Στόχοι αρτηριακής πίεσης σε ειδικούς πληθυσµούς και επιλογή φαρµάκων

Transcription

1 Στόχοι αρτηριακής πίεσης σε ειδικούς πληθυσµούς και επιλογή φαρµάκων Εύα Καρπάνου Δ/ντρια Αντιυπερτασικού Ιατρείου Α ΚΚ Ωνάσειου ΚΚ Θεσσαλονίκη, 14/2/13

2 Η µελέτη δεν υποστηρίχθηκε από φαρµακευτικές εταιρείες ούτε αναφέρει φαρµακευτικά ιδιοσκευάσµατα There is no conflict of interests

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4 HTN PREVALENCE GENERAL vs DM POPULATIONS General population BP > 140/90 30% Utah 25% Age >60y 67% White 29% Black 41% Hispanic 26% BP > 130/80 Persons with DM 67% 76% HTN is more than twice as common in DM! JACC 2012; 60:599, Diabetes Care 2011; 34:1597, Am J Med 2009; 122:443 Utah State Health Department,

5 HTN CONTROL: GENERAL vs DM NHANES BP < 140/90 General population 47% White 52% Black 43% Hispanic 30% BP < 130/ Persons with DM % (37% age > 60yrs) White % Hispanic % Black % Canadian DM control rates to < 130/80 = 56%! JACC 2012; 60:599, Can J Card 2012; 28:367, Diabetes Care 2012; 35:305

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7 HTN: DOMINANT CONTRIBUTOR TO GLOBAL MORTALITY Increases RR by fold for: " CAD, stroke, HF, PAD " Renal failure, AF, dementia, cognition Attributable risk for HTN: " Stroke 62% MI 25% " CKD 56% Premature death 24% " HF 49% Aftermath: " Shortens lifespan 5 years " $ 93.5 billion/year in U.S. Circulation 2012; 125:e12, J Hum Hypertension 2008; 22:63, Hypertension 2007; 50:1006

8 JNC VII: Classification of HTN BP Classification SBP mmhg DBP mmhg Normal < 120 and < 80 Pre - HTN or Stage 1 HTN or Stage 2 HTN > 160 or > 100 The Seventh Report of the Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute. Dec 2003.

9 2007 European Societies of HTN and Cardiology: Classification of HTN BP Classification SBP mmhg DBP mmhg Optimal BP < 120 < 80 Normal and /or High Normal and /or Grade and / or Grade and / or Grade 3 > 180 and / or > 110 Isolated Systolic HTN 140 < 90 Mancia, G. et al Guidelines for the Management of Arterial HTN: The Task Force for the Management of Arterial HTN of the Euro Soc of HTN (ESH) and of the Euro Soc of Card (ESC). J HTN 2007; 25: 1105.

10 Αντιυπερτασική θεραπεία σε ειδικούς πληθυσµούς 2007 ESH/ESH Guidelines

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12 BP thresholds for drug treatment lifestyle modifica/on is recommended for all regardless of BP General population (including CKD) (CHEP 2011) 140/90 Very elderly ( 80) (CHEP 2013) 150 Diabetes (CHEP 2000) 130/80 Very low CV risk (CHEP 2000) 160/100 Year of incorpora,on into CHEP recommenda,ons

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15 STANDARDS OF MEDICAL CARE IN DIABETES

16 Criteria for the Diagnosis of Diabetes A 1 C 6.5% OR Fas/ng plasma glucose (FPG) 126 mg/dl (7.0 mmol/l) OR Two- hour plasma glucose 200 mg/dl (11.1 mmol/ l) during an OGTT OR A random plasma glucose 200 mg/dl (11.1 mmol/ l) ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.

17 Prediabetes: IFG, IGT, increased A 1 C Categories of increased risk for diabetes (Prediabetes) FPG mg/dl ( mmol/l): IFG or 2- h plasma glucose in the 75- g OGTT mg/dl ( mmol/l): IGT or A 1 C % For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range. ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13

18 Arch Int Med 2012; 172:1304 GOAL BP IN DM : HOW LOW TO GO IN 2013? There is no clear optimal target BP in diabetes : Recommended Goal BP in Diabetes JNC-7, 2003 < 130/80 Canada (CHEP), 2012 < 130/80 ADA, 2012 < 130/80 Meta-analysis, 2011: / RCTs; 37,736 pts Circulation 2011; 123:2799 Expert opinion, 2012: < 140/85-90 Lancet 2012; 380:601

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20 Meta-analyses examining SBP targets <140mmHg in patients with diabetes Bangalore et al. Circ 2011 Reboldi et al. J Hyperten 2011 Included only trials that achieved SBPs < 140 mmhg Included all anti-hypertensive trials Outcomes were mortality, CV mortality, MI, HF and stroke Outcomes were MI and stroke only

21 Diabetes and Hypertension Persons with diabetes mellitus should be treated to attain systolic blood pressure of < 130 mmhg (Grade C) and diastolic blood pressures < 80 mmhg (Grade A). These target blood pressure levels are the same as the blood pressure treatment thresholds. The targets for patients with diabetes and hypertension have remained unchanged post- ACCORD-BP.

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25 GOAL BP IN DM: HOW LOW TO GO IN 2013? Newer guidelines for BP goals in patients with DM are likely to suggest a goal of < 140/90 mm Hg based on the totality of evidence. Reasonable data for diastolic BP < 80 3 RCTs ACCORD RCT, 2010; 4733 pts, 134 vs 119 mm Hg 41% in stroke, but small absolute benefit - Limit intensive BP control to high stroke risk subgroups? Meta-analyses of RCTs: No in CVD below 130 mm Hg; 17% in stroke Retrospective analyses of RCTs: Trend to CVD events below 115 mm Hg costs & adherence: more drugs, visits, monitoring No in CVD, MI, death, or microvascular complications Lancet 2012; 380:601, Kid International 2012; 81:586, Arch Int Med 2012; 172:1304

26 Recommendations Hypertension/Blood Pressure Control Treatment (1) Patients with a systolic blood pressure mmhg or a diastolic blood pressure mmhg May be given lifestyle therapy alone for a maximum of 3 months If targets are not achieved, patients should be treated with the addition of pharmacological agents ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S27

27 Recommendations Hypertension/Blood Pressure Control Treatment (2) Patients with more severe hypertension (systolic blood pressure 140 mmhg or diastolic blood pressure 90 mmhg) at diagnosis or follow-up Should receive pharmacologic therapy in addition to lifestyle therapy (A) ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S27

28 Recommendations Hypertension/Blood Pressure Control Treatment (3) Lifestyle therapy for hypertension Weight loss if overweight DASH-style dietary pattern including reducing sodium, increasing potassium intake Moderation of alcohol intake Increased physical activity ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S27

29 Can J Card 2012; 28:270, Am J Hypertens 2011; 24:863, BMJ 2011;3343:d4891 PHARM-Rx IN DM FOR BP > 135/85 ACE-I (ARB)* ACE-I (ARB) + DHP-CCB ACE-I (ARB) + DHP-CCB + Thiazide (chlorthalidone) K + < 4.5 and egfr < 45 > 135/85 a\er 2-4 wks > 135/85 a\er /tra/on to full doses > 135/85 a\er 2-4 wks HR > 84/min K + > 4.5 or egfr < 45 HR < 84/min Spironolactone Consider BB Alpha-blocker BP > 135/85 Consulta4on *If no albuminuria, CVD, and > 1 CVD RF, thiazide or DHP- CCB acceptable Consider ini/al low- dose 2- drug Rx if ini/al BP > 155/95

30 Diuretics and egfr HCTZ Chlorthalidone Loop diuretics > 50 ml/min/1.73m2 > 40 ml/min/1.73m2 < 40 ml/min/1.73m2

31 Dose-effect of diuretics in SBP Reduction in SBP (mmhg) HCTZ Chlorothalidone Drug dose (mg) Carter BL. Hypertens 2004;43:4-9

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33 Diuretic maximization " 25 mg " twice as potent as HCTZ and longer " or Thiazide-like, dizziness can be used with mild HCTZ rash or Combination dizziness pill: tenoretic 25/50mg, 25/100mg " related hyponatremia) " Furosemide BID (egfr < 30 ml/min; thiaziderelated hyponatremia)

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36 ALDOSTERONE BLOCKADE AS STEP 4 Rx Spironolactone, mg/d Study # Patients BP All studies /11 Eplerenone, mg/d Calhoun, /8

37 ALDOSTERONE BLOCKADE AS STEP 4 Rx Clinical use: Contraindicated if egfr < 30 or K Caution if egfr< 45 or K + > 4.5 Minimize hyperkalemia risk: Low K + diet; off K +, salt substitute, triamterene Dosing: Initial Final Spironolactone mg/d 50 mg/d (if PA) Clinical use: Contraindicated Adjust dose q 4 wk if egfr < 30 or K Caution if egfr< 45 or K + > 4.5 J Am Soc Hypertens 2008; 2:462, Curr Hypertens Rep 2008; 10:496 Minimize hyperkalemia risk:

38 ADMINISTER 1 HTN DRUG AT BEDTIME? American Diabetes Association Standards of Medical Care 2012: Administer one or more antihypertensive medications at bedtime (A Level of Evidence). Diabetes Care 2012; 35(Suppl 1):S11

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40 Recommendations Hypertension/Blood Pressure Control Treatment (6) In pregnant patients with diabetes and chronic hypertension Blood pressure target goals of /65-79 mmhg are suggested in interest of long-term maternal health and minimizing impaired fetal growth ACE inhibitors, ARBs, contraindicated during pregnancy ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S27

41 AHA Scientific Statement - Treatment of Hypertension in the prevention and management of ischemic heart disease Diagnosis ( Hg Target BP (mm <140/90 Primary Prevention CAD and Stable Angina ACS UA and NSTEMI ACS - STEMI HF of Ischemic Etiology <130/80 Diabetes, Chronic Kidney Disease, CAD, CAD Equivalents, or Framingham Risk Score 10% <130/80 <130/80, but consider <120/70 Rosendorff et al. Circulation. 2007;115: ASC: acute coronary syndrome, UA: Unstable angina, NSTEMI: Non-ST segment elevation myocardial infarction, STEMI: ST segment elevation myocardial infarction, HF: Heart failure

42 A. Compelling indications for individual drug classes Compelling Indication Initial Therapy Options Clinical Trial Basis Heart failure THIAZ, BB, ACEI, ARB, ALDO ANT ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES Post-myocardial infarction High CAD risk BB, ACEI, ALDO ANT THIAZ, BB, ACE, CCB ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ALLHAT, HOPE, ANBP2, LIFE, CONVINCE

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44 Guidelines for BP target levels Older National Kidney Foundation Bakris GL et al, for the National Kidney Foundation, Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis 2000;36: BP < 125/75 mmhg when proteinuria > 1 g/24h National Institute of Diabetes and Digestive and Kidney Diseases Mulrow C, Townsend R. Guiding lights for antihypertensive treatment in patients with nondiabetic chronic renal disease: Proteinuria and blood pressure levels. Editorial. Ann Inter Med 2003; 139: In patients with chronic renal disease and proteinuria, target SBP 130 to 110, aiming for lower levels within this range when protein excretion > 2 g/day American Diabetes Association and JNC 7 American Diabetes Association. Diabetes Care 2002;25 (Suppl.1):S85-S89 Chobanian AV et al, JNC 7. Hypertension 2003;42: BP < 130/80 mmhg

45 Newer Guidelines for BP target levels European Society of Hypertension & Cardiology Mancia G et al, 2007 guidelines for the management of arterial hypertension. J Hypertens 2007;25: BP < 130/80 mmhg, and at least to 120/80 when proteinuria is present European Society of Hypertension & Cardiology Mancia G et al, Reapprasial of European guidelines on hypertension management. J Hypertens 2009;27: BP < 130/80 mmhg In large trials no patient achieved SBP < 130 mmhg! Latin American Society of Hypertension Sanchez RA et al, Latin American guidelines on hypertension. J Hypertens 2009;27: BP < 130/80 mmhg, and < 120/75 in patients with proteinuria > 1 g and/or reduced GFR Asian Pacific Society of Nephrology Bakris GJ and al, Hypertension and kidney disease. Nephrology 2009;14:49-51 SBP < 130 mmhg, or even < 125 mmhg

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48 CHEP 2012 revisited the CKD BP targets following publication of new data CHEP 2011 CHEP 2012 For patients with nondiabetic chronic kidney disease, target BP is <130/80 mm Hg (Grade C). For patients with nondiabetic chronic kidney disease, target blood pressure is <140/90 mm Hg (Grade B).

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53 CHEP Recommendation: the very elderly III. Choice of Therapy for Adults With Hypertension without Compelling Indications for Specific Agents B) Recommendations for Individuals with Isolated Systolic Hypertension New Recommendation for 2013 ADD: In the very elderly (age 80 years and older), the target for systolic BP should be < 150 mmhg (Grade C).

54 HYVET protocol Goal BP<150/80 mmhg sitting DIURETIC+/- ACE-I PLACEBO STROKE

55 HYVET (treatment target of <150 mmhg): the basis for the new 80+ recommendation The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. N Engl J Med May 1;358(18):

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57 Can we do better? For every complex problem there is a solution For every complex problem H.L. Mencken JCH 2009;11:

58 Kidneys ATRIAL FIBRILATION GLUCOSE GLUCOSE ATRIAL FIBRILATION It is blood pressure first.... it is not that simple BP BP LIPIDS METABOLIC SYNDROME OBESITY Ευχαριστώώ