CV Death, MI, Stroke, Cardiac Arrest, Revasc, HF Cutoffs SBP Mean Diff Placebo Event Rate% HR (95% CI) P Trend ( ) ( ) > ( ) Candesartan + HCTZ Better Placebo Better 17 Meta analysis of BP Lowering Trials in DM Resu ts by Base i e Leve s Brunström & Carlberg, BMJ

12 BP Lowering Arm: Conclusions Fixed dose combi atio of Ca desarta 16 mg + HCTZ 12.5 mg/day reduced BP by 6.0/3.0 mmhg, but did ot reduce CV eve ts CV eve ts ere sig ifica t y reduced i the highest third of SBP >143.5 mmhg, mea 154 mmhg Resu ts ere eutra i the midd e third, a d tre ded to ards harm i the o est third of SBP Treatme t i creased ightheaded ess, but ot sy cope or re a dysfu ctio 19 SPRINT v. ACCORD: Which Target Will Win in Diabetes? 12

13 Which BP Goal for Which Patient? * Blood Pressure Goals Then and Now Blood Pressure Goals Hypertension Hypertension with Diabetes Previous <140/90 mm Hg <130/80 mm Hg Now <120/? mm Hg >140/90 mm Hg Some hat paradoxica y a d co fusi g, o -treatme t Bp goa s have i creased i high-risk patie ts a d are ike y to decrease i patie ts ith a o er risk 13

14 The most ike y exp a atio for the abse ce of be efit at o er Bp is that excessive Bp o eri g, particu ar y i diabetics ith microvascu ar disease, ca impair b ood f o to target orga s I patie ts ith CAD, decreased diasto ic b ood pressure ca o er fractio a f o reserve through the ste otic segme t, givi g rise to myocardia ischemia. 14

15 With microvascu ar disease a d arteria stiffe i g commo y prese t i diabetic hyperte sive patie ts, myocardia perfusio is i creasi g y depe de t o systo ic Bp. The o ger the arteria tree has bee exposed to the hurt of diabetes a d hyperte sio, the stiffer it has become a d the ess ike y it ca to erate o o - treatme t b ood pressure. 15

16 Thus, part of hypothesis for BP guide i es is correct yes, diabetic hyperte sive patie ts are at higher risk tha o -diabetic o es, but o, this risk ca ot simp y be abo ished by excessive b ood pressure o eri g. Treating blood pressure alone does not normalize cardiovascular risk A patie t ith high b ood pressure ho does ot have other risk factors for CVD is u usua This is importa t because of the i creme ta i crease i CVD risk associated ith risk factor aggregatio. i.e. a perso ith o y mi d y e evated Bp cou d be at substa tia risk, ot because of the Bp but because of adva ci g age a d mi d ab orma ities i associated risk factors, particu ar y dys ipidaemia 16

17 A final comment We should remember a simple but obvious truth in medicine: Patie ts are ge etica y, physio ogica y, metabo ica y, patho ogica y, psycho ogica y, a d cu tura y differe t. Accordi g y there ever i be o y o e ay to diag ose a d treat ma y medica disorders, i c udi g hyperte sio. 17

18 To o er b ood pressure of a hyperte sive patie ts u iform y to 120 mm Hg c ear y has to be co sidered si y, regardless of the SPRINT resu ts. Wou d it be to mai tai b ood pressure eve s above 140/90 mm Hg i a diabetic patie ts is a so equa y si y. We ca o y hope that despite (or eve because of) SPRINT, physicia s i co ti ue to treat patie ts a d ot b ood pressure umbers a o e. 18

19 ? What is the goals? Where do we go from here? Consider SPRINT results in new Blood Pressure Management Guidelines Goal SBP for various groups including DM and lower risk patients including < 50 Management of SBP Consider Global CV Risk? Classification of blood pressure? 19

20 A practical goal That eve of b ood pressure at hich i vestigatio a d treatme t do good a d ess harm ith co sideri g g oba risk approach. Thank You 20