surtout qui n est PAS à risque?

Size: px

Start display at page:

Download "surtout qui n est PAS à risque?"

Harriet Wiggins
5 years ago
Views:

1 3*25 min

2 et surtout qui n est PAS à risque?

3 2018 ESC/ESH Hypertension Guidelines 2018 ESC-ESH Guidelines for the Management of Arterial Hypertension 28 th ESH Meeting on Hypertension and Cardiovascular protection Barcelona June 2018 NOUVEAU!!!! Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

2018 ESC/ESH Hypertension Guidelines Treatment of CV risk factors associated with hypertension Recommendations Class Level CV risk assessment with the SCORE system is recommended for hypertensive

8 mmol/l (70 mg/dl), or a reduction of 50% if the baseline LDL-C is 1.8 3.5 mmol/l (70 135 mg/dl). For patients at high CV risk, statins are recommended to achieve an LDL-C goal of < 2.

4 2018 ESC/ESH Hypertension Guidelines Treatment of CV risk factors associated with hypertension Recommendations Class Level CV risk assessment with the SCORE system is recommended for hypertensive patients who are not already at high or very risk due to established CVD, renal disease, or diabetes. For patients at very high CV risk, statins are recommended to achieve LDL-C levels of < 1.8 mmol/l (70 mg/dl), or a reduction of 50% if the baseline LDL-C is mmol/l ( mg/dl). For patients at high CV risk, statins are recommended to achieve an LDL-C goal of < 2.6 mmol/l (100 mg/dl) or a reduction of 50% if the baseline LDL-C is mmol/l ( mg/dl). For patients at low to moderate CV risk, statins should be considered, to achieve an LDL-C value of < 3.0 mmol/l (115 mg/dl). Antiplatelet therapy, in particular low-dose aspirin, is recommended for secondary prevention in hypertensive patients. Aspirin is not recommended for primary prevention in hypertensive patients without CVD. I I I IIa I III B B B C A A Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

5 2018 ESC/ESH Hypertension Guidelines 10-year CV risk categories (SCORE system) <70 <100 <115 Very high risk High risk Moderate risk Low risk People with any of the following: Documented CVD, either clinical or unequivocal on imaging. Clinical CVD includes; acute myocardial infarction, acute coronary syndrome, coronary or other arterial revascularization, stroke, TIA, aortic aneurysm, PAD. Unequivocal documented CVD on imaging includes: significant plaque (i.e. 50% stenosis) on angiography or ultrasound. It does not include increase in carotid intima-media thickness. Diabetes mellitus with target organ damage, e.g. proteinuria or a with a major risk factor such as grade 3 hypertension or hypercholesterolaemia Severe CKD (egfr < 30 ml/min/1.73 m 2 ) A calculated 10-year SCORE of 10% People with any of the following: Marked elevation of a single risk factor, particularly cholesterol > 8 mmol/l (> 310 mg/dl) e.g. familial hypercholesterolaemia, grade 3 hypertension (BP 180/110 mmhg) Most other people with diabetes mellitus (except some young people with type 1 diabetes mellitus and without major risk factors, that may be moderate risk) Hypertensive LVH Moderate CKD egfr ml/min/1.73 m 2 ) A calculated 10-year SCORE of 5 10% People with: A calculated 10-year SCORE of 1% to < 5% Grade 2 hypertension Many middle-aged people belong to this category People with: A calculated 10-year SCORE of < 1% Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

6 2018 ESC/ESH Hypertension Guidelines Classification of hypertension stages according to BP levels, presence of CV risk factors, HMOD, or comorbidities Hypertension disease staging Other risk factors, HMOD, or disease High-normal SBP DBP BP (mmhg) grading Grade 1 SBP DBP Grade 2 SBP DBP Grade 3 SBP 180 DBP 110 No other risk factors Low risk Low risk Moderate risk High risk Stage 1 (uncomplicated) 1 or 2 risk factors Low risk Moderate risk 3 risk factors Low moderate risk Moderate high risk Moderate high risk High risk High risk High risk Stage 2 (asymptomatic disease) HMOD, CKD grade 3, or diabetes mellitus without organ damage Moderate high risk High risk High risk High very high risk Stage 3 Established CVD, CKD grade 4, or diabetes mellitus with organ damage Very high risk Very high risk Very high risk Very high risk Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

7 2018 ESC/ESH Hypertension Guidelines And no : HMOD, CKD grade 3, or diabetes mellitus without/with organ damage, established CVD Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

8 2018 ESC/ESH Hypertension Guidelines Factors influencing CV risk in patients with hypertension - 2 Asymptomatic HMOD Arterial stiffening: Pulse pressure (in older people) 60 mmhg Carotid femoral PWV > 10 m/s ECG LVH Echocardiographic LVH Microalbuminuria or elevated albumin creatinine ratio Moderate CKD with egfr > ml/min/1.73 m 2 (BSA) or severe CKD egfr < 30 ml/min/1.73 m 2 Ankle brachial index < 0.9 Advanced retinopathy: haemorrhages or exudates, papilloedema Established CV or renal disease Cerebrovascular disease: ischaemic stroke, cerebral haemorrhage, TIA CAD: myocardial infarction, angina, myocardial revascularization Presence of atheromatous plaque on imaging Heart failure, including HFpEF Peripheral artery disease Atrial fibrillation NONE OF THOSE!!! Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

9 2018 ESC/ESH Hypertension Guidelines Factors influencing CV risk in patients with hypertension - 1 Demographic characteristics and laboratory parameters Sex (men > women) Age Smoking current or past history Total cholesterol and HDL-C Uric acid Diabetes (except some young people with type 1 diabetes mellitus) Overweight or obesity Family history of premature CVD (men aged < 55 years and women aged < 65 years) Family or parental history of early onset hypertension Early onset menopause Sedentary lifestyle (but < 310 mg/dl) Psychosocial and socioeconomic factors Heart rate (resting values > 80 beats per min) IF SBP < 139 mmhg DBP < 89 mmhg THEN MAXIMUM 2 OUT OF THIS LIST + NO Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

10 2018 ESC/ESH Hypertension Guidelines Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

12 REDUCTION MAXIMALE DE 60%

13 Clinical Therapeutics Volume 35, Issue 8, August 2013, Pages

REVASCULARISATION CORONAIRE revascularisation SECONDAIRE :

14 PRIMAIRE : DECES CARDIOVASCULAIRES, INFARCTUS MYOCARDIAQUE, HOSPITALISATION POUR ANGINE DE POITRINE INSTABLE OU REVASCULARISATION CORONAIRE revascularisation SECONDAIRE : DECES CARDIOVASCULAIRES, INFARCTUS MYOCARDIQUE, ACCIDENT CEREBROVASCULAIRE

Types of CV Outcomes Endpoint Evolocuma b (N=13,784) Placebo (N=13,780) 3-yr Kaplan-Meier rate HR (95% CI)

25) Death due to acute MI 0.26 0.32 0.84 (0.49-1.42) Death due to stroke 0.29 0.30 0.94 (0.58-1.

95) Overall, 74 patients would need to be treated over a period of 2 years to prevent a cardiovascular

15 Types of CV Outcomes Endpoint Evolocuma b (N=13,784) Placebo (N=13,780) 3-yr Kaplan-Meier rate HR (95% CI) CV death, MI, or stroke 7.9 No effect ( ) Cardiovascular death ( ) Death due to acute MI ( ) Death due to stroke ( ) Other CV death ( ) MI 4.4-2% ( ) Stroke 2.2-0,5% ( ) Overall, 74 patients would need to be treated over a period of 2 years to prevent a cardiovascular death, myocardial infarction, or stroke. An Academic Research Organization of Brigham and Women s Hospital and Harvard Medical School

16 ACC.18 Treatment Assignment Post-ACS pa;ents (1 to 12 months) Run-in period of 2 16 weeks on high-intensity or maximum-tolerated dose of atorvasta;n or rosuvasta;n At least one lipid entry criterion met Randomiza>on Alirocumab SC Q2W Placebo SC Q2W Pa;ent and inves;gators remained blinded to treatment and lipid levels for the en;re dura;on of the study Schwartz GG, et al. Am Heart J 2014;168: e1. 16

17 ACC.18 A Target Range for LDL-C We azempted to maximize the number of pa;ents in the target range and minimize the number below target by blindly ;tra;ng alirocumab (75 or 150 mg SC Q2W) or blindly switching to placebo. Below target Acceptable range Target range Alirocumab Undesirably high baseline range LDL-C (mg/dl) Schwartz GG, et al. Am Heart J 2014;168: e1. 17

18 Main Secondary Efficacy Endpoints: Hierarchical Tes;ng ACC.18 *Nominal P-value 18

19 2018 ESC/ESH Hypertension Guidelines Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

20 TNF-α, tumour necrosis factor-alpha; IL-6, interleukin-6; PAI-1, plasminogen activator inhibitor type-1; SAA, serum amyloid A From: Peter Libby MD and CANTOS Eur Heart J. 2018;39(17): doi: /eurheartj/ehy177

21 Hazard ratios for incident CV events in the JUPITER trial according to achieved concentrations of LDL-C and Hs-CRP after initiation of rosuvastatin therapy. History of myocardial infarction and had a blood level of Hs-CRP > 2 mg/l despite the use of aggressive secondary prevention strategies. Nonfatal myocardial infarction, Nonfatal stroke, or Cardiovascular Death

22 2018 ESC/ESH Hypertension Guidelines MERCI POUR VOTRE ATTENTION! Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

Prevention of Cardiovascular Disease

Save Thais from Heart Diseases 2019 Prevention of Cardiovascular Disease Orawan Anupraiwan, MD. Central Chest Institute of Thailand ASCVD Prevention Pyramid Risk categories Very high-risk High-risk Documented